Refugee Council

First do no harm:
denying healthcare to people
whose asylum claims have failed

Nancy Kelley and Juliette Stevenson

June 2006
Acknowledgements Note on terminology

This report was produced with the support Throughout this report the term refused
of Oxfams UK Poverty Programme, and has been used to refer to asylum seekers
Pierce Glynn Solicitors. The authors would whose asylum applications and any sub-
also like to thank the Refugee Councils sequent appeals have been finally rejected.
Specialist Team and health policy adviser
for their work and commitment.

Not even the apparently enlightened

principle of the greatest good for the
greatest number can excuse indiffer-
ence to individual suffering.

Aneurin Bevan, founder of the NHS, In

Place of Fear, 1952

There will always be, as there has been

in the past, a proportion of overseas
visitors who are taken ill while they
are here and receive healthcare to
meet their needs and our international
obligations. These people are visitors in
need, not health tourists.

Lord Warner, Parliamentary Under Sec-

retary of State, Department of Health,
Hansard, 05 March 2004, col. 967
Contents

Introduction 4

NHS charging and health tourism 5

The regulations 7

The health needs of asylum seekers and refugees 9

The impact of regulations 11

Implementing the regulations 15

Access to primary care 17

Conclusions and recommendations 18

Bibliography 19
Introduction

The Refugee Council is the largest refugee- Over the last two years, since the
supporting agency in the UK. In 2005, we Government introduced restrictions on
worked directly with more than 60,000 free healthcare for asylum seekers whose
asylum seekers, refugees and unsuccessful claims are unsuccessful, we have become
asylum applicants. We not only give help and increasingly concerned at the devastating
support to asylum seekers and refugees, impact this denial of healthcare is having
but also work with them to ensure that on individuals and families. This report
their needs and concerns are addressed is based on our experience of working
by decision-makers. We are a membership with refused asylum seekers denied
organisation, and our members range from access to secondary healthcare since the
small refugee led community organisations introduction of tighter charging regulations
to international NGOs such as Christian in April 2004.
Aid, Save the Children and Oxfam.

At our London office we have a Specialist

Team, established to help meet the health
and mental health needs of vulnerable
refugees and asylum seekers. The
Specialist Team is made up of a health
access worker, whose role is to enable
clients to access care, bi-lingual support
workers, who provide counselling and
advocacy for refugees and asylum seekers
with mental health support needs, and a
womens worker, whose role is to provide
gender sentisitive support to vulnerable
women. The Specialist Team works closely
with our health policy adviser, who provides
advice to health practitioners from the
voluntary and statutory sector who are
working with refugees and asylum seekers.

Refugee Council health access report 

NHS charging and health tourism
The first charging system for overseas visitors using the NHS was
introduced in 1982, then revised in 19891, but it was not until 2004 and
the introduction of the NHS (Charges to Overseas Visitors) (Amendment)
Regulation that charging was extended to refused2 asylum seekers.

The rationale given for introducing the for any other chronic condition. The
2004 regulation was to protect finite NHS Departments consultation on changes
resources by closing up loopholes where it to charging rules for overseas visitors
has been identified that certain regulations suggested that cost saving was a key
may be open to abuse:3 a response to reason for reviewing the regulations.
health tourism. We were therefore astonished that,
by the Departments own admission,
Health tourism is a term used to describe these changes have been introduced
situations where foreign nationals travel without any attempt at a cost-benefit
to the UK for the express purpose of analysis, and without the Department
benefiting from free NHS healthcare. It having even a rough idea of the
is important to note that whilst individual numbers of individuals that are likely
instances of health tourism are commonly to be affected.
cited, and there is anecdotal evidence of
its impact on the finances of some NHS Health Select Committees Third
trusts, no robust data on health tourism Report of the Session 2004/5 on New
exists, a fact noted by the Health Select Developments in Sexual Health and
Committee in its 2004 Report on HIV/ HIV/AIDS Policy
AIDS Policy:
Moreover, whatever the validity of the
Despite John Hutton MPs conviction Governments claim that health tourism 1 NHS Charges to
that there is a significant amount of represents a significant challenge for Overseas Visitors
abuse going on, no evidence exists to the NHS budget, characterising asylum Regulations 1989.
objectively quantify the scale of abuse, seekers whose claims have been refused 2 The term refused
either in relation to HIV or more generally. as health tourists is clearly inappropriate. asylum seekers is used
The Departments original consultation The regulation was aimed at stopping: to refer to those whose
provided illustrations of abuses that asylum applications
should be stopped, but these only relate Free hospital care for dependants of and any subsequent
to people coming to the UK for a short someone who is exempt from charges asylum appeals have
period to use the NHS, for example who visits the UK briefly just to obtain free been finally rejected.
during pregnancies to access maternity hospital treatment, including giving birth. 3 Proposed
services, rather than people who are Amendments to
staying in the UK long term without Free hospital care for those whose NHS Health Service
proper authority. The consultation employment is based outside the UK but (Charges to Overseas
document gives no specific examples who fall ill or are injured during a business Visitors) Regulations
of people migrating to the UK as health trip to the UK or for any dependants who 1989: A Consultation,
tourists to use NHS services for HIV or have travelled with them. 28/07/03 para 1.

