(COR0017)

Written evidence submitted by Doctors of the World UK (COR0017)

 

1.1   Doctors of the World (DOTW) UK runs clinics which provide medical care, information and practical support to people unable to access NHS services. Our patients include refugees, people seeking asylum, people who have been trafficked, people experiencing homelessness, sex workers, migrants with insecure immigration status and Roma communities.

 

1.2   To tackle the huge challenge of the COVID-19 pandemic together, it’s critical that the most vulnerable are supported to stay healthy and are included in overall public health measures. Over the last six weeks DOTW UK have become increasingly concerned that the most vulnerable, including our patients, have been largely overlooked in the Government’s COVID-19 response plans and that the Home Office has failed to take adequate steps to protect those in its care. We share the concerns raised by the Joint Council for The Welfare of Migrants and Refugee Action and fully support their recommendations. This briefing will add the immediate concerns arising from the DOTW UK clinic to this body of evidence: the lack of translated COVID-19 guidance for those claiming asylum and survivors of trafficking, the inaccessibility of NHS111 services for non-English speakers, and the continuation of compliant environment policies in the NHS, which deter undocumented migrants from accessing health services.

 

 

Lack of translated COVID-19 guidance

2.1   The Home Office has not adequately prepared to produce up to date, translated COVID-19 guidance for new refugees, those claiming asylum and survivors of trafficking who do not speak or read English well. This has meant that many have not been able to access crucial information on how to identify COVID-19 symptoms, how to access NHS services when needed and how to follow public health measures.

 

2.2   Ensuring access to guidance and NHS services for vulnerable individuals in the Home Office’s care should have been included in the department’s COVID-19 preparations. The need for guidance translated into the languages most commonly spoken by asylum seekers and survivors of trafficking should have been identified, and a system put in place to ensure the translations were updated as government guidance changed. 

 

2.3   Our patient group is extremely vulnerable and at high risk of contracting COVID-19. Most are living in overcrowded accommodation, some are sleeping on the streets or on night buses, and many will have complex health needs. Those in receipt of Government support receive under £40 per week to meet their food, travel and other essential needs, and therefore live in poverty. People who have had an unsuccessful asylum claim do not usually have a regular source of income or access to government support. For many, self-isolation and social distancing will be impossible and for some even regular handwashing will be a challenge.

 

2.4   This population already have very poor access to NHS services; over 90% are not registered with a GP and most don’t know how to access the NHS.[1] Many will not know how to best protect themselves and their families from COVID-19 or where to turn for advice and medical care if they need it. 

 

2.5   Asylum seekers housed in initial asylum accommodation have particularly poor access to NHS services and little knowledge of their right to healthcare. In Initial Accommodation Centres and Emergency Accommodation Centres (such as local hotels) health screening upon arrival is not mandatory. Even though asylum seekers are entitled to access NHS primary and secondary care free of charge, there is no obligation on accommodation providers to register asylum seekers with a GP and so most are not linked into mainstream health services at all. Instead, accommodation providers signpost to private designated healthcare services which, for many asylum applicants, is located several miles away. During normal circumstances this is insufficient to meet people’s needs and some struggle with poor physical and mental health for months.[2] 

 

2.6   Until 20 March 2020, the Government had not produced any advice or guidance on COVID-19 in languages other than English. This means those who do not speak or read English have not been able to receive information on how to recognise the symptoms of COVID-19, understand what to do if they are unwell or how to responsibly access NHS services (via NHS111 rather than walking into NHS services), or how to protect themselves, their families and those they live with.

 

2.7     Concerningly, the absence of translated guidance has also limited people’s ability to observe the crucial public health measures put in place to tackle COVID-19.  In early March the Government published guidance that those with COVID-19 symptoms should self-isolate for 7 days, on 16 March this guidance was updated, so that those sharing a household with a person with COVID-19 symptoms should also self-isolate for 14 days. None of this guidance was available for those unable to read English until 20 March.

