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Gold, incentives and meh

GPs must speak out against plans to charge migrants

Charging migrants is unethical, and would cost taxpayers more than it would save, writes Dr Paquita de Zulueta

I remember trying to talk to a teenager from Afghanistan whose family were killed in front of him and who had been imprisoned, subjected to torture and probable sexual assault. He had tried on repeated occasions to throw himself from the balcony of his cousin’s house. He had received no psychiatric help and had no GP.

I remember seeing two women in one day who were both 39 weeks pregnant, who’d had no antenatal care because they were refused GP registration.

I’ve seen women who have given birth at home, unassisted, because they couldn’t access care. I’ve seen individuals with advanced cancer, heart failure, diabetes, and other conditions -all denied access to care.

These are just a few of the hundreds of cases I dealt with while volunteering for Doctors of the World’s drop-in clinic in east London. Despite the situation already being critical for many here in the UK, this year the government published two consultations to extend current provisions for charging migrants accessing the NHS based on alleged costs of ‘health tourism’.

Some of the proposals in the consultations are reasonable and sensible, such as strengthening mechanisms to recoup charges from other European countries and ensuring that those who should be insured – such as tourists, foreign students and economic migrants – use their insurance to pay for their healthcare costs.

But the economic and ethical justifications fail in the proposal to charge those in clinical need who have no way of paying the £200 levy, or any other costs for that matter. These include vulnerable groups such as undocumented migrants (who have no access to public funds), trafficked people (usually women and children), visa over stayers and domestic slaves.

Debunking myths

We need to get the facts straight and debunk the two main myths propagated by the media, politicians and even some healthcare professionals around this subject: the myth of ‘health tourism’, and the myth of the UK’s ‘soft touch’ on asylum seekers.

Firstly, there is little evidence that access to healthcare services plays a significant role for attracting migrants to the UK and ‘health tourism’ is being deliberately conflated with forced migration. Seven years of data from Doctors of the World’s walk-in clinic in London shows that on average service users wait more than three years before trying to access healthcare and less than two percent come here for health reasons.

The actual sum lost treating foreign nationals is around £12 million, around 0.01% of the NHS budget compared to the £16.3 billion contribution made by migrants to the UK economy. A sobering comparison is the £10 billion (and rising) cost of taxpayers’ money spent on failed IT schemes in the NHS.

Secondly, Britain is a low provider for asylum compared to the rest of Europe and there has been a sharp decline in asylum applicants to the UK since 2002. The UK has less than two percent of the world’s refugees, 0.33% of the UK population. Two-thirds of asylum applications fail here and only one-fifth of appeals are successful.   

The economic case against charging migrants

Ascertaining who should be charged for care would represent an enormous and expensive administrative burden and a huge imposition on a large number of UK residents. It would not be legally permissible to only ask some residents for proof of eligibility, as this would be discriminatory.

Moreover, prevention is better and cheaper than cure. By denying access to primary care, more sick people will be driven to presenting at hard-pressed A&E departments where care is much more expensive. Untreated infectious diseases can spread in communities and lead to more serious illnesses requiring costly secondary care. A Doctors of the World study showed that a timely diagnosis and treatment of Type 2 diabetes amongst irregular migrants would save the NHS £1.2 million.2

Thankfully, the argument has finally been made for HIV with treatment free to anyone diagnosed with the virus in England regardless of their eligibility for NHS care, which was not the case prior to October 2012.  

The UK, despite the recession, is not a poor country and this state of affairs is shocking and unworthy of a civilised nation. Even if we believe some individuals should not be in the country, are we independent professionals or border agents of the state?

Refugees and asylum seekers represent a burden of care for busy practitioners. Many practices already offer them a wonderful service, but CCGs, local authorities and NHS England should ensure there are adequate resources to cover vulnerable people. They should indeed reward, not penalise, practices for their hard work, enabling them to deliver culturally sensitive, competent and compassionate care.

Dr Paquita de Zulueta is a GP working as a volunteer in Doctors of the World’s clinic in Bethnal Green, London.


1 Doctors of the World. “The truth about “health tourism”. 16 August 2013.

2 Economic evaluation of extending entitlement to healthcare to irregular migrants. A case study of Type 2 Diabetes. Final report October 2011 by Matrix Evidence.