Refugee Council health access report 

 Free hospital care for someone who has
come to the UK primarily to receive private
medical treatment but stays for more than
12 months.

Free hospital care for refused asylum

seekers (i.e. those whose applications
and appeals have been finally rejected,
and others with no legal right to be in
the country).

National Health Service (Charges to

Overseas Visitors) Regulations 1989:
A Consultation, Summary of Outcome
(December 2003)
www.dh.gov.uk/PolicyAndGuidance/
International/OverseasVisitors
[Accessed 31 May 2006]

Asylum seekers come to the UK in order to

pursue the internationally recognised right
of refuge. In a world where borders are
ever more tightly controlled, many asylum
seekers are smuggled or trafficked into the
UK, unaware of their final destination. For
those who can choose, available evidence
suggests that the key factors affecting
their choice are the languages they
speak, family connections or historical
connections between their country of
origin and the UK.

The concept of health tourism implies

not only deliberate fraud, but also the
possibility of returning to ones country
of origin for treatment. For many refused
asylum seekers, this is simply not an
option. In some cases, for those supported
or entitled to support under Section 4
of the 1999 Act,4 even the Government
accepts they cannot return home. In other
cases, people are terrified of returning to
face persecution, to countries that are in
the midst of upheaval and war.

Given the insecurity, distress and

discrimination experienced by those who
flee here seeking sanctuary, it is clearly 4 Support available
not the case that asylum seekers are here to those who cannot
to get free healthcare. They come here return to their country
for our protection, and sometimes, whilst of origin for reasons
here, they also need our care. outside of their control.
See page 8 for detailed
explanation.

Refugee Council health access report 

The regulations

Since 01 April 2004, when this amendment to monitor patients immigration status 5 A common
came into force, the charging regulations with care, to ensure that as soon as an law concept: the
require that all NHS trusts, foundation asylum seeker exhausts their appeal regulations requires
trusts and primary care trusts (the Trust) rights, they can be billed for treatment. trusts to consider
providing secondary care, have a legal The Department of Health guidance whether a person is
obligation to: states that trusts should be prepared to living lawfully in the
check that the application is still ongoing UK voluntarily and
establish whether a patient is ordinarily at intervals if treatment is being provided for settled purposes
resident in the UK;5 over a long period. as part of the regular
order of their life
if not, to assess whether they are liable to Charges apply to all forms of secondary for the time being
pay for their treatment, and care, except treatment provided in whether they have an
Accident and Emergency (A&E) depart- identifiable purpose
charge those liable to pay.6 ments. Emergency treatment which is for their residence
given in any other hospital department here and whether
Department of Health (2004) Implementing is still chargeable. Where treatment is that purpose has
the Overseas Visitors Hospital Charging considered immediately necessary, a sufficient degree
Regulations: Guidance for NHS Trusts in the Trust is not obliged to check whether of continuity to be
England, HMSO, London, p8 the patient can afford to pay before they reasonably described
provide treatment, but they must seek to as settled (DH:p43)
In practice, this role is undertaken by trusts recover the costs after the fact. 6 Nationals of EEA
overseas visitors managers, not doctors or countries, and
nurses. The overseas visitors managers By contrast, where treatment is considered countries with which
work with the trust finance departments only urgent, defined as where the the UK has bilateral
and with external debt recovery agencies: treatment is, in the clinical opinion, not health agreements are
in its guidance, the Department of Health immediately necessary, but cannot wait either not liable for the
strongly advises the use of a debt recovery until the patient returns home, trusts are costs of the care, or
agency that is experienced in handling strongly advised to seek deposits equivalent have limited liability.
overseas debt. to the estimated full costs of treatment in This includes countries
advance of providing the treatment. such as Azerbaijan
Whilst asylum seekers claims are being and Bosnia, which
decided, they are entitled to free NHS care. The charging system covers almost all are refugee producing
Once they have exhausted their appeal health needs: the only types of treatment countries.
rights, they remain entitled to continue any that remain free are family planning 7 Provided under the
treatment they were already receiving, but services, compulsory mental health care,7 Mental Health Act
all other secondary care is chargeable. and treatment for a range of communicable 1983, or under a court
In fact, the regulations encourage trusts diseases that might pose a public health probation order.

