1. Introduction and summary
1.1 This paper sets out the formal response of Citizens Advice to the Department of Health’s consultation document Proposals to Exclude Overseas Visitors from Eligibility to Free NHS Primary Medical Services, issued in May 2004.
1.2 Citizens Advice is the co-ordinating body for the 530 Citizens Advice Bureaux (CABx) in England, Wales and Northern Ireland.[1] In 2003-04, these CABx dealt with some 88,000 asylum, immigration and nationality advice enquiries, and some 79,000 health-related advice enquiries.
1.3 In considering these proposals, our main concerns relate to the position of failed asylum seekers and their access to primary care, and how rules to restrict such access might be enforced. We believe that the implementation of these proposals would however have a discriminatory impact on other groups, including those who are entitled to free primary care. We also believe that the costs of administering a system to exclude failed asylum seekers and other overseas visitors from primary health care might well outweigh the (unknown) cost savings of such exclusion.
2. Enforcing the proposed exclusion: identifying ineligible patients
2.1 Under the proposals, failed asylum seekers (and others) would be excluded from free primary health care. GP surgeries and other providers of primary care would be expected to refer the patient to the primary care trust (PCT) wherever there is some doubt over their eligibility. We would suggest that, if this is to be the case, PCTs must have some means of differentiating failed asylum seekers from those whose claims are still being considered.
2.2 The consultation document also states that those who are entitled to free primary health care should be able to certify themselves, and it should be up to the patient to prove eligibility for free primary care. The document proposes that proving ineligibility should not be the responsibility of the PCT.
2.3 Citizens Advice considers these proposals to be unworkable. For, in practice, there is no means for an asylum seeker to prove his or her eligibility in a way that could not also be used by an asylum seeker whose claim has failed. For example, all asylum seekers are now provided with an Asylum Registration Card (ARC), which is used to access benefits under the National Asylum Support Service (NASS), but this card is not physically withdrawn if and when their claim is finally rejected. There are no other reliable pieces of documentation that an asylum seeker would possess but which would have been withdrawn when their claim was rejected.
2.4 Therefore, if PCTs were required to exclude failed asylum seekers from free primary healthcare, they would need to know the individual’s status at the time when they tried to access it. It is difficult to see how a PCT could obtain this information without contacting the Home Office to confirm the status of each and every patient they suspect of being ineligible. The consultation document does not propose what kind of mechanism PCTs will use to make this contact. The Home Office Immigration & Nationality Directorate has a poor record when it comes to providing a way for clients and other stakeholders to contact them. This has implications for how efficient any system of liaison between the Home Office and PCTs would be.
2.5 The consultation paper states that national identity cards might be used as a means of determining eligibility for primary care services. In our view, this is somewhat premature, as identity cards are yet to be approved by Parliament and are not likely to be before the proposed rules, as set out in the consultation document, would come into force. Moreover, even if a national identity card scheme is established, this will not solve the problem of identifying failed asylum seekers, as asylum seekers will not be issued with the proposed national identity cards.
2.6 There are several other problems with these proposals. If PCTs are to be responsible for checking a potential patient’s status, there will need to be some arrangement for clients to liase with the PCT. Yet PCTs are not set up for public access, and would have to establish facilities to allow this, such as interpreters, if they were to be determining the status of large numbers of people. The consultation document does not propose how contact with PCTs would be arranged, or estimate what this would cost.
2.7 In some circumstances, failed asylum seekers are still supported by NASS under section 4 of the Immigration and Asylum Act 1999. A failed asylum seeker may be given full board accommodation by NASS if, for example, they are unable to travel back to their home country due to pregnancy or ill health. It is not clear from the consultation document whether people in receipt of section 4 support will be eligible for free primary care or not, and how they would prove their eligibility for such care.
2.8 The consultation document also states that excluded people who need immediately necessary or emergency treatment will still be eligible for this. There are also certain exempt diseases, charges for which cannot be made. However, we cannot see how a clinician could make a decision on whether treatment is immediately necessary, or if a patient is suffering from one of these diseases, without first examining the patient. If a GP surgery doubts the status of a patient and refers their case to the PCT, they may not get to see a clinician at all, and will not therefore receive treatment even if this is immediately necessary or exempt. People may be forced to wait for their condition to worsen, and then go to Accident & Emergency. In addition to the threat to the health of the patient and the wider public health risk, this would place an unnecessary additional burden on secondary care providers.
2.9 If failed asylum seekers and other overseas visitors are to be excluded from free primary care and have to pay for these services, Citizens Advice fears that many will go without treatment if they have no means to pay these charges. Furthermore, the proposed rules would also serve to limit access to primary care services even for those who can afford to pay, as most GP surgeries do not charge private fees and would not therefore be able to offer treatment to these patients. These patients would then also be displaced to Accident & Emergency departments. It is clear that there are potential risks to public health if people are delaying getting treatment for infectious diseases as a result of being unable to pay for health care.
3. Discrimination
3.1 Citizens Advice fears that limiting the availability of free primary care would also impact on groups other than failed asylum seekers, including those who are not actually excluded. We fear that people who do not appear to be typically ‘British’ would be more likely to be asked to prove their eligibility for free primary care. If they cannot do so due to a lack of documentation (many people do not have a passport, for example) and are referred to the PCT to check their status, they will face delays in accessing the care to which they are entitled. Those most at risk of such discrimination would include those recently granted refugee status, and in this respect we consider the proposed rules to run counter to the Government’s strategy for the successful integration of new refugees, as set out in the recent Home Office consultation paper Integration Matters: A National Strategy for Refugee Integration.
4. Cost implications
4.1 Citizens Advice has serious doubts as to whether the savings to the NHS from the exclusion of failed asylum seekers and other overseas visitors from primary care would outweigh the administrative costs associated with overcoming the difficulties outlined above, and with enforcing the new rules. The consultation document does not include any kind of cost benefit analysis, and does not mention any work that has been done to try and assess the current costs of providing free primary care to the groups that would be excluded. We note, with some surprise, that there is no Regulatory Impact Assessment accompanying the consultation document. Indeed, the consultation document acknowledges (on page three) that the Department of Health does not know how many ineligible people are currently registering for primary care. Without knowledge of the scale of the ‘problem’ that the proposed rules seek to address, there is a real risk that the cost of administering and enforcing the rules would outweigh the associated savings.
4.2 In particular, using the NHS Counter Fraud & Security Management Services (NHS CFSMS) to recover payments from failed asylum seekers would in our view be extremely problematic if not impossible. Some of the individuals concerned would have already left the country by the time fraud was detected. Even if still in the country, failed asylum seekers are by definition extremely difficult to trace, and it is unlikely that they could be found and forced to pay for any treatment that they had received in breach of the proposed rules.
5. Conclusions
5.1 In the view of Citizens Advice, the proposed rules are wrong in principle and would likely prove unworkable in practice. We therefore urge the Government to withdraw these proposals.
[1] CABx in Scotland belong to a separate organisation, Citizens Advice Scotland (CAS).
Social Policy contact: Richard Dunstan Social.policy@citizensadvice.org.uk
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