1Wood LCN, Devakumar D. BMJ Paediatrics Open 2020;4:e000705. doi:10.1136/bmjpo-2020-000705 Open access Healthcare access for migrant children in England during the COVID-19 pandemic Laura C N Wood ,1 Delanjathan Devakumar2 To cite: Wood LCN, Devakumar D. Healthcare access for migrant children in England during the COVID-19 pandemic. BMJ Paediatrics Open 2020;4:e000705. doi:10.1136/ bmjpo-2020-000705 Received 3 May 2020 Revised 29 June 2020 Accepted 3 July 2020 1Sociology, Lancaster University, Lancaster, UK 2Centre for the Health of Women, Children and Adolescents, Institute for Global Health, University College London, London, UK Correspondence to Dr Laura C N Wood; laura. wood@ lancaster. ac. uk Editorial © Author(s) (or their employer(s)) 2020. Re- use permitted under CC BY- NC. No commercial re- use. See rights and permissions. Published by BMJ. HEALTHCARE ACCESS—A CHILD RIGHT Access to healthcare services without discrim- ination is fundamental to the right to health. The principles of equitable, accessible, affordable healthcare are also embedded within the United Nations (UN) resolution on Universal Health Coverage, hailed as ‘the single most powerful concept that public health has to offer’ by the former WHO director- general.1 In 2016, the UN Committee on the Rights of the Child raised significant concerns regarding healthcare access inequal- ities between migrant and non- migrant chil- dren in the UK.2 These unresolved concerns and subsequent serious child health conse- quences have been echoed repeatedly by leading health and migrant support experts.3 The global COVID-19 pandemic and impacts of mitigation policies have dealt multiple blows to the health and well- being of many sectors of the population, particularly those already living precarious lives. Migrant fami- lies and children are recognised as a group already burdened with health challenges and barriers to healthcare access which risk further exacerbation during and beyond the COVID-19 pandemic.3 The ongoing public health crisis presents an urgent and distinc- tive opportunity to permanently address the unacceptable hostile policy and practice envi- ronment that restricts equitable healthcare access, endangers child health and so poorly enables the rights of migrant children to be realised. MIGRANTS IN THE UK In 2017, an estimated 6 208 000 foreign national individuals resided in the UK, including 332 604 children and young people (CYP) from the European Economic Area (EEA+) and 332 000 undocumented CYP. An estimated 133 000 CYP without secure immi- gration status were estimated to be living in London alone.4 Undetected victims of inter- national human trafficking, including family units and children, are likely to number in their thousands.5 In 2018, asylum seekers represented approx- imately 6% of immigrants (34 500 people) in the UK.6 Five thousand six hundred and fifty- five dependent children under the age of 18 years were included in asylum applications, including 2711 under the age of 5.7 Between May 2018 and 2019, 2872 unaccompanied minors applied for asylum. Additionally, around 20 000 refugees have been resettled through government schemes.8 Migrant individuals are therefore very diverse, with potentially complex, nuanced and even harrowing reasons for leaving ‘home’. For those who are fit and able to travel, perhaps entering the UK for employ- ment, study or family reasons, reported that health is often better than their UK coun- terparts.9 For those in need of sanctuary, compounding experiences of profound human cruelty, human rights violations, chronic oppression, threat or severe strangu- lation of opportunity are the burden of many. Migrant children may have been subject to chronic conditions of poverty, food inse- curity, heightened risk of disease, disorder, abuse, injury and trauma both before, during and after migration resulting in underlying malnutrition, prolonged stress, the impacts of active disease and the sequalae of chronic illness and its inadequate management.10 Far from being the great equaliser, the COVID-19 pandemic has starkly exposed and widened the inequalities of society further, with the poor and disempowered dispropor- tionately affected through disease, difficulties accessing healthcare, social support weak- nesses, local economic shocks and the relayed impacts of dangerously unstable global markets.11 12 Many migrants with complex medical histories, subsequent multifactorial o n A p ril 5 , 2 0 2 1 b y g u e st. P ro te cte d b y co p yrig h t. h ttp ://b m jp a e d so p e n .b m j.co m / b m jp o : first p u b lish e d a s 1 0 .1 1 3 6 /b m jp o -2 0 2 0 -0 0 0 7 0 5 o n 1 6 Ju ly 2 0 2 0 . D o w n lo a d e d fro m http://bmjopen.bmj.com/ http://orcid.org/0000-0001-8947-2677 http://crossmark.crossref.org/dialog/?doi=10.1136/bmjpo-2020-000705&domain=pdf&date_stamp=2020-07-16 http://bmjpaedsopen.bmj.com/ 2 Wood LCN, Devakumar D. BMJ Paediatrics Open 2020;4:e000705. doi:10.1136/bmjpo-2020-000705 Open access weakening of the immune system and ongoing chal- lenging socioeconomic circumstances should be consid- ered at high risk of COVID-19 complications.13 Concerningly, the emerging evidence suggests excess mortality due to COVID-19 in Black, Asian and minority ethnic (BAME) populations, with individuals of Black African, Black Caribbean and Asian ethnic groups