[COR0121]

Written evidence submitted by Doctors of the World (UK) (COR0121)

Following the oral evidence session held by the Home Affairs Committee on 21 April 2020, we would like to direct you to further evidence that may assist the Committee in its ongoing inquiry into the Home Office’s preparedness for Covid-19. Firstly, we provide evidence to support JCWI’s statement that medical staff, as well as patients, have low levels of understanding of the complex NHS charging regulations, meaning charging exemptions, such as the exemption for covid-19 services, have little impact in practice. And secondly, we direct you to evidence that the NHS charging regulations cause racial discrimination within NHS services.

1. Evidence that NHS staff and patients have low levels of knowledge about NHS charging exemptions including the exemption for COVID-19 testing and treatment

1.1 During the evidence session JCWI stated a key reason why the exemption for COVID-19 treatment and testing recently added to the NHS charging regulations was not sufficient to ensure everyone could access NHS services during the pandemic was because knowledge of NHS charging exemptions amongst healthcare professionals and migrant and asylum seeking patients is low. Doctors of the World (DOTW) UK agree with this statement and would like to direct the Committee to evidence that supports it:

1.2 NHS frontline staff

• A survey conducted by the BMA of its members raise concerns about the degree to which individual NHS Trusts and NHS England have informed those working on the frontline about the charging regulations and called for a simplification of charging criteria and exemptions to improve clarity for patients and providers and reduce instances of their misapplication:

“According to our survey there is a high degree of awareness of the new regulations within the medical profession, with over 80% of 556 respondents answering that they were aware of the introduction of both the regulations and upfront charging.

However, as nearly 18% answered that they were not aware of either, there is still an issue regarding the communication of these new policies to frontline doctors. It is of particular concern that the lowest rates of awareness were amongst staff grade (71%) and associate specialist doctors (75%), who make up an important proportion of frontline medical staff in secondary care settings.”

• In 2018 DOTW and JCWI commissioned a survey of NHS clinical staff which showed low levels of knowledge of the NHS charging regulations and the complex range of exempt NHS services and patient groups. 54% of respondents reported they did not know which patients were entitled to NHS services, and 11% incorrectly stated that non-EU patients had to pay for NHS services exempted in the NHS charging regulations 

• Research by the Equality & Human Rights Commission on asylum seekers access to healthcare showed medical professionals have poor understanding of the NHS charging regulations which prevented asylum seekers accessing services even though they are entitled to free NHS care:

“What came across clearly in the research is a perception that health service providers (both clinical and non-clinical staff) are not always sure about the policies around entitlement to healthcare and this can pose significant barriers to accessing timely or appropriate healthcare. This was highlighted as an issue across Britain and across different types of healthcare services, As a result, people were refused treatment, faced delays or were billed incorrectly.” (page 41-5)

• In a call on 28.04.2020 with DOTW UK, the Department of Health and Social Care (DHSC) outlined its work to disseminate information about the Covid-19 charging exemption within the NHS. The information has been published on the online PHE Migrant Health Guide but all dissemination activities have been limited to Overseas Visitors Managers, a non-clinical role responsible for identifying migrant patients and raising invoices, and NHS Trust CEOs rather than proactive dissemination to frontline clinical staff.

1.3 Migrants and asylum-seeking patients

• Research by the Equality & Human Rights Commission on asylum seekers access to healthcare showed asylum seekers were not accessing NHS services even though there is an exemption for all asylum seekers because they did not know about the exemption and feared they would be charged for healthcare or that accessing services would have a negative impact on their asylum application:

“The NHS visitor and migrant cost recovery programme…had a clear deterrent impact on the people we spoke to, even for people who were exempt from charging. In some cases this put people’s health at significant risk….. However, those [covered by the exemption] shared the same concerns about costs even though they were entitled to free healthcare and exempt from the charging regulations. It was evident from their experiences that there is a lot of inaccurate and poorly disseminated information about people’s specific healthcare entitlements.” (page 35-7)

• At the time of the evidence session the Home Office and DHSC had not distributed information about the covid-19 charging exemption to people in the asylum system or to migrant communities. This information was not included in any of the online, public facing NHS guidance on covid-19. Following the evidence session (on the afternoon of 24th April) DHSC put a document outlining the covid-19 exemption in different languages on the PHE Migrant Health Guide. This Guide is an online resource for healthcare professionals, and unlikely to be accessed by migrant patients.

