“It’s getting really bad. I’m coughing a lot, and often there is blood.”
Naz is from Afghanistan. When he was just 16, his mother paid smugglers to bring him to the UK after his father and brothers were killed by the Taliban. He is now making his second claim for asylum after his first was rejected.
He says the pharmacy is refusing to provide him with medication for his asthma, an ordinarily treatable condition that in this country nonetheless kills three people every day.
“I am homeless, and sometimes I am struggling,” he says. “Sometimes I am sleeping in a park, which makes my cough worse. When I stay with friends they complain about my wheezing and coughing. And when it stops, they come to see that I’m still alive.”
Asylum seekers are highly vulnerable people. Strict exclusion from employment and a generally lower level of welfare than the rest of the population make economic hardship and poor health common features of everyday life. Support is limited, and an undecided immigration status means that detention and deportation are a real and constant fear.
A study published earlier this year by Doctors of the World UK found that as many as one in four people seeking asylum may be being wrongfully denied access to healthcare. Of those surveyed, more than half said the experience prevented them from seeking further help.
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People seeking asylum, who become refugees only once asylum is granted, are legally entitled to primary and secondary care free-of-charge under NHS policy. They are also supposed to be able to claim financial assistance from the Home Office for associated costs, like prescriptions and travel to appointments.
But legislative changes over the past few years have muddied the waters. Now, with migrants afraid to visit clinics and practitioners unsure of how to fulfil their duty of care, these concrete rights often count for very little.
Doctors of the World run a walk-in clinic in Bethnal Green with a focus on achieving access to healthcare for marginalised groups, including undocumented migrants and asylum seekers.
Lucy Jones is their director of programmes and co-author of the recent report. Speaking of the group’s findings, she says: “We are seeing people who have chronic conditions being turned away and who are now trying to get medications from abroad, or else they aren’t taking any medication at all.”
“We see people who’ve had worrying symptoms, who’ve tried to register with a GP and been refused, so they’ve just been living with those symptoms for a long time,” she adds. “Often they’re just resigned to the fact that they’re not going to get treatment, even if it’s a case of ‘oh my god, you really need to get help’.”
“Instead of being proud to protect, our political parties are proud to be tough.”
The Refugee Council maintains an education and outreach initiative across six cities in the north of England, including Leeds and Sheffield. As project manager at HARP (Health Access for Refugees Programme), Rose McCarthy knows first-hand the consequences of denying healthcare to asylum seekers.
“It’s really frustrating,” McCarthy says. “You get to know people and then when you see them being unfairly treated, it’s just so hard. We’ve got a tradition of being proud to protect people whose lives are in danger in their home country. We signed the Refugee Convention in 1951 because we’d learned from the war that we have a duty of care to other people.”
“Now, instead of being proud to protect, our political parties are proud to be tough,” she explains. “They’ve forgotten that basic humanity.”
In some cases, asylum seekers may receive care but afterwards find themselves handed a bill because of complications or delays to their claim. McCarthy remembers meeting a pregnant woman from Eritrea in 2017.
Mariam had been refused asylum and was destitute. 32 weeks into her pregnancy she applied for Section 4 support, which would have entitled her to free treatment even though her claim was rejected. Her application was not processed until after her son was born two months premature via emergency caesarean section, which left her chargeable for all the care she had received, including a week-long stay in hospital and special care support for her baby.
Soon after, she was moved to sheltered accommodation, miles away from her support network. When the baby was three weeks old, Mariam came to visit McCarthy at the centre. Unable to afford a pushchair or bus fare, she’d walked along the side of A64 to get there.
McCarthy says she dreads to think of what the bill was. “I don’t know if she was charged or not. We lost contact. Why are we charging women to give birth who have no means to pay? It’s putting the lives of mothers and babies at risk.”
Jones also emphasises the prominence of pregnant women among the people Doctors of the World see at their clinic, as well as how the retroactive billing system seriously hinders their access to ongoing care.
In recent paper, Maternity Action included the case study of a woman referred to as Natasha who, having suffered a miscarriage in 2015, was too afraid of further charges to seek follow-up treatment
She told researchers: “My baby was buried and I couldn’t even go. I went to see my GP, I was still bleeding then. There was [some tissue] still remaining so they had to take me into theatre, but since then I haven’t had any examinations or anything to see if it is all OK.”
Her account continues: “At times my period is so painful. I feel cramps when I sit down, and when I get up I can hardly walk sometimes. There are a lot of clots but I am scared to go to the hospital because I don’t know how I will be able to pay on top of this bill. I haven’t even been able to learn what caused the death of my baby.”
While most migrants must pay for secondary care at a rate of 150% of the tariff for the service, the UK government guidance on NHS entitlements states that everyone is entitled to free primary care, and that certain groups are exempt from further charges, including refugees, asylum seekers and some, like Mariam, who have had their claims rejected.
“Patients are more and more worried about whether they’re safe to visit their GPs.”
A spokesperson for the Department of Health and Social Care told Novara Media: “British taxpayers support the NHS, so it is only right that overseas visitors also make a contribution to our health service. But we are very clear that urgent and immediately necessary treatment must never be withheld and as well as being entitled to free NHS primary care, asylum seekers are also exempt from charges for NHS secondary care services.”
In recent years, Jones observes that “health workers have become increasingly unsure about who they should and shouldn’t be treating.”
“As a result,” she says, “patients are more and more worried about whether they’re safe to visit their GPs.”