Refugee Council health access report 

risk if not dealt with. Treatment provided No patient is too vulnerable to escape
in sexually transmitted diseases clinics is charging: a refused asylum seeker involved
also free, except treatment for HIV/AIDS. in a near fatal car accident would receive
HIV testing and counselling is free, but free care in A&E, but once transferred to the
treatment is only provided to those who intensive care unit would begin incurring
can afford to pay.8 charges that would ultimately amount to
tens of thousands of pounds. Children
The guidance requires trusts to take all are charged, people with acute mental
reasonable measures to recover the debts health problems or learning disabilities
incurred, with the only acceptable reason for are charged, and elderly patients with
not seeking payment being death: where dementia are charged.
the patient has subsequently died, the Trust
can decide to write the debt off.9 This
means trusts are required to issue invoices,
threatening letters or even refer to debt
recovery agencies, debts owed by people
they are fully aware are unable to pay.

The vast majority of asylum seekers whose

claims have been refused are destitute,
surviving on the charity of friends, family
and community groups. A very small
number of people qualify for support under
Section 4 of the Immigration and Asylum
Act 1999 on the grounds that they are:

unable to leave the UK due to a physical

impairment (serious illness or late stages
of pregnancy; or

unable to leave the UK due to there being

no safe route of return to their country of
origin; or

they are complying with steps to facilitate

return (applying for travel documents); or

there are exceptional or compassionate

circumstances for their remaining in the
UK; or

they have been given permission to

judicially review their asylum refusal.

People on Section 4 support exist in a

cashless economy: given either full board
accommodation, or accommodation and
vouchers.

Thus, no refused asylum seeker has access

to any legal source of income, apart from 8 Department of
borrowing from family and friends. They Health: 2004:21
quite simply cannot pay the healthcare 9 Department of
bills they are sent. Health: 2004:38

Refugee Council health access report 

The health needs of asylum seekers
and refugees
In addition to experiencing similar health problems as the rest of the
UK population, refugees and asylum seekers also suffer from a range of
physical and mental health problems as a consequence of experiences
in their country of origin, sometimes made worse by poor access to
healthcare and the dangerous and stressful journey to the UK.10

Often, problems are compounded by the Refugee and asylum seeking women may 10 Burnett, A. Peel, M.
conditions they face upon arrival: adapting have experienced assault, sexual abuse (2001) Asylum seekers
to a new culture and language, the and rape as forms of persecution,16 which and refugees in Britain:
complexity of the asylum system, dispersal in addition to psychological trauma causes Health needs of asylum
procedures11 and lack of information about a range of physical health problems that seekers and refugees,
services (Kelly et al: 2005). are left untreated due to flight. Sexual BMJ, 322, pp. 544-547.
health and childbirth can also be affected 11 Since the Immigration
As many as 20 per cent of asylum seekers by female genital mutilation (FGM), and it and Asylum Act 1999,
and refugees have severe physical health is estimated that over 80,000 women and asylum seekers wishing
problems that make their day to day life girls in the UK may have undergone this to access both cash
difficult (Burnett and Peel: 2001). Many of practice, with this number set to rise.17, 18 support and
these problems may have arisen as a result accomodation have
of conditions in their countries of origin, Like women, children are also at risk of been dispersed outside
including poverty, lack of preventative ill health. Refugee children suffer more of London on a no
healthcare, particularly immunisations, and acutely from physical problems associated choice basis. For many
the prevalence of particular diseases.12 with their social deprivation before entering this has meant isolation
For example, tuberculosis (TB) can spread the UK, including malnutrition and disease, and social exclusion
rapidly through cramped and squalid living which is worsened by damp housing as a result of living in
conditions in refugee camps or during flight, conditions in the UK and exposure to communities without
or indeed in the inadequate housing many diseases they are not immunised against.19 a history of inward
asylum seekers and refugees have in the UK migration, and without
(Woodhead; 2000). Some asylum seekers Between 5 and 30 per cent of asylum established refugee
and refugees come from countries where seekers have been tortured.20 The physical or minority ethnic
the risk of exposure to HIV/AIDS is extremely effects of torture include fractures and communities.
high,13 including those where poverty leaves crushed bones, head injuries which may 12 Heptinstall,T et al.
no option open to mothers but to breastfeed, lead to epilepsy, deafness through ear (2004). Asylum
creating a significant risk of mother to child damage and keloid scars from burns Seekers: a health pro-
HIV infection (Woodhead; 2000). and cuts (Burnett and Peel; 2001). Both fessional perspective.
women and men suffer sexual violence, Nursing Standard 18
Women are particularly vulnerable to in particular rape (Peel: 2004). Violence (25), pp.44-53.
deteriorating health, and maternal deaths of this nature triggers feelings of shame 13 Loughna, S. Merheb,
in the UK are significantly higher among and grief, but also brings potential risk N. et al (2006). The State
refugees and asylum seekers than the of infection with HIV and other sexually of the Worlds Refugees
population at large.14 Contributory factors transmitted diseases. Torture survivors Human Displacement
include previous lack of access to antenatal can also suffer from physical symptoms in the New Millennium.
care, poor nutrition, and highly traumatic brought about by psychological stress, UNHCR Oxford Uni-
instances of pregnancy caused by rape.15 including abdominal, neck and back pain, versity Press: Oxford.

