The current NHS regulations for charging those not ordinarily resident in the UK for treatment, such as migrants and short term visitors, are 'unworkable' and harmful to the wider health system, concludes an analysis of survey responses, published in BMJ Paediatrics Open.
The rules are poorly understood and applied by healthcare staff, the responses show, which include several examples of the harmful impact of denying or delaying care to those that need it.
UK Legislation in the past few years has narrowed the eligibility criteria for free healthcare and changed the tariffs applicable, particularly in England.
The UK is out of step with several other comparable European countries in applying more restrictive access to healthcare for undocumented migrant children.
To try and find out what impact these changes might be having on health, and to gauge clinicians' understanding of, and attitudes towards, the regulations, the authors surveyed children's health practitioners working in the UK in January and February 2019.
Some 220 healthcare professionals from all four UK countries responded, with doctors making up the bulk of respondents (44.5%).
The analysis was based on 200 responses, more than two thirds of which (69.5%) came from practitioners working in Greater London, an area with more migrants than other UK regions.
Most respondents didn't feel confident interpreting and applying the charging regulations.
Over half (53%) of respondents said they weren't confident about what constituted urgent or immediately necessary care, which exempts people from upfront charging.
Several groups are exempt from the charging regulations: asylum seekers; refugees; human trafficking victims; and looked after children. Charges don't apply to emergency or primary care.
Most respondents didn't feel confident about which circumstances, conditions, or groups were exempt from charging.
The survey also uncovered cases of children and families being deterred from accessing care despite being exempt and other cases where charging was inappropriately applied .
Six out of 10 (60%) felt that charging migrants for NHS care was unfair, while a similar proportion (58%) felt that healthcare professionals shouldn't be involved in charging.
More than 80% of respondents weren't sure that they would be covered by their indemnity insurers or their professional regulator, should a patient come to harm as a result of their interpretation of the rules.
Three out of four (76%) felt the regulations needed to be independently reviewed, and a similar proportion felt they needed further training on the regulations (72%).
A third of respondents said they knew of examples of how the charging regulations had adversely affected health and care. These included:
- 19 cases of patients and their families afraid to access care for fear of being saddled with unaffordable bills, criminalisation, or deportation
- 18 cases of migrants avoiding care, including screening
- 11 cases of care being delayed or denied to pregnant women and children and victims of trafficking
- 12 cases of potentially avoidable health complications
- Numerous cases of eligible patients being incorrectly billed or threatened with charging
Many respondents felt the charging regulations were placing an undue burden on the health system, and especially those staff working within it.
The regulations not only run counter to the professional duties stated by their regulator, but also their own personal values and those of the NHS, respondents said. And they felt that the rules widened existing health inequalities.
"Our results do not support the argument that harm could be eliminated simply through improved staff awareness or 'better' implementation of regulations," say the authors.
"Our survey results also highlight a breach of the UK's commitment to the [United Nations Convention on the Rights of the Child], as we have recorded clear examples of violations to Article 24 on children's right to good health and healthcare access," they point out.
And they conclude: "We believe there is sufficient evidence of harm to health and wellbeing for the current NHS charging regulations to be revoked, thereby restoring the UK's commitment to universal health coverage."
Peer reviewed? Yes
Evidence type: Survey data
BMJ Paediatrics Open