Eligibility of overseas visitors and people of uncertain residential status for NHS treatment
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《英国医生杂志》
1 Department of Paediatrics, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, 2 Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford OX1 1PT
Correspondence to: A J Pollard andrew.pollard@paediatrics.oxford.ac.uk
Current UK regulations deny free treatment for HIV to illegal immigrants and failed asylum seekers. Is this policy resulting in unjustifiable harm to infants who are born to infected mothers?
Introduction
Although fictional, this case reflects cases that have occurred recently. Do doctors who discover a pregnant woman is infected with HIV have a duty to provide antiretroviral treatment, without seeking to determine her right to reside in the United Kingdom, when intentionally denying therapy would allow as many as one in three babies to be born with HIV?
More generally, what are the rights to free NHS treatment of overseas visitors and people of indeterminate residential status? This is the subject of a current Department of Health consultation,1 which proposes further restricting access of "overseas visitors" to NHS care. We argue that, far from restricting care, we should provide access to free NHS care for overseas visitors and people of uncertain residential status.
Background considerations
Asylum seekers in the United Kingdom are eligible for NHS treatment only if they have made an application to remain in the country or have been detained by the immigration authorities (box 1).1 8 Those who have not made an application for asylum or have had an application refused are not eligible for NHS treatment. The exceptions to this rule are emergency care, treatment of sexually transmitted infections (excluding HIV), and other conditions that threaten public health (box 2).8
Box 1: Eligibility for full NHS treatment
Eligible
Anyone who has been living legally in the United Kingdom for 12 months
Permanent residents
Students in the United Kingdom for > 6 months
Refugees or asylum seekers who have made an application to remain in the United Kingdom
People detained by the immigration authorities
People from countries with a reciprocal agreement
Not eligible
Students on courses for < 6 months
Those who have not yet submitted an asylum or refugee application to the home office
Those who have had an asylum application turned down and exhausted the appeals process
Illegal immigrants
Current and proposed revised regulations to NHS care may deny pregnant women and their infants appropriate medical care.1 9 According to the minister for health John Hutton: "We must remember that the NHS is a national institution and not an international one... The aim of the proposals... is to ensure that the NHS is first and foremost for the benefit of residents of this country."
In 2003, amendments to the National Health Service (Charges to Overseas Visitors) Regulations 1989 were proposed with the aim of preventing free hospital care for failed asylum seekers and others with no legal right to be in the country.9 In the consultation on the revised regulations,9 the Department of Health states:
The Regulations... confer powers to levy charges and to pursue payment of them as far as is considered reasonable... But best practice is to ensure that overseas visitors are aware of the expectation to pay charges, and likely cost, before they start treatment, so they can consider alternatives like a return home, if they are well enough to travel.
Many illegal (undocumented) immigrants and failed asylum seekers will be unable to pay. Additionally, if insensitive discussions about payment for treatment result in inadequate antenatal care and the birth of an HIV infected infant, this creates an avoidable burden on healthcare services, wherever the woman finally resides.
Box 2: Care available to those who are ineligible to full NHS care
Emergency or immediately necessary treatment
Treatment of sexually transmitted diseases (except HIV)
Treatment of specified illness on public health grounds, such as notifiable diseases and those to which specific public health enactments apply
Services provided in an accident and emergency department
Family planning
Compulsory psychiatric treatment
Grounds for treatment
Would providing free treatment act as an incentive to visit the United Kingdom or immigrate illegally for the purposes of medical treatment? Most immigration is driven by economic considerations. But there may be some incentive to visit. The appropriate response to creating such an incentive is not to deny medical treatment to those who are in the United Kingdom. It is important to separate two issues that have been conflated in the Department of Health consultations: firstly, who receives free medical treatment while in the country and, secondly, who is let in or allowed to remain. If the concern is that providing free medical care will act as incentive to come to the United Kingdom, another approach is to police more tightly who enters and remove those with no legal entitlement to be here. This might also reduce the number of people requiring medical treatment who do not have entitlement.
It may be reasonable to deny entry into the United Kingdom if the sole purpose is to seek free medical care without adequate insurance. But that is another issue. The difficulty for the immigration authorities would be policing such a policy. For those without medical insurance, compulsory medical examination (including HIV testing) would raise serious ethical and moral difficulties. A proposal of free treatment for overseas visitors does not affect who is let into the United Kingdom or when someone is deported. Immigration authorities, not doctors, should be enforcing the immigration policy.
Proposal
Department of Health. Proposals to exclude overseas visitors from eligibility to free NHS primary medical services: a consultation. London: DoH, 2004. www.dh.gov.uk/assetRoot/04/08/22/67/04082267.pdf (accessed 19 Jul 2004).
