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Select Committee on Health Written Evidence

Memorandum by the Global Health Advocacy Project (HI 39)

HEALTH INEQUALITIES

THE CONTRIBUTION OF THE NHS TO REDUCING HEALTH INEQUALITIES

The Committee will examine the extent to which the NHS can help to achieve a reduction in health inequalities, particularly through primary care and public health services. The inquiry will focus on:

— The extent to which the NHS can contribute to reducing health inequalities, given that many of the causes of inequalities relate to other policy areas eg taxation, employment, housing, education and local government;

— The distribution and quality of GP services and their influence on health inequalities, including how the Quality and Outcomes Framework and Practice-based Commissioning might be used to improve the quality and distribution of GP services to reduce health inequalities;

— The effectiveness of public health services at reducing inequalities by targeting key causes such as smoking and obesity, including whether some public health interventions may lead to increases in health inequalities; and which interventions are most cost-effective;

— Whether specific interventions designed to tackle health inequalities, such as Sure Start and Health Action Zones, have proved effective and cost-effective;

— The success of NHS organisations at co-ordinating activities with other organisations, for example local authorities, education and housing providers, to tackle inequalities; and what incentives can be provided to ensure these organisations improve care

— The effectiveness of the Department of Health in co-ordinating policy with other government departments, in order to meets its Public Service Agreement targets for reducing inequalities; and

— Whether the Government is likely to meet its Public Service Agreement targets in respect of health inequalities.

The extent to which the NHS can contribute to reducing health inequalities, given that many of the causes of inequalities relate to other policy areas eg taxation, employment, housing, education and local government;

1. The Department of Health must oppose proposals to charge vulnerable migrants, including failed asylum seekers, victims of trafficking and undocumented migrants, for primary care services. Introducing charges will effectively deny access to healthcare for affected individuals, with a resultant increase in health inequality. Migrants have a range of health needs, and should ideally register with a general practitioner when they arrive in the UK to ensure that they have access to primary care.

2. If the proposals are adopted, primary care regulations will be brought into line with those governing hospital care, and those not considered "lawfully residents" in the UK will longer be entitled to freely access most primary care services.

3. In 2004 a similar change was made to the regulations governing access to hospital care. One example of the consequences of the 2004 changes in regulation is as follows:

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4. The rationale behind these proposals is that they will save money and discourage "health tourism". However, the notion of large-scale health tourism remains unproven. In 2005, Minister for Public Health Melanie Johnson admitted that there is no evidence of such a trend. Furthermore, the Home Office has previously stated that migrants do not represent a burden to the NHS with "deliberate" health tourism present only at very low levels[275].

ECONOMICS

5. Minimal savings will result from the denial of primary care without advance payment. It is crucial that a full health and equality impact assessment is conducted prior to the introduction of any further barriers to accessing NHS treatment for vulnerable migrants.

6. Newham PCT is the only Trust to have carried out a Health Impact Assessment on the identification and charging of overseas visitors in primary care. The study found that "The cost benefits of implementing a suitable system must also be viewed in light of a study showing that, in a borough with a high migrant population, it was estimated that approximately 100 GP visits across the borough might be chargeable equating to perhaps £3,000 of income [per month]."[276]

7. Early intervention in a primary care setting is extremely cost-effective. The cost of a GP consultation for chronic asthma is £20, compared with £1488 for an Accident and Emergency consultation, intubation and an overnight stay in ITU for an acute severe exacerbation of asthma[277]. Currently, 86% of all healthcare needs are met cheaply in primary care[278].

8. Denying access to primary care will result in increased numbers of patients, with routine and chronic conditions, presenting acutely to emergency departments, requiring treatment deemed "immediate and necessary"[279]. It is unclear how Emergency Departments are expected to cope with this influx of patients or the additional financial burden that will be placed on their services.

9. Should the proposals be implemented, official guidance on discerning whom to charge will need to be provided. Additional staff will be required to shoulder this new administrative burden at additional cost to the NHS. The UK hosts a multi-racial society, and many patients will object to having their immigration status challenged on the basis of a "foreign-sounding" name. This has already occurred in some instances in secondary care[280].

