NHS £1.7bn Surplus v. Treatment Charges

posted: 21/05/2009

NHS bosses were urged to pump more money into frontline services after it was revealed that the NHS has amassed a record cash surplus of £1.7bn. The underspend, confirmed by the Commons public accounts committee yesterday, represents a rapid turnaround in health finances: three years ago, the organisation recorded a £500m deficit.

The exceptional figures delivered under the current health secretary, Alan Johnson, are in contrast to the experience of his predecessor, Patricia Hewitt, who was slow handclapped at a nurses' conference during a debate about NHS debt.

Large reserves, however, constitute a different form of political embarrassment. "It's not the case that the bigger a surplus the better," said Edward Leigh, chairman of the PAC. "Patients lose out if too much NHS funding is sitting unspent in bank accounts.

"The needs here and now of patients in parts of the country for drugs and better quality care must not be forgotten. [The surplus is] almost twice the amount planned and over £1bn more than the surplus generated in the previous year."

Janet Davies, of the Royal College of Nursing, said: "A £1.7bn surplus is £1.7bn which must be spent on improving patient care and the government must make clear how it plans to use this money. While we are encouraged that the NHS is on a firm financial footing, it is absolutely vital that this surplus goes straight to frontline services."

The £1.7bn represents almost 2% of annual NHS expenditure, the PAC report says. The cash came from a number of sources, including a fall in the price of generic medicines and the underuse of contingency funds. Savings were also made by changing the habit of trusts spending all of their budget at the end of each year "regardless of whether it [was] in the most appropriate fashion".

HIV treatment charges for migrants

Aside from using the money to help meet the costs of providing HIV treatment for all, following the minister's recent announcement of a review of the rules in the House Of Lords, more investment is sorely needed in HIV prevention.

Even more surplus expected this year

The NHS is forecasting that it will return a similar surplus in the year 2008-09. The Department of Health will return part of the unspent funds to the NHS at an annual rate of £400m for the next two years, providing cushioning for the economic downturn. The NHS is receiving above-average annual budget increases of 5.5% up to and including 2010–11.

One immediate threat looming over balance sheets is a change in accounting procedures which will add in £10.9bn of liabilities from the government's public finance initiatives (PFI). These were deliberately kept off government and NHS accounts, but cannot be hidden any longer.

"The Treasury has given a commitment that this will not adversely affect NHS funding in the period up to 31 March 2011," the PAC said. "There are, however, no guarantees beyond that point."

The NHS chief executive, David Nicholson, yesterday said the organisation would have to prepare for leaner times in the future.

The organisation is expected to deliver efficiency savings in the order of £15bn over the three years after 2011.
 

Source

End to HIV Treatment Charges?

posted: 07/05/2009

During the debate on the Health Bill in the House of Lords yesterday, the Government announced its intention to conduct a review of NHS charging for HIV treatment, which affects some migrants.

Deborah Jack, Chief Executive of NAT, comments:

“NAT was instrumental in securing this Government review, which is the first step to making access to HIV treatment in the UK a reality for all. NAT was one of the first organisations to recognise the unfairness in the treatment charges introduced by the Department of Health in 2004, and has worked with parliamentarians to use the Health Bill as an opportunity to review HIV treatment charges. We hope the review of current evidence will show that HIV treatment should be exempt from charges. This would ensure that some of the most vulnerable people in the UK would be able to access the vital care they need, both improving their health and reducing the risk of HIV being passed on.”

George House Trust's response

George House Trust warmly welcomes this announcement of a change of heart by government. In the last ten years the charging rules have been tightened, and the department of health has issued dodgy guidance - and been ticked off for this by the courts.

We need to wait to see the detail but it is excellent news that the government has at last responded positively to end the human rights violations and the harm treatment charging causes individuals and HIV prevention in England.

George House Trust drew attention to the International Covenant on Economic, Social and Cultural Rights which the UK signed over 30 years ago in 1976. Governments since have failed to make this part of our own law. This Coveneant gives everyone in any country the 'right to the highest attainable standard of health' and that means accessible HIV treatment for all in the UK. The current rules deny us this basic right in the Covenant.

The department of health's own guidance advises NHS Trusts to follow a human rights approach in providing healthcare but despite this keeps its charging rules.  Human rights in health - a framework for local action, 2007.
 

The Lords announcement

Court Rules on Treatment for Migrants

posted: 14/04/2009

Almost a year after the High Court said most migrants are entitled to free NHS hosptal treatment, the Appeal Court has now rejected that ruling. The long running struggle to ensure people living with HIV in this country always have free treatment will continue.

