Report into refugee and

migrant access to

health care in Hackney

Report based on interviews

with 54 interviews with

refuges and migrants into

the barriers they experience

in accessing health care.

Produced in partnership with Hackney Migrant Centre

January 2020

Contents Executive Summary ............................................................................................................................. 2

1. Introduction .................................................................................................................................... 3

1.1 What is a migrant? ..................................................................................................................... 3

1.2 Migrant health in Hackney ........................................................................................................ 4

2. Methodology .................................................................................................................................. 4

3. Disclaimer ...................................................................................................................................... 5

4. Acknowledgements ...................................................................................................................... 5

5. Findings ......................................................................................................................................... 5

5.1 GP registration ........................................................................................................................... 6

5.2 Secondary care charging ......................................................................................................... 7

5.2.1 Case study provided by Hackney Migrant Centre; Ms OAO ....................................... 9

5.3 Fear of accessing services ..................................................................................................... 10

5.4 Hostile environment ................................................................................................................. 11

6. Recommendations ..................................................................................................................... 12

7. Conclusion ................................................................................................................................... 13

8. References ...................................................................................................................................... 14

Executive Summary

The NHS was founded on the principle of providing a comprehensive service to all, free at

the point of access, based on clinical need, rather than individual’s ability to pay.

The institution of a Hostile Environment policy in 2012, designed to make staying in the UK

without Leave to Remain as difficult as possible, coupled with changes to the Immigration

Act, has, however, put these principles in jeopardy by making the healthcare system

confusing and hard to navigate for migrants. When language and other cultural barriers are

added to wider determinants of health such as poor housing, it is no wonder migrant health

is worse than average.

In the process of compiling this report, we spoke to 54 individuals accessing support at

Hackney Migrant Centre. Hackney has a hugely diverse population, with nearly 100,000

residents born outside the UK [4, 6]. We do not know how many migrants (documented and

undocumented) live in the borough, however being a marginalised community, it is fair to

assume the numbers are under reported. Our report was limited to only those accessing

support services, however, there are probably many more that are struggling to get support.

GP practices are the first point of access for health care services. Registration should be

straightforward and easy with no proof of address or identity required; however, the demand

for documents such as passports places a barrier that makes it difficult or impossible for

refugees and migrants to register. As a result, basic health is denied, minor problems go

untreated until they become serious, and individuals end up attending A&E to get medical

attention.

Secondary care charging is a huge issue. The charges are inconsistent and not transparent.

Fear of running up a large bill can be a serious deterrent to accessing for example, antenatal

care, which will have an impact not only on the woman but also on her unborn child.

Outstanding debts for secondary care also prevent individuals from regularising their

immigration status and getting on with their lives.

The Hostile Environment, in which doctors are tasked with becoming instruments of

immigration control, has also eroded trust amongst migrant and refugee communities. Many

of the individuals we spoke to talked about their fear of accessing services in case they were

charged or flagged by Home Office. This fear was greater than any anxiety about getting

treatment and meant that individuals were instead relying on home remedies and prayer.

The cost to the NHS in treating conditions at a late stage will undoubtedly be greater than

early treatment and preventative action.

This report looked at services and experiences in Hackney, but we know this is a national

issue. Stories like the ones in this report are unfortunately now not unusual in the UK. But it

should not be usual to have to show your passport when you or your children need to see a

doctor; it should not be the usual for expectant mothers to weigh up the risks of accessing a

prenatal check-up, for fear of the charges that may then stop her and her family from gaining

settled status within a new country.

1. Introduction The Right to Health is enshrined in Article 25 of The United Nations’ Universal Declaration of

Human Rights, which states;

‘(1) Everyone has the right to a standard of living adequate for the health and well-being of

himself and of his family, including food, clothing, housing and medical care and necessary

social services, and the right to security in the event of unemployment, sickness, disability,

widowhood, old age or other lack of livelihood in circumstances beyond his control.’ [1].

The National Health Service in the United Kingdom was founded in 1948, on a principle of

treating everyone in the country, regardless of origin, wealth or status [2].

