Talk at Liverpool.
This talk is based on a recent report for Maternity Action ‘What Price Safe Motherhood?: Charging for NHS Maternity Care in England and its Impact on Migrant Women’
Maternity care charging is a limited part of NHS charging but it’s significant because maternity care is usually regarded as special, so charging for it with no concession to its special status in relation to women’s and children’s rights makes the UK govt’s approach to it particularly problematic – and worth questioning.
NHS charging is a very significant part of bringing the border into everyday life. This is often called the ‘hostile environment’ – a shorthand for hostile environment for undocumented migrants, but actually creating a nightmare for all migrants as shown by the Windrush scandal.
Today I want to focus on what charging for mat care means in practice for the individuals it affects – and if time to explore a bit more its implications. In the workshops we can discuss ways of campaigning about charging and where mat. care might sit in such a campaign.
I will focus on 3 aspects of charging for maternity care in England as there are some differences in rest of UK
- Who is charged
- Charging procedures and practices
- Impact on women affected
- Who is charged
People with visitor visas, UDMs, expats. – people not ‘ordinarily resident’ in the UK. All other migrants who do not have ILR have to pay an Immigration Health Surcharge of £200 per year (doubling in December). This is paid in full in applying for a visa, so it’s £500 per person for 2½ years (£1000 in December) on top of visa charges of £1033.
Our study did not include expats but our advice service has had requests from women who were deemed not to be ordinarily resident because they worked abroad, or had been living abroad for some time. So we interviewed women on visitor visas and women who had overstayed earlier visas.
NB We interviewed 16 women – average length of residence – over 6 years before their last pregnancy.
- 2 women on visitor visas but both had British partners and were waiting to obtain spouse visas – so just in terms of the assumptions that a visitor is a tourist – this was not the case.
- 2 women were EU cits/ dependants – wrongly charged
- Some had come on student or visitor visas and become overstayers, and some were refused asylum seekers, some were very likely trafficked – one certainly was. Some who had overstayed their visas were trying to make further applications for leave, but this is difficult because not eligible for legal aid, and because of UD status had no money.
All those in this situation were very poor, and among the single women, often destitute as the following example shows.
Ayesha came to the UK for an arranged marriage. She had not met her future husband but he was ‘nice and caring’ when she spoke to him on the phone. They stayed together for about 4 months but she fled from him because he turned out to be violent and abusive. At that time she could not speak English and knew nothing about the UK. She survived by helping out different women she met in her mosque who offered her shelter in return for help with housework and childcare. When she became pregnant a family took her in for a longer period but made it clear she would not be able to continue to stay once she had her child. She was afraid to go back to her home country because she had run away from her husband, and she was also worried that her family would force her daughter to have FGM. She applied for asylum just before she was due to give birth.
She became pregnant while sofa surfing (often a euphemism for sex in exchange for accommodation). She did not stay with the father of her child. Ayesha’s story is a good example of how a woman’s immigration status can be dependent on their relationship. It also shows how irregular immigration status for women can give rise to a precarious personal situation in which women can be very vulnerable to abusive behavious by men.
In our study, only 5 of 16 participants continued to be in a relationship with the father of their last baby.
5 women were abandoned when they told their partner they were pregnant
3 – no information about partner (may have also been abandoned or may have been a brief relationship)
3 – separated from abusive partners during or after child was born.
- Women were charged who had lived here several years, sometimes had other children born here, or had British partners, or were incorrectly charged.
- Undocumented women without partners are particularly vulnerable to destitution and exploitation by men.
- Immigration statuses are fluid and changeable. Ayesha came as a visitor, became an overstayer, then claimed asylum
- b) Charging procedures
We did expect the women we interviewed to be very poor and living in difficult circumstances. But we also learnt from the study how harsh the charging regime is.
The charging rules
- Charges to migrants are levied at 150% of tariff charged to CCGs. So current maternity charges are £6993.63 for full package including antenatal care, delivery, and postnatal care. £1353 for termination. (Maternity care to CCG is £4662.42).
- Failure to repay £500 or more within 2 months results in being reported to the HO and can result in refusal of subsequent immigration applications or to re-enter the UK.
- Maternity care is considered Immediately Necessary – this means must not be delayed or refused if a woman cannot pay. But charges must now be levied in advance.
- Our study took place before statutory upfront charging was introduced so the timing of charging was arbitrary. 6 women were billed during pregnancy, 9 women post-natally or post miscarriage. 1 woman was not billed. Some were billed several months after giving birth. Some women were told the day their baby was born.
