Migration Pulse

Five points which must not be lost in the debate on NHS access

The Government’s plans to further limit migrant access to NHS services as part of the forthcoming Immigration Bill are a striking example of how quickly the terms of public debate can change on an issue - and how rapidly such a shift can undermine years of evidence-based policy-making.
July 2, 2013
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Sarah Radcliffe

Sarah is Policy and Campaigns Manager at NAT (National AIDS Trust). NAT is the UK's HIV policy charity. We champion the rights of people living with HIV and campaign for change. Sarah works on policy issues around migration and asylum, access to healthcare, poverty and welfare.

The existing rules around NHS access for overseas visitors (terminology used in the charging regulations) are complex, but for those working in migrant and refugee health these have become very familiar and can be fairly easily boiled down: No charging in primary care; charging in secondary care but with many exemptions.

We know that those we most need to advocate on behalf of are refused asylum seekers, visa over-stayers, undocumented and short-term migrants. We know that the rules around charging are not always well-understood by people within the health service, and that myths persist that certain migrants may not access primary care (when in fact all may, if a GP will register them).

But the debate is rapidly shifting away from this familiar ground. Those who claim that migrants are depleting public resources no longer blame asylum seekers for the problem, but EU citizens exercising their treaty rights. Recent news coverage on migrant healthcare access does not even attempt to distinguish chargeable from non-chargeable overseas visitors when tallying up costs to the NHS, but speaks simply of ‘foreigners’ using health services.

With a new Immigration Bill everything is to play for – these will not be tweaks around the edges of the current NHS charging regulations. We cannot assume that the fundamental healthcare entitlements we have come to expect will remain. We will need to start at the beginning again and show the Government and the general public why making health services accessible to all people living in the UK, regardless of migration status, is good for the NHS and can only improve our health as a society.

NAT campaigns for policies which uphold the rights of people living with HIV and which will help stem the spread of HIV in the UK. Here are some of the points which we will be making in response to these new proposals and we urge others to do the same:

1.    There is no evidence of a trend of ‘health tourism’

Number 10 has so far reported a “known cost” to the NHS of between £10million and £20million pounds, whilst Jeremy Hunt says it more like £200million. But what are they costing? What exactly is ‘health tourism’? Charges for NHS secondary care are accrued by a range of migrants, many of whom live permanently in the UK but as irregular migrants, may not legally work and are ineligible for public funds. Some of these debts will have been accrued by short-term visitors to the UK, people who are here on tourist visas. But are they ‘health tourists’ if they come for a holiday and they get in an accident, or become seriously ill? The small number of doctors who have been given substantial column space on this issue make their case with anecdotal reports of people arriving at A&E straight from an airport, but does this really illustrate an intention to come to the UK in order to use NHS services? Sometimes people become ill while travelling; as long as we are dealing purely in anecdotes this explanation is surely as compelling as any other.

In the case of HIV, which as a comparatively high-cost condition to the NHS has attracted ‘health tourism’ claims over the years, there is simply no evidence of people coming to the UK specifically to get free treatment. In fact, migrants living with HIV often arrive in the UK completely unaware of their condition. Data from the Health Protection Agency (now part of Public Health England) showed an average of five years between arriving in the UK and HIV diagnosis.

The lack of robust data on migrant access to the NHS - or even the application of the current charging regime - leaves a space that can easily be filled with estimates and anecdotal reports. We must challenge these, however, and put the onus back on the Government to prove there is a financial problem, and one which outweighs the costs which will be created if we further restrict our health services.

2.    Universal primary care services are vital for individual and public health

Primary care is successful when it reaches the widest range of people possible. Unlike secondary care services, which are restricted to only those with specific, identified needs, the purpose of primary care is to assess the broadest range of health needs and identify how best to meet them. Sifting whole categories of people out of the system at the very first stage will shut them out of health services altogether, until they become so ill they must present at A&E.