Despite this, the UK’s record in ensuring the realisation of Article 25 has been criticised by

the United Nations Committee on Economic, Social and Cultural Rights, who in their 2016,

report stated;

“Access to health

55. The Committee is concerned that refugees, asylum seekers and refused asylum

seekers, as well as Roma, Gypsies and Travellers, continue to face discrimination in

accessing health-care services. The Committee notes that the Immigration Act 2014 has

further restricted access to health services by temporary migrants and undocumented

migrants (art. 12).” [3].

Nationally, there are huge differences in the wider determinants of health between migrant

and non-migrant populations, which impact their health and wellbeing. These include living

conditions, access to healthcare and social isolation [2]. In Hackney, there are over 100,000

residents born overseas, who will statistically, have higher morbidity and mortality rates than

those born within the UK [4].

We know that after a migrant’s arrival into the UK, their health will deteriorate over time [2].

The constantly shifting healthcare provider regulations, current political climate and language

and cultural barriers make it increasingly difficult for migrants to settle into a new country, not

to mention when faced with health and social care concerns and complications.

Whilst we know that migrant health is significantly worse than non-migrants, through this

report, Healthwatch Hackney set out to provide a more in depth understanding of whether

migrants in Hackney were accessing the health and social care services they need to live a

healthy life and the barriers they face in accessing health care.

It also looks at the services and organisations working in the health and social care sector

and those working with migrants, to identify just how largescale these barriers are, as well as

recommendations to ensure all people in Hackney are aware of their universal human rights

to healthcare and are receiving the care they need.

1.1 What is a migrant? The United Nations states that an ‘international migrant is someone who changes his or her

country of usual residence, irrespective of the reason for migration or legal status’. This can

be due to many reasons and can be classed as a general migrant (someone moving for

work, family or education) or a forced migrant. Forced migrants are ‘individuals who has

been forced to leave their country of origin due to war, conflict, persecution or natural

disaster’. These include asylum seekers (those seeking international protection) and

refugees (people who have been granted asylum and are protected by international law) [5].

In this report, the term migrant will encompass forced migrants, including both refugees and

asylum seekers.

1.2 Migrant health in Hackney Hackney is an extremely diverse and multicultural borough, with over one third of residents

born outside the UK [6]. It is the sixth most ethnically diverse borough in London and the 11th

most deprived local authority in England [6, 7].

A 2018 needs assessment conducted by the Hackney Council found that there are huge

differences in the determinants of heath between migrant and non-migrant populations in

Hackney, which results in increased morbidity and mortality rates in migrants, compared to

non-migrants.

The report also found that migrant’s health deteriorates quickly after arrival in the UK which

gives rise to poorer mental health outcomes. Migrants have higher rates of depression when

compared to non-migrants, however rates of depression and anxiety are twice as high for

refugees than they are for migrants [2, 4, 8]. This can be attributed to a multitude of factors,

including the current hostile environment and the many barriers in accessing healthcare [2],

which we will cover in this report.

2. Methodology To produce this report, Healthwatch Hackney worked in partnership with many refugee and

migrant organisations and stakeholders, our key partner being the Hackney Migrant Centre

(HMC). HMC provides advice and assistance to migrants on immigration, welfare and

healthcare. Working with other specialised local services and made up of predominately

dedicated volunteers, HMC work on individual cases as well as providing a welcoming drop-

in service for those seeking assistance and those at risk of isolation. In 2017/2018, the drop-

in centre saw over 850 different visitors from 88 different countries [9]. Healthwatch Hackney

worked with the centre, visiting the drop-in service once a week, over five weeks, to

interview community members who were waiting to access the service and to provide sign-

posting material relevant to them. Over five weeks, Healthwatch Hackney spoke to 54

individuals, who each gave interviews regarding their experiences, thoughts and concerns

with accessing health care services. These individuals were not all Hackney residents,

however have still been included in the report, as they were accessing services based in

Hackney.

Healthwatch Hackney also consulted with numerous organisations working with migrant

communities in health and social care. These involved individual and group meetings and

phone interviews.

Table 1.1 Migrant and health care services

Service

Hackney Migrant Centre

Doctors of the World

Dr Miriam Beeks, Lower Clapton GP

Hackney Public Health Scrutiny Committee

The North Hackney Welcome Project

DocsNotCops

Migrant Organise

MedAct

New Economics Foundation

3. Disclaimer The themes and experiences discussed in this report are the views and experiences of those

interviewed at the Hackney Migrant Centre only and are not reflective of all Hackney

residents, migrant communities and individuals.

