Bryony Hopkinshaw, Jonathan Broad, Lisa Murphy, and Sarah Boutros
Khalid is a 7-year-old boy who had an episode of severe asthma 6 months ago and was discharged with an asthma plan. The family missed two follow-up outpatient appointments, but he has now presented with a life threatening asthma exacerbation requiring PICU. You ask the family why they have missed his follow up appointments and initially they tell you they did not get information about them. On further probing, they tell you that the appointment letters asked them for their passports and advised they may get charged; they can not afford medical bills.
The NHS was founded on the principle of universality. This has changed in recent years, with increasing legislation to restrict access to patients with uncertain or irregular immigration status. This means some children experience delays to or denials of healthcare, and many families are fearful of accessing the NHS.
This 3-part guide explains the laws around NHS charging for healthcare in the UK, and how you can support your affected patients. This is Part 2, which focuses on access to primary care, the impacts of destitution, and what to do if patients suffer harm due to the regulations. Part 1 gives an overview of the legislation, with a specific focus on general inpatient care. Part 3 looks at how the regulations relate to maternal & neonatal care, and recognising survivors of human trafficking. Although this guide is specific to the UK, restrictions on healthcare for migrants are widespread in Europe & elsewhere. This guide is written for paediatric trainees, but the information on the regulations is also applicable to adult patients!
You ask them if they have been able to at least arrange for a GP review and they tell you they have recently moved area and are struggling to register with a new GP, so they have been unable to get repeat prescriptions for inhalers. Due to their immigration status they have no access to state benefits or universal credits and live in a house with other families. Khalid’s parents appear very distressed when explaining all of the above.
Who is entitled to primary care?
- Everyone is entitled to register with a GP, regardless of immigration status
- There is no legal requirement to show a passport or proof of address when registering with a GP
- Despite this, many practices do ask for ID documents on registration, which can cause a significant barrier for vulnerable groups, including migrants.
Everyone is entitled to register with a GP regardless of immigration status
Why might children with insecure immigration status have worse health outcomes?
- Many families are scared to access the NHS because of fear of medical bills, or of Home Office involvement. This can be exacerbated by hospital appointment letters which often mention that entitlement to treatment will be checked, or ask families to bring passports to appointments.
- Fear can lead to delays in care seeking, and missed opportunities for health promotion. This is exacerbated further if there are difficulties in accessing a GP.
- Children newly arrived in the UK may have missed healthcare previously, particularly if time has been spent in refugee camps or in long journeys. They may also have suffered physical or psychological trauma. This RCPCH guideline has a useful section on these health considerations.
- Legal entitlements to NHS treatment differ from entitlements to other state benefits, however many children will lack access to both. All children have the right to attend school. However families with “No Recourse to Public Funds” will not be able to get housing benefits, free school meals, or many other support services, including help for domestic violence.
- Parents may not be entitled to work, and the Right to Rent scheme means they will face immigration checks for tenancy, so may be forced into insecure housing.
- All of these barriers combine to put children and families at significant risk of destitution. This can affect all aspects of a child’s life including nutrition, dental care, and psychological wellbeing.
Support inpatients to register with a GP prior to discharge, advocating for their right to do so if necessary.
What can you do if you think a child has suffered harm due to regulations?
- Work with the family to minimise further harm. Ensure there is good communication – using translators if necessary – to explain treatment and safety netting plans.
- Failure to bring a child to medical appointments is a safeguarding concern, but this is a complex area – requiring senior input – as the issue here is not necessarily a lack of parental care for the child, but instead barriers faced when they try to seek it.
- Support inpatients to register with a GP prior to discharge, advocating for their right to do so if necessary.
- You can print basic “Health Rights Cards” for families in multiple languages here.
- Report harm or near misses using your local incident reporting system (e.g. Datix)
- The RCPCH is collecting anonymous cases of harms or near misses here
Key Learning points
- Everyone has the right to access care at a GP and in A&E, regardless of immigration status.
- There is widespread misconception about these rights among both NHS staff & among patients, meaning many families face barriers in accessing primary care.
- Consider fear of charging/immigration checks as a potential risk factor in patients who present late or miss clinic appointments.
- Winters, M., Rechel, B., de Jong, L. et al. A systematic review on the use of healthcare services by undocumented migrants in Europe. BMC Health Serv Res 18, 30 (2018). https://doi.org/10.1186/s12913-018-2838-y
- Nellums DLB et al. Access to healthcare for people seeking and refused asylum in Great Britain. 121. Research Report: Equality and Human Rights Commission, 2018.
- Murphy L, Broad J, Hopkinshaw B, et al. Healthcare access for children and families on the move and migrants. BMJ Paediatrics Open 2020;4:e000588. doi: 10.1136/bmjpo-2019-000588