Who is charged for healthcare in the UK?

In the UK, access to primary care and to emergency departments is free of charge to all. Anyone who lacks formal immigration status, however—in other words, is ‘undocumented’—can be made to pay for NHS secondary care, such as inpatient treatment.3–6 In England, hospitals are mandated to withhold treatment until bills are paid, for all but urgent and immediate care.6 There are exemptions for certain vulnerable groups including recognised victims of trafficking and refugees with right to remain. However, in contrast to many European countries, being under 18 is not in itself an exemption to being charged in the UK. There are an estimated 200 000 children in the UK who are ‘undocumented’,7 for reasons which include being born to undocumented parents, losing legal residency, having had their asylum application rejected, or being unrecognised victims of human trafficking. Unless they meet a specific exemption, all of these children are deemed ‘chargeable’ for NHS secondary care.8

The number of families subject to healthcare charging in the UK is likely to be increasing rapidly.9 Children and young people who are nationals of other European countries may have unwittingly lost legal residency in the UK as a result of Britain’s exit from the European Union.9 This particularly affects young people in state care and recent care-leavers, who are reliant on Local Authorities to apply for the EU Settlement Scheme on their behalf in order to maintain legal residency once leaving care. In early 2021, less than half of the potentially eligible children in the care system had had such applications for settled status made for them.9 Proposed UK legislation (The Nationality and Borders Bill) is likely to exclude additional people from regular immigration status by tightening conditions on refugees who travelled by ‘irregular’ routes and increasing requirements for stateless children born in the UK to obtain citizenship.10 The crisis in Afghanistan, compounded by the scarcity of approved routes to refuge in the UK, will likely drive the numbers of children and families in this vulnerable position up even further.11

What are the harms caused by healthcare charging?

From the RCPCH perspective, we find denying children and young people full access to healthcare deeply worrying: the UK is a signatory to the UN Convention on the Rights of the Child, which states that signatories ‘shall strive to ensure that no child is deprived of his or her right of access to healthcare services’. We are a professional body for paediatricians; one of our four core missions is: ‘To inform, influence and shape policy and practice so that UK health services provide high quality, safe and sustainable healthcare services for all children in all settings’.12 Healthcare charging conflicts with this vision because of overwhelming evidence that the policy harms children’s health, because it exacerbates societal inequalities, and because it negatively impacts on child health professionals, jeopardising their ability to provide the highest quality healthcare.1 2 13–20

Globally, it is known that child health outcomes are better in countries which offer universal access to healthcare,21 and evidence from three European studies suggests that offering universal healthcare—including to refugees and migrants—is more cost-effective than restrictive policies, due to factors including the increased costs of delayed treatment.22–24 In the UK, evidence of harm from healthcare charging is growing rapidly.13–15 Harm can result directly from hospitals refusing or delaying healthcare, for example, delaying a child’s cancer treatment due to uncertainty regarding immigration status.2 Harm can also arise from a family avoiding healthcare, due to fear of unaffordable bills or of immigration enforcement authorities.15 16

Deterrence from healthcare affects a wider group of patients than those actually targeted for charging, and limits opportunities for advocacy for exemptions. A devastating example of someone being too scared to access care despite being eligible for free treatment, was seen in April 2020 when an adult died at home of COVID-19 due to fears of charging and immigration control, despite the fact that treatment of COVID-19 is exempt from charging.17 Similarly, a mother and her baby had potentially avoidable health consequences after avoiding antenatal care due to fear of charging, despite being a victim of trafficking and therefore exempt.2 The dangers of spreading fear and distrust are one of the key reasons why we oppose healthcare charging for all patients, not just for children and young people. When parents and carers have distrust in the healthcare system, how can we expect them to bring their children into contact with it?

Charging for access to healthcare also risks worsening poverty and health inequalities, and detriments other child public health priorities. We know that child poverty is a contributor to poor physical and mental health, reduced employment opportunities, and social deprivation, and that families in these circumstances experience significant stigma. Many families who are subject to NHS charging are also subject to significant restrictions on accessing employment, housing and state benefits.18 Debt from healthcare costs can, therefore, exacerbate existing poverty, and can push previously coping families into destitution. Deterring families from healthcare also means opportunities are missed to identify and safeguard vulnerable children, including victims of trafficking and modern slavery. Charging policy is also exacerbating racial inequalities: patients from black and ethnic minority backgrounds are more likely to have their eligibility for free NHS care questioned, and more likely to be inappropriately charged.19

Not only are children affected by charging when they themselves are subjected to fees, but also indirectly through the impact these policies have on their families. If a child’s loved ones come to harm due to lack of access to healthcare, if their family becomes destitute due to charges or if their carers are deported—then children’s health and well-being may be affected, despite the charging itself not applying to the child.

Policies that introduce such NHS charges do not affect our patients alone—professionals in child health are also affected by the moral injury of denying care and the added pressures this dynamic introduces into working relationships with patients.20 Twelve per cent of the UK’s healthcare workforce are themselves migrants,25 and while they are unlikely to be charged directly, many face disproportionate costs to their families from immigration charges related to healthcare, and may have extended family and friends charged for care from the very service they work for.26

Why is it important that we speak up as paediatricians on healthcare charging?

The RCPCH makes it a core mission to advocate for child health,12 particularly recognising that many of our patients do not yet have the ability to speak up for themselves. Paediatricians are trained to keep the best interests of the child at the centre of their practice, and to consider it a safeguarding concern if someone is obstructing the health and well-being of a child: we have a duty to speak up even if it is the state itself obstructing access to healthcare.

We know that our professional voice can add weight to political arguments: for example, the RCPCH was recently part of a successful campaign to maintain free school meal provision in England in school holidays during the COVID-19 pandemic.27 Professional bodies globally have played important roles in a number of campaigns, for example, medical professionals have helped shift public opinion on off-shore migrant detention in Australia,28 American doctors have lobbied government to reduce harm from firearm injuries29; and UK Royal Colleges played a role in widening access to abortion in Northern Ireland.30

What is the RCPCH doing, and what change do we want?

At the RCPCH, we have written guidance for health professionals to provide them with the knowledge and tools to advocate for families impacted by charging,8 and host a tool where professionals can report on the impacts of charging on child health.31 We continue to support our members in advocating for the right of all children to access healthcare, and encourage other professional bodies to join us in our position against this legislation.

The UK healthcare charging regulations are incompatible with good paediatric care and with optimum public child health. The RCPCH is calling on the UK government to:

• Abolish the legislation that provides for NHS charging in all four nations of the UK.

• Ensure that patient data remain confidential within the NHS, is not shared with the Home Office, and cannot be used for immigration enforcement purposes.

• Stop any expansion of NHS charging and protect universal access to primary care and public health services.