UKBA proposals to deny entry or stay to migrants with NHS debt: a public health disaster waiting to happen

The biannual announcement of changes to the Immigration Rules this month will include a new provision allowing refusal of immigration applications for entry or stay where a migrant has an unpaid NHS debt. The Department of Health have agreed to share information about individuals’ NHS debts with UKBA to make this possible.

Photo: aldenchadwick (Flickr)

The Government has brought out the familiar narrative of ‘health tourism’ to justify using immigration controls as a form of punishment for people with NHS debts. The DH and UKBA consultation documents outlined a plan of deterring people who are not entitled to free NHS secondary care from accessing it, by escalating the personal consequences of leaving an NHS debt unpaid.

Of course, what these proposals do not acknowledge is that it often in the best interest of the NHS, and the public generally, for chargeable migrants to access secondary healthcare. A key illustration of this is accessing treatment for HIV, the only STI and communicable disease which is subject to treatment charges.

HIV treatment is highly effective at keeping people well and out of hospital.  It is also highly effective at helping prevent onwards transmission of HIV – being on treatment reduces the probability that someone will pass on HIV by 96%. To get maximum benefit from HIV treatment, it is important that someone is diagnosed in good time.  People who are diagnosed late, or not at all, are most likely to become unwell and need to access more expensive treatment options.  The majority of new HIV cases come from someone who has not been diagnosed.

Charging for HIV treatment is highly effective in deterring people from accessing the individual and community benefits of treatment. It also is an effective way of deterring people from accessing testing, even though this is free, because why find out you are living with a lifelong condition if you won’t be able to afford treatment?  Migrant communities affected by HIV are already very likely to be diagnosed late, after they should have already started treatment.  In 2009, two thirds of new HIV diagnoses among African migrants were ‘late’. 

This deterrence effect goes beyond those who are actually chargeable. Charging regulations are complex and it is not always clear to an individual migrant if they will or won’t be charged for their treatment. If they know that others in their community are pursued for debts that they can’t pay, they may assume they will also be charged and never seek treatment.  By the same token, it may not be clear to a migrant that they can still access treatment for other infectious diseases such as TB for free, if they have been charged for HIV. Patients stay away from TB treatment for this very reason.

Far from the image of the ‘health tourist’, entering the UK for the sole aim of using the NHS, most chargeable migrants with HIV are in the UK precariously, as refused asylum seekers or irregular migrants, and are living in destitution. Their NHS debts could be written off, but are often pursued, due to inconsistent application of the charging rules. 

Threatening migrants with refusal of further applications for entry or stay in the UK will add to the deterrence effect already created by NHS charging rules – the Government has got that much right. What they are yet to acknowledge, though, is that these plans will succeed to the detriment of public health.