Access to health care for asylum seekers

January 2001

The BMA has produced this guidance note in response to queries from doctors treating asylum seekers. (This particular briefing only addresses the rights of asylum seekers and not broader questions of the eligibility of overseas visitors to receive medical treatment in the UK. Information about the latter is available from the Department of Health web site here. The BMA has repeatedly expressed its concerns to government about the plight of asylum seekers. Such concerns are based both on humanitarian and public health arguments which support the timely provision of appropriate care to this vulnerable group of patients. (Go to the note on BMA views at the end of this briefing.)

The BMA is concerned about the uncertainty expressed by some health professionals as to whether and to what extent asylum seekers are entitled to free health care. Previous BMA guidance on this subject was published in 1997, following the 1996 Asylum and Immigration Act. Like this note, it emphasised their right to timely and appropriate medical care. Some rights of asylum seekers (although not the right to health care) were subsequently affected by the 1999 Asylum and Immigration Act. This guideline clarifies the current situation and also addresses the implications of the Human Rights Act 1998.

The BMA has published a general note on the implications of the Human Rights Act (HRA) for various aspects of medical care [Go to reference 1] including the right of access to medical treatment. The Act (HRA) brings into national law the majority of the rights and freedoms set out in the European Convention on Human Rights. As yet, it remains a matter for speculation how the Act will be applied although it is possible, for example, that withholding proper medical care from someone with a serious illness could be held to contravene Article 2 (right to life) or 3 (freedom from torture). Those rights are now actionable directly in the domestic courts and create an obligation for courts, and "public authorities" to interpret the provisions of all legislation in a way that is compatible with the Convention. The NHS, Trusts and health professionals working within the NHS are seen as "public authorities" and therefore need to be aware of the Act. Although many aspects of care remain unchanged, the HRA is likely to have a great impact on the public awareness of patients’ rights in relation to medical care.

The legal situation in summary
- All asylum seekers are entitled to free health care.

- All asylum seekers have the right to be registered with a doctor.

- Health professionals must not discriminate against asylum seekers or unfairly prioritise other patients in preference to them.

- Asylum seekers who do not receive benefits may still be entitled to free prescriptions (read more below).

Information about health care
The BMA recommends that on arrival in the UK asylum seekers should be provided with information in a language they understand about access to health care and other social services and how to register with a doctor. Those alleging torture need information about how to contact an experienced medical expert. Early referral in such cases can be crucial to the patient's asylum case as well as providing assessment for treatment. (See in useful addresses the note on the Medical Foundation for the Care of Victims of Torture.) In 1999, the Refugee Council launched a Health Directory which provides a comprehensive guide to health services. Some local health authorities in areas which have long accommodated large numbers of asylum seekers have also included details of local health services in "welcome packs" for asylum seekers and refugees.

Clearly, asylum seekers like all other patients need to be informed about any testing or screening proposed for them. The BMA has been concerned by some anecdotal reports of asylum seekers being HIV-tested without their prior knowledge or consent. The government currently encourages universal antenatal screening for HIV. This is generally offered by hospital based maternity services but in some areas GPs may be providing antenatal care and offering screening. Asylum seekers from countries of high HIV prevalence may obtain their first positive result from a routine antenatal HIV. Such possibilities should be anticipated and discussed in advance with the patient. Local treatment providers and public health teams should consider whether additional services and support are likely to be required in areas receiving large numbers of asylum seekers.

Right to health care
The Human Rights Act, in addition to the provisions mentioned previously guaranteeing the right to life and protection from torture, also prohibits unfair discrimination. This provision supports asylum seekers’ right to medical treatment without reference to their origin.

Refugees, anyone who has formally applied for asylum, and those with Exceptional Leave to Remain, are exempt from charges for medical treatment under the NHS. This is set out in Health Circular HC(82)15 paragraph 20, and updated in Statutory Instrument No 306, NHS (Charges to Overseas Visitors) Regulations 1989.

