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

Good Guide - Detention and Removal

posted: 23/06/2009

NAT (National AIDS Trust) and the British HIV Association (BHIVA) have launched the first ever best practice guidance to support detainees living with HIV in Immigration Removal Centres (IRCs).

There is growing concern about the failure to meet the HIV-related needs of asylum applicants. The process of detention and removal has resulted in real difficulties for asylum seekers living with HIV. Research shows that people living with HIV have not always received the care they need and in some cases asylum seekers have had vital antiretroviral treatment interrupted whilst at an IRC.

The advice entitled Detention, Removal and People Living with HIV, produced in partnership with IRC healthcare managers, is a practical resource for healthcare, voluntary sector and other professionals working with detained HIV-positive asylum seekers in IRCs.

Deborah Jack, Chief Executive of NAT, comments:

“With many asylum-seekers coming from countries with high HIV-prevalence, it is important that those working in removal and detention centres understand the needs of people living with HIV. Healthcare managers and HIV clinicians working in IRCs have a duty to ensure asylum applicants living with HIV receive the best possible treatment, care and support throughout the process. We hope this guide will become a constant reference and useful tool for those working in this field.”

Dr Ian G. Williams, Chair of BHIVA, said:

“It is extremely important that asylum seekers with HIV infection detained at IRCs receive best care for their HIV infection. Failure to do so increases the risk of adverse consequences of HIV infection on their future health. It is important the IRCs recognise this and that HIV specialist clinicians are able to liaise effectively with the IRCs to ensure continuing best care for HIV infected detainees. This guide is an important and useful resource to enable this to happen.”

Download Detention, Removal, and People living with HIV

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