Passed in 2016, the Immigration Act significantly expanded the power of the home secretary to obtain information from public institutions about service-users. It was on this basis that a memorandum of understanding (MOU) was drafted between the Home Office and NHS Digital. The goal of the arrangement was to set up an avenue of communication whereby immigration officials could actively request non-clinical information on suspected undocumented migrants (i.e. migrants without a visa who are not claiming asylum) from public healthcare providers, such as name, address, place of origin, and time and date of entry into the country.
This, in turn, created the culture of clinical surveillance that eventually led to the wrongful deportation of dozens of members of the Windrush generation, betrayed to the authorities as they were by their own health needs.
In the wake of public outcry against the scandal, the MOU was itself suspended in May 2018, pending formal investigation. But the legacy of this arrangement, and the endemic mistrust and undue scrutiny of migrant patients, has meant that damage has continued for the most vulnerable all the same.
Alongside the introduction of provisions under which immigration officials could request non-clinical patient details from practitioners, the 2016 act also increased pressure on employers, landlords and public service-providers to hand over information on suspected undocumented migrants. As a result, GPs now often ask people for proof of identity, address or immigration status when registering, even though there is technically no regulatory requirement for them to do so.
Because the asylum process usually requires applicants to hand in their passports and other documents to immigration officials, meaning asylum seekers frequently lack access to the right kind of documentation, they can often find themselves locked out of care through no fault of their own.
As Jones explains: “Sometimes an asylum seeker will have proof of ID but often they won’t; they might just have a letter from the Home Office. They also tend to have their own accommodation arrangements, especially if they live in London where they’re more likely to be staying with friends.”
“On other occasions, the practice simply does not want to deal with the complications that could arise from taking patients from these backgrounds.”
“The idea that GPs are actually required to go and check somebody’s immigration status, that’s a misconception,” she adds. “It’s a misunderstanding.”
Priya Manjaly is a pre-medical student at Boston University. During her semester in London she has been volunteering at Doctors of the World’s clinic, and has spent time advocating on behalf of patients there.
“In many cases, the individuals working at medical practices are not up-to-date on the current NHS guidelines,” says Manjaly. “They don’t understand that while the practice has a right to request ID and proof of address, the practice does not have the right to deny GP registration if the patient is unable to provide that ID or proof of address.”
She adds that “on other occasions, the practice simply does not want to deal with the complications that could arise from taking patients from these backgrounds, or believes that by denying access the person will just be able to get treatment somewhere else.”
The spectrum of healthcare needs among asylum seekers is a broad one. Jones speculates that one in ten patients seen by the team at her clinic is a pregnant woman. Living conditions mean infectious diseases such as tuberculosis can often be a concern, and the organisation has a visiting x-ray unit equipped to make these sorts of checks.
Largely, she says that health complaints tend to be the same as your average person might have if they hadn’t been able to see their GP for some time. These could be troubling symptoms such as an unfamiliar lump or, like Naz, chronic conditions that get worse without ongoing treatment.
Physical illness and injury among asylum seekers is also significantly more likely to be accompanied by mental health concerns than among the rest of the population.
“Mental health is a big one,” Jones explains. “People will come to us fairly frequently with symptoms of anxiety or depression or a diagnosed mental health condition. Often it’s a natural reaction to things they’ve been through. A lot have experienced trauma, torture, violence, losing their family, and have not had any support to deal with that.”
McCarthy points out that it’s not just securing access with GPs that can be difficult, as other primary care providers can be misinformed about the rights of their patients and clients.
She explains: “Torture often involves the teeth, and we have a real problem with people suffering and in pain because some dentists say they won’t give them treatment unless the person can provide their own interpreter. I mean, NHS guidelines are really clear on interpreters, it’s just that no-one’s enforcing it in these contexts.”
“I’m also working with someone who has really bad eyesight,” she continues. “He’s broken his glasses and for some reason the optician’s told him he’ll have to wait two years before he can get another pair. I haven’t gotten to the bottom of that one just yet.”
An obvious effect of the Immigration Act has been that many people’s health has needlessly gotten worse. Jones describes how volunteers at the clinic will often have to refer patients straight to A&E, and ambulances are called out on a fairly regular basis.
But its other effects have been more subtle. Jones observes that the present culture of undue scrutiny has damaged the trust between doctor and patient, having heard stories from walk-ins at the clinic about getting friends who are registered to describe their symptoms in order to get prescriptions on their behalf. Many who are refused registration are scared of going back and trying again, and some leave their GP with an impression of institutional racism among British medical practitioners.
“I think it’s certainly true that requiring NHS staff to think about whether somebody might or might not be entitled to healthcare because of their immigration status does result in some staff asking questions of particular people and not of others,” Jones says.
She adds: “They’re much more likely to ask somebody who’s black or Asian than anybody who has white skin. There are obviously people who are racist working in all sectors, but these government policies have not helped in terms of making staff think about who they should be asking questions.”
Both Jones and McCarthy say that the hostile environment has simply not proven cost-effective in respect of public health. Checking immigration status is a time-consuming process, and refusing primary care can place greater strain on resources elsewhere, as those who are refused treatment may then be forced to visit already overburdened emergency departments.
There’s a sense from both that there’s been an increasing recognition that legislation has gone too far and that, at some point, something will have to change if any commitment to providing for the most vulnerable is to be taken seriously
But Jones is cautious about being too hopeful for the future.
“The government has been clear that it does want to continue rolling out charges and checks in healthcare among A&E departments and GP surgeries,” she explains. “Post-Brexit there may well be more capacity to roll out those changes, and we’d be massively concerned about the impact of that.”
Will Neal is a reporter at Global Investigations Review and The Guardian.
Some names have been changed at the request of interviewees.