Charging Systems for Migrants in Primary Care: The Experiences of Family Doctors in a High-Migrant Area of London

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1 Charging Systems for Migrants in Primary Care: The Experiences of Family Doctors in a High-Migrant Area of London 13 Sally Hargreaves, BSc, MSc, PhD, * Alison H. Holmes, MA, MD, MPH, FRCP, * Sonia Saxena, MBBS, Dip GUM, MSc, MD, MRCGP, Peter Le Feuvre, MA, MB, Bchir, MRCGP, Wayne Farah, Ghias Shafi, MBBS, Jehanzeb Chaudry, MBBS, Hamed Khan, MBBS, and Jon S. Friedland, MA, PhD, FRCP * * International Health Unit, Department of Infectious Diseases and Immunity, Faculty of Medicine and Department of Primary Care and Social Medicine, Imperial College, London, UK ; Dover Health Centre, Shepway Primary Care Trust, Dover, Kent, UK ; Newham Primary Care Trust, Plaistow, London, UK ; St Bartholomew s and The London, Queen Mary s School of Medicine and Dentistry, London, UK DOI: /j x Background. There is speculation that a high number of migrants use free UK National Health Services to which they are not entitled. In response, the UK government has sought to develop and expand current overseas visitors (OVs) charging systems to target these noneligible migrants for payment. Current guidance to UK primary care providers is ambiguous, and little is known about existing procedures for dealing with new migrants. We aimed to explore the impact of OVs on primary care services and to assess the views of health-care providers about current charging systems. Methods. We undertook a 23-point semistructured questionnaire survey of family doctors working within a highmigrant area of London. Outcome measures were the following: the impact of OVs on their practices, current procedures for registering this patient group, and doctors concerns around expanding existing charging systems. Results. Ninety-two doctors from 53 practices completed the survey (practice response rate 82.8%). Fifty-one (55.4%) of the 92 doctors reported having systems in place to identify and charge OVs requesting registration, and follow-up procedures differed across practices. Significantly more doctors [65 (70.7%)] reported not having any OVs on their practice lists receiving free consultations ( p < 0.001; 298 OVs reported in total). Of the 24 (26.1%) doctors who did, this equated to approximately 3,000 monthly lost income in total for uncharged consultations across all the practices within the survey site. Seventy-eight (84.8%) doctors want a better system to identify and charge OVs in primary care but question the workability of proposals to streamline charging procedures across primary and secondary care. Concerns were raised about the implications for migrants unable to access appropriate health care and the impact on public health priorities. Conclusions. We identified variations in current procedures for identifying and registering OVs, which may result in the inappropriate exclusion of new migrants from free primary care services in the UK. Our findings suggest that the number of OVs receiving free primary care services is low. We need to explore models of appropriate health-care delivery to new migrants in the UK context, drawing on models of best practice from established health services in other migrant-receiving countries. Research into the impact of migration on health services is increasing in its importance across Europe. In particular, questions remain around how best to provide access to an appropriate quality of Corresponding Author: Professor Jon S. Friedland, MA, PhD, FRCP, International Health Unit, Department of Infectious Diseases and Immunity, Faculty of Medicine, Hammersmith Hospital Campus, 8th Floor Commonwealth Building, Imperial College, London W12 ONN, UK. j.friedland@imperial.ac.uk health care to the growing population of irregular migrants who may not be eligible to access national health services on arrival 1 and the level of healthcare provision afforded to vulnerable groups such as asylum seekers and refugees. 2 These issues are particularly pertinent amid rising rates of infection with human immunodeficiency virus and tuberculosis, which have been associated with immigration. 3 Increasing UK immigration and asylum trends since the 1990s 4 have posed particular challenges and dilemmas for the UK s National Health Service 2008 International Society of Travel Medicine, Journal of Travel Medicine, Volume 15, Issue 1, 2008, 13 18