10. Doctors should not be required to use denial of healthcare as a lever for immigration policy. To do so would be in breach of the professional and ethical duties of medical professionals, which include making patient care paramount and protecting public health[281]. The NHS was founded on fundamental principles that health care should be freely available to all irrespective of an individual's background.

11. Previous resolutions at their annual meetings of the British Medical Association have deplored "the planned withdrawal of rights to medical care from asylum seekers whose applications have been refused" [2004] and later asserted that it is "not appropriate for medical staff to act as proxy immigration officers in seeking to determine the immigration status of people presenting for care and treatment." [2005].

Whether the Government is likely to meet its Public Service Agreement targets in respect of health inequalities.

Life Expectancy and Infact Mortality

12. The current regulations applicable to secondary care state that all antenatal, birth and postnatal care is to be considered immediately necessary, and should be provided irrespective of ability to pay. This not mean that maternity care is free but instead that women should not be denied care if they cannot pay the charges. However, the current arrangement for levying charges has resulted in instances of vulnerable women being denied antenatal care[282].

13. In 2006, 86% of women having their first child made first contact with their GP, and this figure was higher amongst black and minority ethnic women. While policies promote direct access to midwives, the most common pathway into maternity care is through a GP appointment[283]. Excluding vulnerable migrants from free GP services is likely to prevent or delay access to maternity care. Late booking for maternity care is a major risk factor for maternal death[284] and is linked to infant mortality[285].

14. Vulnerable migrants are at particular risk of maternal deaths and infant mortality. Social disadvantage, living in poor communities and minority ethnic status are associated with significantly higher maternal mortality rates[286]. The CEMACH Report "Saving Mothers' Lives" found that "Black African women, including asylum seekers and newly arrived refugees have a mortality rate nearly six times higher than White women. To a lesser extent, Black Caribbean and Middle Eastern women also had a significantly higher mortality rate[287]." Infant mortality is closely associated with socio-economic status and babies born to the most socially disadvantaged group (NS-SEC Other) have infant mortality rates almost twice that of the population as a whole[288].

15. The CEMACH Report recommends that "All pregnant mothers from countries where women may experience poorer overall general health, and who have not previously had a full medical examination in the United Kingdom, should have a medical history taken and clinical assessment made of their overall health, including a cardio-vascular examination at booking, or as soon as possible thereafter. An appropriately trained doctor, who could be their usual GP, should perform this. Women from counties where genital mutilation, or cutting, is prevalent should be sensitively asked about this during their pregnancy and management plans for delivery agreed during the antenatal period."

16. The above evidence suggests that the Government is unlikely to meet its PSA Target in respect of health inequalities if the proposals to charge vulnerable migrants for primary care services are introduced. Vulnerable migrants are more likely to be living in poor communities, such as those Local Authorities included in the Spearhead Group, which contains 44% of the Black and Ethnic Minority population of England. Life expectancy is increasing for both men and women nationally, including the Spearhead areas. However, the increase in the Spearhead areas is slower, and so the gap continues to widen. The gap is widening more for men than women[289]. The negative impact the proposals will have on access to maternity services is likely to further increase the maternal mortality of vulnerable migrants, many of whom will live in Spearhead areas, serving to further exacerbate this gap in life expectancy.

Mental Health

17. Objective 1 of the Spending Review 2004 Public Service Agreement is to substantially reduce mortality rates by 2010, including those from suicide and undetermined injury by at least 20%[290]. Migrants from refugee generating countries that face war, upheaval and / or economic decline, who include refugees, migrant workers, and undocumented migrants, are known to be a particularly vulnerable population facing many barriers to accessing appropriate primary care[291]. These arise from communication problems, social,exclusion, cultural differences, poverty and poor accommodation[292].

18. Furthermore, asylum seekers whose asylum claim has failed or who do not have support from refugee organisations or family have also been noted to experience hardships accessing primary care services[293]. This has huge implications for this population's welfare. For example, many refugees and asylum seekers have been victims of rape, torture and numerous violent attacks or have witnessed these atrocities occur to family members or friends. Consequently, numerous mental health issues such as anxiety, depression, post-traumatic stress disorder and feelings of guilt and shame are more prevalent in this population and increased suicide rates[294].