Registering with a General Practitioner
All asylum seekers have the right to be fully registered with a NHS doctor. The BMA has been concerned by reports that some practices only agree to register them as temporary patients or refuse to register people with very poor English. There is no obligation or expectation for doctors to check the immigration status of people registering to join their lists. Many GPs, however, feel under pressure by the programme of dispersal of asylum seekers. In some cases hundreds of asylum seekers have been moved into a surgery's catchment area without prior notification. Nevertheless, GPs must not discriminate against any particular group. Clearly this does not mean that a practice which is already over-subscribed and has closed its list has to accept new applicants. Where spare capacity exists, however, local inhabitants should not be given unfair precedence over newcomers. If they are unable to find a practice to accept them, asylum seekers are likely to rely on inappropriate use of emergency hospital services.

GPs can refuse to take an individual onto their lists but they must take into consideration the HRA's ban on discrimination (article 14). (Although there is some debate about the extent to which GPs, as non-employees of the NHS, are covered by the Act, its provisions such as that against unfair discrimination correspond to good practice to treat all patients equitably.) Health professionals must also be careful not to breach section 20 of the Race Relations Act by discriminating against asylum seekers (by refusing to provide them with health care services, for example, or by providing lower standards of care.) The BMA has consistently emphasised that it is unethical to refuse to accept particular patients solely because they may require expensive treatment (so-called 'uneconomic' patients).

Additional resources
Because of the upheavals, family separation, traumas and social difficulties faced by many asylum seekers, they often have complex health problems. Some have been imprisoned or tortured prior to immigration and many have lived in situations of poor health care provision in their own country. Recognising the additional support they often need, the BMA has argued for additional payments to be available for doctors offering an extended range of services to this group of patients. Health Authorities can approve additional payments, funded by local development schemes under the NHS (Primary Care Act) 1997, if an extended range of services is provided to asylum seekers. Nevertheless, this is dependent upon local resources and is not invariably forthcoming.

All patients should be able to expect that their personal health information will be kept confidential. Doctors express concern, however, about the requests they receive to disclose information about patients for planning, administrative or other purposes. They also feel that this contributes to the reluctance of some patients to allow their GP to have some important information, such as that concerning the patient's HIV status. Particular problems can arise in this respect for asylum seekers, especially those who need access to specific support services. It is clearly important that when they are dispersed around the country, asylum seekers with very specific health needs are not sent to areas where there are insufficient sources of help. Not only do they need services such as health care, housing and education but many are also particularly dependent upon assistance from voluntary support groups. They should be placed so as to be able to be in contact with the relevant voluntary sector infrastructure and with medical services for conditions which may be rare in the indigenous population but common in those coming from abroad. Patients need to know and agree, however, if some of their personal health information is needed by third party agencies for dispersal, health care planning and other purposes.

Many asylum seekers have a complicated medical history, information about which can be difficult to confirm. Tuberculosis and HIV are among the health problems prevalent in this group of patients who may not be included in community screening programmes and health promotion. Even establishing the immunisation status of children, for example, can prove difficult. Providing care for people who have experienced violence or persecution can be very demanding. They may be unable to discuss their health problems openly or be fearful of examination. Some cannot discuss their experiences even with family or friends and it can never be assumed that they are willing for relatives to be asked about their health background. Many focus on non-specific pain, avoiding discussion of details or of psychological problems. If they are willing to talk about what happened to them, the situation described can be disturbing for the health professional as well as for the patient. This is one of the reasons why the BMA emphasises the importance of referral to a specialised centre if torture is alleged. (Go to Useful addresses.)

Asylum seekers are entitled to the same high degree of confidentiality as other patients.[Go to reference 2] As made clear above, it cannot be assumed that patients would be willing to have their health discussed with their relatives. In some communities, however, patient expectations are that family members are included in consultations. It should be made clear to individuals that they can always see a doctor alone unless they want others present and that information will not be passed on to relatives without consent.

