Primary care

Whereas detailed regulations exist governing access to secondary care (i.e. hospital services), no legislation exists to restrict access to primary care on the basis of immigration status. Nonetheless, some NHS staff may wrongly believe that the same regulations apply to primary care as secondary care.

The rules on how GPs should deal with new patients are set out in the National Health Service (General Medical Services Contracts) Regulations 2004.

General practitioners manage their own practice lists and have the discretion to register patients, regardless of immigration or residency status. There is no obligation or expectation for them to check patients’ immigration status.

The regulations state that GPs may refuse a patient if there are reasonable grounds for doing so (this could include not living in the GP’s catchment area), but that the reason for refusal must not relate to the applicant’s race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition.¹

A GP who refuses an application should notify the applicant in writing within 14 days, giving the reason for the refusal.

GPs also have the discretion to register temporary patients (those in the area for less than three months). They have the obligation to provide ‘immediately necessary’ treatment for up to two weeks to anyone who requests it, as long as the person is not already registered with a local GP.

Primary care trusts may employ staff to oversee the use of secondary care services by overseas visitors. However the PCT does not have the power to veto a patient application that has been accepted by a GP.

Also, primary care trusts have a legal obligation to provide primary care to people who are not ‘resident’ in the area but are ‘present’.² This suggests that primary care trusts should not take actions which make it especially difficult for people who are not ‘ordinarily resident’ to access primary care.

The Department of Health guidance on charging overseas visitors notes that the regulations only apply to services provided in a hospital or by hospital staff. Primary care and other community services do not charge overseas visitors. Specifically, the guidance states:

“GPs have discretion to accept any person, including overseas visitors, to be either fully registered as a NHS patient, or as a temporary resident if they are to be in an area between 24 hours and three months. There is no minimum period that a person needs to have been in the UK before a GP can register them. Furthermore, GPs have a duty to provide free of charge treatment which they consider to be immediately necessary or emergency, regardless of whether that patient is an overseas visitor or registered with that practice.”³

In practice, undocumented migrants and other people subject to immigration control often find it difficult to register with a GP. One reason is that GPs often request specific identity documents and proof of address that many migrants are unable to provide. Their documents may be held by the Home Office, they may be homeless or they may be staying with friends as a temporary measure.

Many primary care trusts put pressure on GP practices to establish the identity of each new patient. This is often done in the name of counter-fraud measures, in order to prevent individuals from registering at multiple GP practices and then obtaining opiates or other prescription drugs either for personal use or to sell on. However when GPs apply rules on identity documents in an inflexible way, with no consideration of an individual’s particular circumstances, they have the additional effect of preventing a group of vulnerable individuals from accessing primary care.

Some lawyers believe that refusing to register a patient because of their immigration status breaches the legislation because it would be for reasons relating to race (most refused applicants are from BME groups).⁴ Relevant legislation may include the Equality Act and article 14 of the Human Rights Act, as well as General Medical Services Contracts Regulations.

The charity Doctors of the World UK has experience of helping migrants to register with GPs. In its experience, advocates should avoid mentioning nationality or immigration status when talking with receptionists, and explore the possibility of completing a registration with whatever documents the person does have (e.g. a letter from the Home Office, a photocopy of the passport). It may be necessary to ask to speak to the practice manager or a doctor, to focus on the medical needs of the person and to encourage the practice to use the discretion it has to register patients.⁵

It has also found it helpful to refer to the Department of Health guidance mentioned above, as well as guidance from the Royal College of General Practitioners (RCGP)⁶ and the British Medical Association (BMA)⁷ which states that doctors should not be expected to police entitlement to healthcare and which remind doctors both of their discretionary powers and their responsibility not to discriminate.

People with limited financial resources, including refused asylum seekers and undocumented migrants, may be able to get free prescriptions and help with other health costs. Immigration status is not a factor in assessing this entitlement. Patients should complete an HC1 form.

The policy implemented by the The Department of Health, Social Services and Public Safety is more restrictive than in other parts of the UK. They wish to prevent people living in the Republic of Ireland from registering with Northern Ireland GPs.

Moreover they believe that publicly funded GP services cannot be legally provided to people who are not ‘ordinarily resident’ in the local area. This interpretation of the law is challenged by the Northern Ireland Human Rights Commission.⁸

As a consequence, current practice is that primary care services are frequently denied to migrants who cannot demonstrate that they are ‘ordinarily resident’.