19. GPs provide an essential gateway service to recognising these issues and referring this population to various multidisciplinary mental health services depending on their needs. Consequently, the proposed government plan to exclude certain migrant population groups from accessing free primary healthcare threatens to widen the health and life expectancy gap between the UK migrant population and the rest of the UK and may enhance suicide rates within this population.

The distribution and quality of GP services and their influence on health inequalities, including how the Quality and Outcomes Framework and Practice-based Commissioning might be used to improve the quality and distribution of GP services to reduce health inequalities;

20. The financial incentive provided by QOF may affect the internal motivation of doctors[295]. Full points are available for the majority of QOF targets with less that 100% coverage, and inevitably those who do not attend and are most difficult to follow up and achieve target with are the most vulnerable. Where only 90% coverage is needed, GPs are less inclined to follow up the most difficult to reach 10%, and doctors may be less likely to chase up and give adequate care to the most vulnerable patients.

21. The focus of QOF on individual diseases does not encourage practitioners to use a patient-centred approach. This is particularly harmful to those with multiple co-morbidities or mental health problems, both of which are more prevalent in lower socioeconomic groups. QOF should focus more on outcome measures, such as complications of diabetes rather than blood pressure, and a patient-centred approach should be encouraged. There is evidence to show that current outcome measures do not accurately reflect the effectiveness of clinical care[296].

The effectiveness of public health services at reducing inequalities by targeting key causes such as smoking and obesity, including whether some public health interventions may lead to increases in health inequalities; and which interventions are most cost-effective;

22. Public health interventions in schools have great potential to reach individuals at a young age and regardless of social status. The EPODE study[297] in France shows good results for community interventions aimed at decreasing obesity in childhood. This is an example that the UK Department of Health should be following.

The success of NHS organisations at co-ordinating activities with other organisations, for example local authorities, education and housing providers, to tackle inequalities; and what incentives can be provided to ensure these organisations improve care

Reduce Economic Inequality to reduce Health Inequality

23. Economic inequality is the strongest predictor of health inequality, and must thus be reduced. Economic inequality can be reduced through more redistributive taxing systems and more equal pay systems, with a higher minimum wage and higher pay for those employed by the state with the lowest wages. [Providing government loans to enable employees to buy out the companies that they work for is another means to reduce inequality, as where employees own companies, pay differentials between highest and lowest paid workers would tend to decrease. Employee buyouts could also be incentivised by offering tax breaks to companies that are owned by their employees[298].]

24. Poorer people are less able to afford their own vehicle and are therefore more dependent on public transport. In order to reduce inequality, the Department for Transport must ensure that services are made cheaper, more joined-up and more accessible. A health impact assessment in Edinburgh finds that:

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January 2008

274 Medact. Proposals to exclude overseas visitors from eligibility to free NHS Primary Medical Services: impact on vulnerable migrant groups. London, 2005. Available at: http://www.medact.org/content/refugees/Briefing%20V1%20agreed.pdf Back

275 Home Office. Enforcing the rules: a strategy to ensure and enforce compliance with our immigration rules. London: Home Office, 2007. Back

276 Hargreaves S, Friedland JS, Holmes A. The identification and charging of Overseas Visitors at the NHS Services in Newham: a Consultation. London. 2006. Available at: http://www.newhampct.nhs.uk/docs/publications/IHUEntitlementReport06.pdf Back

277 Health Care Commission. State of Healthcare. London, 2006. Back

278 Pereira Gray D. Dozen Facts about General Practice. London. Revised 2005. Back

279 Department of Health Statutory Instrument 2004 No. 614 (S1614). Available at: http://www.opsi.gov.uk/si/si2004/20040614.htm Back

280 Yates T, Crane R, Burnett A. Rights and the reality of healthcare charging in the United Kingdom. Medicine, Conflict and Survival 23(4): 297-304. Back

281 http://www.gmc-uk.org/guidance/good_medical_practice/duties_of_a_doctor.asp

HPA, Migrant Health. Infectious diseases in non-UK born populations in England, Wales and Northern Ireland. A baseline report-2006." Available at: http://www.hpa.org.uk/publications/2006/migrant_health/default.htm Back

282 Joint Committee on Human Rights, The treatment of asylum seekers: tenth report of session 2006-7, 2007. Back