Charging for NHS care and its impact on maternal health

CHARGES

Undocumented migrants are not deemed ‘ordinarily resident’. They are chargeable unless covered by complex exemptions.¹² Unlike most secondary care, maternity care is deemed urgent and immediately necessary and should not be refused if upfront payment is impossible. However, charges are set at 150% of cost,¹³ for example, £7373.42 compared to £4915.61 charged to clinical commissioning groups for the same services.¹⁴ Abortion charges are £1426.67. NHS debts of over £500, not repaid within 2 months, or without a repayment plan, are reported to the Home Office¹³ and can be used negatively in determining immigration applications. There are many reported incidents of erroneous charging. Overseas visitors officers seem ill-informed of what constitutes a realistic repayment plan for women who have no permission to work nor entitlement to benefits.⁴ It can take years to challenge charges, during which time women are pursued aggressively by debt collection agencies, generating high levels of anxiety.

RISKS

Undocumented migrant women are superdiverse, initially entering the UK with visitor visas, seeking asylum, or with other entitlements. A woman’s status may change before or during pregnancy, can remain ‘complex and fluid’,⁴ and is hard to track without legal training. This change may be a consequence of escape from forced or abusive relationships.⁴ These circumstances often necessitate strategies such as ‘survival sex’.¹⁵ Complex social situations require material support, which is unavailable from the state, and they often rely solely on charitable means until 34 weeks’ gestation when they are given shelter and a financial allowance well below the poverty line. Over-the-counter medication becomes out of reach and good nutrition difficult to achieve. Remote access to care is restricted by digital poverty and telephone interpretation misses opportunities for safeguarding.

Underlying undiagnosed or undertreated medical conditions include gestational diabetes, fibroids, haemoglobinopathies, blood-borne virus or other infections, depression, or post-traumatic stress disorder. These necessitate more frequent, specialist antenatal care; however, the prospect of incurring unaffordable charges, and fear of immigration sanctions including deportation, prevents or delays these women from accessing care. Moreover, many women eligible for free care are deterred through fear of being charged, a lack of clear information using professional language interpretation, and sometimes false identification of ineligibility.^4,12

RECOMMENDATIONS

While we have focussed on NHS maternity care, we recognise the wider impact of healthcare charging and call on the UK government to urgently abolish charging policy, unless it can publish good-quality and transparent data to affirm its claims of no harm.

Meanwhile, a unified voice from the medical professions is essential.¹⁶ Advocating for reform, exclusions, or revisions to charging is insufficient for a truly universal NHS. We urge the Royal College of General Practitioners and other representative organisations, including the British Medical Association and Royal College of Midwives, to extend their position to include the blanket removal of all charges. Representation from people with lived experience and systematic case identification by experts from nongovernmental organisations, such as Maternity Action, Doctors of the World, Asylum Matters, Medact, and Patients Not Passports, is essential.

Primary care remains accessible to all, irrespective of immigration status or ability to pay. GPs can equip undocumented migrants, and service providers, with accurate information on NHS entitlements. There is first an imperative to ensure timely GP registration, without demanding proof of address or immigration status; second, to undertake non-judgemental consultations, using independent professional interpretation; and third, to undertake positive action to protect undocumented migrants and their children through care that emphasises continuity and advocacy.