 

2.8   On 20 March, the Government produced translated guidance in 6 languages[3] including just two of the languages most commonly spoken by people seeking asylum in the UK[4]. On 24 March, four more languages were added. The Government’s translated guidance is in plain text without any visuals, and not suitable to print to display on notice boards in asylum accommodation or distribute among community groups, which is particularly important for communities with poor access to the internet, a smart phone or data. By contrast, the Irish Government has produced 4-5 different resources (a 16-page information booklet and posters on symptoms, prevention and good hygiene and those at high risk) in 19 languages.[5]

 

2.9   As the COVID-19 pandemic has progressed, DOTW UK has supported patients through our clinics and advice line, providing advice to patients about COVID-19 symptoms and how to access NHS111. Data and case studies collected by our staff shows our patients have poor understanding of how to identify COVID-19 symptoms, access the NHS or follow the public health advice: 11% of patients who have contacted our advice line in the last week did not know the COVID-19 symptoms or what to do if unwell.

 

2.10           “A man called the Doctors of the World advice line this week, concerned that his brother had ‘the flu’.  There was the sound of coughing in the background. The patient had heard about Corona Virus, but didn’t know what 111 was, how to use the service, or how it could help… we gave the website address and went through the questions over the phone” DOTW UK Clinic Coordinator notes.

 

2.11           Case study: On 26 March one of our GPs was contacted by a patient living in asylum accommodation in need of regular medications. The patient’s list of medications made it clear  they had two major co-morbidities that place them in the category of high vulnerability to COVID-19 and, under current public health guidance, they should be shielded for 12 weeks.  The patient told the GP they had been spending significant amounts of time outside the of the asylum accommodation as they were concerned about their vulnerability to COVID-19. The patient said they had been advised by the asylum accommodation provider to spend time elsewhere, and was moving between the asylum accommodation and relatives’ accommodation on foot, returning to the asylum accommodation only to sleep.

 

2.12           Healthcare professionals providing care to residents in asylum accommodation and voluntary organisations supporting asylum seekers, refugees and victims of trafficking have been in desperate need of translated NHS guidance for their patients and service users. One asylum accommodation provider has produced translated guidance themselves, but this has been limited, in few languages and not updated after government advice changed. Despite many attempts (a letter to DHSC, Public Health England (PHE) and NHS England, four emails to PHE, a phone call with DHSC and two parliamentary questions), DOTW UK were unable to get confirmation that the government had plans to translate the COVID-19 guidance into additional languages.

 

2.13           On 13 March DOTW UK published NHS COVID-19 guidance in 15 languages in partnership with the British Red Cross. Following a large number of requests for guidance in additional languages from voluntary sector organisations and healthcare professionals working in the asylum system we now have guidance in 34 languages. The translated resources have been downloaded over 25,300 times and DOTW UK have been inundated with responses and requests for the guidance in additional languages from voluntary sector organisations and healthcare professionals and police forces:

 

 

2.14           Recommendation: Translate all COVID-19 guidance for the general public into the languages most commonly spoken by those going through the asylum system and National Referral Mechanism and launch a public health information campaign to reach asylum seekers and survivors of trafficking.

 

 

Barriers to NHS111

3.1   DOTW UK is concerned NHS111 services are not accessible to new refugees, those in the asylum system and survivors of trafficking unless they have a good grasp of English. The NHS111 online assessment tool is only available in English and, although NHS111 call handlers do have access to translators, the initial switchboard is in English. We have seen a patient who was unable to understand the switchboard and could not get through to a call handler.

 

3.2   “This gentleman, who speaks little English, had trouble accessing 111 because he couldn't understand the automated service. I suspect this might be an issue as time goes on. ….. I think it is vital to have better access to 111 as this gentleman has underlying health issues that could well be related to his fever.” DOTW Clinic Caseworker email.

 

3.3   While the operation of NHS111 is a matter for the Department of Health and Social Care (DHSC), the Home Office should have anticipated the challenges asylum seekers and survivors of trafficking who do not speak English would face accessing NHS111 online and phone service and worked with DHSC colleagues to adapt the service accordingly.

 

3.4   Recommendation: Adapt the NHS111 service to enable non-English speakers to access the phone service and translate the online tool into the languages most commonly spoken by those going through the asylum system and National Referral Mechanism.