2 14 (NHS), which has historically adopted a free open access approach to delivery of health care, with limited focus on policing access by noneligible migrants at primary and secondary services. In April 2004, however, the UK government issued new guidance to NHS Trust Hospitals in England on the identification and charging of overseas visitors (OVs), with the aim of tightening up and expanding current systems. 5 An OV is a patient not considered to be ordinarily resident in the UK and therefore ineligible for free NHS care. At hospital services, OVs are initially identified by front-line staff as patients who have not resided lawfully in the UK for 12 months prior to presentation for new treatment as an inpatient or outpatient. Such patients are referred to the Overseas Payment Officer who will then decide whether or not the patient is eligible in accordance with current exemption criteria. 5 New guidance 5 explicitly includes as OVs individuals who have had their claim for political asylum refused (failed asylum seekers) and other irregular migrants (individuals who are liable to be deported for issues related to immigration status), of which there may be up to 570,000 in the UK. 6 In 2004, a new set of regulations were outlined in a consultation, with the aim of streamlining, where feasible, hospital charging systems with current procedures at primary care services in England. 7 We and others have questioned the implications of these new systems for service providers and vulnerable migrant groups. 8,9 Under current rules, family doctors have considerable discretion around whether to register OVs, charge them as private patients, or exclude them from care, though systems must be operated in a nondiscriminatory way. 10 Little is known about how primary care services currently operate these systems, despite their key role as gatekeepers to the full range of health services available through the NHS. Guidance to doctors is considered ambiguous in terms of who constitutes an OV in the primary care context and procedures for identifying these patients. 11 Family doctors are encouraged to permanently register all patients who state that they will remain in the UK for at least 6 months, and they must provide emergency care and treatment for exempt diseases of public health significance to all who request it. 6,12 However innercity practices, where numbers of OVs and other temporary migrants are likely to be higher, may struggle to accommodate this additional workload in addition to meeting their targets for health improvement. 13 There are clear tensions between these more restrictive policies that seek to limit access to health care and screening and ongoing Hargreaves et al. initiatives in the UK to tackle ill-health and inequalities among wider ethnic minority communities, and many remain skeptical about the scale of the problem and the justification for this new approach. 14 We explored the impact of OVs on primary care services in one London borough with a high proportion of migrants. We explored both the current systems in place to deal with this patient group as well as the views and concerns of doctors about charging and registration procedures. Methods Survey Site and Sampling Frame The survey site, the London borough of Newham in East London, was specifically chosen because of its unique and diverse migrant population: 62% of residents are from an ethnic minority group and it is ranked second highest in England in terms of the numbers of non-european Union citizens living there. 15 Family doctors based in this borough have more than 310,000 patients registered on their practice lists. The borough is home to many new arrivals and remains one of the main areas where asylum seekers and refugees are known to settle. 16 Our sampling frame comprised all family doctors within Newham Primary Care Trust (PCT). Questionnaire Development There were no suitable preexisting questionnaires that could be adapted for this purpose; therefore, the study entailed the prior piloting of a questionnaire tool that was developed in conjunction with local doctors and the PCT. A consultation process, involving a series of in-depth interviews, was carried out prior to designing the questionnaire to inform the questionnaire development and to ensure that it covered relevant issues. Because primary care services do not routinely collect data on the number of OVs using practice services, we obtained information by asking doctors about individual patients on their practice lists. After development, the questionnaire was piloted on three doctors and slight adaptations were subsequently made. Ethical approval for this study was subsequently granted by the local research ethics committee. Following this, the research used a self-completion, semistructured questionnaire survey tool, comprising 23 structured and semistructured questions: 8 questions related to procedures for dealing with OVs at the practice and the current impact of OVs on the practice, 14 questions related to their current concerns and views on the consultation proposals, and 1 open-ended question invited doctors to expand on previous responses.