Refugee Council health access report 

weakness and headaches (BMA; 2001, 14 Benjamin, A. (2005). 21 Medical Foundation.
Burnett and Peel; 2001). They are often Forced to go it alone, (2001). Suicide in
unwilling or unable to discuss past traumas The Guardian, 14 Asylum Seekers and
due to their magnitude, and many survivors December. Refugees MF
prefer active forgetting to reliving these 15 British Medical response to the
acutely distressing experiences.21 Association. (2001). Department of Healths
Asylum Seekers and consultation document
Refugees and asylum seekers commonly health - A British National Suicide
experience significant mental health Medical Association Prevention Strategy
problems. Past experiences of torture, and Medical for England. [Internet]
rape, death of loved ones, social upheaval, Foundation for the Medical Foundation
detention and other forms of persecution Care of the Victims July 2001. Available
give rise to intense crisis emotions of Torture dossier. at: www.torturecare.
such as fear, grief and shame (Medical [Internet] October org.uk/UserFiles/File/
Foundation; 2001) and these experiences 2001. Available publications/brief29.rtf
can both cause mental health problems, at: www.bma.org. 22 Hill, M. Hopkins P.
or exacerbate pre-existing conditions.22 uk/ap.nsf/ Content/ (2006). This is a good
Mental distress is a taboo subject in Asylumseekers place to live and think
some refugee producing countries, so healthdossier about the future the
problems may have been left untreated, [Accessed 09 May needs and experiences
and are subsequently intensified with the 2006] of asylum seeking
further trauma of relocation (Burnett and 16 Peel, Dr. M. children in Scotland.
Peel; 2001). Once in the UK, the stress (Ed.)(2004). Rape as a The Glasgow Centre for
caused by poverty, living in a hostile Method of Torture. The the Child and Society/
environment and attempting to adapt to Medical Foundation for Scottish Refugee
a new society can themselves cause or the Care of Victims of Council: Glasgow.
contribute to significant mental health Torture: UK. 23 Cowen, T. (2003).
problems (Kelly et al; 2005, Burnett and 17 Burnett, A, Peel, M. Suffering Alone An
Peel; 2001). Symptoms include: disturbed 2001, Asylum seekers examination of the
sleep, anxiety attacks, violent outbursts, and refugees in Britain: mental health needs
self harm, erratic behaviour and extreme Health needs of asylum of asylum seekers and
mood swings (BMA; 2001).23 The despair seekers and refugees, refugees in Barnet.
people often feel can also trigger them to BMJ, 322, pp. 544-547. Refugee Health Access
re-experience past trauma, which in the 18 Powell, R, 2002. Project: London.
extreme can lead to Post-Traumatic Stress Female Genital 24 During the
Disorder (PTSD). Sadly, asylum seekers Mutilation, asylum consultation period, the
and refugees are among the highest risk seekers and refugees: BMA described their
categories for suicide in the UK (Medical the need for an application to failed
Foundation: 2001). integrated UK policy asylum seekers as
agenda. Forced utterly unacceptable
It is clear that refugees and asylum seekers Migration Review, 14, and the RCN voiced
have complex health needs, arising from July 2002, pp.35. concers about
trauma and deprivation in their countries 19 British Medical endangering patient
of origin, compounded by trauma and Association. (2002). care Health Tourism
deprivation in the UK. Meeting those care Asylum seekers: Rules Unveiled: BBC
needs should be the sole focus of the meeting their news http://news.
NHS, not assessing immigration status healthcare needs. bbc.co.uk/1/hi/
and invoicing.24 BMA: London. health/3355751.stm
20 Burnett, A. Peel, M.
(2001). The health of
survivors of torture
and organised
violence. BMJ, 322,
pp.606-609.