Readers' comments (10)

  • Whilst I would agree that it is impractical for individual GP surgeries to identify migrants who needed to pay for health care here, this is precisely why the government needs to look at a charge being levied before entry to the country, to enable migrants to, effectively, 'buy-in' to the British National Insurance system.
    I would have to disagree with a properly planned shceme to achieve this (if it is possible) being 'unethical'. No-one is saying that we should deny provision of care to those in need, but that the understanding on them coming to britain should be equal in fairness to a long-standing british resident and contributor to the NI/NHS who travels abraod and contributes to another country's economy: at preent the situation is vey one-sided: british residents abroad have to pay for a level of care equivalent to what migrants can get here for free.
    It cannot be overlooked that this is a cause of considerable social dissatisfaction and could contribute to 'anti-foreigner' feeling amongst british taxpayers. To fail to do something about this could be considered unethical!

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  • I tried to comment, but the website gave an error message on several attempts - so I blogged my response:

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  • I have a story about a patient I saw recently who has come from Africa to see her family solely so she can access nhs care. The family are paying for the costs to secondary care for the treatment she needs but she has extensive comorbiditiy and is now receiving free NHS prescriptions for all of these as she is over 60! This can't be right. Basically this says to the rest of the world 'Come over everyone and stock up while you're here'. Contrast this to the situation I faced as a student on holiday in Spain when a friend collapsed and had a fit. The Doctor was callled who wouldn't even attend to him until we could provide evidence of insurance. We are a soft touch so people come here to get healthcare. If we weren't so soft they would go elsewhere.

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  • This lady comes from another planet. She's selective of her experiences and use of statistics and allows her heart to dictate her thoughts. Please continue your good works but without supporting economically preposterous arguments.

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  • I am sorry but if you want to come to the UK and don't live here you either need to buy in to the system or have travel insurance, that's how it works everywhere else. GPs should not be asked to enforce so the only way this will work is for everyone to have an ID card to access care. Why are people to opposed to this? We all have a driving licence if we want to drive, or a passport if we want to travel. So why not an ID card to access health care and benefits?

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  • We do not have the money to treat the whole world. Other nations and peoples should pay at least a part of any health care they access. I am altruistic, I hope, but I do not like to work for nothing.

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  • The numbers of elderly relatives coming 'on holiday' from abroad visiting family and then surprisingly becoming too ill too return home and then being able to access the NHs services is increasing. I see this every day as a district nurse in Birmingham. Also some of the relatives have many health issues and require expensive treatments eg dialysis and access both health and social care resources. Posted annon as fearful of job if you speak out!!!!

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  • Abdul QADRI

    After working as principle GP for 30 years , it has been privilege to look after these underprivileged human beings especially when they are in need of significant investigations or treatment. There are millions of people world over who have no access to medical faculties and that is a real shame. The fact is this: these immigrants are right here in our country and if they are in of need of urgent medical care then how on earth can we as Doctors turn a blind eye. Either they should have been allowed to come in this country then burden lies with the establishment. We can't be acting like police man and be forced into a situation where a wrong decision might cost some bodies life and the burden of that will our conscience for rest of our life. Remember one thing my colleagues , the only truth in life is that ultimately all of us have to taste death and as a professional Doctor if our creator gives you chance to help one of his creation , grab the chance and come forward with open to do it. Don't let politics play in your minds. Today you are young lively Doctor and tomorrow after few decades you will enter into geriatric age and will have no energy or even mental strength to do so.
    Good luck & stay blessed with your good rewarding job.

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  • The government's proposals that would restrict access to care aren't about immigrants. Immigrants are entitled to care in the same way as long-standing residents. The proposals are about overseas visitors. Why should visitors get free care, at the expense of the UK taxpayer? Visitors can afford to travel here, so they can certainly afford travel insurance. There may be an issue about vulnerable illegal immigrants and access to care, but that's a poor argument for offering free care to everyone. And immediately necessary treatment and treatment of infectious diseases is always free to everyone.

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  • GPs should not be made to police this, because they will be particularly bad at it. If a GP wants to see a patient for free he/she should be entitled to; NHS England should be allowed to withhold the payments to the surgery for registering that patient. If the NHS does not want to fill his prescription or decline his referral they should be entitled to, but they should police this themselves.

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