3 Charging Migrants at Primary Medical Services Survey and Statistical Methods Family doctors are known to have a key role in delivery of community health services and are frequently asked to take part in questionnaire surveys a factor associated with low response rates in past surveys among this health-care-provider group. 17 A one-toone interview approach was therefore deemed to be the most appropriate method to adopt in this context. We targeted all practices in the survey site. All doctors at each practice were contacted individually via telephone and asked to take part in a voluntary and anonymous survey. Those who agreed were visited in the same week by a trained researcher. Doctors were given an information leaflet summarizing the consultation proposals. 6 They were asked to self-complete a semistructured questionnaire survey. The questionnaire took 5 to 10 minutes to complete once the general practitioners (GP) had read the information leaflet. Data analysis was done using Statistical Package for Social Sciences Program 13 (SPSS Inc., Chicago, IL, USA): a comparison between re s ponses was done using the chi-square test. The main concepts and themes from the semistructured questions were identified and coded manually. Results There are a total of 64 practices within the survey site, incorporating 159 doctors in total. Forty-nine practices were multi-handed and 15 single-handed. Ninety-two of 159 doctors completed the questionnaire survey (doctor response rate 57.9%); 53 of 64 practices were included (practice response rate 82.8%), including all single-handed practices. 15 Family doctors were significantly more likely to report that they had systems in place for identification and charging of OVs than not ( p < 0.05; Table 1 ). Of 51 (55.4%) doctors who had such systems in place, 49 (96.0%) reported that reception staff primarily then practice managers, but not clinical staff, took the lead role in identification of OVs. These were checks to ensure that patients planned to stay in the UK for up to 6 months at the time of presentation before facilitating permanent registration, or 3 months for temporary registration, in accordance with local guidance. 12 Nine doctors elaborated on current procedures in the open question, and we identified practices not accepting any private patients, practices only treating OVs presenting with a registered relative, practices referring all OVs to the Walk-In Centre or Accident and Emergency (A&E) department, and practices registering OVs as NHS temporary patients. Eightyfour (91.3%) doctors reported having systems in place to enable excluded groups to access primary care for emergency or immediately necessary treatment, in accordance with their contractual obligations ( Table 1 ). Only 19 (20.7%) doctors reported that the decision to treat was exclusively theirs, with most decisions made by nonclinical reception staff and/or practice managers. Sixty-five (70.7%) doctors reported that there were no OVs registered or receiving free treatment at their practice ( Table 1 ). Of the 24 (26.1%) doctors who had OVs using practice services free of charge, estimates from the 6 months preceding this survey varied across doctors from between 2 and 100 OV attendances, with a total of 298 OV attendances reported; eight doctors could not identify Table 1 Doctors responses regarding current systems for OVs Practice procedures Yes, n (%) No, n (%)* Estimated proportions (95% CI); p value Doctor is currently running systems 51 (55.4) 32 (34.8) P = 0.56 ( ); p < 0.05 yes to identify OVs Doctor is aware of OVs registered at the 24 (26.1) 65 (70.7) P no = 0.73 ( ); p < practice OVs are able to access emergency 84 (91.3) 5 (5.4) P yes = 0.94 ( ); p < treatment at the practice Doctor has had registered OVs identified 34 (37.0) 56 (60.9) P no = 0.37 ( ); p < 0.05 through hospital referrals Doctor is unclear about current guidance 54 (58.7) 34 (37.0) P no = 0.38 ( ); p < 0.05 for OVs Doctor would welcome a better system to deal with OVs in primary care 78 (84.8) 12 (13.0) P yes = 0.86 ( ); p < GP = general practitioner; OVs = overseas visitors. * Where yes and no responses do not equal 100%, there were missing values or response was do not know. P yes and P no relate to the estimated proportion of respondents who responded yes or no to this question; the p value relates to the difference in proportions. 35 (66.0%) of 53 responding GP practices had systems in place.