Although the Appeal Court ruling says there is no legal right to treatment, they did rule that the Department of Health Guidelines are unlawful.

Almost a year ago the High Court ruled that most migrants were "ordinarily resident" even if their asylum claim was refused. About a year before that the application was made to the High Court after a NHS hospital refused free treatment to a migrant. The Courts are very slow because there aren't enough courts and judges to deal with this type of case - a 'judicial review.'

Appeal Court rules

On the 30 March 2009 the Court of Appeal decided that the Department of Health's own guidance restricting access to healthcare for migrants is unlawful.

Solicitors brought a test case for the HIV and migrants organisations on behalf of a Palestinian former asylum seeker who is unable to return home and could not pay for treatment.

He was given the treatment he needed after the solicitors applied to court but the case went ahead anyway as a test case and to challenge to the government’s guidance.

At the High Court a year ago Mr Justice Mitting decided that refused asylum seekers could get free NHS treatment. His ruling was that migrants, including refused asylum seekers, are just as 'ordinarily resident' as any British person, and this entitles people to free NHS treatment.

Not lawfully resident

The Department of Health then appealed and now the Court of Appeal has overturned the High Court decision. The Court of Appeal rejected the High Court's approach, finding that refused asylum-seekers could not be lawfully resident in the UK. Anyone not lawfully resident cannot be ordinarily resident, and that means no right to free treatment.

However, the Court also decided that the guidance is unlawful because it fails to explain what hospital’s should do if a patient cannot pay for treatment and cannot return home immediately.

The solicitors are considering whether to appeal to the House of Lords or not, and would need the House of Lords permission to make an appeal. 

In the meantime there is likely to be confusion about how to apply the judgement and the new guidance. The Department of Health has wasted no time in telling NHS Trusts to follow the Appeal Court's ruling.

Reactions to ruling

Solicitor Adam Hundt of Pierce Glynn, who took the case commented:

“The Dept. of Health guidance said that hospitals should not provide treatment unless patients paid for it in advance, but this ignores the fact that many of these patients, like A, are destitute, and many cannot return home, so they are not treated until they require life-saving treatment. In my experience, sadly, by that time it is often too late, and that treatment is usually far more expensive, so the current rules don’t make clinical, economic or humanitarian sense, and I am glad that the Court has recognised this. I hope that the Dept of Health will now make it clear to hospitals that they must treat patients who cannot pay and cannot return home for the time being - and not just wait until they are at death’s door.” 
 

The decision disappointed refugee and health welfare groups. Donna Covey, of the Refugee Council, said she was concerned that the charging regime for failed asylum seekers was still in place. She said those people who were unable to go home straight away often ended up destitute and homeless. "To refuse treatment to them simply because they cannot pay for it is appalling and inhumane," she said.

Deborah Jack, of the National Aids Trust, said anxiety over medical bills would deter many people from seeking the care they needed. She said the government should use its review of healthcare charges to end its policy of ill-health for the most destitute.

Department of health advice letter

The Department of Health has issued a letter to NHS trusts before the new Guidance is published in the autumn.

The letter says 

• Trusts shouldn't charge people treated free as 'ordinarily resident' for the period of time between the two court rulings
• people already on treatment are entitled to have it continued for free
• Trusts must always provide any immediately necessary treatment, including all maternity treatment. It's a matter for clinical judgement if care is 'immediately necessary.' HIV care could fall within this - especially if there is symptomatic illness, or CD4 count is low.
• Trusts must provide urgent treatment (which is treatment that isn't immediately necessary but which can't wait until the person can be reasonably be expected to return to their home country). This is likely to include HIV care under BHIVA treatment guidelines. It is a matter of clinical judgement whether the care is 'urgent'.
• Treatment should not be delayed or cancelled if the person can't pay for urgent or immediately necessary treatment.
• Trusts have the option to write off debts where it proves impossible to recover them, or where it would be futile to begin pursuing them, for instance when the person is known to be without funds (our emphasis - this will apply to most migrants with HIV).
• even non-urgent routine elective treatment can be provided depending on how long the person is likely to remain in this country - eg if the return home is not likely to be within a 'medically acceptable time.'
• immediately necessary, urgent and non-urgent treatment will require Trusts to assess when a patient is likely to return home based on "their plans, intentions or ability to do so."
• Trusts must not charge anyone identified as actual or suspected victims of human trafficking by either the UK Border Agency, or the UK Human Trafficking Centre. This is nothing to do with the Appeal Court, but because the European Convention on human trafficking came into force on 1 April.
• can't now bill the person's local Primary Care Trust for treating any people who are "chargeable."