Refugee Council health access report 10

The impact of the regulations
Since the introduction of the regulations, the Refugee Council has
worked with hundreds of refugees and asylum seekers experiencing
serious problems accessing healthcare, but a smaller number of cases
where refused asylum seekers have been completely denied secondary
care that they desperately need. As distressing as these cases are, more
distressing still is the thought of people who had no idea where to turn,
and have been left to suffer.

The 37 cases explored below give us passed to a collection agency. She was
an indication of the serious impact 15 years old, and destitute.
the regulations are having on the lives
of individuals and families, and some The consequences of the charging process
understanding of the wider potential extend well beyond maternity care. There
impacts of limiting access to care. is a very real risk that having experienced
the charging process, vulnerable people
Maternity care with acute health needs will not seek
Since the introduction of the regulations, treatment, and will suffer terribly or even
we have worked with 17 women who have die. This is illustrated by the experience of
been denied access to maternity care. The one of the women who had been charged
women came from a range of countries for her maternity care:
including China, Democratic Republic of
Congo, Vietnam and Somalia. They were C gave birth in hospital, and her baby was
all completely destitute, living on the admitted to the special care unit after birth.
charity of friends and community groups, C was invoiced for 3,024 in maternity
and many were very young, including one costs, an amount she was wholly unable
17 and one 15-year-old child. to pay. She then refused to attend follow
up checks with her baby because of her
A is a young woman from China. When fear of the debt collectors, and that the
she came to us, she was eight months hospital would use the appointment as a
pregnant, destitute and homeless, way to deport her.
sleeping on her friends sofa. She was
terrified about the safety of herself and The guidance for implementing the
her unborn child. Her local trust had told regulations is clear:
her that she would be charged nearly
3,000 for the care she needed, and Maternity services are not exempt
that if she didnt pay, her debt would be from charges. However, because of
passed on to a debt collection agency, the severe health risk associated with
and her information passed onto to conditions such as eclampsia and pre-
Home Office, who would prevent her eclampsia maternity services should
ever re-entering the UK. not be withheld if the woman is unable
to pay in advance.25
B is from Vietnam. She arrived in our
office with a letter telling her that unless Despite this guidance, eight of the women
she paid the 2,300 cost of her maternity and girls we worked with had been told 25 Department of
care within five days, her debt would be that unless they paid in advance, they Health: 2004:42

Refugee Council health access report 11

would not be provided with maternity Cancer
care. This breach of the regulations had Four people came to see us who had been
particularly damaging consequences: diagnosed with various forms of cancer,
but denied treatment.
D, another young Chinese woman, was
given an upfront payment schedule by F from Romania has stomach cancer.
the trust. She borrowed 800 for the first He was operated on, but then billed
payment, then was unable to find the 1,085 and denied radiotherapy
subsequent payments of 800 and 700. unless he was able to pay for it in
She gave birth at home, but was still advance. When he came to Refugee
billed by the Trust for the full amount. Council, he was so distressed he cried
throughout his conversation with our
E, a young woman from China, was health advice worker.
turned away several times by her local
NHS trust, who told her that unless G, is an Arab man whose nationality is
she could pay them several thousand disputed. He suffers from bowel cancer,
pounds upfront, they would not support and was admitted in an emergency
her through the birth of her baby. She because of uncontrolled bleeding. The
gave birth at home, with no medical clinicians in A&E scheduled him for
care, and then both she and her baby an operation as soon as the bleeding
had to be admitted to hospital with stopped. However, once the hospital
serious health problems relating to discovered G was a refused asylum
the traumatic birth. Once discharged, seeker, he was given a bill for many
the hospital continued to send E bills, thousands of pounds, and his operation
which frightened her so much she fled was cancelled. He was discharged from
her home. The whereabouts of her and hospital and told to come back when
her child are not known. his condition deteriorates.

