What are the barriers to healthcare for migrant children?
With one billion people on the move in 2018 — a number that is expected to rise as a consequence of natural disasters and climate change — migration is a central part of 21st century life. And while the topic is polarising in political discourse, it also has significant implications for health services.
There are now around 600,000 undocumented migrants living in the UK, including 120,000 children, over half of whom were born here. The health needs of these children are different to the wider population as they face, in particular, additional risks to their mental health and wellbeing.
Many of these children have restricted access to healthcare as a result of changes to NHS charging regulations. These were initially justified as a means to minimise so-called health tourism, an idea that some people travel to the UK for free healthcare, and an idea for which there is little evidence.
Charging regulations have been expanded, since then, leading many long-term residents who lack the right immigration status to be charged for healthcare. Writing in the BMJ, critics have called the changes to regulations an “unprecedented departure from the founding principles of the NHS”.
“A doctor shouldn’t have to change their practice based on the financial circumstances of their patient.” — Dr Bryony Hopkinshaw
For many migrants, the new charging regulations act as a deterrent against seeking medical help. Both adults and children are liable to pay and, as a result, parents and carers in migrant families may be reluctant to engage with the health service when they or their children get sick.
“Our research has shown that there are widespread fears around charging and financial costs,” says Dr Bryony Hopkinshaw who, along with RCPCH Health Policy and other paediatric colleagues, recently surveyed 200 UK health professionals on the impacts of charging. “This can lead to delays in seeking medical help and, ultimately, poorer child health outcomes”.
Bryony says that fears among migrant communities are not unfounded, as they genuinely face additional barriers to healthcare. She also notes how important public health measures that affect us all, such as vaccination uptake rates, can suffer as a result of people being afraid to seek help.
“Clinicians also find themselves in the difficult position of having to think about the financial risks to their patients,” says Bryony. “This comes into conflict with our duty to provide the best possible care — a doctor shouldn’t have to change their practice based on the financial circumstances of their patient”.
Who’s in charge here? Regulation, education, and data collection
Nick Watts is a co-founder of Together with Migrant Children, a non-profit that supports migrant communities through advocacy and social work. Following an outreach model, Nick and his team work with migrant communities to help them deal with various challenges — including undeserved debts.
“For children, the most common problem we see is being incorrectly charged for something that should have been free,” says Nick. “We get these debts written off, eventually, but by that time they’ve already taken a huge psychological toll on the child and fostered mistrust in the healthcare system”.
Nick says that a typical NHS debt ranges from £500 to £800. Patients with unpaid debts of £500 or more automatically have their data sent from the NHS to the Home Office after two months. This, in turn, can serve as grounds for denying an immigration or asylum application.
Bryony’s survey found that the majority of healthcare professionals were not confident in interpreting or applying charging regulations. One-third reported examples where charging regulations had impacted patient care. This included patients delaying seeking help and avoiding care entirely.
Patients with unpaid debts of £500 or more automatically have their data sent from the NHS to the Home Office after two months. This, in turn, can serve as grounds for denying an immigration or asylum application.
Essentially, doctors are being asked to deal with the complexities of immigration regulations in addition to the medical task at hand, often without any training. And this situation is compounded by the fact that many children simply aren’t aware of their rights or immigration status.
Rosalind Hodder Compton is a solicitor at Coram’s Migrant Children’s Project, where she offers legal advice to children and young people on immigration and asylum: “It’s common for children to not even know that they’re not British until they’re an adult — or to be British but unable to prove it”.
Rosalind says that many young people may only realise they don’t have British citizenship when they try to apply for student finance or, for those in care, council housing. On the other hand, children who have British citizenship may be unable to provide proof of their status, which she says often occurs in cases of child abuse.
“The people who come to us for advice are often terrified of data sharing between the NHS and the Home Office,” says Rosalind. “In many cases, they won’t even seek advice until all other avenues of support within their community have dried up. This is happening much more frequently in 2020”.
The horrible trinity: COVID, Brexit, and rising inequality
Aliya Yule is a campaigner at Migrants Organise, a platform that connects migrant communities: “On top of existing fears, the pandemic has added a new one — the risk of contracting the virus while in hospital. This fear is, quite rightly, particularly strong within BAME, including migrant, communities”.
Patients Not Passports is a joint campaign between Migrants Organise, Docs Not Cops, Medact, and the New Economics Foundation. Its latest report found that 57% of migrant organisations surveyed reported that migrants were avoiding seeking healthcare during the pandemic due to fears involving charging and data sharing.