4 16 a precise number. Doubling this figure to allow for the response rate, we calculated that 100 potentially chargeable OVs per month could be accessing GPs across the borough. Because a typical doctor consultation charge for a private patient is 30, this equates to 3,000 monthly lost income for all 64 practices in the borough. Thirty-four (37.0%) doctors reported cases of registered patients on their practice lists who had been identified as OVs during outpatient hospital referrals by the Overseas Payment Officer, though doctors were more likely to report that this had not occurred to them ( p < 0.05; Table 1 ). During the 6- month period preceding the survey, doctors collectively reported that this had happened to 92 patients on their lists; three doctors could not identify a precise number. According to routinely collected Trust data, there were a total of 30,581 referrals from all doctors in the survey site to acute Trusts in this period. Doubling the number of OVs identified to allow for the response rate, we estimated that 0.6% of doctor referrals from across the borough to outpatient departments per month are subsequently identified as OVs. Seventy-eight (84.8%) doctors believe that better systems are needed to address the issue of OVs in primary care ( Table 1 ). Concerns were raised about the current workability of the consultation proposals to streamline primary and secondary care charging systems. Eighty-five (92.4%) doctors reported that nonclinical reception staff and practice managers would need training before implementation of hospital charging systems, which are administered in hospitals by dedicated Overseas Payment Officers. Sixty-eight (73.9%) doctors felt that the system of emergency access would need to be adapted to ensure that noneligible patients could access some form of primary health care or clinical opinion through community-based doctors. According to 49 (53.2%) doctors, such proposals could impact disproportionately on A&E departments (emergency rooms) and Walk-In Centres in the borough. Forty-seven (51.1%) doctors felt that there were OVs in the area who would be unable to pay private patient fees. Sixty-four (69.6%) doctors requested a statutory health impact assessment be carried out prior to implementation of new charging procedures. Conclusions Hargreaves et al. We identified considerable variation in how family doctors in the primary care context identified and dealt with new migrants. Sixty-six percent of practices in the borough had systems to identify noneligible migrants requesting registration onto their practice lists, which may result in the exclusion of some migrants from doctors practices by front-line reception staff. The numbers of OVs currently using primary care services and not being charged were relatively low, despite the high migrant population at this survey site. Our data suggest that there may be little benefit in terms of increased revenue to expanding hospital charging systems into primary care where consultation and treatment costs are lower, in light of the considerable organizational restructuring that this might entail (and require financing) and concerns around ensuring access to appropriate health-care provision for vulnerable migrants. There are no previous data on the use of primary care by OVs. Although the data are subject to doctors reporting bias, we found during the pilot phase that doctors are often aware of the status of temporary migrants attending their surgery, particularly with respect to OVs such as family visitors and irregular migrants who disclose their situation to family doctors and have identifiable health and social needs. Actual numbers may well be somewhat higher, for example, data on OVs identified at hospitals will exclude patients who did not return to their family doctor, and certain OVs may well be unidentifiable by doctors. However, local Trust data for the only Walk-In Centre, currently checking the eligibility of all presenting patients as per current hospital regulations, show that this service too sees low numbers, generating only an average of 900/month from OVs ( 25/consultation plus prescription charges; S. Banga, personal communication 2007). Our findings run contrary to the extensive speculation about the burden of OVs on the UK s NHS; 18 however, the relatively low numbers of OVs identified within this primary care setting could be explained by additional factors. Doctors may be reluctant to register OVs as permanent or temporary patients or to consider them as private patients. This may be a specific issue for family doctors in high-migrant areas, who are concerned about the impact of temporary migrants on practice targets. The new services contract between family doctors and the government has largely removed financial incentives for these doctors to register temporary patients, 19 which could result in the high exclusion rates suggested by our data. The exclusion of other new migrants by doctors, such as asylum seekers who are eligible for free NHS care, has been previously described. 11 Alternatively, these migrants may not be big users of primary care services, having few

