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Revealed: How GPs are split on migrant health provision

Practices remain confused over the rules for registering migrants, with some going much further than current rules allow, finds Michael Woodhead.

It’s been a decade since Birmingham GP Dr Vijay Abrol was castigated for refusing to treat asylum seekers at his Edgbaston practice. In 2002, Dr Abrol put up a sign in the window of the City Road Medical Centre saying he would not register any more asylum seekers until he received more support and funding.

The chair of his local PCT described Dr Abrol’s actions as ‘smacking of xenophobia’ – but, 10 years on, it seems many GPs still share some of Dr Abrol’s concerns.

According to a survey conducted by Pulse of 229 GPs, 52% believe NHS provision for migrants is too generous and only 7% believe it should be better.

Ten years on, Dr Abrol says his workload has continued to rise with migrants now arriving from Eastern Europe and hospitals becoming like ‘border posts’.

He says: ‘If I send a patient, they ask to see their passport. It has created a situation where they are suspecting all non-white patients of being illegal.’

It’s a subject many GPs are still reluctant to speak openly about.

When asked to comment on the findings of the Pulse survey, one leading GP asked not to be named to avoid appearing a ‘ranting racist’.

He said: ‘I treat a lot of migrants and asylum seekers, quite happily, but I think there needs to be a public debate. It’s going to become an increasing issue as we get people from countries like Bulgaria and Romania becoming eligible for NHS treatment in 2014.

‘The problem is that everyone tiptoes around the issue. There is an increasing burden of patients coming to the UK who are entitled to treatment – but whether we can afford an open-ended system in the future is a matter for debate. The UK has got to decide what it can and can’t afford and who is eligible.’

Ambiguous rules

There is considerable uncertainty over current regulations, with our survey showing more than three-quarters (77%) of GPs are confused about the rules for treating and registering migrants, overseas visitors and illegal immigrants.

Practices are split on the approach they take, with 58% routinely asking new patients for proof of identification when registering, but more than a quarter not asking for any proof of residency or identity. Nearly 15% break the current rules by only asking patients ‘sometimes’ for proof of identity.

Dr Nick Simpson, Loughborough GP and chair of Leicestershire and Rutland LMC, says the rules on treating migrants are incredibly complex. His practice has drawn up a summary of eligibility rules for people from countries seen most often in the practice.

He says: ‘Our practice manager compiled a list, which the receptionist keeps, so when the person turns up requesting medical care, we can say “you’re from such-and-such country that can have medical care”, or “there will be a charge for it” – that’s appropriate, but obviously not if it’s a dire emergency.’

Caught in the crossfire

Dr Paul Roblin, chair of Berkshire, Buckinghamshire and Oxfordshire LMC, says the lack of clarity is a major source of frustration for GPs.

He says: ‘The Department of Health has abrogated its responsibility. It has failed for decades to provide a rule book that is understandable to all.’

According to Dr Roblin, practices and PCTs are wrongly led to believe by NHS counter-fraud authorities that they have an obligation to conduct identity and proof-of-residency checks on patients.

He says: ‘GPs are not obliged to do that. The bottom line is there is only an obligation for GPs to accept a request for registration and to provide immediately necessary medical treatment.’

This lack of clarity has seen GPs caught in the crossfire. In 2011, a GP practice in Essex found itself facing legal action if it did not register failed asylum seekers from Nigeria, even though the practice had been advised by the UK Border Agency that they were not eligible for NHS treatment.

At the same time, some primary care organisations have warned practices they may be investigated by the NHS Counter Fraud Service if they have ‘knowingly registered ineligible patients’.

GPC deputy chair Dr Richard Vautrey says there can be no threat of action against GPs from the NHS for registering patients without checking whether they are eligible for NHS services. He says: ‘Nothing within GMS regulations obliges GPs to take on that role.

‘We have spoken directly to the NHS Counter Fraud Service about this and it has amended its guidance. If you look at its guidance there are procedures that could apply, but you would need to do that for everybody.

‘If GPs ask for evidence of immigration status or residency from one patient, but not every other patient, they could be deemed to be applying discrimination and that’s something that they should not be doing – so they either need to do it for every patient or do it for none.

‘I think it’s better to accept that it’s a role for other bodies in the health service to assess whether someone is eligible for NHS care or not – not for GPs.’

Government review

The most recent Government review of migrant and visitor access to NHS services took place in 2010. It noted that free NHS hospital treatment was a right of all current, lawful residents of the UK.

Non-residents and visitors are required to pay for hospital treatment, but this does not extend to primary care – yet. GPs have a contractual duty to provide free emergency treatment and immediate necessary treatment for up to 14 days to any person within their practice area. Practices can – at their discretion – accept overseas visitors for inclusion in their patient list if the person is staying more than three months, but cannot discriminate on grounds of race.

The review concluded no major changes were needed in the rules of NHS entitlement for migrants, but it did flag up areas of concern where eligibility criteria should be tightened up. ‘Medical tourism’ was highlighted, with claims that some people were travelling to the UK with the specific intention of receiving medical treatment or to use maternity services.

It proposed foreign visitors who incurred significant debts to the NHS be denied the right to re-enter the UK and urged an investigation into ways of making health insurance compulsory for visitors who do not qualify for reciprocal healthcare.

GP charges

No changes were proposed in access rules for foreign nationals to primary care, but this is now being reconsidered. An ‘ongoing’ Government review is considering extending the system of charging for NHS treatment from hospitals to primary care. A spokesperson says: ‘The review is looking at whether we could introduce [charges] into primary care and how that would work.’

But Dr Vautrey says practices might come to be seen as an arm of the immigration service. He says: ‘This would create a heavy workload, would place general practice in a difficult position and would be almost impossible to put into practice. The GP role is to treat the patient as best as they are able.’

He adds: ‘The reality is the vast majority of people who are asking to see a GP are doing so appropriately.’

Others disagree. Dr Roblin says: ‘GPs are expected to practise with limited funding, and if we are using that for treating visitors, the taxpayer loses out. It may be more appropriate to have a system where we say that if you can’t provide proof of residence, you have to pay for treatment.’

To read our case study, Dr Les Goldman, a GP from Bradford,click here

What the rules say

  • Overseas visitors, ‘whether lawfully in the UK or not’, are eligible to register with a GP practice.
  • There is no formal requirement for patients to prove identity or immigration status. Practices can ask patients for documentation but, if they do so, must ask every patient.
  • GPs can only refuse an application if their list is closed or if they have other reasonable grounds, for instance if
    a patient is violent or lives outside the practice area.
  • Asylum seekers and refugees are entitled to register. GP practices ‘have the discretion to accept failed asylum seekers’ as NHS patients, although the BMA advises this discretion applies only as it would for any other patient.
  • If a patient is turned down, a GP must nonetheless provide ‘immediately necessary’ treatment for up to 14 days.

Source:  NHS PCC 2012, Access to primary medical services for overseas visitors and BMA 2011, Overseas visitors: who do you treat?