Bryony Hopkinshaw, Jonathan Broad, Lisa Murphy, and Sarah Boutros
A 28 week gestation child is born premature requiring NICU admission following an unbooked pregnancy. Mum’s English is limited and you book an interpreter to get further information on the pregnancy and to explain how her baby is doing. Mum appears distressed when you ask her why she did not attend any antenatal care services and only says she did not know how to get care. One week later, mum comes extremely distressed in NICU and mentions something about a bill and that she has no money. You discuss this with the nurse in charge and with your Consultant. You find out that the family is chargeable and an initial bill has been given to mum.
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 3, which looks at how the regulations relate to maternal & neonatal care, and recognising survivors of human trafficking. Part 1 gives an overview of the legislation, with a specific focus on general inpatient care. Part 2 focuses on access to primary care, the impacts of destitution, and what to do if patients suffer harm due to the regulations. 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 book an interpreter again to speak to mum – your aim is to hear her concerns, and to try to establish if she may qualify for any exemptions. You prepare your meeting with mum by looking through the exemptions to charging. The start of the conversation is quite distressing to mum, who asks on a couple of occasions if she should give up her child for adoption so that they can get proper medical care. You reassure her that her child will be looked after on NICU regardless of her ability to pay (as this care is immediately necessary) and that you are here to support and to try and find ways to help. Slowly she becomes less distressed and you are able to ask her about her background.
How can you sensitively approach this and what questions would you start with?
- Explain why you are asking certain questions
- Clarify your role as a healthcare professional, and NOT a Home Office official. The information discussed will remain confidential unless safeguarding concerns are elicited
- Start by asking non-threatening questions such as:
- Do you have any support around you at this time?
- Are you managing to access food? Where do you sleep?
You find out she is staying on a friend’s couch and is getting some food from a local church. She has been unable to work since the pregnancy. She was working in a restaurant managed by her boyfriend, but she got kicked out once he found out she was pregnant. He has kept most of her wages and has her passport and few belongings. She feels ashamed that she has been unable to send money back to her family, who had taken a loan to send her to the UK with a promise of a well-paid job. She is scared for her family as the debt they have incurred remains unpaid.
Start by asking non-threatening questions.
You thank her for sharing these very difficult experiences with you and you explain that you will have to discuss her case with your safeguarding team and with specialist organisations that may be able to support her. She agrees to this.
Who is entitled to maternal healthcare?
- Maternity care is billed, but retrospectively, unless people meet exemption criteria.
- In practice, however, women start receiving bills once they book in and often feel pressured to pay part of the bill upfront. Standard maternity care (including antenatal care and uncomplicated normal vaginal delivery) costs around £7000 for women who are chargeable.
Maternity care is deemed always “urgent” which means it should be billed retrospectively rather than up-front.
What exemptions might families in this situation have?
- This mother appears destitute and this could be used to argue for a writing off of the debt.
- There are some suggestions that the pregnancy may have been as a result of domestic violence / sexual abuse. If you are able to explore that further on another occasion, this can be used to entitle her to free NHS care for any care that arises as a consequence of this violence.
- The history you have gleaned so far strongly suggests possible human trafficking. If the mum is found to be a victim of trafficking and is granted ‘reasonable grounds’ decision by the National Referral Mechanism, her bill – and that of her baby – is cancelled (including any previous bills incurred).
The National Referral Mechanism is the UK’s framework for identifying victims of human trafficking and ensuring they receive the appropriate protection and support.
Listen to your patient and avoid re-traumatisation by only asking relevant questions.
What to do if you suspect human trafficking in your patient or parent of a patient?
- Discuss with your Consultant and with your safeguarding leads
- Call the Modern Slavery Helpline for advice
- Listen to your patient and avoid re-traumatisation by only asking relevant questions (you only need to be suspicious to refer)
- Speak to the person alone away from accompanying persons
- Use professional interpreters
- Involve your patient in every step of decision making. Gain consent before referring, unless immediate danger to life or child is the victim of trafficking.
- Refer to support organisations available locally
Key Learning points
- Charging for hospital based services – including maternity & neonatal care – can lead families to fear coming to hospital, as well as delays in treatment once they arrive.
- Maternity care is deemed always “urgent” which means it should be billed retrospectively rather than up-front. Neonatal care is likely to usually also fall into this category.
- Consider fear of charging/immigration checks as a potential risk factor in patients who present late or miss clinic appointments.
- Find ways to look for exemptions in a non-judgemental, supportive manner.
- RCPCH guideline on charging (upcoming)
- 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