In the final months of his life, Mohammed Ali slept on a bed in the TV room of
his son's North London home. The 80-year-old was often short of breath and
so fragile that he could hardly walk, let alone climb the stairs to reach
the only bathroom.
Doctors first suspected that Ali had lung cancer in 2006, soon after he
arrived in the UK from Denmark to live with his son. But instead of
receiving treatment, he was pursued by debt collectors who were told by the
NHS to recover money for hospital bills that he could not afford.
Haider Mosa, his son, says that the collection agencies first called once a
month, then once a week. “It was a very stressful time,” he recalls. Until
they paid up, the hospital refused to treat Ali further and said that he was
not entitled to free care because of his immigration status.
“I was walking with my father out of the hospital and I felt like I was
walking him to his death,” Mosa says.
Ali's lawyer, Adam Hundt, says that his client was in the UK legally (he had
been waiting to hear from the Home Office about his right to remain here,
which was finally granted in April) and should have received free hospital
care. But “because of confusion at the level of the trust” and because the
Department of Health was giving “illegal guidance” to the hospital, telling
it to charge Ali, Hundt says that his client was wrongfully denied
treatment. On November 2, after the lawyer intervened and the hospital
agreed to treat Ali and refund part of his money, he died.
This is not an isolated case. Four of Hundt's clients, including a girl of 13,
have died after treatment was refused: three of them had cancers.There are
thousands living in the UK stuck in limbo, including the estimated 155,000
to 283,500 failed asylum seekers, who, after their refugee status is
refused, have nowhere else to go and often no means to pay for healthcare.
Charities that work with migrants say that the Government, in its effort to
crack down on “health tourism”, is victimising people such as failed asylum
seekers and that because of confusion over entitlement, migrants often
receive patchy and inconsistent care. Last month, in the latest
controversial statement since he was appointed Immigration Minister, Phil
Woolas claimed that lawyers and charities working for asylum seekers are
“playing the system”. He has also attacked migrants for exploiting the NHS,
claiming that they arrive in Britain as “health tourists”. He believes that
only people here legally should have access to the free NHS, and disagrees
with the proposal by Boris Johnson, the Mayor of London, for an
asylum-seekers amnesty.
Susan Wright, the director of the charity Médecins du Monde UK, says that
there is no evidence for Woolas's accusations about health tourists. She
says that research on patients who visit the Médecins du Monde clinic in
East London, which provides access to healthcare for people regardless of
immigration status, contradicts his claims. Of the 628 patients who visited
in 2006 and 2007, less than half had illegal immigrant status and the
average patient had already been in the UK for three years.
Many patients are confused about their entitlement. Wright mentions the failed
asylum seekers' paradox: they cannot be deported immediately, yet cannot
access free healthcare; nor can they afford to pay for it because they are
not allowed to work. “We can't send them back tomorrow, so what can we do in
the meantime?” she asks.
The seeds of the confusion around entitlement were sown in April 2004, when
NHS Trust hospitals were told by the Government to charge patients who were
not “ordinarily resident” in the UK, a term that then included both
undocumented migrants (illegal immigrants) and failed asylum seekers. This
ruling was challenged in a landmark case brought to the High Court by Hundt
in 2006, involving a failed asylum seeker from the Middle East. The man was
stranded in Britain with chronic liver disease but was denied free hospital
treatment after his immigration status was revealed. In April the High Court
ruled in his favour, saying that some failed asylum seekers can be
considered “ordinarily resident” and entitled to free NHS hospital care, a
decision that was thought to affect 11,000 people. The court also ruled that
it was unreasonable to expect healthcare professionals to determine who is
“ordinarily resident” and so entitled.
Now the Department of Health is appealing against the ruling. A decision is
expected this month. But the department and the Home Office appear intent on
restricting access to the NHS even further by extending rules to cover
primary healthcare, such as GPs. The department has been sitting on the
results of a consultation on the proposed changes for four years, but is
expected to release them shortly.
Wright says that restricting migrant groups from primary care could put an
even greater burden on the NHS. “We don't want diabetics to go into a coma
and take up a hospital bed. We can get these things under control if these
people get primary care. It becomes expensive if people need a hospital
bed.” Others, such as the British Medical Association, say that there is no
evidence that the Government saves money by excluding people from free care.
There are also public health risks that arise when GP access is limited.