Finding an appropriate interpreter is often a problem. In some cases, other members of the patient's family or cultural group offer to interpret, causing confidentiality problems. These can be particularly acute if patients want to discuss sensitive information or need to access services such as family planning, abortion or HIV testing. Some UK health authorities, including most in London, have interpretation services, although paying for them can present problems as they are not necessarily funded by the authority. In Scotland, the concept of three-way telephone interpreting has been considered. The disadvantages are that it has to be booked and paid for in advance and the asylum seeker has to understand and adhere to the concept of an appointment at a specified time. In practice, doctors and patients often have to make do with patients’ friends or other volunteers to interpret.

Wherever possible, sensitivity should be exercised in selecting interpreters, with regard to factors such as gender, political or cultural background (e.g. avoiding asking a Serb to interpret for an ethnic Albanian). Sensitivity in choice of interpreter is also advised in cases where patients need to discuss very personal issues such as sexual behaviour or sexually-related conditions. It is essential that health services do not rely on embassies or official agencies of the patient's home country when the patient claims to have been persecuted or tortured there, since information may be collected which puts patients at risk (if they return) and may jeopardise the safety of their relatives.

It is worth noting that the Royal College of General practitioners has recommended that:

- There should be training for GPs on the nature, purpose and correct use of advocacy and interpreters;

- All GPs and their practice colleagues should undergo training in racism awareness which includes among other things the status of refugees in the UK. [Go to reference 3]

Referral for specialist services
In some countries, primary care is not well developed and some asylum seekers may expect to be referred to hospital for relatively minor complaints. Sensitivity and skill are required to introduce them to the way medicine is practised in the NHS.

GPs increasingly need to be able to recognise conditions which may be more common in asylum seekers’ countries of origin than in the UK, including tuberculosis (TB) and HIV. Increasingly, screening for conditions such as TB is carried out on entry to the UK and that information should be made available to GPs when patients are dispersed in order to avoid duplication. It is also important, however, that GPs remain vigilant for early symptoms of such conditions in undiagnosed patients who seek help for other routine health problems. They also need to be able to offer appropriate pre-test discussion and testing or know where patients can be referred for such tests. GPs with a large number of patients who are asylum seekers may find it helpful to be in contact with specialist patient support organisations for a range of conditions.

Some asylum seekers need specialist help because of the violence and trauma they have encountered. Identifying the sequelae of torture requires additional training and should be done by experienced health professionals. The principal UK centre for expert examination (including for the provision of medical reports to support asylum applications) and for treatment is the London-based Medical Foundation for the Care of Victims of Torture. (See useful addresses.) The government has made clear that asylum seekers who claim to have been tortured are entitled to be referred to such a specialist service for assessment and treatment. It has also said that the National Asylum Support Service may be able to meet the travel costs of asylum seekers who need to travel to the Medical Foundation for assessment. [4] (The BMA provides a separate guidance about examining victims of torture [5].)

Registering at hospitals
The current system for registration for hospital services already provides for determining free entitlement consisting of the following three questions:
  • Have you been living here for the last 12 months?
  • On what date did you arrive in the UK?
  • What is the basis of your stay in the UK?
    This process has not been expanded and no new checks are required. Where a hospital wishes to verify that the patient is an asylum seeker or refugee the patient should be able to produce one of the following:
    i. a travel document which shows that it was issued in the UK in accordance with the Convention on the Status of Refugees;
    ii. a letter from the Home Office stating that the patient is a refugee or has been granted refuge in the UK;
    iii. an acknowledgement letter from the Home Office confirming that the applicant has made an application for asylum.
    Hospitals may directly contact the Home Office (on 020 8686 0688) if a patient claims to be a refugee or to have made a formal application, but is unable to produce any of the documents mentioned above and wishes his or her status to be confirmed by the Home Office. When practicable the hospital should contact the Home Office in the patient's presence, giving only the patient's nationality, name and date of birth.