4. Acknowledgements Healthwatch Hackney wish to acknowledge Daf Viney and the staff at the Hackney Migrant

Centre for the instrumental work carried out by the centre and for allowing Healthwatch

Hackney to visit the drop-in clinic to consult with community members. Thank you also, to all

the other stakeholders who contributed, assisted with and provided input into this report.

5. Findings From interviews with individuals visiting the Hackney Migrant Centre and consultation with

health and social care stakeholders, we found a multitude of multifactorial barriers facing

migrants when it comes to accessing health care.

Our findings were reflective of previous research carried out in Hackney, which has found

there is generally a lack of understanding and confusion from migrants about their rights and

entitlements when it comes to health care, which can lead to underuse of services [4].

Confusion surrounding the current political climate and the already hostile environment,

makes it near impossible for migrants to receive the quality of health care they require.

There is also variation and confusion between GP practice staff and service providers on

what is required in order for someone to receive quality health care.

Table of findings

Number of individuals (total n=54)

GP Registration

Asked for passport when registering with GP

11

Asked for proof of home office status when registering with GP

1

Required assistance from other charities or organisations, to register

4

Previously had documents, however no longer have any

8

Currently, do not have a GP 1

Secondary care charging

Charged for secondary care 3

Have outstanding debt from NHS 5

Fear of accessing services

Expressed fear of accessing services 3

Hostile environment

Discriminated against when accessing services

25

We have identified four main issues surrounding migrants access to health care in Hackney.

These include GP registration, secondary care charging, fear of accessing services and the

hostile environment.

5.1 GP registration Out of the 54 individuals interviewed at the Hackney Migrant Centre (HMC), 11 were asked

for their passport and one was asked for evidence of their Home Office status, when

attempting to register with a GP. Many were asked for proof of address and four individuals

stated that they were only able to register after assistance from other charities and

organisations.

Doctors of the World work with migrants to provide basic medical care, information and

practical support [10]. They believe that the biggest barriers to migrant’s access to health

care are the administrative barriers. GP registration has always been unclear and

inconsistent, varying between boroughs and GP practices [10]. Since the immigration policy

changes, many people face discrimination when registering and are often asked for

documents they are not required to provide, including passports and proof of immigration

status [2, 8, 10].

While Hackney has lower GP registration refusal rates compared to other boroughs [11], it is

still commonly occurring at many GPs, where there may be staff confusion or lack of training

over what is required for correct patient registration.

Dr Miriam Beeks from Lower Clapton Practice believes that people should be able to register

without an address or passport. If in doubt, Doctors can register patients temporarily, to

ensure they are being treated and their health care needs addressed [12].

Eight of the individuals spoken to at HMC were unable to register with a GP, as they no

longer had access to any of their documents, despite previously being registered with a GP

and accessing healthcare in the UK. This was due to various factors. Some of the individuals

were experiencing homelessness and had lost their documents or had them stolen. Others

were affected by the 2014 Immigration Act and no longer had identifiable documents on

hand. This Act put the onus on individuals to prove they were a resident in the UK before 1

January 1973, the date the 1971 Immigration Act came into force. However, a key clause

from 1999 legislation, which had provided longstanding Commonwealth residents with

protection from enforced removal, was deleted from the 2014 Immigration Act. One younger

individual, stated;

“…used to get services before, but had problems with documents…grew up in the UK”

(Male, 25-30 years old)

This individual was not able to provide proof of ID when attempting to register with his

doctor. Despite growing up and being educated in the UK, he did not have identification

which in turn meant he was not able to access his old GP or obtain any employment. He was

at HMC for assistance on how to organise proof of identification documents, which would

help him access health care, employment and housing; essentially, his basic human rights.

Another individual stated that while his previous GP did not ask for proof of passport, when

he and his family transferred to a practice closer to their home, despite having a GP

previously, they were all asked for passports, including his young children, for which he had

to show their birth certificates.