Open primary care services are also vital for public health. It is astonishing that, so soon after the measles crisis in Wales, we are contemplating access restrictions which will surely undermine efforts to achieve herd immunity in children for a full range of vaccines. In the case of HIV, public health experts agree that routine testing in primary care is the new frontier in tackling the UK epidemic, diagnosing people who are living with HIV before they become ill. Reducing rates of undiagnosed and late diagnosed HIV will also prevent people from unwittingly passing their infection on to others. We also know that getting people on HIV treatment (when needed) not only keeps them healthy but makes it virtually impossible to transmit HIV to other people. But as BME communities are significantly less likely to attend a sexual health clinic than white British people, it takes a GP to recommend the test before this benefit can be achieved.

3.    Prompt access to services saves the NHS money

Blanket restrictions on access to health services will not save the NHS money. As outlined above, if people cannot access a GP in the early stages of a health concern, they are more likely to present at A&E when they are seriously ill and in need of (often expensive) treatment. Some will have to start using A&E as a first port of call, in lieu of a GP service.

Early presentation can also prevent serious problems from arising in the first place. Antenatal care is a perfect example of this. The ‘ASAP’ campaign currently running encourages women to tell their doctor ‘as soon as they know they’re pregnant’, so that they may benefit from appropriate interventions early in their pregnancy.

For pregnant women living with HIV, prompt access to antenatal care is vital, especially as many are only diagnosed during routine antenatal screening. With appropriate interventions, mother-to-child-transmission of HIV will happen in less than 1% of cases, but where transmission does occur, this is associated with late access to antenatal care (or with the mother presenting for the first time while in labour). The costs of lifetime care for a child born with HIV is significantly greater than the costs of the mother’s antenatal care.

4.    Greater surveillance of NHS access will create a poorer healthcare experience for everyone

The only way to check eligibility for NHS services in a way which does not contravene equality law is to check everyone. The only way to do this fairly would be for everyone to have to bring ID to any GP appointment, including their NHS number. This will create a brand new barrier to health services for everyone and an administrative burden (which will not come cheap).

Given this new surveillance burden, it is inevitable that some people will attract greater attention than others – BME people, people who don’t speak English fluently or who generally ‘appear foreign’. This will lead to discrimination in frontline service delivery on an unprecedented scale.

5.    Ours is not a contributory health system and we ALL pay for the NHS

This is a brief point, but so important: The NHS is not paid for by National Insurance contributions, it is paid for by all our taxes. This includes the VAT paid by anyone who has every bought food from a local shop – regardless of their residency or immigration status. Everyone living in this country pays taxes which fund our NHS. We must not be dragged into arguments about ‘contributions’. These will pit migrants against non-migrants, and also migrants against migrants (e.g. those with permission to work against those who cannot work). It is vital to resist this line of argument.

NAT urge everyone with an interest in health or migrant rights to engage with the consultation on this issue.

A coalition of organisations have created a website which collects information and resources on this issue.  This is a hub for our shared campaigning and will, in time, also include model consultation responses. Please visit and also submit your own evidence and resources:http://migrantsandthenhs.wordpress.com


Having read your fascinating article about migrant access to NHS services I thought you might might be interested in something which my organisation is doing which could have a beneficiakl impact on this situation. We are seeking to use technology, primarily mobile technology, to help reduce the ridiculous amounts of money expended by the NHS on translators and interpreters to provide vital information to non-English speakers. We propose to make much of that information available as text or preferably audio feed on a mobile, the device which most people have with them 24:7. You can see an overview of what we are attempting to do at

Please contact me if you would like to discuss talking Leaflet.

I think we need to remember that refugees are here because they have often fled for fear of their lives. Many have horrific stories of what has happened to them on their journey to the UK. This also means that many of the women don't read or write in their own language so reading text messages is really difficult for them. It may be useful for some information but there are times when it is really important, particularly in health care, where it is really important to know that people have been heard correctly as well as having heard correctly. Communication is a 2 way process not just a one way system.
I use interpreters on a daily basis and without them it would be impossible to do the work I do with asylum seekers and vulnerable BME women.

Where possible interpreter needs to be paid for by users, it not right to ask taxs payers to pay for the service. And those that lived in this country for more then a year should be made to pay unless they can proof free lessions has not been offered.