Report into refugee and migrant access to health care in Hackney - Healthwatch Hackney

 
Report into refugee and migrant access to health care in Hackney - Healthwatch Hackney
Report based on interviews
Report into refugee and                                 with 54 interviews with
                                                        refuges and migrants into
                                                        the barriers they experience
                                                        in accessing health care.

           migrant access to
 health care in Hackney
  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       11
 GP
 Asked for proof of home office status when     1
 registering with GP
 Required assistance from other charities or    4
 organisations, to register
 Previously had documents, however no           8
 longer have any
 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          25
 services

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,
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.

   “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)

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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