The National Health Service (NHS), founded in 1948, is the umbrella term for the publicly funded healthcare systems in place throughout the United Kingdom. The NHS is a unique system and so it understandably is one of Britain’s biggest pull factors for migrants and refugees. At first glance, the system appears to support refugees, migrants, and asylum seekers. However, a closer examination reveals that this is not true at all, and in reality refugees struggle to access the services provided by the NHS.
It is worth outlining before analysing refugees’ access to healthcare what services the NHS provides. This can be split into two groups: primary care and secondary care. Primary care services are the first point of contact in the healthcare system, including general practice, community pharmacy, dental, and optometry services. Secondary care services can be planned care, such as a cataract operation, or urgent and emergency care such as treatment for a fracture. Whilst people who are not ordinarily resident in the UK may be required to pay for their care, refugees and their dependents are listed on the government website as being exempt from this charge.
Yet the system is not as clear cut as this rule makes out, meaning that refugees are still cut off from healthcare access due to its price. The rules differ across Britain. For example, in England, primary care is free of charge. However, refused asylum-seekers or undocumented migrants are charged for secondary care. This is being enforced by a government regulation introduced in 2017, whereby all hospitals were legally required to check patient eligibility for free national health system (NHS) healthcare. Patients must now pay upfront before receiving treatment if they cannot prove their eligibility, unless it is ‘urgent’ or ‘immediately necessary’. In Wales, both primary and secondary healthcare are free-of-charge for overseas visitors, including undocumented migrants and asylum-seekers. Even here, secondary care charges ‘may occur’. In Northern Ireland, not all migrants are eligible for free GP primary care. For example, undocumented migrants are liable to charging for primary and secondary care, with the exception of Accident & Emergency (A&E) treatment or compulsory detention. It is worth noting that since 2015, refused asylum-seekers have had the same entitlements as other residents. Scotland has the most financially accessible system. Primary and secondary healthcare is free-of-charge for asylum seekers and refugees, and undocumented migrants or refused asylum seekers are not charged. Moreover, the Scottish refugee policy states that anyone who has made a formal application for asylum, whether pending or unsuccessful, is entitled to treatment in the same way as any UK national ordinarily resident in Scotland. Overall, the financial aspects of care in some parts of Britain may cut refugees off from treatment that is available to UK nationals.
It would be short-sighted to assume that the only barrier facing refugees accessing healthcare services is a financial one. Refugees are often subjected to wrongful exclusion from healthcare services. The Refugee Council have stated that the asylum support model creates uncertainty that leads to refused access to primary care such as GP registration. They are routinely refused interpreting by GPs, dentists, and even at hospitals. This creates a significant barrier as interpretation of medical results is integral to an understanding of health issues any individual faces. The British Journal of General Practice (BJGP) investigated this matter further and discovered that 13% of vulnerable migrants who attempted to register with a GP were incorrectly refused because of their immigration status.
Receiving secondary care presents a similar problem as refugees are often incorrectly refused secondary healthcare or are asked to pay upfront for assistance that is not urgent and immediately necessary. The Refugee Council states that this often happens when the administration and medical staff are not familiar with refugees’ rights and treat them as foreign visitors. One consequence of this is that pregnant refugees do not access antenatal care and eventually present themselves at the point of delivery.
Another issue that refugees face is a lack of awareness of what healthcare services are even available in the first place. Without a knowledge of what care they are entitled to, how are refugees expected to utilise these services? A few participants in the BJGP survey reported receiving information about the NHS on arrival to the UK. When this occurred, it appeared to enhance knowledge of how to access services. On the whole, however, the majority reported a lack of awareness of NHS structure and described confusion over how to navigate and negotiate access to health care, including uncertainty about how to arrange appointments. There was significant confusion regarding which service to turn to. Many participants did not know how to call an ambulance in an emergency, whereas others reported ringing the ambulance service to ‘get advice’. Hassan, for example, told the BJGP that ‘I don’t know … how to use an ambulance service to call them or, like, how to get ambulance.’ If refugees are not given adequate information on what services are available, they inevitably will struggle to use them.
The difficulty of navigating a complex system in a foreign language only makes it harder for refugees to access Britain’s healthcare services. Many of the participants in the BJGP survey struggled to complete the GP registration paperwork, and none reported being offered linguistic assistance by staff. This meant they were reliant on informal social contacts, which not every refugee will have access to.
The language barrier is a consistent problem in Britain’s healthcare services that extends beyond initial registration. Refugees have reported struggling to communicate their healthcare issues to staff as well as struggling to understand the outcome of any examination they receive. This issue is exacerbated by the lack of interpreters, meaning that refugees are reliant on family members and communicating with hand gestures. This barrier has resulted in incorrect treatment. An account given in the BJGP reveals the danger of the language barrier. Aisha reported that a visit to the dentist resulted in the wrong tooth being removed due to a miscommunication. This situation highlights the danger that refugees are put in when accessing healthcare services, as the language barrier can result in wrong treatment and has the potential to cause further harm to the patient.
A major problem is that the British healthcare service does not take into consideration the unique position refugees requiring healthcare are in compared to UK nationals. Many refugees have been traumatised by their past experiences, some even experienced abuse and torture at the hands of medical professionals in their home country. The British healthcare system is already inaccessible to refugees, and so this environment combined with refugees’ past experiences makes navigating healthcare treatment all the more difficult, as refugees may be unwilling to engage with complex and unfamiliar healthcare services.
The British Medical Association (BMA) are aware of the complexity of health issues that impact refugees, and have stated that common health challenges include chronic conditions, and mental health and specialist support needs. These challenges make refugees’ healthcare more complex than most UK nationals, and so existing systems are not designed to deal with this. Chronic conditions, such as diabetes and hypertension, pose a unique challenge to refugees, as they may have been poorly managed in the past. This is likely to be the result of long periods without access to regular care, either in their home countries or during their journey to the UK. These gaps in treatment means that some refugees have old injuries that have not healed properly, which can cause chronic pain or disability.
It is important not to assume that most migrants experience mental health problems. However the BMA have stated that refugees and asylum seekers can be at increased risk, particularly if they have experienced violence and trauma, including exploitation, torture or sexual and gender-based violence. Refugees with trauma may particularly struggle to engage with healthcare services, as they may be unable to discuss their health problems openly or be fearful of examination. They may also have difficulty trusting people in positions of authority, including doctors. These complexities mean that the British healthcare system is even harder for refugees to navigate, as it has not been designed to accommodate those with previous traumatic experiences.
To conclude, it is clear that the British healthcare system is set up in a way that makes it significantly harder for refugees to utilise it than UK nationals. Refugees are subjected to being refused treatment and being given wrong treatment. Moreover, they often have complex issues that both make it harder for them to use the healthcare system and the healthcare system has little experience dealing with.