Charging Migrants for HIV Treatment

posted: 04/04/2011

The government has said it will soon change the rules about charging people from abroad for most treatment at NHS hospitals in England. At the moment the rules do not affect many people in North West England with HIV but that is likely to change. New Rules will probably appear in June.

The government has also announced another, bigger review of NHS charges. This will look at anything and everything and is intended to save the NHS a lot of money.

The next step is the department of health will publish the new rules for NHS hospital and clinic charges and guidance quickly – probably before June.

They have just published their response to a public consultation so now we know something about what the new rules from June will probably say. George House Trust gave evidence and comments to this consultation.

The Department of Health's plans for the June rules are 

• They won’t change which treatments will be charged for yet – but may do so later.
• The rules will be changed to make it clear that refused asylum seekers who get Section 4 and Section 95 payments do not pay for NHS treatment
• Unaccompanied children will no longer have to pay, but children with parents here can be charged
• They will make clear in the new rules that anyone who has begun HIV treatment that is free of charge (e.g. because they have an asylum claim which has not been finally decided) will continue to receive free HIV treatment
• They will keep putting up posters about charging for treatment in hospitals and clinics, even though they know this frightens some people that need treatment away and can lead to discrimination by hospitals
• They will change the guidance that tells doctors to think about the cost of treatment, because this encourages discrimination
• They will start a new system of telling the UK Borders Agency about the people who owe the NHS money. This will mean people will be refused permission to stay longer, applications for citizenship may be refused and people will be refused a visa to return to the UK if they leave
• They will consider introducing a rule that will force visitors from overseas to have health insurance
• They will look at charging people for primary care (treatment by family doctors)

Free HIV treatment for all?
The Government still has not decided whether to make HIV treatment free for everyone who needs this on public health grounds, like for all other sexually transmitted infections. They say they are still considering this and will report “in due course”.

Next, an even tougher review
They have also announced another major review which is designed to save the NHS a lot of money. This will look at

• Changing the residence rules, including the definition of ordinary residence
• Changing some or all of all the types of treatment and types of people who do not have to pay for NHS treatment
• Making people pay for primary care (that is treatment by family doctors and dentists)
• Changing which bit of the NHS has to pay when people cannot pay
• Making the procedures for checking who should pay tougher before treatment begins
  Making the procedures for collecting charges tougher
• Using new ways to collect charges 
• Requiring migrants to have health insurance 
• They will consider anything and everything else.

They try to soften this tough new cost-saving review by saying “the NHS is, and must remain, ultimately a humanitarian organisation. In undertaking the review, we will be mindful of the NHS’s core values, in particular its obligations to provide urgent treatment to any person irrespective of their status or ability to pay, to protect the vulnerable and respect our obligations on healthcare provision under international treaties . There is no intention to consider policies that would deny access to any group, only whether an individual should be charged. It will consider the full benefits and costs of introducing new charges including risks of deterred or delayed treatment and any other societal costs. In addition, we will ensure that public health considerations are fully factored into proposed rules and processes (ensuring in particular that access policies do not compromise the identification and control of infectious diseases).”

A comprehensive package of confirmed proposals will be put to full public consultation on completion of the review work, in 2012. We may consult separately at an earlier stage on some options, such as primary care charging.
 

You can read the details of the government's proposals for the June regulations and this new review here. The new review details begin on page 24. 

Proposals and Review report

HIV Treatment Charging Harms

posted: 28/06/2010

The UK rules that mean some migrants have to pay for HIV treatment are harming the health of migrants and the UK public, says a new study in the journal AIDS Care.

The study of African migrants with HIV in London found some migrants delay taking HIV tests, some only go for HIV treatment when they are so sick they need an ambulance to take them to hospital, some use herbal treatments that don't work, and others send abroad for HIV drugs but don't take enough of these.
 

Findings and the government review

This Wednesday the government ends its public consultation on changing the rules and guidance about who has a right to free NHS treatment. Anyone who has a sexually transmitted infection (STI) or an Infections Disease always has a right to free treatment, but not if they have HIV. The proposed new rules and guidelines still bar some migrants from automatic free HIV treatment. While asylum seekers and those with leave to remain are entitled to free care in NHS hospitals, refused asylum seekers and undocumented migrants, including pregnant women with HIV, among others, are sometimes handed very large bills for HIV and other medical treatment.
 

The researchers interviewed HIV-positive migrants from Zimbabwe, Zambia and South Africa who live in London. 70 people took part in eleven focus group discussions.
 

Problems getting a GP
Even though there is no law stopping migrants from having a GP or free primary care, people said they had problems even registering with a GP. They are often asked to show documents that they do not have (for example, their passport – these are often held by the Home Office / UK Borders Agency because they are making an asylum claim or other application).
 