Professor Ali Zumla, who specialises in infectious diseases at University
College London, says that it is “foolish” to limit free primary care. In his
work on TB, he has found that some areas of East London have TB rates
comparable with those in the least developed countries in the world. “If
these people spread TB in the community, it will cost the Government more,”
he says.
Under the current system, asylum seekers who are awaiting a decision on their
status are entitled to free primary healthcare, while even those who have
been refused can be treated at a GP's discretion. But clinical decisions
about who gets free care at times never reach doctors, says Dr Sally
Hargreaves, of Imperial College London.
In a study of GP practices in Newham Primary Care Trust, she found that almost
70 per cent of practices asked for passports and about where patients had
come from. She says that this suggests frontline reception staff may be
inappropriately excluding migrants from seeing a GP. Adam Hundt often gets
calls from doctors who are unsure about what they should do with patients.
“The clinicians are left with the decision between disobeying management or
disobeying their Hippocratic oath,” he says.
Frustration and confusion surrounding who is entitled to free healthcare is
echoed by the NHS. Nigel Edwards, director of policy for the NHS
Confederation, says that the rules are “quite complex and keep changing. The
Home Office has got to get its act together in not having large numbers of
people waiting for their status.”
Donna Covey, chief executive of the Refugee Council, says: “The rules are
complicated and people don't know how to apply them. You have the
Immigration Minister not knowing the difference between asylum seekers and
economic migrants, and if the minister responsible doesn't understand those
differences, then you can't expect overworked and underpaid healthcare
professionals to understand them.”
Some clarity might have eased Ali's suffering. His son says: “The doctors
said, ‘Your father's got cancer. We have to do X-rays to confirm the size of
it and which treatment we can give him'. [But first:] They said ‘you have to
pay the whole balance to at least start the new treatment'. After I found
out that my father was entitled for free NHS, the fact they said he wasn't
entitled makes me very upset.”
CASE STUDY: BEN, DEMOCRATIC REPUBLIC OF CONGO
Ben, a refugee from the Democratic Republic of the Congo, was subjected to the
lottery of NHS care for migrants when he arrived in London seeking asylum in
2003. Although anyone can access free primary care, even failed asylum
seekers, Ben hit a wall when he first tried to register with a GP.
It wasn’t until two years after his arrival, when he got help from a local
refugee charity who argued on his behalf, that he was able to register with
the NHS.
At the time, he was suicidal and needed to speak to a doctor about his
blackouts, bouts of depression, and anxiety caused by a mixture of brain
damage from torture he endured in the DRC, worry about his missing wife and
son, and the uncertainty over his immigration status, which hung in the air
until he was granted asylum last summer.
In the meantime, there had been no attempts to deport Ben because the UK does
not send even failed asylum seekers back to his country.
Today, the 33-year-old lives in National Asylum Support Service housing in
Tottenham with other migrants, and subsists on vouchers. He often cannot
sleep and when he begins to talk about his wife and five-year-old son,
Benedict, he becomes quiet, and rubs his face, his fingers hiding tears.
In the late 1990s, Ben was a pastor in Kinshasa. He preached for peace and
non-violence. For this crime, he was stabbed in the head with a bayonet by a
militiaman, causing brain damage and leaving him in a coma for six months.
In 2002, his home in the DRC was raided after it was suspected that he was
harbouring militants loyal to the rebel leader Jean-Pierre Bemba. He was
detained, tortured and due to be executed when a member of the detaining
party arranged to have him released.
After several nights hiding near an airport, he fled to London, seeking
asylum.
“Nobody from the government chases you here,” he said. “But mentally, the way
they treat asylum seekers is like they put you in prison again.”
How other European countries do it
Susan Wright, director of the health charity Médecins du Monde UK, says
that the case against the existence of a “pull factor” - that people come to
the UK for free healthcare - is that other countries in Europe offer equally
flexible, if not more flexible, policies for free healthcare for
undocumented migrants or asylum seekers.
Italy: There are payment exemptions for asylum seekers and those with
low incomes from the national health service.
France: Undocumented migrants can access a state-financed insurance
fund.
The Netherlands: The Government has set aside money for “medically
necessary” care for undocumented migrants.
Belgium: Undocumented migrants can access government-sponsored
Emergency Medical Aid, which gives free access to A&E and other
services.