Many individuals reported travelling long distances to access their old GP, as they were

unable to register with a new one, closer to their new home. This was due to a number of

factors, including moving boroughs after initially registering with a GP and fearful to change

practices or change Doctor, lost or missing documents that were needed to register

elsewhere or having registered previously and now not able to register anywhere else due to

fear of information sharing. For some, travel time and cost of public transport was a barrier in

accessing health care, with one individual stating that she would go straight to A&E, as her

GP in Croydon was too far and too expensive to get to from her new accommodation in

Hackney. In this case, Doctors of the World were able to assist in re-registering this

individual and her family to a GP practice closer to her home in Hackney.

Many organisations, including Migrant Organise and Doctors of the World have found a

trend in unregistered patients going straight to A&E services when they need medical

attention, which results in greater cost to the NHS [2, 10, 13]. Migrant Organise believe that

when GP’s ask for documents they do not really need, a person’s access to healthcare can

stop there [2, 8, 14], with patients bypassing primary health care and going to A&E when

their condition has deteriorated. In some cases, easily treatable or preventable conditions

are made much worse as they are treated much later than they would have been, had the

person gone to see a GP or accessed planned care [10].

5.2 Secondary care charging Since the new regulations came into action in 2017, both the Hackney Migrant Centre and

Doctors of the World reported a significantly high number of cases of secondary care

charging. This includes treatments and surgeries carried out by hospitals [9, 11, 13, 15]. If

not considered urgent or emergency treatment, the patient is charged upfront, prior to

treatment, however if urgent treatment is required, the patient is treated and then charged.

Doctors of the World reported that under government policy, charges facing migrants

accessing secondary care were 150% in excess of standard NHS charges, with costs for

treatments varying within and between hospitals and no set procedure for charging and no

clear breakdown of individual costs [11, 13]. This presents a huge barrier for people already

facing disparity and who do not have access to money to pay beforehand, who are deterred

by the debt which they know will soon follow. It also identifies the income opportunity that the

Department of Health are taking advantage of.

Hackney Scrutiny Committee has had secondary care charging on their agenda since

November 2018. Homerton University Hospital, as do all hospitals, has an obligation to

comply with the Government’s regulations on charging, however there is no consistency of

charging, nor guidelines for patients and no transparency within and between the hospitals

[16, 17]. Maternity Action highlights that since the charging was introduced in 2004 and

changes to immigration legislation in both 2014 and 2017, there has been no national

investigation into how the policy works in practice [18, 19]. Doctors of the World reported that

in some instances, if a patient owes £500 or more after 2 months of initial charges, these

debts are reported to the Home Office, which places patient’s immigration status at risk and

establishes the hospital and health care system as a ‘policing tool’ and therefore a barrier

and obstacle for accessing health care [11, 13].

Requests by Healthwatch Hackney for meetings and feedback from Homerton Hospital were

not responded to, however the Hackney Scrutiny Committee reported that despite 51

migrants being charged at Homerton in 2018, if a migrant has a repayment plan in place with

an NHS provider, their details are not passed on to Home Office [16, 17]. Migrants Organise

believe that the Hospital Trusts are under an extreme amount of pressure from the NHS to

comply with secondary care charging, especially if some hospitals are more ‘lenient’ than

others [2, 8, 14].

Out of the 54 individuals interviewed at HMC, there were three cases of secondary care

charging, all of which were for maternity services. These charges are hugely inconsistent,

ranging from £1,000 to £6,000 [15]. Being a new parent is overwhelming enough, however

being a migrant new parent in a new country can be hugely isolating and daunting. Add to

this, receiving an invoice for the birth of your child, with threats of Home Office reporting and

debt collectors, and the stress is unimaginable. Unfortunately, this is the case for many

migrants, who have received and continue to receive secondary care charges.

“…holds it against me, like a crime”

(Female, 41-50 years old)

The individual quoted above travelled for over four hours and slept at a train station in order

to be seen by HMC. She was after assistance with the maternity charges she received five

years ago when she gave birth to her first child. She has a payment plan in place, however

still owes £1,000. This counts against her and her young family’s immigration record, making

it impossible for them to further their visa and settlement process, until the debt is paid.