These are just a few examples of women H is Rwandan, and when he came to
who came to Refugee Council for help. Refugee Council was living on the
There is no way of knowing how many street and destitute. He had bowel
more women are giving birth at home, cancer and a colostomy bag from a
unaided and alone. The risks associated previous operation. Not only had the
with childbirth are significant, and without Trust refused to provide care without
proper medical care, women may risk advance payment, his local GP was
lifelong harm to themselves and their refusing to register him.
babies, or even death. These risks are
particularly high for HIV positive mothers Bowel cancer is the second most
and their babies (Williams: 2005). common form of cancer in the UK, and
even with treatment, only 50 per cent
Clearly, there is also a risk that these of those diagnosed with bowel cancer
mothers will be scared of seeking medical survive for more than five years.26 Although 26 www.cancer
treatment for their babies. For babies who less common, stomach cancer has a screening.nhs.uk/
are born with conditions that need care, the lower survival rate: with treatment, less bowel/index.html#how
potential impact is clear, but equally, failure than 40 per cent of people with stomach [Accessed 05 June
to give children routine inoculations and cancer survive.27 2006]
care can cause life long health problems. 27 Stomach Cancer
Diabetes Survival Statistics
Acute / Chronic health needs We have also worked with two diabetic http://info.cancer
Over the last two years, we have worked patients, both of whom are insulin depen- researchuk.org/
with a smaller number of people with acute dent, one in renal failure. cancerstats/types/
or chronic health needs, many of whom, left stomach/survival/
without treatment, would almost certainly I is a diabetic in renal failure who was [Accessed 05 June
die in unbearable pain. referred to Refugee Council by his 2006]

Refugee Council health access report 12

 own primary care trust, after they were refused to treat him without payment.
unable to make any impact on the L is destitute.
charging of the local trust. By the time
he was referred to us, he had been M is a Ugandan woman. After being
charged more than 70,000 pounds for raped, she was experiencing serious
his care. He was destitute. abdominal pains and bleeding. She
came to us after both her GP and her
J is a Roma woman with diabetes and local trust had turned her away.
high blood pressure. She was referred
to us after being turned away by every General operations
local GP in her area. When she went Four clients came to us who had had
to her local Accident and Emergency or needed operations for a range of
department, they too turned her conditions. One had been charged more
away, saying her condition wasnt life than 66,000 for his care, another charged
threatening or an emergency, that if she 145 for a consultation where he was
wanted healthcare, she would have to told he needed an operation, but could
pay. J is destitute. only have it if he paid for it. Another man,
from the former Yugoslavia, managed to
Left untreated, insulin dependent diabetes raise the money for his operation from
can lead to circulatory problems so severe members of his community, but when the
that amputations become necessary. It can operation went wrong, and he needed
cause blindness, cataracts and retinopathy aftercare, was told that he would have
and miscarriage or stillbirth for pregnant to wait until his condition deteriorated to
women. Ultimately, untreated diabetes the point he needed emergency care, or
can cause renal failure and death.28 With pay. Two of these four clients were living
minimal care and treatment, diabetes on Section 4 support on the grounds that
can be controlled, and these devastating the Government accepts that they are too
consequences avoided. unwell to travel.

Trauma recovery Communicable diseases

Six of the people we worked with needed Many communicable diseases are exempt
treatment for injuries sustained both in the from charging in order to protect public
UK and in their country of origin. health. Thirty four communicable diseases
are specifically listed in the regulations
K is a Zimbawean who sustained and in addition all treatment given in or
multiple leg and hip fractures in a recent on the basis of a referral from a sexually
car accident. He experiences acute pain, transmitted diseases clinic is also free
needs physiotherapy and may need of charge. One important exception to
bone grafts in the future. He was charged this rule is HIV/AIDs, where initial testing
4,572 for his emergency treatment, and and counselling is free, but treatment
told that if he wants physiotherapy or is chargeable. Two people came to the
other treatments, he will need to pay. K Refugee Council:
is on Section 4 support on the grounds
that the Government accepts he is too N is an Eritrean man who tested positive
unwell to travel. for HIV after his appeal rights were
exhausted. His trust have refused to
L is an Eritrean man and a survivor prescribe him anti-retroviral therapies
of torture. He was given poor quality unless he is able to pay.
treatment after a serious road accident
14 years ago. He is a wheelchair user, O is a Zimbabwean woman with cancer
and experiences significant spasming and possible HIV infection from her 28 www.nhsdirect.
and pain. He wants to be able to walk husband who died of AIDs. Her Trust nhs.uk/articles/article.
again. His GP tried to refer him to denied her cancer care, and offered to aspx?articleId=128&se
a specialist spinal injuries unit, who test her but not treat her, for HIV. ctionId=15589

Refugee Council health access report 13

Not only is it inhumane to diagnose but
not treat HIV, it also undermines the
Governments commitment to managing
the spread and effects of HIV worldwide.29

29 Ainsworth, Dr
J. Anderson, Dr J.
Gazzard, Prof. B.
Wood, Dr. C. (2004).
Treat with Respect
HIV, Public Health and
Immigration. [Internet]
Available at:
www.ukcoalition.
org/migration/HIV-Treat
_With_Respect1.pdf
[Accessed 01 March
2006]

Refugee Council health access report 14

Implementing the regulations
During the consultation on the new regulations, they were strongly
opposed by the medical profession partly on the basis that clinicians had
an ethical duty to provide care, and therefore could not be involved in
turning away sick patients who are too poor to pay. The Governments
response was to make it clear that the clinicians only responsibility
would be to refer people they suspected of being liable to charging to the
overseas visitor managers for assessment.