The Department of Health letter says they will update the Guidelines, as required by the Court, in the autumn. HIV and migrants organisations will be pressing for a practical, humane approach.

People living with HIV in NW England who have problems with treatment charging for hospital care should always contact our services team.

The Appeal Court's ruling

Migrant Treatment Charges

posted: 17/12/2008

Before Christmas we expect the Appeal Court's decision on the government's appeal against the ruling early this year that all refused asylums seekers and many other migrants are in fact "ordinarily resident" and so fully entitled to all NHS free treatment, including HIV.

We are hopeful the Appeal Court will uphold the High Court's decision in the case which was supported by the entire HIV sector. But the Department of Health and the Home Office both still appear intent on restricting access to the NHS even further. They plan to extend the rules to cover primary healthcare, such as GPs. The department has been sitting on the results of a consultation on these proposed changes for four years, but is expected to release them shortly.

There is concerted opposition to banning migrants from primary healthcare, because a stitch in time saves nine - catch problems early and they are cheaper to treat and diseases don't spread; delay treatment by putting up charging barriers and we can safely predict expensive emergency hospital treatment and the spread of transmissable infections costing society far more than earlier care. But more important, it is the human and "right" thing to do for people in the country - and we made a commitment to treating all who need it to the world over 30 years ago in an international Convention that we are still breaking. The department does know what to do - it has recently published a guide to NHS trusts on the Human Rights approach to local healthcare.

Passports for treatment

Under the current system, asylum seekers who are awaiting a decision on their status are entitled to free primary healthcare, while even those who have been refused can be treated at a GP's discretion. But clinical decisions about who gets free care at times never reach doctors, says Dr Sally Hargreaves, of Imperial College London.

A study of GP practices in Newham Primary Care Trust, London, found that almost 70 per cent of practices asked for passports and about where patients had come from. This suggests frontline reception staff are inappropriately stopping migrants from seeing a GP. The government has said that the new ID cards now being issued to migrants (coming to everyone else over the next few years) will soon be used instead of passports to prove the right to healthcare and other services.

Confusion

Adam Hundt, the lawyer who won the court case, often gets calls from doctors who are unsure about what they should do with patients. “The clinicians are left with the decision between disobeying management or disobeying their Hippocratic oath,” he says.
 

Frustration and confusion surrounding who is entitled to free healthcare is echoed by the NHS. Nigel Edwards, director of policy for the NHS Confederation, says that the rules are “quite complex and keep changing. The Home Office has got to get its act together in not having large numbers of people waiting for their status.”
 

Donna Covey, chief executive of the Refugee Council, says: “The rules are complicated and people don't know how to apply them. You have the Immigration Minister not knowing the difference between asylum seekers and economic migrants, and if the minister responsible doesn't understand those differences, then you can't expect overworked and underpaid healthcare professionals to understand them.”

Thousands in healthcare no-man's land

There are thousands living in the UK stuck in a healthcare no man's land, including the estimated 155,000 to 283,500 failed asylum seekers, who, after their refugee status is refused, have nowhere else to go and often no means to pay for healthcare.

Charities that work with migrants say that the Government, in its effort to crack down on the supposed problem of “health tourism”, is victimising people such as failed asylum seekers and that because of confusion over entitlement, migrants often receive patchy and inconsistent care.

Treatment Catch-22

Many people are confused about their rights. Refused asylum seekers are caught in a Catch-22 situation: they cannot be deported immediately, yet cannot have free healthcare; nor can they afford to pay for it because they are not allowed to work. “We can't send them back tomorrow, so what can we do in the meantime?” 

 
How other European countries do it
Susan Wright, director of the health charity Médecins du Monde UK, says the problem with the government's claim that a “pull factor” exists - that people come to the UK for free healthcare - is that other countries in Europe offer equally flexible, if not more flexible, policies for free healthcare for undocumented migrants or asylum seekers.

• Italy: There are payment exemptions for asylum seekers and those with low incomes from the national health service.
• France: Undocumented migrants can access a state-financed insurance fund.
• The Netherlands: The Government has set aside money for “medically necessary” care for undocumented migrants.
• Belgium: Undocumented migrants can access government-sponsored Emergency Medical Aid, which gives free access to A&E and other services.

Includes material from source