 

 

Failure to remove barriers to NHS services for people seeking asylum and undocumented migrants

4.1   When managing communicable disease, it is essential the entire population, including vulnerable groups such as asylum seekers, undocumented migrants and people experiencing homelessness, is included in the healthcare system and public health measures. Communicable diseases do not distinguish between a person’s immigration status, and nor must the healthcare system. Those countries with the most universal and equitable health systems will be most resilient to COVID-19.

 

4.2   In its response to COVID-19, the Home Office should have taken steps to suspend the NHS Charging Regulations and end the practice of sharing patient data between the NHS and the Home Office for immigration enforcement. These measures, which are part of the Government’s compliant environment policy and intended to prevent and deter undocumented migrants from accessing NHS services, are wholly inappropriate and dangerous during a pandemic.

 

4.3   DOTW UK and other organisations, including the Faculty of Public Health, have long warned that the presence of compliant environment measures in the NHS undermines public health and presents a grave risk to the whole UK population.[6]  Removal of these measures are critical to ensure asylum seekers, refused asylum seekers who have not been removed from the UK or are unable to return to their country of origin and undocumented migrants, feels safe and able to access COVID-19 testing and treatment.

 

4.4   Although the NHS Charging Regulations were made by the Secretary of State for Health and Social Care, the Immigration Act 2014 introduced the restrictions on NHS treatment for people without indefinite leave to remain and the Home Office was the driver of this policy[7].  Faced with a deadly pandemic and global travel restrictions meaning no one can return to another country, suspending these measured should be a top priority for both the Home Office and Department of Health and Social Care.

 

Suspend the NHS Charging Regulations

5.1   Recognising the need for the whole UK population to access NHS services during the pandemic, including people seeking asylum and migrants with insecure immigration status, COVID-19 was added to the list of conditions exempt from charges under the National Health Service (Charges to Overseas Visitors) Regulations 2015 & 2017. But this change to the regulations does not go far enough to ensure that patients with insecure immigration status will feel safe to approach the NHS.

 

5.2   There is a wealth of evidence showing that NHS charges and the presence of immigration status / healthcare entitlement checks in NHS hospitals deters migrant and asylum-seeking patients from accessing services.[8] All medical royal colleges have called for the NHS Charging Regulations to be suspended because of the risk they present to public health and management of communicable disease[9], and the Faculty of Public Health (the leading professional body for public health specialists and practitioners in the UK) has stated:   “Despite exemptions for charging for many infectious diseases, the regulations risk undertreating and underdiagnosing infectious diseases in undocumented migrants, which may present a risk to both the wider migrant and general populations.” [10]

 

5.3   At present NHS trusts across England are still carrying out patient immigration checks on arrival – including in A&E departments. Yet, over the last two years, DOTW UK has seen a number of incidents where seriously unwell patients have left A&E services before triage or receiving treatment when asked to provide information about their immigration status.

 

5.4   Although the NHS Charging Regulations only apply to undocumented migrants, Research commission by the Equality & Human Rights Commission found the Regulations had a clear deterrent impact asylum seekers who avoided accessing NHS services because of their fear of being charged.[11]

 

5.5   On 24 March DOTW UK were contacted by the Director of Say it Loud Club, a community support group for LGBTQA+ refugees and asylum seekers in the UK, describing the impact that the compliant environment has on people seeking asylum’s relationship with the NHS during the pandemic: “Despite all the efforts by the government to keep everyone safe, some of our members unfortunately feel left behind by the system that is supposed to support and understand every member of our community. The NHS unfortunately is not for everyone as some of our members do not have the right documents in order to access NHS support. To these members, the impact of coronavirus is having major impacts. Fortunately, we haven’t heard any positive cases within our members but I am concerned about people not been able to report ill health due to fear and not being able to access primary health care at all.”

5.6   The current COVID-19 exemption is too narrow as it does not guarantee that all treatment required for a person to recover from COVID-19 will be free of charge. Those most likely to require inpatient care for COVID-19 are those with pre-existing conditions, such as heart disease, diabetes, lung disease, cancers and renal failure, yet there is no guarantee that these patients will not be charged for the treatment and management of their pre-existing conditions whilst in hospital, even if it is a clinically necessary part of their recovery.