Although it is easy to understand why the full amount chargeable for your
doctors and nurses refused to participate confinement and subsequent care.
in a practice which is in conflict with their Any unpaid invoices are registered with
own professional ethics, the practical effect Debt Agencies, and this information is
of this system has been to allow clinicians available to the Home Office, who can
to deny care. Overseas visitors mangers then prevent re-entry into the UK.
and trust finance departments are thus
free to pursue debts without taking any All of these letters were sent to people who
account of the situation or vulnerability of are destitute with no source of income at
the patients. all, or to people supported under Section
4, which provides voucher support and no
Common sense might dictate that where cash. Many asylum seekers will be unable
dealing with refused asylum seekers, who to understand either the letters or the
are almost certain to be living in poverty implications of non-payment. Someone who
or are destitute, trusts might take a more has grown up in the UK with access to the
lenient approach. However, evidence from NHS, and to a robust legal system protecting
our casework suggests that these clients their human rights, might assume that no
are pursued with vigour, as the following terrible consequences would flow from
extracts from charging letters indicate: refusing to pay their healthcare bill. Someone
who has grown up in Eritrea, or Zimbabwe,
Failure to respond to this letter before or China, might be very frightened indeed
(DATE) will result in this matter being to receive threatening letters from state
transferred to (DEBT COLLECTION agencies: perhaps frightened enough to go
AGENCY) who will take all necessary underground, as some of our clients did.
steps including litigation to recover
this debt. Even with the support of organisations such
as Refugee Council, it is extremely difficult
Your account with us is now seriously to get trusts to use their discretion and
overdue for payment and we now request treat patients who are desperate for care.
immediate settlement of the stated In some cases, despite repeated calls from
amount if we do not receive a response our specialist health worker to the Trust in
from you within 7 days, you will leave us question, and to the Department of Health,
with no other option than to begin legal we were unable to get our clients treated
proceedings to recover this debt. without paying in advance.

If we do not hear from you by (date) A tiny minority of patients are able to find
invoices will be issued to you for lawyers to take up their cases, as illustrated

Refugee Council health access report 15

by the following case studies, kindly became ill due to hepatitis and was
provided to us by Pierce Glynn Solicitors: afraid that she might lose the baby.
As a result, the father of her child who
P is a failed Somali asylum seeker in was working on a low income borrowed
her 20s who was referred to us by the two amounts of money, firstly 360 and
Red Cross in February of 2005. She then 800 in order to cover the delivery.
had been refused maternity services The overseas visitors patient manager,
including ante-natal care by the Barking, threatened to contact the Home Office
Havering & Redbridge Hospital NHS about her case and in fact contacted her
Trust. They had advised her that they GP as a result of which her GP refused
would charge her for the delivery of to continue treating her. After the birth,
her baby who was due in May 2005. P she continued to receive invoices. It was
had been referred to the local hospital only at this stage that she was referred
for ante-natal treatment and had a to us and asked for our help because
particular need for treatment due to her childs father was under pressure
complications in her first pregnancy from those who had lent him the money
(she has a 2-year-old son) because her to repay it. She was also very frightened
son had to be induced 10 days after the that the health trust might take action to
expected date of confinement. We sent enforce the outstanding debt. She had
a letter threatening court action to the no income at all except for some food
NHS Trust pointing out that since our and rent payments made by the father of
client was now 6 months pregnant and her child and was due to be evicted from
had received no ante-natal treatment, her private rented accommodation.
we considered that they were placing
her and her child at risk violating We have made a formal complaint to the
Article 3 and 8 of the Human Rights NHS trust in particular about the breach
Convention. We requested a scan and of confidentiality which resulted in her
blood pressure checks. We later pointed losing access to primary care even
out that the Department of Health though the rules about primary care are
Guidance on Charges for Overseas different from those relating to hospital
Visitors specifically states that maternity treatment and the GP had discretion to
services should not be refused because continue treating her. As a result of the
of the risk of infant mortality due to pre- Trust action, she lost her GP at a crucial
eclampsia. Although the Trust then time since her hepatitis status means
agreed to provide maternity care and that her child needs regular check-ups.
not to pursue our clients treatment,
she continued to receive invoices for A more humane approach would be that
the delivery and maternity services healthcare providers would use their
of 2,100 at a time when she was 8 discretion when applying the charging
months pregnant and found this very regulations. Our experience suggests that
distressing. As we had explained to the trusts commonly apply the regulations
Trust in our letter before action, P was without regard to the poverty or
in receipt of NASS Section 4 support vulnerability of the patient, and that they
which is supermarket vouchers only of will often defend this decision in the face
70 per week for her and her son so of professional advocacy by NGOs, and
she was not in any position to pay for even legal action.
maternity services.

