NHS charging implementation: impact on patients and patient experience in London. Doctors of the World UK

Transcription

1 NHS charging implementation: impact on patients and patient experience in London Doctors of the World UK

2 DOCTORS OF THE WORLD UK Primary care clinic in East London for people with difficulty accessing mainstream NHS; Staffed by volunteer GPs, nurses & support workers; Advocacy service for GP registration and secondary care; Influencing health policy and practice.

3 WHO COMES TO THE CLINIC? 1,617 patients attended the DoTW clinic in Patients were mostly migrants, incl. asylum seekers & survivors of trafficking. Patients had been in UK on average 6 years before coming to us. 89% of patients were not registered with a GP Patients were from a wide range of countries, e.g.: Philippines (17.7%), China (15%), India (11.8%).

4 WHO ARE UNDOCUMENTED MIGRANTS? Undocumented migrants find themselves without the right documents for a variety of reasons, often beyond their control. People who don t claim asylum due to lack of legal advice Survivors of trafficking Refused asylum seekers People who came to the UK as children with undocumented parents People who came to UK to work without a visa People on spousal visas whose relationship breaks down People whose visa has expired (student/ working) Domestic workers on expired visas which their employer doesn t renew

5 CASE STUDY: MIRIAM Miriam (28) fled Eritrea after escaping conscription into national military service. Imprisoned in Libya; street homeless in Italy and was raped by a group of men. Smuggled to the Jungle in Calais and then to London. Street homeless in London, after 2 months taken to a church by a lady she met on the street. I started to beg her, my feet were swollen and I had been walking up and down for 2 days She could see that I was pregnant.

6 CASE STUDY: MIRIAM WHAT IS MIRIAM S IMMIGRATION STATUS? WHAT BARRIERS IS SHE LIKELY TO FACE IN SEEKING HEALTHCARE?

7 BARRIERS TO PRIMARY CARE Of 1,717 attempts by DOTW to register patients with a GP in 2017, 1/5 were refused. The main reasons were: Lack of ID (34%) or proof of address (33%); Gatekeeping behaviour (27%); Immigration status (10%).

8 CASE STUDY: MIRIAM Turned away from GP practices 3 times. Came to DoTW clinic and was registered with a GP. 29 weeks pregnant before first antenatal appointment. WHAT BARRIERS TO GETTING ANTENATAL CARE IS MIRIAM LIKELY TO FACE?

9 CHARGING IN SECONDARY CARE

10 A HOSTILE NHS? Immigration Act 2014: Extended hostile environment for undocumented migrants into schools, banks and the NHS. Since 2017, there is obligatory upfront charging and immigration checks in: hospitals; NHS / non-nhs community health services. Looking ahead: DH has announced intention to charge in primary care and further consult on charging in A&E.

11 CHARGING IN SECONDARY CARE 1. Chargeability in secondary care depends on immigration status. Undocumented migrants (incl. refused asylum seekers) are charged. 2. Charges must be paid before treatment, which can be withheld if a patient can t pay. 3. Urgent or immediately necessary treatment to be provided regardless of ability to pay (charged for after). 4. Some services are exempt: A&E, some communicable diseases and family planning. 5. Some groups are exempt...

12 GROUPS EXEMPT FROM CHARGES Refugees and asylum seekers; Some refused asylum seekers, i.e. those receiving s.95 destitute families s4(2) destitute and unable to return to country of origin; Survivors of sexual or domestic violence, FGM, torture only for treatment related to experience of violence; Survivors of trafficking; Children looked after by a local authority; People being treated under the Mental Health Act; People held in immigration detention.

13 URGENT OR IMMEDIATELY NECESSARY CARE Must be given regardless of ability to pay. Only clinicians can make this assessment. Maternity services are always immediately necessary. Source: Guidance on implementing the overseas visitor charging regulations, p IMMEDIATELY NECESSARY Life saving, will prevent a condition becoming life-threatening or will prevent permanent serious damage. URGENT Cannot wait until they can leave the UK. Should take into account pain, disability, and the risk of the delay exacerbating their condition. For undocumented migrants assume may not be able to return within 6 months.

14 CASE STUDY: MIRIAM At the hospital the Overseas Visitors Manager identifies Miriam as an undocumented migrant. She is sent an invoice for her ANC. IS THE OVERSEAS VISITORS MANAGER CORRECT?

15 CHARGING AS A BARRIER TO HEALTHCARE 1. Deterrence: Patients fear ID checks & unaffordable bills. Debts of 500+ reported to the Home Office after two months affects immigration applications. 2. Incorrect/untransparent assessments of urgency Clinicians or OVMs wrongly apply definitions & deny care. 2. Gatekeeping by admin staff Reception staff delay or deny access to doctor due to ID checking bureaucracy / incorrect record of patient s immigration status.