Waiting until you need an ambulance
The law says all treatment in a hospital Accident & Emergency department is free-of-charge for everyone. Many people in the survey knew this, and said they did not try to get treatment until their condition was so serious that an ambulance was needed. One man said:
“You would rather wait for a situation where you get taken to hospital by ambulance because even if you walk in they want to know who is your GP. And if you don’t have one they become very suspicious.”
Accident & Emergency (A&E) treatment is extremely expensive to provide. Moreover, in most cases, the person then needed immediate HIV treatment and a lengthy stay in hospital.

The rules say if you are admitted to a hospital ward after A&E, or are referred to another department (eg the HIV clinic) then you will be charged; but HIV treatment should always be provided because it is 'immediately necessary.' If you can't pay the bills, the hospital will have to cancel the debt anyway.

Some people had received bills for several thousand pounds for hospital admissions, surgery and treatment. The researchers found that these experiences often affected people’s feelings toward health providers.
 

In hospital but fearing bills and immigration
People who were entitled to free NHS care feared intrusive visits from immigration and hospital officials. For example one woman who had been recently diagnosed with HIV received a bill for hospital treatment:
“I was worried how am I going to pay this £4000? So what kills you first is the stress and worry . . . I found myself thinking if I did not have indefinite leave to remain in this country then what would I do?... You’d just try to go away, you’d remove the drip and run away from there before immigration got there.”
 

Do it Yourself treatment
Some people said they treated themselves. Some sent for drugs in their home countries, but said they took too few pills for them to work properly, for example. Some had depended on herbal remedies and other alternative treatments, and sometimes delayed taking a HIV test until it was clear herbal and alternative treatments were not working. One woman said:
"There are some people who do not have papers in this country, who can’t have access to a GP or a hospital and they have to rely a lot on the traditional medicines."
Although HIV testing is free for all (on public health grounds), HIV treatment is not. People said this discouraged others from HIV tests:
“If I cannot access services, then there is no reason for me to test. If I test and I know I’m HIV-positive, I know it will be very difficult to access [treatment].”

The researchers end by saying that current policies for charging some migrants may appease a part of the UK electorate but act as a barrier to the uptake of HIV testing and treatment. Moreover, these policies are pushing some people to resort to other forms of treatment that may be costly, harmful or ineffective. As well as having implications for the health of individuals, the policies are likely to have an impact on the onward transmission of HIV.
 

Campaigning for free HIV treatment for all
This Wednesday the Department of Health closes its public consultation on planned changes to the rules and guidance for free NHS treatment. This does not include adding HIV to the list of sexually transmitted infections and infectious diseases that would mean free treatment for everyone. George House Trust and the HIV sector are campaigning for free HIV treatment for all.

Source and reference 
Thomas F et al. ‘‘If I cannot access services, then there is no reason for me to test’’: the impacts of health service charges on HIV testing and treatment amongst migrants in England. AIDS Care 22: 526-531, 2010.

HIV Treatment Rights Review

posted: 23/06/2010

Wednesday 30 June is the last chance to tell the Department of Health whether its plan to update the law and official guidance on who is entitled to free NHS hospital treatment is right. At present some migrants with HIV are charged for HIV treatment, although every other sexually transmitted infection (STI) and infectious disease is always treated for free, for everyone. The rules affect lots of other people in other ways but our focus is on access for all people in this country to free HIV treatment.

Free treatment for STIs like HIV, and infectious diseases makes financial and disease management sense. It saves money and stops diseases spreading when states provide free treatment for these for public health reasons. Untreated conditions spread diseases and increase the total bill.

New Regulations - useful changes
The new regulations propose some useful changes:

• Refused asylum seekers getting Section 4 or Section 95 support will be exempt from charges
• Primary care services are explicitly excluded from charging
• Unaccompanied migrant children will be exempt from charges
• People with an Article 3 claim will be included alongside people seeking asylum or humanitarian protection, and so will be exempt from charges

New Guidance - some good bits

The new official Guidance is also better:

• Maternity treatment is now defined as 'immediately necessary' treatment. This means there will always be a right to treatment and it must be provided. But a bill could follow.
• The Guidance does not yet say, but we are hopeful that HIV will also be defined as ‘Immediately necessary treatment’ because that is what the British HIV Association has formally told the Department of Health.
• Overseas Visitors Managers and clinicians are instructed to tell patients that all ‘immediately necessary’ treatment will not be withheld, regardless of their ability to pay.

Want to help?