The report also highlighted that few respondents were even aware that, like other communicable diseases, treatment for coronavirus is exempt from charging regulations. But even in situations when respondents were aware, fears of engaging with the health service remained a powerful deterrent.
“The number of migrant families living in destitution is rising at an alarming rate,” says Nick. “Families with No Recourse for Public Funds who were just about managing before the pandemic are being pushed into destitution, as there’s a lack of resources in their communities. Things are much worse than they were back in March”.
The No Recourse for Public Funds (NRPF) rule prevents most migrants from accessing a range of welfare benefits, including Universal Credit and homelessness assistance. If someone with NRPF loses their job, they risk becoming destitute and reliant on support from charities, social services, and their community — something that Nick says is becoming increasingly unsustainable.
“Families with No Recourse for Public Funds who were just about managing before the pandemic are being pushed into destitution, as there’s a lack of resources in their communities.” — Nick Watts, Together with Migrant Children
“Beyond the pandemic, a looming concern is Brexit,” says Rosalind. “From July 2021, any EU nationals in the UK who are not registered, which includes many vulnerable young people, will fall under the same immigration system as everyone else. We expect that this will compound existing problems”.
Dr Claire van Nispen tot Pannerden leads the Women’s and Children’s Project for Doctors of the World UK: “We know that the pandemic has affected young people’s mental health, and this is exacerbated in migrant communities. As well as the largest likely barrier to mental health — access to existing services — they face the additional barriers of language and digital poverty”.
Claire’s team has translated much of the NHS information into other languages, to assist those who do have access to internet and devices — something that has become more difficult for migrant communities during lockdown, when libraries and other public spaces have been closed.
“Coming from the Netherlands, I was amazed at how much support is provided by the UK charity sector rather than the state,” says Claire. “This might just about work in normal times, but the pandemic has shown that many charities on which people depend just can’t run under such pressure”.
Claire says that while it is wonderful that the UK charity sector is strong, many of the problems it seeks to address should be dealt with by the state. In other words, certain charities shouldn’t need to exist. When it comes to access to healthcare for migrant children, Claire says that our efforts would be better spent on creating changes that tackle the seed of the problem.
All hands on deck: Policy change and the power of story
James Skinner is a campaigner at Medact, who frequently collaborates with Migrants Organise: “It was clear when the crisis began that it would have a huge impact on access to healthcare. But the reality for migrant communities is that not much has changed — they’ve been excluded from engaging with the health service for years”.
In their recent report, the Patients Not Passports campaign calls for practical changes that will help eliminate the barriers to access within migrant communities during and beyond the pandemic. This includes removing NHS charging, ending data sharing with the Home Office, and educating doctors and the public.
Ultimately, James says that any meaningful change is going to involve several groups taking action simultaneously. When this occurs, James says, the policy itself will become untenable.
“Narratives are also extremely important,” adds Aliya. “At the moment, there’s a lot of support for the NHS, and the understanding of the importance of universal healthcare in the interests of public health has never been higher.
“The fact is that children and many young people don’t have autonomy over their healthcare. So we need policies in place to protect them.” —Dr Bryony Hopkinshaw
“We now have an opportunity to highlight how charging undermines any public health response, and undermines the founding principles of the NHS — a universal service based on need, and not ability to pay”.
“Access to healthcare should be a priority for all children and young people — and they certainly shouldn’t be charged for that basic right,” says Claire. “Otherwise, we’re at risk of violating our commitments under the United Nations Convention on the Rights of the Child”.
“If a parent or carer denies healthcare to their child, that’s a major child protection issue. Yet when the state does the same thing, it’s sanctioned,” says Bryony. “The fact is that children and many young people don’t have autonomy over their healthcare. So we need policies in place to protect them”.
Last year, we supported the suspension of NHS charging regulations. We’ve since published new guidance on the rights to access healthcare in migrant communities. By eliminating barriers to access, we can better serve all children and young people — and provide them the healthy lives they deserve.
Listen to our full interview with Dr Bryony Hopkinshaw on RCPCH Podcasts — available on Spotify, Apple Podcasts, YouTube, and wherever you get your podcasts.
If you’ve seen or experienced NHS charging in practice, help us document the impact it is having on patients using our online tool.
Doctors of the World UK has translated NHS information and other health advice and launched a coalition campaign with Lancet Migration, the Faculty of Public Health and over 60 other organisations calling for universal and equitable access to NHS services, during COVID-19 and beyond.
Find out how you can support Patients Not Passports at act.patientsnotpassports.co.uk.
