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‘Impact on migrant women of NHS charging for maternity care’ – a talk by Rayah Feldman from Maternity Action at UEA

Maternity Action have launched an important report called ‘What Price Safe Motherhood’. On March 11th, Rayah Feldman from Maternity Action gave a talk about the report at UEA as part of their University of Sanctuary lecture series. The following is a brief summary with more detailed notes below.

In the report, Maternity Action highlight how NHS charging for migrants, including refused asylum seekers, is part of a broader pattern of using welfare and civil society as a form of internal border controls. Many women interviewed for the report had been in the UK for many years (up to 17 years). The fear of being charged is stopping many people from seeking health care with some women even avoiding abortions in case they are told they must pay. This fear is heightened by the fact that anyone with a £500 or greater debt after 2 months must be reported to the Home Office and there is evidence this is being used to deny people the right to remain.

Women are particularly vulnerable as many are dependent on men for their visas. Women on visitor visas to join a partner lose their right to free health care if the relationship breaks down before they get their spouse visa.

There is no need for the NHS to charge for healthcare. Maternity Action has found that all the cost recovery form charging represents less than 0.1% of the NHS budget even before the costs of the recovery itself are taken into account. Yet the risks to maternal and child health are huge, and in many cases huge pressure is put on midwives who face a contradiction between the duty of care and the pressure put on women due to charging.

Maternity Action are calling on individuals and supportive organisations to put pressure on their local MPs and hospitals to call for an end to unfair charging. Some hospitals are beginning to find ways to resist the Home Office pressure for charging – it would be great to see Hospitals of Sanctuary who find ways to support vulnerable women in particular.

Notes below made by Ben Margolis who attended the talk – [email protected].

Impact on migrant women of NHS charging for maternity care 

Rayah Feldman – Maternity Action

Talk based on a recent report she has led on – ‘What Price Safe Motherhood’

‘NHS charging for migrants part of a broader pattern of using welfare and civil society as a form of internal border controls that have intensified over the years (a lot of years – more than the hostile environment).

NRPF introduced in 1999 which excluded some people subject to immigration control from most mainstream benefits. Also introduced a meaner support stream for asylum seekers.

‘Maternity is a feminist issue.’ Can’t avoid looking at gender within the system of immigration control.

Since 2012 more stringent income thresholds for spouses to join their partners – discriminates against women as they are generally lower paid.

Maternity care – case of using charging as a form of border control and form of inequality within immigration control. There are rights to access maternity care in international conventions – CEDAW and Rights of the Child.

Who is chargeable?

  • UK citizens – not ordinarily resident
  • Visitors – less than 6 month visa
  • Undocumented migrants including refused AS with no HO support and visa overstayers

Found some cases where people were charged who shouldn’t have been

Women who are recognised as having been trafficked aren’t charged

Women with LLR aren’t charged – since 2015 they have had to pay a surcharge on their visas (£200/year). In January that was doubled to £400/year – so £1033 visa application fee if you are getting Limited Leave to Remain for 2.5 years. Immigration surcharge is another £1000. Renewable every year for 10 years until you can get indefinite leave.

AS waiting for a decision and those granted refugee status are not charged.

Principles of NHS charging

A & E– free

Immediately necessary treatment– Must not be delayed or refused if patient unable to pay – but patient must pay later

Urgent care – (can’t reasonably wait until you could be expected to return to your country) – Must not be delayed or refused if patient unable to pay – but patient must pay later (terminations are now under this category as of Christmas Eve 2018 – evidence women who wanted abortions were not seeking them because they had to pay in advance).

Non-urgent care– Must be paid in advance

Government now recognises ALL maternity care is ‘immediately necessary treatment’. All patients have to be identified as chargeable or non-chargeable. All chargeable patients get billed and must pay it.

Exemptions–    infectious diseases

Conditions caused by domestic, sexual violence, torture

Not always cross over. E.g. Patient with TB recently died. TB treatment was free. Also had lung cancer. Doctor decided treatment wasn’t immediately necessary to chargeable. Couldn’t pay in advance so he wasn’t treated and died.

Grey area around HIV. Wasn’t exempt for many years. Became free in 2012. BUT lack of crossover makes it complicated as there are other issues related that are chargeable particular if woman is pregnant.

Cost of treatment is 1.5 times tariff charged to CCG in locality. With maternity care it is even higher.

Hospitals and most community services must identify and record all eligibility of patients and issue bills. Include abortion clinics etc.

Patients with debts of over £500 unpaid after 2 months must be reported to the HO. Future immigration applications may be refused.

Women most likely to be charged

  • Undocumented women and women on visitor visas
  • Often dependent on men for immigration status
  • No right to work or claim benefit
  • Vulnerable to abuse
  • Precariously housed

In research did in-depth interviews with 16 women. One here for 17 years. Average 5 years. Some incorrectly charged. Many abandoned by their partners when they got pregnant.

Research found

  • Hard to determine chargeability – immigration managers are not lawyers, very complex
  • Women who have been trafficked are not always aware that they shouldn’t be charged
  • Size of the charges massive issue. Over £6k for a full package of maternity care. 2x what the tariff is for non-charged women (weighted for complexity)
  • Hospitals check records to see if they were charged before and if not they may bill them for previous care
  • Guidance says overseas visitor charging departments should be sensitive to vulnerable patients and help to ensure they receive the support and information they need. Found this doesn’t happen at all. Some advocacy done by midwives but very limited.
  • Charging procedures – women receive formal invoices requesting payment. People harassed by phone calls from debt collection agencies.

Causes increased stress and anxiety. Deters people from accessing care. Affects mental and physical health of the mother but also the babies.


Clear charging pregnant women doesn’t make a big difference to the NHS. Income last year was £100m which represents less than 0.1% of the NHS budget. On average cash recovered is half the amount charged.

Huge risks to maternal and child health. Contradiction for midwives between their duty of care and the pressure put on women.

Increases barriers to health care for all migrants and minority ethic people. People questioned over eligibility. Leads of ethnic profiling.

Plea to raise awareness of this issue. Quite a hidden problem.

Campaigns for individual hospitals to make statements about how they deal with this issue.

Some hospitals are being encouraged to stop issuing pre-attendance forms so it is more difficult to identify chargeable patients.

UEA pushing for a motion that the university covers costs for staff and families who are having to pay for their own health care.