United Nations High Commissioner for Refugees. Convention and protocol relating to the status of refugees. Geneva: UNHCR, 1996: www.unhcr.ch/cgi-bin/texis/vtx/ basics/%2BSwwBmeJAIS_wwww3wwwwwwwhFqA72ZR0gRfZNtF qtxw5oq5zFqtFEIfgIAFqA72ZR0gRfZNDzmxwwwwwww1FqtFEIfgI/opendoc.pdf (accessed 19 Jul 2004).
Heath T, Jeffries R, Lloyd A. Asylum statistics United Kingdom, 2002. www.homeoffice.gov.uk/rds/immigration1.html (accessed 19 Jul 2004).
Health Protection Agency. Renewing the focus, HIV and other sexually transmitted infections, in the United Kingdom in 2002: an update November 2003. London: HPA, 2003. www.hpa.org.uk/infections/topics_az/hiv_and_sti/publications/annual2003/annual2003.pdf.
Ioannidis JP, Abrams EJ, Ammann A, Bulterys M, Goedert JJ, Gray L, et al. Perinatal transmission of human immunodeficiency virus type 1 by pregnant women with RNA virus loads < 1000 copies/ml. J Infect Dis 2001;183: 539-45.
Blott M, deRuiter A, Hawkins D, Lyall H, Mercy D, Mitchla Z, et al. Guidelines for the management of HIV infection in pregnant women and the prevention of mother-to-child transmission. London: British HIV Association, 2001. www.bhiva.org/guidelines/2003/pregnacy/index.html (accessed 19 Jul 2004).
Medical Foundation for AIDS and Sexual Health. Recommended standards for NHS HIV services. London: Medical Foundation for AIDS and Sexual Health, 2002.
Department of Health and Refugee Council. Caring for dispersed asylum seekers: a resource pack. Leeds: DoH, 2003. www.dh.gov.uk/assetRoot/04/05/09/15/04050915.pdf (accessed 19 Jul 2004).
Department of Health. Proposed amendments to the National Health Service (Charges to Overseas Visitors) Regulations 1989: a consultation. London: DoH, 2003. www.dh.gov.uk/assetRoot/04/06/83/76/04068376.pdf (accessed 19 Jul 2004).
Rawls J. A theory of justice. Oxford: Oxford University Press, 1972.
Singer P. Practical ethics. Cambridge: Cambridge University Press, 1993.
Department of Health. The NHS trusts and primary care trusts (sexually transmitted diseases) directions 2000. London, DoH, 2000. www.dh.gov.uk/PublicationsAndStatistics/P ublications/PublicationsLegislation/PublicationsLegislatio nArticle/fs/en?CONTENT_ID=4083027&chk=eFwepg (accessed 19 Jul 2004).(Andrew J Pollard, senior )
Correspondence to: A J Pollard andrew.pollard@paediatrics.oxford.ac.uk
Current UK regulations deny free treatment for HIV to illegal immigrants and failed asylum seekers. Is this policy resulting in unjustifiable harm to infants who are born to infected mothers?
Introduction
Although fictional, this case reflects cases that have occurred recently. Do doctors who discover a pregnant woman is infected with HIV have a duty to provide antiretroviral treatment, without seeking to determine her right to reside in the United Kingdom, when intentionally denying therapy would allow as many as one in three babies to be born with HIV?
More generally, what are the rights to free NHS treatment of overseas visitors and people of indeterminate residential status? This is the subject of a current Department of Health consultation,1 which proposes further restricting access of "overseas visitors" to NHS care. We argue that, far from restricting care, we should provide access to free NHS care for overseas visitors and people of uncertain residential status.
Background considerations
Asylum seekers in the United Kingdom are eligible for NHS treatment only if they have made an application to remain in the country or have been detained by the immigration authorities (box 1).1 8 Those who have not made an application for asylum or have had an application refused are not eligible for NHS treatment. The exceptions to this rule are emergency care, treatment of sexually transmitted infections (excluding HIV), and other conditions that threaten public health (box 2).8
Box 1: Eligibility for full NHS treatment
Eligible
Anyone who has been living legally in the United Kingdom for 12 months
Permanent residents
Students in the United Kingdom for > 6 months
Refugees or asylum seekers who have made an application to remain in the United Kingdom
People detained by the immigration authorities
People from countries with a reciprocal agreement
Not eligible
Students on courses for < 6 months
Those who have not yet submitted an asylum or refugee application to the home office
Those who have had an asylum application turned down and exhausted the appeals process
Illegal immigrants
Current and proposed revised regulations to NHS care may deny pregnant women and their infants appropriate medical care.1 9 According to the minister for health John Hutton: "We must remember that the NHS is a national institution and not an international one... The aim of the proposals... is to ensure that the NHS is first and foremost for the benefit of residents of this country."
In 2003, amendments to the National Health Service (Charges to Overseas Visitors) Regulations 1989 were proposed with the aim of preventing free hospital care for failed asylum seekers and others with no legal right to be in the country.9 In the consultation on the revised regulations,9 the Department of Health states:
The Regulations... confer powers to levy charges and to pursue payment of them as far as is considered reasonable... But best practice is to ensure that overseas visitors are aware of the expectation to pay charges, and likely cost, before they start treatment, so they can consider alternatives like a return home, if they are well enough to travel.