16 CHARGING AS A BARRIER TO HEALTHCARE 1. Deterrence: Patients fear ID checks & unaffordable bills. Debts of 500+ reported to the Home Office after two months affects immigration applications. 2. Incorrect/untransparent assessments of urgency Clinicians or OVMs wrongly apply definitions & deny care. 2. Gatekeeping by admin staff Reception staff delay or deny access to doctor due to ID checking bureaucracy / incorrect record of patient s immigration status.

17 Fear, debt and maternal health Midwife: We try to persuade [pregnant patients] that they really need to go to the hospital but the fact that they are frightened means that they often need more than one visit with us before we manage to convince them by which time they have missed 1 scan, they ve missed blood tests and, if there is anything wrong, it takes that much longer to identify. Very often, you think you ve helped a lady, and then they ring us and say sorry, I can t do this and that s dreadful. And you think, what s going to happens to them? Where are they going to deliver? Interviewer: And do you ever find out? Midwife: Sometimes not because they then stop answering our phone calls They are in a real fix these women and that conversation is a horrible thing. And I really want them to have antenatal care.

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20 Roll-out of checks & charging visible in community mental health

21 CHARGING AS A BARRIER TO HEALTHCARE 1. Deterrence: Patients fear ID checks & unaffordable bills. Debts of 500+ reported to the Home Office after two months affects immigration applications. 2. Incorrect/untransparent assessments of urgency Clinicians or OVMs wrongly apply definitions & deny care. 2. Gatekeeping by admin staff Reception staff delay or deny access to doctor due to ID checking bureaucracy / incorrect record of patient s immigration status.

22 Denial of urgent cancer treatment Djibril had been living in the UK 17 years after fleeing political persecution in his home country. He claimed asylum, but this was turned down. Twice the Home Office tried to return him, but local authorities refused to allow him back. He remained living in limbo in the UK. Djibril was diagnosed with cancer and told he needed surgery, but the hospital cancelled the operation because of his status. Djibril s medical notes explained that there was a risk of the cancer spreading if he did not receive treatment. Despite this, the hospital declined to treat him unless he paid for the surgery in advance. Unable to pay or return home, Djibril came to Doctors of the World. The treatment was provided after a significant delay after we supported Djibril to get legal help to challenge the hospital s decision.

23 CHARGING AS A BARRIER TO HEALTHCARE 1. Deterrence: Patients fear ID checks & unaffordable bills. Debts of 500+ reported to the Home Office after two months affects immigration applications. 2. Incorrect/untransparent assessments of urgency Clinicians or OVMs wrongly apply definitions & deny care. 2. Gatekeeping by admin staff Reception staff delay or deny access to doctor due to ID checking bureaucracy / incorrect record of patient s immigration status.

24 GP testimony: administrative gatekeeping at A&E When Pauline presented at DOTW, she was suffering with acute psychosis and was experiencing delusions, as well as suicidal ideation and paranoia. Our GP, Jean, decided to escort her to A&E for a prearranged assessment with the duty psychiatrist. On arrival, two staff members immediately presented Pauline with a pre-attendance form (English only) asking how long she had been living in the UK. When Jean objected, she was told that Pauline couldn t be seen without completing the form first. Jean was asked to sign the form on Pauline s behalf. Jean said: This was with a very unwell person with psychosis, who was at significant risk of suicide, who did not have the mental capacity to sign the form in question, and who had only agreed to attend the department through careful medical management and persuasion. Only after Jean rang the duty psychiatrist directly was Pauline admitted and her suspected diagnosis confirmed.

25 'COST RECOVERY or HOSTILE ENVIRONMENT? Cost burden of migrants is widely exaggerated. Tiny proportion of NHS budget (DH estimate 1.83%) There is no costeffectiveness evidence for the charging regime. No human rights/equality impact assessment has been carried out.

26 Use an interpreter. GOOD PRACTICE TIPS Encourage engagement with treatment despite charges. Be conscious of fears around bills & Home Office. Classify treatment as urgent or immediately necessary ; record decision and flag in notes. Identify exemptions and flag them for coding. Always ask about violence. Question trust policy on protecting vulnerable patients: transparent decision making; use of payment plans; training for OVMs and clinicians? Consider holistic needs & GP registration.

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28 DHSC patient assessment form

29 HELPFUL RESOURCES 1. DoTW UK tools for healthcare professionals: Safe Surgeries toolkit and guidance; Safe Surgeries training; Policy and practice explainers. 2. DOTW Guide to identifying U/IN care (charging flowchart) 3. DH Guidance on implementing the overseas visitor charging regulations 4. DHSC Clinician patient assessment form (U/IN)

30 This training resource was funded by: For more information: @DOTW_UK Please complete the evaluation form: bit.ly/ssevaluation