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Maternity Action Report: Duty of Care: The impact on midwives of NHS charging for maternity care: September 2019

Background – Charged for Using the NHS?

By way of background to this report, in 2004 the government withdrew free access to secondary healthcare for certain groups of overseas visitors.  Following the introduction of new Regulations, overseas visitors, or those not normally ‘ordinarily resident’ were to be asked to pay for their treatment.  This followed reports of ‘health tourists’ or those perceived as abusing the system. There were and remain some exemptions for refugees, asylum seekers who do not yet have a decision or those refused asylum, supported by the Home Office and victims of modern slavery.  

Purpose of the Report

This study was commissioned for the following reasons: 

Strict government regulations for charging some migrants for NHS care have introduced new concerns for midwives in caring for women who are charged. They raise questions about midwives’ professional duty of care, their responsibilities to try to reduce health inequalities, and their role in advocating for the women in their care”.

This report is the ‘first study to investigate the impact of the policy of charging ‘overseas visitors’ for NHS care on midwives’ practice or professional responsibilities’.

The report was published in September.  A full copy of the report can be accessed: here and makes interesting reading. 

The report begins with a foreword from Gill Walton, Chief Executive of the Royal College of Midwives (RCM):

“This report makes for sobering reading as it demonstrates the dilemma midwives in England face when caring for women who are required to pay for their maternity care. Women affected by these charges are some of the most vulnerable people in our society. But attempts to recover money from these women seem to be driving a wedge between midwives and the women who desperately need their care”.

Concerns and Contradictions

The report outlines how midwives find themselves in very difficult situations and ‘contradictions between professional standards in midwifery and the requirements of the charging regulations’.

Many midwives want to remove themselves from the charging procedures and most had little if any knowledge of the system for charging.  The report identifies that ‘Maternity care is charged in the same way although all maternity care is designated as immediately necessary. This means that it must not be delayed or refused because of a woman’s inability to pay in advance’.

Midwives expressed concern for those undocumented and vulnerable people, where leave has expired and they cannot afford a further application.  The report reminds us about IHS charges: “At the time of writing, each individual (adult or child) renewing residence permits is charged £1033 plus £1000 Immigration Health Surcharge. Thus the cost of renewal for a family of 4 is £8132”.

The report identifies that all ‘the midwives interviewed recognised that most of the women who were being charged, with whom they came into contact, lived in particularly vulnerable situations………..Several midwives spoke with great feeling about the women in their care and personally supported women who were destitute and/or isolated during their pregnancies, far beyond their immediate professional responsibility’.

Charges had wide reaching consequences with midwives repeating concerns ‘about how the stress of being charged by the NHS impacted on women’s mental health and thus their maternity care’.

Midwives thought that perhaps individuals were booking late to avoid antenatal care and potential charges and some were selective in their care to avoid charging.

The report identifies that charging can result in trust issues: “The erosion of trust caused by charging undermined the quality of the care midwives could give as women were less likely to disclose sensitive issues and information to them because of fears of repercussions”. 

Importantly the report identifies the difficulty with legal responsibility: 

“Neither midwives nor other clinicians are legally responsible for informing patients about charging. Nevertheless, it sometimes fell to midwives to inform women that they would be charged for their maternity care……… when women have a problem understanding charging procedures, they turn to their midwife for help as a trusted individual, meaning the midwife then becomes the messenger of the charges. It is clear that it is difficult to make a clear cut distinction between midwives and Overseas Visitor Managers’ roles in informing women about charging”.

Report Conclusions

In conclusion the following three consequences for midwives were identified:

“● Midwives face conflicts in their professional practice as a result of charging 

  • They also experience an increased workload as a result of women’s responses to charging 
  • They find themselves having to deal with ethical dilemmas about how far they need to engage with the charging regime”.

The report concludes that ‘there is an irreconcilable conflict between midwives’ duty of care as set out in professional midwifery standards and in relation to NHS principles and values, and measures required by trusts to identify chargeable women. In our view this conflict can only be resolved by ending charging for NHS maternity care’.

NHS Debt – Impact on Immigration Applications – Leave to Enter or Leave to Remain

Aside from the social complications, NHS debt has consequences for applications for leave to enter or remain.  NHS debt features as a ground for refusal in Part 9 of the Immigration Rules and the suitability requirements in Appendix FM of the Immigration Rules.

The General grounds for refusal Section 4, version 29.0, published on 11 January 2018, guidance makes clear that in assessing an application for leave to remain, a caseworker must check whether an Applicant has NHS debt and this may lead to refusal.

Since the publication of the report Maternity Action has launched legal action over NHS charges for destitute migrant pregnant women.  The charity demands a full and independent review. We await the outcome with interest. 

Contact Our Barristers

For expert advice and assistance with an application or for advice as to the impact of an NHS debt on an application for leave to enter or remain please contact our Barristers on 0203 617 9173 or complete our enquiry form below.


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