5.7   DOTW UK are currently supporting patients who are being denied NHS services by NHS trusts in the following circumstances due to their immigration status:

 

5.8   These patients are all seriously unwell, most fall into the COVID-19 high-risk group and their pre-existing conditions are poorly managed. They are at increased risk of requiring in-patient care if they contract COVID-19 and, if hospitalised, it is unclear what treatment would be provided under the current exemption, what treatment would be withheld pending payment and how much they would be billed afterwards.

5.9   Recommendation: Suspend NHS patient charges for the period of the COVID-19 pandemic accompanied by a clear and widespread information campaign to assure the public - including all migrants and NHS staff - that NHS care will be free and safe for everyone.

 

End data-sharing between the NHS and the Home Office

6.1   Most worryingly, there is evidence that asylum seeking and migrant patients distrust and avoid NHS services because they fear information about them will be shared with the Home Office and could lead to deportation. [13] For a number of years NHS trusts have routinely sent letters to patients notifying them they will be reported to the Home Office if they are unable to clear their bill for treatment within two months, and that unpaid bills may affect immigration applications.[14] Many asylum-seeking and migrant patients believe they must avoid the NHS at all costs if they are ever to have a chance of regularising their status.

 

6.2   Although a memorandum of understanding that facilitated the sharing of patient data between the Home Office and NHS Digital has been withdrawn, individual NHS trusts still share patient data with the Home Office on a regular basis as they verify a patient’s immigration status and report unpaid NHS bills. Home Office immigration enforcement teams then use this data to inform their enforcement visits.[15] DOTW UK has been contacted by patients who have received immigration enforcement visits at their home address after visiting NHS services for the first time. In 2017 Public Health England (PHE) was commissioned by DHSC to research the impact of data-sharing on migrants’ health seeking behaviour.[16] DOTW UK and other organisations provided PHE with evidence of the deterrent effect on migrant patients, yet the research and its findings were never published. 

 

6.3   Research by the Equality & Human Rights Commission found the NHS’s reputation of sharing patient data with the Home Office effected asylum seekers with a valid claim even though they are exempt from NHS charges and data-sharing, with many thinking accessing NHS care would have a detrimental effect on any asylum application or appeal: “People also talked about being scared to see a doctor because of what being ill might mean for their asylum application. They were concerned that if they were not healthy, they would not be granted asylum. For example, a woman seeking asylum in London told us: ‘I was afraid to go to the doctor. I was afraid sometimes that it would affect my asylum case – I didn’t know.’”[17]

 

6.4   The current charging exemption for COVID-19 services is insufficient to ensure patients undergoing COVID-19 testing or treatment are not reported to the Home Office. Although these COVID-19 services are free and there should be no reason for an NHS trust to share a patient’s details with the Home Office to verify immigration status or to report a bill, misapplication within trusts is common, and DOTW UK have seen patients who should be exempt from charges, such as asylum seekers and victims of trafficking, incorrectly charged for NHS care, and the Government’s own review of the regulations showed that 22 people had care incorrectly withheld.[18] DHSC have not provided a guarantee that COVID-19 patient’s data will not be shared with the Home Office.

 

6.5   Recommendation: End all data-sharing between NHS trusts, DHSC or NHS Digital and the Home Office for immigration decision making or enforcement, and launch an information campaign to assure the public - including all migrants and NHS staff - that patient information will no longer be shared in this way.

 

March 2020

 


[1] Doctors of the World UK (2019). Registration Refused: Access to GP registration for migrants in vulnerable circumstances in England, 2018. Available from: https://www.doctorsoftheworld.org.uk/wp-content/uploads/2019/08/Registration-Refused-final.pdf

[2] In 2019 DOTW UK provided consultations to a number of people living in asylum accommodation and found unmet healthcare needs and evidence that people had poor access to the NHS. Every patient had unmet healthcare needs and 22% needed an urgent GP appointment based on their clinical condition. None of the patients were registered with a GP or demonstrated proper understanding of their entitlement to NHS services.

