UK Policy Consultation & Briefing

Health Rules Campaign

Immigration status and the new overseas visitor health rules pose dangers to maternal health argues Rhian Beynon

This article previously appeared in the October 2005 edition of JCWI's quarterly membership magazine Bulletin

A chilling report into higher than average maternal deaths at NW London Hospital Trust has highlighted problems with the rules restricting non-urgent secondary care to failed asylum seekers and undocumented migrants.

The Health Commission investigated the Trust's maternity services after nine women, eight of them from black and ethnic minority groups, died in, or soon after childbirth, at the Trust's hospitals between April 2002 and June 2004. NW London Hospital Trust have since refused to confirm the immigration status of these women to JCWI on grounds of patient confidentiality.

However, the Commission did find that migrant women lost out on ante-natal care because staff were confused about what they were entitled to receive. This finding is worrying in the light of Why Mothers Die 2000-2002, a study which found that Black African women, especially asylum seekers and newly arrived refugees, have a childbirth mortality rate up to seven times higher than white women.

Meanwhile the Department of Health has not yet heeded JCWI's call for a full race equality impact assessment of the secondary and primary health care rules on restrictions on non-urgent treatment to overseas visitors to be carried out according to the statutory requirements of the Race Relations (Amendment) Act 2000.

The Health Commissions' critique of the NW London Hospital Trust, published this summer, is wide-ranging. Problems with management culture, staff turnover and lack of interpreters for non-English speaking women were just a few of the issues which came under the spotlight.

But importantly, given that the Trust serves Brent, a borough with some 5,000 asylum-seekers, the Commission also notes "a lack of clarity about the entitlement to maternity care for overseas visitors including women described as asylum seekers."

Although this was not given as a cause of death among the women who died
"……on at least two occasions lack of clarity resulted in women leaving an antenatal clinic without receiving care and treatment. … a female asylum seeker was told by the financial department that she would have to pay £2,300 to have her baby.

"The woman was in the advanced stages of pregnancy and said that she had no money and could not pay so would have her baby at home."

Of course asylum seekers still in the process of applying for or appealing on leave to remain are entitled and should not be charged in any case - and even failed asylum seekers or undocumented migrants should not be turned away if they cannot pay immediately, according to former Secretary of State for Health, John Hutton.

In a letter, seen by JCWI, Hutton stated "that the NHS is essentially a humanitarian service and no one in need of immediately necessary treatment will ever have that treatment refused or delayed because it is not clear whether charges are payable.

"…….. guidance to the NHS on the operation of the charging regime makes clear that, because of the particular risks associated with pregnancy, maternity services, which may include HIV treatment, where that is considered clinically appropriate, should always be treated as immediately necessary."

The DOH while asserting that maternity services remain chargeable has confirmed this position. A Department spokesperson said:

"Clearly it is not acceptable if someone in need of immediately necessary treatment, whether maternity or otherwise, has had that treatment delayed or withheld because of their chargeable status. That is entirely contrary to our guidance on this issue."

However, evidence that NHS confusion reigns, and that pregnant women may not even get as far as the midwife, has also come from Médecins du Monde UK.

In their evidence to the Health Select Committee MDM cite two cases of pregnant failed asylum seekers refused antenatal care by the Hospital Manager without seeing a midwife or a doctor.

One, suffering pre-term bleeding at seven months, was evidently in need of "immediately necessary treatment". She was not seen by a doctor and was told antenatal care was only available to her if she signed to guarantee she would pay for it. The Hospital Manager also reported her visit to the Home Office.

In each case, the midwives were uninformed of the fact that these pregnant women were turned away and were surprised to learn, upon the women arriving for delivery, that they were previously refused antenatal care.

The secondary care rules are still expected to be extended to cover primary care. At the moment primary care for "non-entitled" groups such as failed asylum seekers and undocumented migrants is at local GPs' discretion.

However, two years ago Migrant and Refugee Communities Forum were already reporting that entitled migrant women - refugees and asylum seekers - had problems realising their right to access GP care in Westminster, and Kensington and Chelsea.

Failure to provide their passports meant these women were sometimes being refused registration. Inability to secure their own interpreters resulted in them being refused appointments. The extension of the secondary care rules to primary care can only create further barriers to migrant women accessing maternity care.

The GP is generally the first port of call for any pregnant women. A woman who cannot access a family doctor as a result of immigration status may be unable to access a midwife and consequently may not be monitored for, or motivated to report, conditions which put her, or the unborn child, at risk.

As a result, high risk health conditions which may lead to maternal death, such as disposition to the convulsive condition eclampsia, will not be spotted unless an emergency arises. It is also unclear how access to abortion services may be affected.

JCWI is perplexed as to why rules to counter health tourism apply to failed asylum seekers or undocumented migrants who are not here for the principle purpose of accessing public health services for free. In any case the scale of the alleged abuse of the NHS by health tourists has never been demonstrated.

We also do not understand, given the risks to an unborn child -who can have no say in their whereabouts - why maternity care cannot be exempted from charges. But most puzzling of all remains the Department of Health's failure to initiate the race equality impact assessment of the new rules given the findings of Why Mothers Die and the Health Commission's findings on NW London Hospitals Trust.

A CRE spokesperson said: "We have written to the Department of Health asking them for evidence of the race equality impact assessment of the new policy, and are waiting for a response."

In the meantime the DOH has told JCWI that it does not believe it had to conduct an REIA of the secondary care rules because they have been in place since 1989, and the April 2004 measures only represented a closing of the loopholes.

"Should Ministers decide to change the current primary care rules, the Department of Health will work closely with representatives of the NHS as well as with key external stakeholders from national organisations including the Joint Council for the Welfare of Immigrants to develop the new policy further," the Department spokesperson promised.