Interestingly since the birth of her first child five years ago, she has since had another child,

at a different hospital, for which she did not receive any invoices, charges or debts. There

were no changes to her immigration status between the births.

On speaking to a specialist volunteer at HMC, who works with vulnerable migrants to help

overturn demands for payment, it was reported that despite the 2017 regulations leading to

an increase in charging cases, there is still no consistency or clarity for patients. It is near

impossible to receive individual case-specific information on what makes up the charges and

the disparity between debts varies for each case. The case worker highlighted the renewed

efforts to chase up unpaid charges, after Heath Secretary Matt Hancock announced earlier

in 2019, the £1 million to be spent on recruiting ‘cost recovering experts’, to chase up debts.

This has resulted in renewed invoices, debt collectors working with hospitals and a further

push into the ‘hostile environment’ which exists within our health care services.

One individual we spoke to at HMC was pregnant with her third child, her first to be born in

the UK. Her GP mentioned she would receive an invoice after the birth, because of her

immigration status, however was not able to provide insight into how much or when she

would be charged. When she went to hospital check-ups and appointments, there was no

mention of any costs and she is afraid of what will await her after her baby is born. At her

most recent appointment, the staff told her there were potential complications with the

placement of the baby, however did not provide any other information or book any extra

appointments. When asked why she did not ask for more check-ups between that one and

the next one, she stated;

“when you have no immigration status, you are happy for any appointment”

“how do I know my baby is safe?”

(Female, 25-30 years old)

Despite the worries of a risky pregnancy and a need and desire for more regular check-ups

and monitoring, she spoke of being grateful for what she is given, not wanting to ask for

extra and a fear of the expenses and costs which could accumulate if she insisted for more

regular checks. Her worry of the future charges which may or may not appear post birth, as

well as the stress of having a new baby, together with two young children in a new country,

are unfortunately a scenario Maternity Action UK know all too well.

5.2.1 Case study provided by Hackney Migrant Centre; Ms OAO

Ms OAO was charged around £15,000 for treatments for the births of her two children, for

which she was not made aware of prior to treatment. OAO has remained unclear about

when and what treatments were charged for, as she does not have an itemised bill.

Shortly after birth, letters chasing payment were issued and the threat of debt retrieval via

court orders were included in these. OAO was vulnerable after birth, suffering from post-

partum mental health issues that were only exacerbated by such harassment.

OAO was extremely distressed and anxious due to her precarious immigration

circumstances, as well as looking after two small children, under the punitive conditions of

No Recourse to Public Funds. A lengthy back and forth took place between debt

management teams within the Trust, and her attending paediatric doctor, who explained

multiple times that OAO was destitute, suffering from mental distress exacerbated by these

charges (and the subsequent impact they may have on her immigration claim) and had no

financial means to make any meaningful repayments.

OAO has stated multiple times that this treatment has greatly deterred her from seeking any

further treatment from the NHS – something which is practically unavoidable having two

small children, potentially putting their long-term health at risk.

In their scoping study conducted in 2017, Maternity Action reported that secondary care

charging directly impacts on the health and health inequalities of the most excluded groups

of people, vulnerable pregnant women, both undocumented migrants and those with

pending immigration status [18]. For many, these fears are enough to prevent them from

accessing prenatal health care in the first place. For those who are accessing care, there

were still negative health implications; anxiety of oncoming bills and a fear of being reported,

“I heard you had to show passport to see Doctors, so I wouldn’t go. If I’m sick, I pray or go to

Church.”

(Female, 61-65 years old)

could potentially impact the unborn child, resulting in greater health problems at birth and

infancy [18-21].

5.3 Fear of accessing services Since the 2017 legislation changes, Doctors of the World have reported an increase in

patients who have a fear of accessing services [11]. The relationship between healthcare

and immigration status is now clearly established and known throughout migrant

communities, and is a major deterrent for accessing health services. For many, the fear of

being reported to Home Office is very real and vastly outweighs receiving quality health care.

All Hospitals currently have to comply with the Government’s regulations to a). share

information to Home Office regarding overseas patients who have outstanding debts with the

NHS, and b). Share information on patients to local CCGs [16, 17]. But the impact of these

policies on migrants’ health, both physical and mental has yet to be fully investigated or

understood.