    Prescription charges
    Asylum seekers are entitled to free prescriptions under the same conditions as any other patient. They must be aged under 16, under 19 if in full-time education, over 60 or holding an exemption certificate on maternity or medical grounds. Details are in the leaflet “Are you entitled to help with health costs?[6] Unless asylum seekers are already entitled to free prescriptions under the existing categories or remain entitled to income support, they have to make a Low Income Scheme HC1 claim.

    Applicants will either receive an AG2 exemption certificate in order to receive free prescriptions, vouchers for sight tests and glasses, and hospital travel costs under the NHS or an AG3 which is an NHS Charges certificate for limited financial help. HC1 forms are freely available from the address below [7] and from any Benefits Agency office or NHS hospital. They can also be obtained from the Health Benefits Division, Sandyford House, Newcastle upon Tyne NE2 1DB. Tel: 0191 213 5000.

    Refugee agencies are concerned that:
    i) asylum seekers may be unaware that they might be entitled to free prescriptions;
    ii) form AG1 is some 16 pages long which some asylum seekers with limited English will find difficult to complete.
    Ideally, doctors should help patients understand whether or not they are entitled to free prescriptions, indicate the form that is required and from where it can be obtained. Patients need to know that they will have to present proof of their exempt status. Doctors who treat a large number of asylum seekers or other low income patients may wish to acquire a number of HC1 forms and distribute them directly at the surgery. Large order copies are available from The Stationery Office, Broadgate, Chadderton, Oldham, Greater Manchester OL9 OJA.

    If it becomes clear that the asylum seeker has limited English and may have difficulty in completing the HC1 form, doctors are requested to direct that patient to either:
  • The local Refugee Community Office or Citizens Advice Bureau or
  • The Refugee Advisers Support Unit on 020 7582 9927 who will try to put the patient in touch with a local community group for refugees.
    Some other useful addresses are given at the end of this guidance.

    BMA views
    Clearly, good health is dependent upon more than the provision of health care services but on other factors such as good nutrition, appropriate housing, transport and social support. Since the introduction of the 1999 Immigration and Asylum Act, concern has mounted about the health effects of the dispersal system and use of food vouchers instead of cash benefits. This was highlighted by the BMA in 2000 when it drew attention to the special nutritional needs of many asylum seekers and also called on government to withdraw the vouchers’ scheme which replaced monetary benefits for asylum seekers. In December 2000, research published by the King's Fund indicated that the imposed system of dispersal of asylum seekers and the introduction of food vouchers was damaging the health of refugees and asylum seekers. [8] The research drew attention to the fact that although they are often very resilient people, refugees and asylum seekers have high levels of physical and mental health problems. Living in poverty with very restricted freedom of movement can exacerbate these. The voucher scheme makes it difficult for families to budget. Some fail to get enough food to keep healthy.

    At its annual meeting in 2000 the BMA endorsed a resolution with respect to refugees and asylum seekers, stating that the Association:
    (i) deplores the creation by the Immigration Act 1999 of an underclass within the group, surviving on food vouchers and 70 % benefits;
    (ii) demands that the Government implements a more sufficient and compassionate approach, including a fully funded translation service;
    (iii) demands that the Department of Health monitors the health consequences of the Immigration Act 1999;
    (iv) rejects the current approach on the assessment of refugees and asylum seekers as inhumane and detrimental to health;
    (v) deplores the lack of co-ordination and planning in their health care and distribution to regions of the UK.”

    Useful addresses
    For further information the following addresses might be helpful:

    Medical Foundation for the Care of Victims of Torture (MFCVT)
    96-98 Grafton Road, London NW5 3EJ
    Tel: 020 7813 7777; Fax: 020 7813 0011
    Provides services for survivors of torture and other forms of organised violence. Centre staff carry out casework, counselling, advice regarding welfare rights, physical and mental health care, individual and group therapy, complementary therapy, family therapy and child and adolescent psychotherapy. They also give advice and help with the access to statutory health care. Foundation Staff run training sessions and workshops for professional groups working with refugees and survivors of torture and can discuss issues with health care workers.

