So far, charges have only been incurred for hospital-related care. But the government is now consulting on proposals to extend charging into primary care – A&E, ambulances, prescriptions, dental care, eye care and some aspects of GP services. This is despite a promise not to introduce further charges until after a detailed evaluation of the impact of the earlier phases. No such evaluation has been published.
The reality already is difficult choices for pregnant women. Many are trying to regularise their immigration status but meanwhile they have no right to work or to access benefits. They also face a penalty from the Home Office if they owe more than £1000 to a hospital trust, which will bar them from obtaining a new visa or extending their stay.
The effect of the charging regime is to deter many vulnerable migrant women from receiving maternity care which they and their baby need to remain healthy.
Take, for example, the case of a woman who became pregnant by a British man whom she met in her country of origin. She then came to the UK on a 6-month visitor’s visa. While she was here she developed complications with her pregnancy. Clinicians told her that it was likely her baby had died, and that she would have to be induced, but the treatment would cost approximately £2500. She refused treatment – continuing to carry the dead foetus - because she couldn’t afford to pay and knew that the debt would prevent her applying for a 2-year spouse visa to live with her husband in the UK.
The rules about charging are complex and poorly understood, even by NHS staff responsible for charging, so women are frequently asked to pay even though they are eligible for free care. Others have been wrongly refused maternity care, despite Department of Health guidance stating that maternity care should never be delayed or refused, even if a woman cannot pay at the time.
The consultation proposals
In regard to the new proposals for primary care charges for migrants, the government has agreed a restrictive list of exemptions from charging for vulnerable groups - but pregnant women are not among them.
This is despite the fact that the UK is a signatory to the Conventions on the Rights of the Child and the Elimination of All Forms of Discrimination against Women (CEDAW). These conventions oblige states to provide appropriate antenatal and postnatal health care for women. CEDAW specifically requires states to ‘ensure to women appropriate services in connection with pregnancy, confinement and the postnatal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation’.
Impact on vulnerable migrant women
These proposals will further reduce access to maternity care for vulnerable migrant women. GPs are the normal route of entry to maternity care and GP services are integral to good maternity care. Deterring pregnant women from accessing antenatal care, especially in primary care, is likely to increase the already existing health inequalities in the UK.
Migrant women have poor pregnancy outcomes compared to the British-born population, particularly associated with no or insufficient antenatal care. They are more at risk of having undiagnosed HIV infection. Mother to child HIV transmission can be virtually eliminated by routine antenatal HIV testing ,but charges for maternity care can mean that some women at risk are not reached.
Similarly, vulnerable migrant women are at heightened risk of domestic violence, and pregnancy is a particularly vulnerable time for women at risk of domestic violence. Victims of domestic violence are exempted from NHS charges – but to get this help, women need to provide evidence of violence. Their first port of call for help is likely to be their GP. In our view access to GPs is a lifeline for the most vulnerable migrant women, especially in pregnancy.
Cost-saving for the NHS?
The government claims to want to recover costs from people who have no right to NHS treatment. It asserts that ‘the NHS [is] more generous than most other comparable systems’, but maternity care is free to undocumented migrant women in several of other European Union member states, even where there are restrictions on other types of health care. These include France, Belgium, Italy, Spain, Sweden, Netherlands, Portugal, and Germany.
It’s not even a cost saving measure. Charges for services cannot be recovered from impoverished women – so charging in these cases does not save money but actually incurs significant administrative costs.
And it is much more cost-effective to treat any patient in primary care than in hospital. Without free ante-natal primary care, undetected or untreated health conditions in pregnancy may require complex – and costly - interventions at a later date.
Respond to the Consultation
You – just – have time to respond to the government’s consultation on extending charges to Primary Care and A&E services and for you to express your concerns about the impact of the proposals. The consultation closes at 5pm, 7 March 2016.
Maternity Action has prepared a response to the consultation covering the impact on pregnant women and new mothers, which you might like to draw on – though it’s good if you can also include examples of the impact of charging from your own experience.