By Catarina Alves Soares, Jonathan Broad, Bryony Hopkinshaw and Sarah Boutros
Ayda is a 7-year-old migrant. She was brought into the emergency department by ambulance after having a seizure. On reviewing her notes, you notice that she has had two similar episodes in the past and has not attended either her first seizure clinic appointment or EEG appointment.
Her parents are very distressed. When bringing up the follow-up plan with her parents, they say that they were not told about it. Later, after some gentle questioning, they share that they had received letters telling them that they would be liable to pay for their appointment because of their immigration status. The family could not afford this and so did not attend.
Discussions with parents who act against medical advice can be challenging, particularly when it appears that socioeconomic factors have driven their decisions.
Why is this migrant family liable for NHS care?
People not considered ordinarily resident in the UK are not eligible for free NHS care. In practice, this means that undocumented migrants cannot access care. A child may become undocumented for many reasons, such as being born to undocumented parents, overstaying a visa, being an unrecognised victim of human trafficking or staying in the UK after an asylum claim has been rejected.
In such cases, patients, including children, must pay up to 150% of the cost of their treatment to the trust providing their care. There are exemptions for certain services, patient groups, and conditions (see the non-exhaustive list below). For a more comprehensive list, you can visit the RCPCH guidance.
Most of the time, patients have to pay upfront. In other words, they are denied care until they can pay for it. In some cases – when it is considered immediately necessary or urgent care – when a senior clinician believes that the care can’t wait until they can be reasonably expected to leave the UK due to risk of deterioration, pain or other impairment – they may pay afterwards. In the case of inpatient treatment for seizures, for example, they may be charged. This would occur after the event, whereas they might not be charged for emergency department care.
It is essential to bear in mind that some parts of this legislation don’t apply in all four nations of the UK. Upfront charging and charging 150% of the cost of treatment only occur in England and Wales.
How does this practice impact child health?
Several organisations have studied the impact of the charging regulations on child health, including Maternity Action, Doctors of the World and Medact, and the Royal College of Paediatrics and Child Health (RCPCH). They have found that some patients avoid seeking healthcare until they can’t put it off any longer due to fear of the charges. Many healthcare providers working in the NHS are unaware of how the regulations work. This may result in patients who would be rightfully exempt being charged. This can have the knock-on effect of patient harm from denial of care.
Debts to the NHS of over £500 must be reported to the Home Office. This can also impact patients’ immigration status – for example, a future visa application may be denied, or a person or family may be detained and deported.
These regulations directly impact the health of children. They are being denied care, or their parents avoid presenting to the hospital.
What can I do for my patients in this situation?
The RCPCH has produced guidance to support those working in child health when facing the charging regulations.
The most important thing is to keep the child or young person at the centre of your actions. This includes doing as much as possible to minimise harm – involve a senior early and carefully consider any risks that could result from denying care. You may need to advocate for them to other professionals or organisations engaged in their care. Families may require interpreters. It is good practice to ensure you use trained interpreters rather than relying on ad-hoc interpretation from a relative or even the patient.
Avoiding necessary medical care is a safeguarding concern, but bear in mind the situation’s complexities. You can always seek advice from the hospital’s ethics or safeguarding team if you are unsure how to proceed.
It is helpful to carefully document any possible exemptions to charging. Some exemptions may only become apparent during a clinical review, and it is essential to provide evidence supporting exemption from charging. If you suspect a child or their parent is a victim of human trafficking, this should be discussed with your local safeguarding team, and a referral to social care should be made.
This group of marginalised patients access care via general practitioners or the emergency department. They may be vulnerable, so it is helpful to ensure that billable families know what care they can access for free. There are patient resources available in several languages detailing this information. Support families to register with their GP. Once a speciality accepts a patient for inpatient treatment from the emergency department, they may be billed for care provided from that point on.
You may also want to signpost families to charitable organisations that can advocate on their behalf if they cannot register with a GP, such as Doctors of the World. You may advise them to access trusted legal advice, such as the Coram Children’s Legal Centre. Families will need legal support to regularise their status, and you may want to give them information about some of the organisations that provide this service for free. You can find a complete list of relevant organisations at the end of the RCPCH guidance or on the Patients Not Passports website.
Finally, consider other ways in which these families may be vulnerable. They are likely not eligible for government support such as benefits or universal credit or may not qualify for many women’s refuges when fleeing domestic abuse. Some of the legal aid organisations linked above may be able to support them to obtain help through the local authority and to regularise their status so they can be eligible for government funding.
What else can I do to support these children?
Whilst doctors and clinicians are used to advocating for individual patients; we must address the broader injustices that contribute to harm. Systemic issues must be addressed to avoid tokenism.
Many organisations are advocating for migrants’ right to health. The RCPCH guidance advises reporting any harm to a child or young person that has taken place as a result of these regulations. This can occur through local processes (such as Datix) and directly to the RCPCH via their harm reporting tool (link here)
Suppose you’re interested in learning more about this and advocating for all children and young people’s right to health. You can contact the Medact Migrant Solidarity Group, Docs Not Cops or the Patients Not Passports coalition. Get involved in national events, tell colleagues about the legislation and its impact on child health, and write to your MP. There are many ways to fight for equitable healthcare for all.
You have the chance to sit down with Ayda’s parents to talk about what has happened. You explain to them that Ayda will be discussed at the local safeguarding meeting because of the delayed presentation and missed appointments; you’re able to counsel them on their rights to free care in A&E and primary care and signpost them to organisations that can support them in regularising their status. You also explain that they can request a payment by instalment scheme rather than paying a single bill. You discuss how they might obtain legal advice and the possibility of having their fees waived for poverty.
Murphy L, Broad J, Hopkinshaw B, et al. Healthcare access for children and families on the move and migrants. BMJ Paediatrics Open 2020;4:e000588. doi: 10.1136/bmjpo-2019-000588 n. Available here.
Royal College of Paediatrics and Child Health (2021). Guidance: Rights to access healthcare for migrant and/or undocumented children. Available here.
Royal College of Paediatrics and Child Health (2022). Guidance: Child Modern Slavery and Human Trafficking.