Many illegal (undocumented) immigrants and failed asylum seekers will be unable to pay. Additionally, if insensitive discussions about payment for treatment result in inadequate antenatal care and the birth of an HIV infected infant, this creates an avoidable burden on healthcare services, wherever the woman finally resides.
Box 2: Care available to those who are ineligible to full NHS care
Emergency or immediately necessary treatment
Treatment of sexually transmitted diseases (except HIV)
Treatment of specified illness on public health grounds, such as notifiable diseases and those to which specific public health enactments apply
Services provided in an accident and emergency department
Family planning
Compulsory psychiatric treatment
Grounds for treatment
Would providing free treatment act as an incentive to visit the United Kingdom or immigrate illegally for the purposes of medical treatment? Most immigration is driven by economic considerations. But there may be some incentive to visit. The appropriate response to creating such an incentive is not to deny medical treatment to those who are in the United Kingdom. It is important to separate two issues that have been conflated in the Department of Health consultations: firstly, who receives free medical treatment while in the country and, secondly, who is let in or allowed to remain. If the concern is that providing free medical care will act as incentive to come to the United Kingdom, another approach is to police more tightly who enters and remove those with no legal entitlement to be here. This might also reduce the number of people requiring medical treatment who do not have entitlement.
It may be reasonable to deny entry into the United Kingdom if the sole purpose is to seek free medical care without adequate insurance. But that is another issue. The difficulty for the immigration authorities would be policing such a policy. For those without medical insurance, compulsory medical examination (including HIV testing) would raise serious ethical and moral difficulties. A proposal of free treatment for overseas visitors does not affect who is let into the United Kingdom or when someone is deported. Immigration authorities, not doctors, should be enforcing the immigration policy.
Proposal
Department of Health. Proposals to exclude overseas visitors from eligibility to free NHS primary medical services: a consultation. London: DoH, 2004. www.dh.gov.uk/assetRoot/04/08/22/67/04082267.pdf (accessed 19 Jul 2004).
United Nations High Commissioner for Refugees. Convention and protocol relating to the status of refugees. Geneva: UNHCR, 1996: www.unhcr.ch/cgi-bin/texis/vtx/ basics/%2BSwwBmeJAIS_wwww3wwwwwwwhFqA72ZR0gRfZNtF qtxw5oq5zFqtFEIfgIAFqA72ZR0gRfZNDzmxwwwwwww1FqtFEIfgI/opendoc.pdf (accessed 19 Jul 2004).
Heath T, Jeffries R, Lloyd A. Asylum statistics United Kingdom, 2002. www.homeoffice.gov.uk/rds/immigration1.html (accessed 19 Jul 2004).
Health Protection Agency. Renewing the focus, HIV and other sexually transmitted infections, in the United Kingdom in 2002: an update November 2003. London: HPA, 2003. www.hpa.org.uk/infections/topics_az/hiv_and_sti/publications/annual2003/annual2003.pdf.
Ioannidis JP, Abrams EJ, Ammann A, Bulterys M, Goedert JJ, Gray L, et al. Perinatal transmission of human immunodeficiency virus type 1 by pregnant women with RNA virus loads < 1000 copies/ml. J Infect Dis 2001;183: 539-45.
Blott M, deRuiter A, Hawkins D, Lyall H, Mercy D, Mitchla Z, et al. Guidelines for the management of HIV infection in pregnant women and the prevention of mother-to-child transmission. London: British HIV Association, 2001. www.bhiva.org/guidelines/2003/pregnacy/index.html (accessed 19 Jul 2004).
Medical Foundation for AIDS and Sexual Health. Recommended standards for NHS HIV services. London: Medical Foundation for AIDS and Sexual Health, 2002.
Department of Health and Refugee Council. Caring for dispersed asylum seekers: a resource pack. Leeds: DoH, 2003. www.dh.gov.uk/assetRoot/04/05/09/15/04050915.pdf (accessed 19 Jul 2004).
Department of Health. Proposed amendments to the National Health Service (Charges to Overseas Visitors) Regulations 1989: a consultation. London: DoH, 2003. www.dh.gov.uk/assetRoot/04/06/83/76/04068376.pdf (accessed 19 Jul 2004).
Rawls J. A theory of justice. Oxford: Oxford University Press, 1972.
Singer P. Practical ethics. Cambridge: Cambridge University Press, 1993.
Department of Health. The NHS trusts and primary care trusts (sexually transmitted diseases) directions 2000. London, DoH, 2000. www.dh.gov.uk/PublicationsAndStatistics/P ublications/PublicationsLegislation/PublicationsLegislatio nArticle/fs/en?CONTENT_ID=4083027&chk=eFwepg (accessed 19 Jul 2004).(Andrew J Pollard, senior )