A healthy approach to asylum that will help us all

The Health Department has widened the net of provision for asylum seekers, opening up access to primary care for those whose legal status here is complicated or whose applications have failed.

The humanitarian benefits of this move are obvious, and its announcement has been timed to coincide with the start of Refugee Week 2015.

However, perhaps the most interesting aspect of this reform is that it is a money saver.

Previously some people in legal purgatory – such as those appealing rejected asylum applications, processes that can take years – were not entitled to free healthcare in Northern Ireland, pending some exceptions.

The starting point for free health provision locally is the Ordinarily Resident test. The spirit of the idea of ordinary residence is simply understood but a strict legal characterisation has proved more difficult. We won’t dwell on the intricacies here.

Those who are not ordinarily resident could not access free Health and Social Care barring three categories of exemptions – different types of people (e.g. cross-border workers, members of the armed forces), certain specific services (such as A&E), and also nationals from a particular list of nations with which we have a reciprocal agreement.

The announced changes amounting to an extension of the first two categories – including extending the “people” category to include everyone who has made an asylum application.

More care, better value

In general the expanded services will cost less than the previous model because prevention or early treatment are both much cheaper than last-minute care.

Lobbying from the Red Cross, Law Centre NI and the Northern Ireland Community of Refugees and Asylum Seekers brought about these changes – and a June 2013 report from the Law Centre lays out the staggering gulf in costs across healthcare, with a list of some average costs to the NHS of different services:

• An appointment with a GP - £25
• Providing one prescription – £12.87
• A visit to A&E - £83
• Hospital bed per day - £225
• An ambulance journey to A&E - £300
• Intensive Care bed per day - £1,500

Norma Nyamambi is an asylum seeker from Zimbabwe. Once her initial application was refused, pending appeal, under the previous guidlelines she lost access to her local GP.

However, Norma suffers from asthma, and this meant that eventually she was left without an inhaler, nebuliser and other medicines.

Instead of being able to manage her own condition, it was left to deteriorate. The previous model only entitled her to treatment via A&E – i.e. at a point close to catastrophe – and in recent years she visited hospital on a number of occasions.

In one case she required a five-day stay in intensive care.

Norma said: “I was born with asthma and so have always lived with an inhaler. When my application was refused I lost my doctor and so I had to go to the emergency room every time I was in trouble, rather than being able to look after myself.

“On one occasion in the Mater Hospital it got serious, my breathing was very, very short. It was so bad that the medical staff thought I might die.”

Speaking at the announcement of these changes in legislation, local Operations Director of the Red Cross, Sharon Sinclair, said: “[Previously] It was neither humane or any good value for money. There were times when there was not an excess of logic in play.”

Healthier regulations

Situations like the above have obvious problems for the health of the individuals concerned.

However, the public health risks can go further – disallowing people from accessing GP services, and withholding vaccinations that are standard amongst the population here, opens up the risk to communicable diseases that are otherwise well controlled.

No-one would want an outbreak of some apparently anachronistic plague at their local primary school. And now that’s a lot less likely to happen. The Law Centre’s 2013 report notes:

“The majority of newcomers to Northern Ireland are young and healthy on arrival, with no greater health needs than the general population. Nonetheless, there is a clear public health argument for ensuring that migrants have access to primary healthcare. For example, rates for both TB and HIV are higher for non-UK born people.

“There is also evidence that, while the highest rates of TB among migrants occur among people who are recent arrivals in the UK, just under a quarter are diagnosed within two years of arrival. Such data emphasises the importance, from a public health perspective, of ensuring migrant communities have immediate access to primary care.

“Indeed, the measles outbreak in a migrant community in Belfast during the festive period 2012/ 2013 illustrates this point. Measles is rare in Northern Ireland yet fifteen cases emerged in a short space of time among a migrant community – many of whom had no access to a GP and consequently had not been vaccinated. Unfortunately, a number of the cases required hospital admission, some for several days.”

There are around 200 asylum applications in Northern Ireland every year. Those numbers aren’t huge, but this new policy is better for everyone.