Many of the individuals contacted at HMC expressed concern about the effects of accessing

health services, however three individuals stated they have a fear of accessing services in

case they were charged or flagged by Home Office.

This individual reported not accessing a GP or any health service, despite needing care. She

has been living in the UK for 18 years and previously accessed services, however was wary

about her GP and the role they have in immigration and reporting. She did not want to be

flagged by Home Office. The risk of getting reported was, for her, worse than being unwell.

Several individuals spoke of home remedies, religion and waiting for the illness to pass,

when asked what they would do if they were ill and required health services.

One patient reported that despite living in Hackney for over 30 years, she was scared she

was going to be sent ‘back home’. She commented on how she was always stressed and

she felt helpless and afraid for her future. Her passport and personal details were currently

with Home Office, however she was still afraid to seek medical help at health services, as

she did not want the Doctors to pass on information that could further compromise her

immigration status.

“nothing I can do, just have to wait… struggling”

(Female, 51-60 years old)

Data from Migrant Organise shows that 80% of migrants seen by the organisation have

mental ill health [8, 14]. The impact of a health care policy which generates fear in the most

vulnerable members of society, places them at an increased risk of physical and mental

health ill health and further isolates individuals from accessing and receiving care they are

entitled to [22].

5.4 Hostile environment 25 of the 54 individuals spoken to at HMC believe that they were discriminated against in

some way, when it came to accessing health and social care services. The fear of accessing

services due to potential reporting to Home Office, secondary care charging and the

implications of unpaid debts on immigration status, are a result of the hostile environment

the Government and the NHS has created, which links Government policies to healthcare

and directly effects the most vulnerable and destitute members of society; those that need

help the most.

Instead of creating a welcoming and inclusive environment, practices are acting as a barrier

for accessing healthcare, meaning that unless an individual goes to a charity organisation

(such as Doctors of the World, Migrant Organise), healthcare can stop there. Whilst many

GP practices and hospitals have since removed hostile environment posters that were

distributed after the change in immigration laws, speaking to the individuals at HMC proved

that the lack of visual posters does nothing to rectify the hostile and isolating environment

that continues to exist in healthcare services today.

One patient, though not charged with secondary care costs at the time of interview,

presented at HMC with a threatening hospital letter asking to prove he was entitled to free

care or else he would be fined and his information would be passed on ‘for the purpose of

determining your immigration status’. He was given 14 days from the letter being sent to

when the hospital deadline was, to provide documents as proof. This particular individual

was previously entitled to care, however at the time of his urgent treatment, his HC1 form,

giving him free access to chargeable NHS services such as prescriptions and dentistry, had

just expired. Without providing any methods of support or assistant the letter had caused him

great stress and despair. Not having the documents to prove his entitlement, he was facing

the very real possibility that the hospital would pass on his immigration details to Home

Office.

Whereas in the past, a Doctor was one of the most trusted and respected societal figures,

many individuals reported that there was a lack of trust amongst their communities of all

health professionals, with some experiencing discrimination and hostility when they were

able to access health care services.

“Doctor told me I was costing the NHS and asked, ‘when did you come to the country?’”

(Female, 61-65 years old)

This individual spoke of her ‘nasty’ experience with her new GP, one that she said she would

not be going back to. She was assisted by a charity organisation to register with the practice,

as she was living in a shelter and did not have the documents required. Her negative

experience left her shaken and left her resolute that she would not be accessing other

practices, when she believed she would just be treated the same elsewhere.

A lack of translation services at GPs is another barrier which further discriminates and

isolates those seeking health care. Migrant Organise states that not only do GP practices

ask for documents they don’t need; they often fail to provide or promote adequate translation

services which can assist migrants in understand their rights and the situation [8, 14]. A

review of GP websites, undertaken by Healthwatch Hackney, also brought to light the lack of

translation services available for community members wanting to access GP information.

6. Recommendations

The following recommendations are based on the findings highlighted in this report.

Healthwatch have a duty to influence the commissioning and delivery of services, therefore

the recommendations are at a governance level and are for City and Hackney Clinical

Commissioning Group, Homerton Hospital NHS Trust and City and Hackney GP

confederation, as well as individual GP practices.