The major problem with the rules is that there is still no automatic right to free HIV treatment. The Department of Health says it is reviewing this rule. We think this shouldn't wait a moment longer and HIV community organisations are making the case now for free HIV treatment for all.

The review of the rules and guidance was started before the election. Now there has been a change of government, an emergency budget, cuts and more cuts to come in the autumn Spending Review, so it is important to support the positive changes they have made. We want to push the Department of Health to take the sensible next step of adding HIV treatment to the list of Sexually Transmitted Infections and Infectious Diseases which are all treated for free, whoever you may be. And we want to discourage the Government from making some unhelpful changes that it plans.
 

NAT (National AIDS Trust) response

NAT have prepared a fairly simple response for some HIV organisations. This deals with the key points. You could use this - just add your name and details in the first pages and send it to them by email. You can of course say whatever you wish and make your own points.
 

If you want to comment in more detail you could look for more in the Model Response you can find on a blog set up by Medact and other community organisations that are campaigning together.
 

Here are all the Department of Health papers for the consultation. 

George House Trust draft response

Here you can read the draft response of George House Trust.
Please note that this is not our final or official view but we are sharing this to help others, before the official deadline. We welcome any comments and suggestions.

We have considerable experience with HIV treatment charging and this draft is built on our experience, expertise, and we are especially grateful to NAT and the blog for their detailed work on this. 

This George House Trust draft is more detailed than the NAT response above and it includes some significant additions. 

Two of these George House Trust extras are 

• much better Guidance is needed on who fits the definition of 'ordinarily resident'. The details are for legal experts BUT this is really important. The poor Guidance on who is 'ordinarily resident' has caused most of the problems with charges for HIV treatment in NW England. We have won almost every case we have argued on this point. We have been able to argue that most migrants with HIV who are charged are in fact 'ordinarily resident' in this country and so should never have been charged. If you can show you are 'ordinarily resident' none of the charging rules apply.
• There is no system for independent reviews or appeals - like there is if your claim for a state benefit is refused, or your asylum claim or immigration appeal is refused. In the 21st century, basic rights like hospital care deserve a system of independent reviews and appeals considered by an independent Tribunal chaired by a judge, so people can obtain justice and justice is seen to be done.

‘Health Tourism’ Mischief

posted: 08/06/2010

Sunday Times deputy editor Isabel Oakeshott has written an ignorant and mischief-making scare story about people from abroad using NHS money. People with HIV were included among those the NHS ‘counter-fraud unit’ listed as responsible.
 

The story calls it health tourism. The Department of Health has published no evidence that people with HIV come here as tourists deliberately to get HIV treatment. The only evidence there is (a snapshot survey by George House Trust and Terrence Higgins Trust) shows people do not know they have HIV when they travel here (to seek asylum, to start a university course, or to work, or visit family …. ).
 

Legal rights ignored
Most people from abroad who do have HIV treatment have every legal right to this. The few who are chargeable under the legal rules usually only find out they have HIV months or years after arrival, and their HIV diagnosis is always a big shock.

The NHS charging rules worsen public health in the UK by discouraging people from taking (always free) HIV tests. Untested and untreated people with HIV are likely to be much more infectious and lead to more HIV infections in the UK. Testing and HIV treatment can make people with HIV almost uninfectious, and that can save the NHS a lot more money than not treating everyone who needs this. HIV is the only sexually transmitted infection that can be left untreated because of these charging rules.
 

The Times report says that in eight-months last year, hospitals reported £24m in “bad debts”, 'most linked to patients from abroad'. The article suggests hospitals recover some of the cash later, but not much. The report says ‘According to the NHS’s counter-fraud unit, health tourism has a particularly heavy impact on maternity services, HIV care and cancer and heart units’.
 

Wrong about pregnant women, cancer, serious heart disease, HIV rights
The newspaper report is mischievous and malicious. The law and official guidance to NHS hospitals tells hospitals they must provide ‘immediately necessary’ or ‘urgent’ treatment.

Who would or could refuse a pregnant woman emergency care, or someone with life-threatening heart conditions, cancer, HIV?
 

Accident and Emergency – wrong again
It claims, without quoting any evidence, that “thousands of foreigners have been diagnosed in their own countries who cannot afford treatment there simply turn up at accident and emergency units in British hospitals and demand to be seen”.

Again this completely ignores the law and official NHS guidance – anyone needing accident and emergency care is always entitled to it without any charge. We get and would expect this if we are abroad and need emergency care.
“6.7 Some NHS services provided in NHS trusts are free to everyone regardless of the status of the patient. This Regulation says what these services are. The current list includes: a. treatment given in an accident and emergency department or casualty department......”
 