- Bills that women received were not itemised. Women who were charged in advance were not given advice on whether anything could be omitted. They were not told about possibility of payment plans, nor asked about their financial situation even though the Department of Health Guidance is very clear on the care that should be taken with vulnerable people (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/742251/guidance-on-implementing-the-overseas-visitor-charging-regulations-may-2018.pdf See Chapter 7).
“When operating the charging rules it is very important to consider the position of vulnerable overseas visitors, including those unlawfully resident in our communities, both those who are exempt from charge and those who are chargeable.
“Overseas Visitor Managers (OVMs), and other NHS staff are strongly encouraged to speak to their safeguarding leads if, in the course of their work, they are concerned about the welfare of any patient. It can also be helpful for OVMs to build constructive relationships with local agencies which support people in various types of need, or to seek advice and information from relevant national agencies and organisations.” (DH Charging Guidance p53)
- Some women asked for information and were not given it.
- 2 women were wrongly charged and needed legal help to cancel charges.
- Some women were billed for previous births which took place years ago after they were billed for the most recent birth. This is now very common. Home Office officials are now often embedded with social services when they are asked for support by undocumented migrants. The Home Office then inform hospitals that someone had given birth there and was chargeable.
- Most women were not told anything about charging prior to receiving a letter or invoice.
- Subsequently they were harrassed with letters and phone calls, often from debt collection agencies. If English wasn’t their first language they could often not understand what people were saying on the phone.
The following are extracts from letters demanding payment which women had received:
FINAL DEMAND FOR PAYMENT
We wish to notify you that if this account is not settled within 7 days of this letter it will be referred to a debt collection agency and you may face litigation.
Furthermore, under immigration rules 320, 321, 321A and 322, a person with outstanding debts of over £1,000 for NHS treatment which are not paid within three months of invoicing, may be denied a further immigration application to enter / remain in the UK. If full settlement is not made, information relating to this debt will be provided to the UK Border Agency and may be used by them to apply the above immigration rules.
NB The demand about repayment of £1000 was out of date and inaccurate. The letter threatens litigation and provides no invitation to talk to hospital)
One woman was told that as she had not paid
“the required deposit an invoice will be sent to the address you have given us. Please be aware that failure to pay this invoice may result in future appointments being cancelled.”
NB The letter made no reference to the fact that maternity care is designated as Immediately Necessary.
- c) Impact of charging on women
- Deterrence from attending care – women refused to attend further antenatal appointments. Natasha, on leaflet, would not go back for a checkup to find out why she had a miscarriage. One woman with high blood pressure went to hospital just before delivery after refusing to go to more antenatal appointments. One woman – the only one who paid in full, refused to go to NHS for anything. Even those who did go were scared.
“Whenever I’m going to the midwife I’m really scared to go. I’m not happy about going there now. I’m always scared. I don’t know what’s going to happen whenever I have an appointment with the midwife. I don’t know what I’m going to hear from them. Maybe they will stop me from getting care. In the hospital I was so scared.”
- Mental health– charging has a really bad effect on women’s mental health, increasing their stress and impacting on the family as a whole.
“When they were calling me and saying I have to pay, I have to do this, there was a point I felt like just dying. And my son was crying, I’m like, shut up! You know what I mean? I just screamed at him like, shut up! It’s just… It does have an impact (on the child) because I shouted at him when I wasn’t meant to. Because he was just a baby then, he was a crying baby. So the whole thing was just too much for me.”
- d) Conclusion
- This isn’t about recouping money for the NHS Of the 16 women interviewed, only 1 paid in full. 1 has 45 year repayment plan! 1 not charged because she claimed asylum. None of the others will be able to pay.
- It is well known and acknowledged by the government that mental health, poverty, homelessness, and being a migrant adversely affects pregnancy outcomes. So why are they not excluding maternity care from charging? In my view it’s racism in immigration policy combined with misogyny and hostility to family formation and reproduction among foreigners. e.g. Anwar Ditta case and the Primary Purpose rule in the 1980s and 90s.
- Also the approach to maternity deeply misogynistic. It sees women having babies in the UK only as maternity tourism, and refuses to see women as students, spouses, workers etc.
- The implementation of the charging policy is decentralised and not monitored and so is not consitent. There are no audits of the health impact of charging on women or its impact on deterring them from care.
- Failure to properly examine immigration status of chargeable people let alone their social and financial circumstances as advised by guidance gives rise to mistakes and undoubtedly to racial profiling e.g. in our study two Latin American women with EU rights were charged.
- Charging has an insidious impact on NHS. Divisions between entitled and unentitled become normalised, for example banners in hospitals saying “NHS Hospital Treatment is Not Free for Everyone” “The NHS is a Residency based provider and is not free for everyone.