[3] Arabic, French, Mandarin, Cantonese, Polish and Welsh

[4] Pashto, Dari, Albanian, Bengali, Mandarin, Spanish, Tigrinya, Hindi, Farsi, Kurdish Sorani and Arabic

[5] See: https://www.hse.ie/eng/services/news/newsfeatures/covid19-updates/partner-resources/COVID-19-translated-resources/

[6] Doctors of the World UK (2017). Deterrence, delay and distress: the impact of charging in NHS hospitals on migrants in vulnerable circumstances. Accessed 02/10/18 from https://www.doctorsoftheworld.org.uk/publications

 

Doctors of the World UK (2017). BRIEFING ON AMENDMENT OF THE NATIONAL HEALTH SERVICE (CHARGES TO OVERSEAS VISITORS) REGULATIONS 2015. Available from: https://www.doctorsoftheworld.org.uk/wp-content/uploads/import-from-old-site/files/2017-08-29_NHSChargesRegs_DoTWbriefing.pdf

 

Doctors of the World UK (2018). Response to the Independent Chief Inspector of Borders and Immigration’s call for evidence: Home Office partnership working with other government departments. Available from: https://www.doctorsoftheworld.org.uk/wp-content/uploads/import-from-old-site/files/DOTW_EvidenceForICIBI_2018.pdf

 

Faculty of Pubic Health (2019). FPH briefing on the NHS Charging regulations for overseas visitors in England. Available at : https://www.fph.org.uk/media/2158/final-fph_briefing_nhschargingregs_1.pdf

[7] Windrush Lessons Learned Review (2020), para 2.3.5. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/874022/6.5577_HO_Windrush_Lessons_Learned_Review_WEB_v2.pdf

[8] Doctors of the World UK (2017). Deterrence, delay and distress: the impact of charging in NHS hospitals on migrants in vulnerable circumstances. Accessed 02/10/18 from https://www.doctorsoftheworld.org.uk/publications

 

Maternity Action (2018). What Price Safe Motherhood? Charging for NHS Maternity Care in England and its Impact on Migrant Women. Accessed 02/10/18 from https://www.maternityaction.org.uk/policy/publications/what-pricesafe-motherhood-charging-for-nhs-maternity-care-in-england-and-its-impact-on-migrant-women/ 10

 

[9] NHS charges to overseas visitors regulations: A statement from the Academy of Medical Royal Colleges - https://www.aomrc.org.uk/wp-content/uploads/2019/03/2019-03-14_NHS_charges_overseas_visitors_regulations.pdf

[10] FPH briefing on the NHS Charging regulations for overseas visitors in England  https://www.fph.org.uk/media/2158/final-fph_briefing_nhschargingregs_1.pdf

[11] Equality & Human Rights Commission (2018). The lived experiences of access to healthcare for people seeking and refused asylum. Available from https://www.equalityhumanrights.com/en/publication-download/lived-experiences-access-healthcare-people-seeking-and-refused-asylum

[12] Patients refused further haematology services, HIV antiretrovirals still being provided.

[13] Equality & Human Rights Commission (2018). The lived experiences of access to healthcare for people seeking and refused asylum. Available from https://www.equalityhumanrights.com/en/publication-download/lived-experiences-access-healthcare-people-seeking-and-refused-asylum

[14] Department of Health and Social Care, Template Letter-patient-information-request. Available from : (3)https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/777484/letter-patient-information-request.odt

[15] Independent Chief Inspector for Boarders and Immigration (2019). An inspection of Home Office (Borders,

Immigration and Citizenship System) collaborative working with other government departments and agencies Available from : https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/774736/An_inspection_of_Home_Office_collaborative_working_with_OGDs_and_agencies_web_version.pdf

[16] House of Commons (2018). Memorandum of understanding on data-sharing between NHS Digital and the

Home Office. Available from: https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/677/677.pdf

[17] Equality & Human Rights Commission (2018). The lived experiences of access to healthcare for people seeking and refused asylum. Available from https://www.equalityhumanrights.com/en/publication-download/lived-experiences-access-healthcare-people-seeking-and-refused-asylum

[18] The Guardian (2019). Ministers accused of cover-up over migrant health reports. Available from: https://www.theguardian.com/uk-news/2019/apr/03/ministers-accused-of-cover-up-over-migrant-health-reports-nhs