Q was a Chinese refused asylum seeker

in her 20s who was referred to us by the
Refugee Council. She was informed by
the same health trust that she must pay
2,300 to cover maternity treatment. In
the late stages of her pregnancy, she

Refugee Council health access report 16

Access to primary care
Finally, there is some evidence that the regulations are having unintended
impacts on access to primary care services, making it even harder for
failed asylum seekers to get even basic care.

Although refused asylum seekers are S is an Iranian woman with depression

entitled to free primary healthcare, relating to the recent death of her
accessing that care in practice can be husband. Although her asylum claim
challenging in the extreme. Language had been refused, her husband had
barriers make it hard for people to get been granted refugee status prior to his
the care they need,30 with this problem death. Ss doctor refused to see her or
particularly acute for people with mental prescribe her regular anti-depressants
health problems (Woodhead: 2000). unless she paid.

Lack of interpreting services means family Not only are the regulations preventing
members are sometimes used, causing desperately ill people getting the help
misinterpretation, embarrassment and lack they need, it appears they are also
of disclosure, particularly amongst women preventing people getting the care they
(Heptinstall; 2004). are entitled to.

Even registering with a GP can be difficult,

because of closed lists and lack of
entitlement knowledge by staff. Practices
in some areas lack the resources to deal
with time-consuming assessments with
an added language barrier, so will refuse
to provide services. This can be made
worse by prejudice amongst frontline staff
(Cowen: 2003).
30 Coker, N. (2001).
From our health casework, there are Asylum Seekers
indications that misinterpretation of the and refugees health
charging regulations is causing more and experience. [Internet]
more surgeries to turn people away, as the Health Care UK:
examples below illustrate. London. Available
at: www.kingsfund.
R is a Somali woman with high blood org.uk/applications/
pressure. She was turned away by her site_search/search.
GP practice and told that as a refused rm?term=refugee+child
asylum seeker, she would have to ren&searchreferer_id=1
pay 45 for an appointment and her [Accessed 16 March
regular prescription. 2006]

Refugee Council health access report 17

Conclusions and recommendations
The first core principle of the NHS is:

The NHS will provide a universal service for all based on clinical need,
not ability to pay. Healthcare is a basic human right. Unlike private
systems, the NHS will not exclude people because of their health status
or ability to pay.

NHS Core Principles

www.nhs.uk/England/AboutTheNhs/CorePrinciples.cmsx
(Accessed 05 June 2006)

When the NHS was founded, universal and asylum seekers whose claims have
access to free treatment was seen as the been refused.
only way to make sure that the poor and
disenfranchised got the care they needed. We call on the Health Select Committee to:
Today, we are turning away some of the
most vulnerable and impoverished people Conduct an enquiry into the impact that
in the UK to suffer and in some cases to die. the NHS Charges to Overseas Visitors
We are violating that basic human right Regulations 1989, and the NHS (Charges to
and we are excluding people because of Overseas Visitors) (Amendment) Regulation
their inability to pay. 2004 are having on access to healthcare for
asylum seekers whose claims have been
Refugee Council calls on the Department refused and other vulnerable migrants.
of Health to:

Amend the NHS Charges to Overseas

Visitors Regulations 1989, and the NHS
(Charges to Overseas Visitors) (Amendment)
Regulation 2004 to specifically exclude
asylum seekers whose claims have been
refused from liability to pay.

Issue guidance to all Primary Care Trusts,

NHS Trusts and Foundation Trusts making
it clear that asylum seekers whose claims
have been refused are entitled to both
primary and secondary healthcare.

Issue guidance to all primary care trusts,

NHS trusts and foundation trusts requiring
them to monitor the outcomes of all
charging decisions made by the overseas
visitors managers.

Support primary care trusts, NHS trusts

and foundation trusts to make their services
fully accessible to refugees, asylum seekers

Refugee Council health access report 18

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Refugee Council health access report 21

The Refugee Council is the largest charity
working with asylum seekers and refugees
across the UK. We campaign for their rights
and help them to rebuild their lives in safety.

Asylum is a human right.

240250 Ferndale Road London SW9 8BB

T 020 7346 6700 F 020 7346 6701
www.refugeecouncil.org.uk
Registered charity no.1014576 Registered company no.2727514 Registered address 240250 Ferndale Road London SW9 8BB