Hackney Migrants Health Needs Assessment [4], made a clear recommendation to provide

clear, accurate and up to date guidance on migrant’s entitlements regarding health and

social care. A year later it is clear that this recommendation has not been implemented and

that more work needs to be done to ensure this recommendation is met in Hackney.

Another key recommendation to come from the 2018 report, and which was a recurring issue

found in our consultation with community, was for clear advice and guidelines to be

established and provided for those accessing maternity care as well as all who may be at

risk of secondary care charging.

The potential data sharing between the NHS and Home Office was and still is, a huge

deterrent for people accessing services. Clear and accurate information for patients, as well

as increasing the awareness amongst service providers was a recommendation in the 2018

report [4] which is still valid more than a year later.

1. Promote safe surgeries

Doctors of the World run the Safe Surgeries program, which supports GP practices to offer inclusive services for all [23]. They provide free advice, training and resources and is an established membership of a network of GPs with good practice. Currently, at time of writing, there is only one registered Safe Surgery in all of Hackney. It is important that there is engagement and buy-in from the CCG and the GP Confederation, who have the authority to promote and encourage the uptake of Safe Surgeries for GP practices within the borough.

2. Provide clear information at hospitals for people turned away

Hospitals have a duty of care for all patients. For all people who may be at risk of secondary care charging, clear and concise information should be provided to them by the Hospital Trusts, in a form that is understood by all, whether it be supported by translation services, in person or over the phone. This information should detail; a). What an individual’s treatment options are, whether it be within the hospital or alternate options.

b). What, if any, the charges will be and a breakdown of the costs. c). External services and support they can access for more assistance and ongoing support. d). A contact within the hospital that can assist them with their treatment and case. e). Clear information on the hospital’s duty to report to Home Office.

3. Translation services at all GPs

It should be mandatory that all GP practices provide free translation services to any patient who requires it. Translation services should be provided at initial communication with reception and registration and the services should be made visible and available to all patients. The 2018 Hackney Migrants Needs Assessment also made recommendations for there to be more visibility of translation services in all GP practices [4].

4. GPs should register people without passports or proof of address

All GP practices should issue a statement and display information within their clinic, highlighting that passports and proof of address documents are not required to register at the practice. This will attempt to rebuilt trust and respect between GP practices and the migrant community and attempt to repair the damage that the hostile environment has created. This is not a new idea however; in the Hackney Migrant Health Needs Assessment [4], published in February 2018, one of the key recommendations was to provide guidance to GPs within the borough on accepting patients without documentation. This ongoing recommendation needs to be addressed immediately as it is evidently still a huge issue and is instrumental in improving the health of migrants in Hackney.

5. Acknowledge the influence of doctors

Doctors are highly regarded and exercise a large amount of weight with the Government and the NHS. Doctors have a moral duty to speak out on the treatment of migrants and their barriers to accessing health care. Despite being eligible for free healthcare, certain groups are not identified as being able to access care. Doctors have a role in this and can use their influence to ensure all those entitled to care are able to access it.

We have sought a response to our recommendations from City and Hackney CCG,

Homerton University Hospital Trust and City and Hackney GP confederation.

In November 2019 CCG issued a letter promoting a collaboration with Doctors of The World

Safe Surgeries program to all City and Hackney GP practices. The letter also highlights the

importance of patient registration without passport of proof of address. These steps directly

influence Recommendations 1 and 4. Prior to this, from 2015 to 2019 the CCG funded local

migrant groups to help migrants understand and make appropriate use of NHS Services.

This sought to helped local practices be aware of the barriers migrants face when accessing

primary care.

7. Conclusion This report identifies key issues affecting migrants access to health services within the

London Borough of Hackney. Through interviews with community members accessing the

Hackney Migrant Centre, as well as consultations with those working in the sector, several

themes were identified as barriers and issues which impacting the health of the migrant

community. The inability to register with a GP, secondary care charging and the fear of

accessing services within the current hostile environment are recurring themes that surround

migrants and impact their access to health care.

Through this report, Healthwatch Hackney have made recommendations for both the Clinical

Commissioning Group and GP services within Hackney, which when implemented, will make

accessing health services easier for migrants, which will in turn, improve their health and

their quality of life.

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