Intended for healthcare professionals

Reviews PERSONAL VIEWS

Why failed asylum seekers must not be denied access to the NHS

BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7460.298 (Published 29 July 2004) Cite this as: BMJ 2004;329:298
  1. Paul D Williams, general practitioner (paul.williams2{at}nhs.net)
  1. Arrival, the general practice for new refugees in Stockton-on-Tees

    The UK government is consulting on implementing proposals to exclude overseas visitors from eligibility for free primary care (www.dh.gov.uk/assetRoot/04/08/22/67/04082267.pdf). Recently published rules state that failed asylum seekers are not entitled to free nonurgent primary or secondary care from the day their asylum claim failed.

    Failed asylum seekers are not bogus asylum seekers. Of 58 475 decisions on asylum made by the Home Office in 2003-4, 87% were refused. Most people appeal, and of 79 385 appeals received, 21% were accepted, leaving 60 000 failed asylum seekers. Although some of these people may not be in need of protection, many certainly are but are unable to establish to a “reasonable degree of likelihood” that they would suffer persecution if returned to their country. Amnesty International recently criticised decisions made on “inaccurate information, unreasoned decisions about credibility and a failure to properly consider complex torture cases.”

    It is unethical to refuse to provide care for some of the most vulnerable people in society

    Most of the people refused asylum in 2003-4 were not removed, including more than 4000 Sri Lankans, 4000 Iraqis, 3500 Afghans, 3000 Turkish people, 3000 Somalis, 3000 Iranians, and 2500 Zimbabweans. These are people from countries where there is anarchy, war, or human rights abuses, living in the United Kingdom without support or official status. They are unable or unwilling to return to their country, and the government is unable or unwilling to return them.

    Each day in my general practice I see people who have been refused asylum who fear being returned home. Frequently this is because they have been imprisoned, tortured, or raped. Sometimes it is because they have witnessed relatives being killed, have been evicted from their homes, or have been beaten because of their politics or sexuality. Many carry no documentary evidence because they fled in fear of their lives, or carry “only” psychological scars that do not convince decision makers of their suffering. Some have physical scars but because, as is often the case in medicine, the patterns of scarring are not irrefutably from beatings or torture their stories are not accepted. The culture of disbelief and cynicism within the system places intimidating and often insurmountable barriers in the path towards being granted “status.”

    Failed asylum seekers are among the most desperate people living in the United Kingdom. Once refused a person loses their weekly payment of £38.96 ($71.75; €59.00). They become destitute and homeless, relying on charity for shelter and food. Failed asylum seekers suffer psychological distress because they fear being returned to the situation from which they fled, but also cannot understand why they were not believed and have not been given the protection that they requested. Each week someone tells me that they would rather end their life than be returned home.

    The UK government has no obligation to people whose asylum applications have failed but this does not mean that they should be denied health care. The proposals for excluding visitors from free NHS services do, on the grounds of “public health,” list some exempt infectious diseases for which no charge can be made. This list markedly does not include HIV/AIDS. They also state that a person is entitled to free care if they “require treatment which… is an emergency or is immediately necessary.” GPs are “encouraged to offer to treat… as a private patient and to charge for any routine treatment,” an interesting concept when people are destitute. If a failed asylum seeker is being treated at intervals of seven days or less then they can “continue to receive the treatment free of charge until such time as that person no longer needs such treatment.” This allows a GP to treat for conjunctivitis, but not to provide care for pregnancy, post traumatic stress disorder, or incontinence. Somebody with diabetes would need to have a complication before being entitled to treatment and somebody with rheumatoid arthritis would be denied methotrexate.

    Notwithstanding the practical difficulty of establishing when the end of the asylum process has been reached, as appeals and even judicial review can occur, it is unethical to refuse to provide care for some of the most vulnerable people in society. Even though the immigration system has passed judgment, the NHS should not. The first line of the Duties of a Doctor is “make the care of your patient your first concern.” It makes no reference to first ensuring a patient's eligibility for free NHS treatment.

    Although most health professionals will be appalled at the new regulations, others will use them to justify denying care to people refused asylum and will be confused about the entitlements of people seeking asylum. There are already substantial barriers to accessing health care for refugees. These include language problems, difficulty in understanding the system, concerns about confidentiality, and racism and xenophobia within the NHS. To make access even more difficult does nothing to redress health inequality.

    There is no hard evidence that health tourism exists, and plenty of evidence that failed asylum seekers are desperate and needy, and have physical and psychological health needs. To systematically deny them health care is unnecessary, unethical, and impractical. Healthcare professionals should not allow denial of care to failed asylum seekers to be used as a tool by which the government can beat these already broken people.

    Footnotes

    • Competing interests PW is the holder of a PMS contract from North Tees Primary Care Trust to provide primary medical services to newly arrived refugees in the North Tees PCT area. He also receives payments from the Legal Services Commission for the preparation of independent medico-legal reports for asylum applications.