At the MRN conference "Universal Access to Healthcare in the Age of Migration" Dr Boomla looked specifically at the practical implications of proposed changes within the NHS and how this will influence access to healthcare for specific communities.

1. How the new commissioning framework will affect eligibility and entitlement to NHS services by individuals from migrant communities Dr Kambiz Boomla Senior Lecturer Queen Mary University of London Chair, City & East London Local Medical Committee

2. Primary Care Entitlement and Eligibility - Refugees Definitions: Entitlement – services available as of right Eligibility – services discretionary upon decision of provider A refugee is a person who has applied for and has been granted asylum in the UK Refugees are entitled to receive all NHS services

3. Primary Care – Asylum seekers An asylum seeker is a person who has applied for asylum in the UK and is either awaiting a decision or appealing a negative decision Asylum seekers are entitled to receive all NHS services A failed asylum seeker is a person who has applied for asylum in the UK and their application and all levels of appeal have been rejected The DH’s position on failed asylum seekers has been ambiguous Health Service Circular 1999/018 states failed asylum seekrs should not be registered in primary care BUT that GP practices have discretion to accept applications as registered NHS patients HSC 1999/018 has been withdrawn, but not formally replaced

4. Overseas visitors Apart from asylum seekers and refugees, the courts have decided that entitlement to NHS services is defined the status of being “ordinarily resident in the UK” Ordinarily resident means a person is “lawfully living in the UK voluntarily and for a settled purpose as part of the regular order of his or her life for the time being. A person must have an identifiable purpose for residence here, and that purpose must have a sufficient degree of continuity to be properly described as settled.” It’s likely that those staying in the UK intending to stay in the UK for longer than 6 months would be regarded as ordinarily resident. Overseas visitor describes a person who is not ordinarily resident in the UK.

5. Primary Care – Eligibility for Overseas Visitors GPs do not have to accept anyone onto their lists for NHS treatment, even UK citizens, unless the patient is specifically assigned to them by the PCT. BUT they cannot use discriminatory criteria of: race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition in making that decision GPs can chose to accept an overseas visitor onto their list, but do not have to, as long as they do not discriminate on any of the above grounds The overseas visitor is thus eligible but not entitled to NHS primary care treatment If a GP accepts such a person as an NHS patient they cannot charge (with minor exceptions) for services If a GP accepts an overseas visitor as a private patient, the GP if free to charge

6. Emergency and immediately necessary treatment in general practice Practices have a contractual obligation to provide this free of charge to any patient in their practice area. New conditions Exacerbations of pre-existing conditions Practices choosing not to register visitors as NHS patients would need to have procedures in place to ensure that patients in need of this treatment can be identified and assessed by a healthcare professional

7. Should practices register visitors etc as NHS patients? Our LMC and PCT recommend that practices in general register all patients as NHS patients because Procedures to identify those needing emergency treatment would be difficult to implement Timely access to primary care may prevent serious illness and expensive hospital admissions Access to healthcare is a human right, and doctors denying such access, particularly to those who cannot afford private care, may be in conflict with their professional responsibilites But the decision is for the practice, provided they do so in a non-discriminatory fashion Option of registering patient as a temporary resident if resident for less than 24 hours to 3 months, or if longer than 3m then as a regular patient.

8. Identity checks Overseas visitors have no formal obligation to prove their identity or immigration status to register with a practice over and above those of UK residents Some asylum seekers will have an Application Registration Card (ARC) or other official documents to confirm their status Where practices have a policy of asking applicants for identification, then it should be for all patients, not just for those thought likely to be overseas visitors We advise practices to use their discretion and consider the individual circumstances of an overseas visitor who cannot provide documents that they would normally require for patients registration

9. Secondary (hospital) care Failed asylum seekers, overstayers of visas, and overseas visitors are generally not eligible for free hospital treatment However, immediately necessary treatment to save lives or prevent a condition from becoming life threatening should always be given Any course of treatment already underway at the time the asylum seeker’s claim (including appeals) is rejected remains free of charge until completion. Any new treatment is chargeable Certain services are exempt Treatment solely provided in A&E Treatment provided in a walk in centre Treatment of certain communicable diseases Family planning services Treatment of sexually transmitted diseases, except HIV, BUT HIV diagnostic tests and counselling are free of charge

10. Referring overseas visitors for secondary care It is not the responsibility of a GP to establish a person’s entitlement for free NHS secondary care treatment This is the responsibility of the NHS secondary care provider (hospital) Trusts will ask patients questions on admission or arrival in outpatients, and the process will be handled by an overseas visitor manager GPs must avoid making any judgements about the likelihood of an individual patient being charged for secondary care and should refer whenever clinically appropriate

11. The New Commissioning Framework – Will it make a difference? HSC 1999/018 has been withdrawn and not formally replaced In 2004 in England, the DH launched a consultation on overseas visitors to England, but no action was taken and no further guidance issued Risk that new guidance will force primary care to follow secondary care rules, removing eligibility of overseas visitors to free NHS primary care. This would have major public health implications, and potentially put Britain in breach of human rights obligations

12. Health & Social Care Bill PCTs currently funded according to formula based on census projections of population size, not on the basis of GP list size Consequence – areas with large numbers of under-enumerated populations are underfunded compared to areas where more of the resident population filled in their census forms Health and Social Care Bill proposes that NHS commissioning board will calculate practice level budgets and allocate these direct to the Clinical Commissioning Consortia Implication is that this is a shift from census projections to funding based on GP lists Incentive may therefore be to ensure all locally resident people are registered with a GP However if eligibility for NHS primary care is further restricted, then areas like east London will get reduced funding for their actual resident population, and this includes secondary care GP practice boundaries Currently GPs have practice areas Proposal is that practice boundaries to be abolished and patients can register with any GP. This could further skew funding formulae in unpredictable directions