1.4 In 2018 the Government carried out a review into the NHS charging regulations (which, to date, has not been published). The review received evidence of 22 cases in which the regulations were incorrectly applied to patients and, in a Ministerial Statement on 12 December 2018, the Secretary of State for Health & Social Care acknowledged poor understanding of the charging regulations amongst NHS staff and patients contributed to these mistakes and made commitments to address this:

“Some case studies presented did reveal that there is more to do to ensure some groups of vulnerable overseas visitors understand their entitlements and treatment options……We will improve information and support for NHS staff and patients and work with stakeholders and interest groups to ensure that key messages and safeguards are understood by all.

To ensure clinicians, NHS and community care staff fully understand our guidance and how it should be implemented in practice, we will revise and relaunch our focused e-learning training programme, and work with NHS Improvement’s support teams to promote it.

To combat any misconceptions around how the cost recovery regulations affect access to care, the Department and NHS Improvement will continue the close partnership with community groups and stakeholders representing vulnerable individuals to develop user-friendly, culturally-appropriate guidance, and ensure this reaches those who may be impacted by this policy.”

1.5 To the best of DOTW UK’s knowledge, the NHS staff e-learning training programme has not been revised and relaunched, and DHSC has not published guidance for patients since the review.

1.6 DOTW UK therefore support’s JCWI’s call for the need for simple and clear rules during the pandemic rather than narrow exemptions that are not effective in practice.

2. Impact of the NHS charging regulations on BAME communities

2.1 Due to the evidence that covid-19 is disproportionately impacting black and minority ethnic communities that has come to light since we submitted written evidence to the inquiry, we would like to direct the Committee to the evidence that the NHS charging regulations cause racial discrimination in NHS services.

2.2 Equality impact assessments carried out by DHSC as the Department implemented the NHS Charging Programme have continually identified that the charging regulations risked discrimination on the grounds of race:

• A 2012 DHSC Equality Impact assessment stated: “In the application of the Charging Regulations, the greatest risk of inadvertently effecting people adversely within the ordinarily resident population lies with the protected characteristic groups of race and religion/belief.”
• A 2015 DHSC Equality Impact assessment stated: “there is evidence (anecdotal and qualitative research commissioned by the Department from Prederi) that non-white people or people for whom English is not their first language are, on some occasions, targeted in the application of the 2011 regulations due to speculation or assumption that they are not resident in the UK.”

2.3 There is evidence that healthcare entitlement checks continue to be targeted at BAME patients as Overseas Teams in some NHS trusts single out people who do not appear or sound British, or those with non-British sounding names for these checks.

2.4 BAME people who are entitled to NHS services are less likely to be able to provide the paperwork required to prove their entitlement to NHS services, facing increased risk of treatment being delayed or withheld. Providing proof of identity and residence in the UK is a key part of NHS entitlement checks, yet BAME people are less likely to have a driving licence or passport. The case of Albert Thompson, a member of the Windrush generation who had cancer treatment withheld for months because he lacked paperwork, demonstrates the challenge certain patients face accessing life-saving care when unable to provide documents proving their identity and entitlement to NHS services.

2.5 Finally, there is evidence that the existence of the charging regulations puts BAME people off going forward to NHS services altogether because they fear they will be asked to provide documents and prove their entitlement to care. A case reported by a GP in 2019 shows how a black British citizen with a deteriorating condition put off accessing health services for years because of the NHS charging regulations.

2.6 The above examples demonstrate the NHS charging regulations create additional barriers for BAME people accessing healthcare and, in light of the evidence that BAME communities in the UK are disproportionately impacted by Covid-19, making the need for the NHS charging regulations to be suspended during the pandemic all the more urgent.

May 2020