A London teaching trust is working on proposals to deny free maternity care to ‘non-eligible’ women from overseas, by requiring all patients to prove they are entitled to use the NHS.
But the Royal College of Midwives has responded to the proposals with “concern”, warning that they were potentially “dangerous” and that midwifery staff should not be expected to act as “border guards”.
“We also have a duty to ensure we use our resources wisely”
The proposals have been revealed as part of a pilot scheme being devised by St George’s University Hospitals NHS Foundation Trust.
It said the government was also working on new rules to ensure charges for overseas patients were enforced, and that the Home Office was “very keen to formally support this pilot”.
The trust’s board meeting documents, for October, stated that if the pilot study was successful “the aim would be to roll it out across the hospital to safeguard all ‘front door’ access”. The board papers also said:
- The Cabinet Office and Department of Health are currently working on new national guidance that is “likely to advocate routine presentation of proof of identity and eligibility” for NHS care
- Legislation is due to incorporate charging for accident and emergency and ambulance services, which will mean that trusts will have to insist that this documentation is provided before care is given, unless it is an emergency/life or death situation
- St George’s has been “made aware that individuals are currently offering paid assistance to women in Nigeria to have their babies for free on the NHS” at St George’s because the trust is viewed as an “easy target”
The trust board papers said the cost of non-eligible overseas patients to the local health economy was £4.6m a year.
According to the proposals, current trust policy for assessing eligibility “is generally not being followed” and “system weaknesses” mean some relevant information is either not recorded or lost. At present, frontline staff in A&E and obstetrics are responsible for working out if a patient is eligible for treatment.
However, the papers said in many cases staff were “too embarrassed” to ask whether a patient was eligible, and there were “several categories for non-eligibility, which makes the legal framework very complicated”.
Clawing back money after treatment has been given can take many months and only leads to a small proportion of costs being recovered.
“This move could be dangerous because it could deter women from seeking care in a timely fashion”
Under the proposals, women will have to prove their right to use the NHS when their procedure is booked in. “At booking every patient will need to show a form of photo ID or proof of their right to remain (asylum status, visa, etc),” the board papers said. “Any patient who is unable to do this will be referred to the trust’s overseas patient team for specialist document screening, in liaison with the UK Border Agency and the Home Office.”
To avoid charges of discrimination, the trust said it would create a “blanket process for every woman referred or self-referred to St George’s for obstetric care”, the papers said. They added: “No one will be discriminated against… The intention is for this to become standard procedure.”
Because “there will always be exceptions and patients may need to have access to services for clinical, ethical or moral reasons”, the papers said the trust “would advocate that patients are always treated as individuals and that each case is assessed on its own merits”.
However, the trust claimed that discussions about the proposals with Wandsworth Clinical Commissioning Group have been “slow to get off the ground” due to reluctance on the CCG’s part to “fully engage” with the issue from St George’s perspective.
St George’s Hospital
A letter to the trust from Michael Lane, joint clinical lead and board member for Wandsworth CCG, said he supported the trust’s desire to protect itself financially.
However, he said: “I have a commissioner duty to ensure that your proposals don’t result in unwarranted delays, poorer clinical outcomes or serious incidents, that national targets, [for example] early booking rates, don’t suffer, and I know our public health colleagues will share my hope that health inequalities don’t increase.”
A spokesman for St George’s said: “This is a proposal and not a plan. Further work would need to be undertaken, including speaking to key stakeholders before we would be in a position to proceed with the pilot.
“Like many London trusts, we treat a high number of patients from overseas who are not eligible for NHS treatment,” he said. “All patients in need of emergency NHS care at St George’s are treated and prioritised accordingly, regardless of their eligibility.
“Our priority at all times is to provide care and treatment to patients requiring our services. However, we also have a duty to ensure we use our resources wisely,” said the spokesman.
“Guidelines state that hospitals should endeavour to check patients for their eligibility when accessing non-emergency NHS treatment,” he said. “We are not doing this effectively enough at present, and are looking at ways in which we can improve this.”
He added: “We will continue to treat patients presenting to St George’s, whilst also looking at ways of tightening up our existing processes for ineligible patients accessing non-emergency treatment.”
But Professor Cathy Warwick, RCM chief executive, stated that the move by the trust was “a concern”.
Professor Cathy Warwick
“I am sure no trust would deny care to women in labour or who are pregnant and arrive at a hospital needing urgent care related to their pregnancy,” she said. “To be clear, the law says, and government policy states, that trusts must offer care to women in labour, irrespective of their immigration status.
“On the wider level, midwives also have more than enough to do without checking women’s eligibility and determining their immigration status,” she said. “They are not border guards, they are healthcare professionals there to deliver clinical care to all women.
“This is not their job and never should be and we must assume that the trust will not require them to do this,” she said. “Their job is to care for the women who walk through the doors of their maternity unit and it is the responsibility of trusts to care for and treat these women.
“Most importantly this move could also be dangerous because it could deter women from seeking care in a timely fashion. This could potentially have a serious impact on the health of the mother and their baby and the outcome of the pregnancy,” added Professor Warwick.
She asked the trust to “clarify” its policy and to “give assurances that all pregnant women who need care will receive it, no matter what their immigration status”.
Trust board papers and information provided to HSJ