5 Charging Migrants at Primary Medical Services health needs on arrival and other priorities 20 or they may use alternative sources of care such as free A&E departments directly. 21 It is also possible that some doctors, confused about current guidance, did not consider failed asylum seekers or irregular migrants who have resided in the borough for several months or years to be OVs. Our findings compare favorably with the only other study detailing the impact on family doctors of irregular migrants in Holland, which too relied on estimates from doctors themselves and which reported similarly low use of primary care services. 22 These findings were explained by the fact that irregular migrants are younger and their access to health care is limited in part because they fear registering with GPs and being picked up by the police. UK doctors felt that the identification and charging of OVs in primary care was an important part of practice management and would welcome a better system and clearer guidance. However, the proposals to streamline hospital procedures with those in primary care will generate training requirements for front-line staff, require the development of new access procedures for emergency patients and those with exempt diseases presenting to GP practices, and will require coordination of the various different charging systems currently in operation across practices. In addition, there will be implications for A&E departments, which may be called upon to provide primary care or to admit patients who have not been treated earlier in the course of their diseases. Such issues concern other health-care professionals, 9,11 who have noted also the adverse public health implications of excluding migrants from routine care, a new patient health check, and screening, and the absence of alternative provision for noneligible migrants (including women and children) living in the UK who are unable to afford private patient fees. There is an urgent need to explore models of appropriate health-care delivery to new migrants in the UK context. Health systems in other migrant-receiving countries will deal with migrants in different ways; therefore, these data are UK specific. However, better documentation of the different models adopted in other countries is urgently needed to assess best practice and to inform the current policy debate around access to services for this patient group. Acknowledgments We thank Sampana Banga and all members of the Newham PCT Project Board for their input into this research. We acknowledge the input from 17 Moyra Rushby (Medact) and Jane Shenton (Médecins Sans Frontières). We thank Fabiana Gordon (Imperial College Statistical Advisory Service) for data analysis. Declaration of Interests S. H., A. H. H., S. S., and J. S. F. received a grant from Newham PCT to carry out this work. W. F. from Newham PCT was involved in all aspects of the study. The other authors state that they have no conflicts of interest. References 1. Romero-Ortuno R. Access to health care for illegal immigrants in the EU: should we be concerned? Eur J Health Law 2004 ; 11 : Norredam M, Mygind A, Krasnik A. Access to health care for asylum seekers in the European Union a comparative study of country policies. Eur J Pub Health 2006 ; 16 : Gushulak BD, MacPherson DW. Globalization of infectious diseases: the impact of migration. Clin Infect Dis 2004 ; 38 : Kyambi S. Beyond black and white: mapping new immigrant communities. London, UK : IPPR, Department of Health. Implementing the overseas visitors hospital charging regulations: Guidance for NHS Trust Hospitals in England. London, UK : DoH, Institute for Public Policy Research. Irregular migration in the UK: an IPPR fact file. London, UK : IPPR, Department of Health. Proposals to exclude overseas visitors from eligibility to free NHS primary medical services: a consultation. London, UK : DoH, Hargreaves S, Holmes A, Friedland JS. Charging failed asylum seekers for health care in the UK [commentary]. Lancet 2005 ; 365 : Pollard AJ, Savulescu J. Eligibility of overseas visitors and people of uncertain residential status for NHS treatment. BMJ 2004 ; 329 : NHS Executive. Health Service Circular HSC 1999/018. Overseas visitors eligibility to receive free primary care. London, UK : NHS Executive, Reeves M, de Wildt G, Murshalie H, et al. Access to health care for people seeking asylum in the UK. Br J Gen Pract 2006 ; 56 : Newham PCT. Guidance for general practices on the registration of all Newham residents. London, UK : Newham Primary Care Trust, Department of Health. Quality and outcomes framework. London, UK : DoH, 2004 Available at : www. dh.gov.uk/assetroot/04/08/86/93/ pdf. (Accessed Jul 2007)

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