    Family Tracing Unit of the Red Cross
    54 Ebury Street, London SW1W 0LU
    Contact via local branch of the Red Cross - go to the website here.

    Refugee Council
    3 Bondway, London SW8 1SJ
    Tel: 020 78203000
    Advice Line: 020 7582 9929 (Mon.-Fri. 10 am - 1 pm for specific advice), 020 7820 3085 (Mon.-Fri. 9 am - 5 pm for general enquiries)
    The Refugee Council runs a mixture of direct and indirect services for refugees and asylum seekers in the UK. The main services include the One-Stop Service at 240 Ferndale Road, Brixton, London SW9, which is open every day except for Wednesdays, for advice and day centre services.

    Joint Council for the Welfare of Immigrants
    115 Old Street, London EC1V 9JR
    Tel: 020 7251 8708
    Advice Line: 020 7251 8706 (Mon., Tues., Thurs. 10 am - 12.30 pm)
    Advice, information and representation for people with immigration or nationality problems.

    Language Line
    Swallow House, 11-29 Northdown Street, London N1 9BN
    Enquiries: 020 7520 1400 or 0800 793 3503
    A commercial telephone interpreting service across a wide range of languages. A number of Health Authorities and trusts have contracts with Language Line.

    Additional guidance
    'The Health of Refugees - A Guide for GPs', (1999) Levenson R & Coker N, King's Fund bookshop . Go to the King's Fund website here.

    'The Health of Refugee Children' (1999), The Royal College of Paediatrics and Child Health and the King's Fund, London. Available from the King's Fund bookshop . Go to the Royal College website here and to the King's Fund website here.
    This book covers a wide range of children's general health issues, including the importance of containing the child's consent, the introduction of child health surveillance, screening, immunisation and child accident prevention. It also stresses the importance of their often disregarded rights of medical confidentiality.

    'Asylum Applicants - Medical Reports: Guidelines for Examining Doctors' (1993)
    Joint guidelines from the British Medical Association and the Medical Foundation for the Care of Victims of Torture.

    'Guidelines for health workers providing care for Kosovan refugees' by Dr Angela Burnett is one of a number of guidelines available from the Department of Health's Kosovo Public Health Network, Room C202, London Regional Office, 40 Eastbourne Terrace, London W2 3QR. This guidance by Dr Burnett is also available from the Medical Foundation for the Care of Victims of Torture and provides much general advice as well as information specific to Kosovan refugees.

    'The Medical Profession and Human Rights: Handbook for a Changing Agenda', BMA (2001) has a chapter on asylum seekers and a chapter on rehabilitation services. Read more here.

    Requests for further information and all enquiries should be directed to:
    Medical Ethics Department
    British Medical Association
    BMA House, Tavistock Square, London WC1H 9JP
    Tel: 020 7383 6286; Fax: 020 7383 6233
    Email: [email protected]

    [1] 'The Impact of the Human Rights Act on Medical Decision Making'. Read more here.

    [2] The BMA has a general guidance note on confidentiality which addresses the exceptional circumstances in which confidentiality can be breached. Full text on the Ethics page of the BMA's web site. Read more here.

    [3] Royal College of General Practitioners, 'Breaking barriers - towards culturally competent general practice'. London, RCGP, 1997.

    [4] Hansard, vol 355, 145, col 44, 23/10/00.

    [5] 'Asylum Applicants - Medical Reports: Guidelines for Examining Doctors' (1993) Joint guidelines from the British Medical Association and the Medical Foundation for the Care of Victims of Torture. Read more here.

    [6] Free from the following address: Department of Health, PO Box 777, London SE1 6XH. Fax: 01623 724524.

    [7] Department of Health, PO Box 777, London SE1 6XH. Fax: 01623 724524.

    [8] ‘New report highlights negative health effects of UK asylum system', Lancet, vol 356, 23/12/00 p2168.

    � British Medical Association 2006