Doctors opposed
It correctly reports that most doctors dislike the charging system because medical ethics and the Hippocratic oath mean it is unethical to turn away patients who need urgent medical help.
 

Blame the Irish and Welsh – wrong
It also falsely blames people from the Irish Republic. Irish Citizens have always had the right to come and go freely and live here and use UK services. Brits can do the same in Ireland.

It seeks to create divisions within the UK by blaming people living in Wales for using NHS services in England, although the Welsh pay UK taxes just like everyone else. The Welsh are not foreign or migrants.
 

The Department of Health is already reviewing its policy on foreign patients.
 

Times article

Free HIV Treatment Plans

posted: 27/07/2009

The government may relax the rules on which migrants can have free HIV treatment in England, the junior health minister Ann Keen announced in the House of Commons last week.

The government also announced some other plans:

• that access to primary care services should not bar refused asylum seekers or others (the recent consultation on this produced furious opposition to tougher rules),
• that a limited number of refused asylum seekers should be exempt from all charges, and
• that foreign nationals with large debts to the NHS could be refused permission to remain in the UK or to re-enter the country.

Health and Home Office review

These plans have emerged from a joint review by the Department of Health and the Home Office, and were briefly described in a statement to the House of Commons and in a Department of Health press release.

Some propositions are in one of these documents, but not in the other. None are final decisions - consultations are likely to take place later in the year. The plans are only for England (Wales and Scotland decide their own health policy). 

Commons statement on HIV treatment for migrants

In the statement to the House of Commons, Ann Keen reiterated the government’s commitment that “immediately necessary and other urgent treatment should never be denied or delayed from those that require it” and confirmed that NHS guidance is being revised to ensure that this is made clear.

Moreover she made the following statement on HIV specifically:

“The Government recognise that clinical evidence on treatment, including their role in prevention, is developing constantly. Moreover, HIV is a major global problem, the control of which creates significant financial as well as human costs. We will therefore undertake further analysis of the latest medical and public health evidence together with consideration of how the current policy on treatment aligns with the Government’s wider international aid strategy for HIV. This analysis will inform a future decision on whether the current treatment policy (that only initial diagnosis and counselling is offered free of charge to non-UK residents or individuals who are not otherwise exempt) should be revised.”

This follows an earlier statement in the House of Lords.

Primary care

She also announced that she did not plan any change to the current system of access to primary care services for foreign nationals, which is at the discretion of the general practitioner. Over the last two years, the government consulted about and made it pretty clear it intended to restrict the access to primary care for irregular migrants and other foreign nationals. The outcry seems to have halted this plan.

Section 4 support eligible for free treatment?

She also proposed that those refused asylum seekers who are receiving ‘section 4 support’ should be able to access all NHS services without charge. Section 4 support is given to individuals who are destitute and whose asylum claim has been refused, but are unable to return to their country (often because of war or instability, or because the individual is ill or pregnant). Some newspapers reported that this change would affect one million individuals; in fact only 10,850 people currently receive section 4 support.

Unaccompanied children

The government is also proposing making treatment free-of-charge to all children who are in the country without a parent or guardian.

Bad news in the press release but not Commons staement

HIV advocates may be less encouraged by some other suggestions which were not included in the Commons statement, but described in the press release:

• working with the UK Border Agency to recover money owed to the NHS
• exploring options to amend the Immigration Rules so that visitors will normally be refused permission to enter or remain in the United Kingdom if they have significant debts to the NHS
• investigating the longer-term feasibility of introducing health insurance requirements for visitors.

The British Medical Association unhappy at restrictions

Dr Vivienne Nathanson, Head of Science and Ethics at the BMA, said:

“There are many people who have had an asylum claim refused, cannot return home, and need urgent treatment. This announcement, while positive, applies to only one group of people in this situation, and does not go far enough.

“We believe no-one whose asylum claim has been refused should be turned down for care which cannot be delayed, and which clinicians determine they need. Doing so affects our ability to control communicable disease, and ultimately puts additional pressure on the NHS, particularly on emergency services.

“The role of clinical staff is to determine what care a patient needs, and how urgently they need it - not to assess their immigration status. More must be done to ensure that those who need urgent care can access it.”

Dr Nathanson welcomed the proposal for additional research on the policy of charging non-residents for HIV treatment beyond diagnosis:

“The policy of refusing non-resident HIV patients treatment after diagnosis has public health implications. It carries the risk that their health will decline to the point at which costly emergency treatment is required. We would expect further research to cover these areas. A research-base to support policy in this area would be welcome.”

Commons Statement by Ann Keen

Department of Health press statement

Section 4 statistics

Source