at the highest increased risk.14 Socioeconomic factors, working environments, the legacy of racism and the hostile polit- ical environment towards migrants are likely to have critical contextual roles in understanding this data. Early evidence regarding BAME children has suggested that they are at greater risk of COVID-19 complications requiring hospitalisation.15 Migrant BAME children experience the pandemic differently to children not exposed to these additional challenges, and as a group are facing greater risks of caregiver illness, bereavement, poverty, racism and vicarious racism, lack of educational access and healthcare, all with significant consequences for their physical, mental and developmental well- being. The overarching public message that COVID-19 poses little threat to children directly risks isolating migrant and BAME children further from much needed policy consideration, needs assessment and support. ELIGIBILITY FOR NATIONAL HEALTH SERVICE (NHS) HEALTHCARE Free NHS healthcare access eligibility in England is tied to immigration status and lawful, settled residence. Eligi- bility may change rapidly in line with immigration deci- sions and is very complex for both migrants and profes- sionals to navigate. All adults and children in England are entitled to register with a general practitioner and receive free primary care, regardless of immigration or other status. Accident and emergency treatment is also exempt from charge as are a number of defined condi- tions including COVID-19 testing and treatment and direct health consequences of torture and domestic violence. Many migrants are exempt from NHS charges in line with British nationals including refugees, asylum seekers, recognised victims of modern slavery and their children (<18 years), unaccompanied minors looked after by a local authority and immigration detainees. Non- EEA migrants in the UK under visa restrictions (ie, for work or study) must pay an annual immigration health surcharge, currently standing at £400 per adult and child (rising to £624 this October) that enables them to use the NHS in line with British nationals. In May 2020, the govern- ment responded to pressure to commit to removing the health surcharge requirement for non- EEA migrant NHS staff and care workers (many on minimum wage).16 It is not confirmed whether the exemption applies to their dependents, or if the surcharge will be dropped for other staff groups. All individuals outside of these exemption groups, including undetected international human traf- ficking victims, non- EEA migrants with a visa for less than 6 months stay and those without lawful residence (including visa overstayers) may be charged for NHS care at 150% tariff. This includes charges for maternity and paediatric care. Immigration and residence status does not only deter- mine healthcare access, but government legislation in 201517 and 201718 has embedded mechanisms of immi- gration enforcement within the NHS in England. Active measures include immigration status checks on patients and sharing of non- clinical patient data and outstanding debt with the Home Office,19 risking adverse immigra- tion outcomes. BARRIERS TO HEALTHCARE ACCESS FOR MIGRANT CHILDREN Migrants still face many barriers in the realisation of their right to free NHS care even when eligible, and thousands of children and their caregivers subject to restrictions remain in very precarious health contexts. While England’s ‘hostile environment’ (since renamed ‘compliant environment’) had been hailed as a mech- anism to tackle unauthorised immigration, ripples of perceived pervasive discrimination and threat have disseminated throughout the wider migrant population. For many, the sense of being unwelcome has been pain- fully exacerbated by the Windrush Scandal in 2018,20 widespread racist and xenophobic narrative surrounding ‘Brexit’ (the departure of the UK from the European Union, 2020),21 unsympathetic responses to refugees and current incidents of anti- Asian hate crimes, stigmatisa- tion and bullying of children perceived to be Chinese in the wake of COVID-19.22 Murphy et al demonstrated that healthcare professionals have recorded recent instances of profound harm to migrant families and children, including interuterine death and delayed treatment of childhood cancer where access to necessary healthcare has been deeply feared and avoided, denied (without payment) or delayed.3 Testing and treatment of COVID-19 have been decreed free of charge and exempt from immigration status checks,23 yet urgent and substantial concerns remain that these exemptions cannot mitigate the extensive barriers to migrants accessing healthcare and the subsequent severe mistrust in the integrity of the NHS generated by hostile policies.24 Possible symptoms of COVID-19 are diverse in presentation and severity, particularly in chil- dren,25 and many will be deterred from accessing the help they need risking increased community transmis- sion, health complications, inappropriate use of home treatments and avoidable deaths. MOVING FORWARD—ENABLING MIGRANT CHILDREN TO ACCESS HEALTHCARE In order to enable migrant children to realise their right to health, we recommend that: ► All migrant children have the same access to health- care as British nationals with immediate and ongoing o n A p ril 5 , 2 0 2 1 b y g u e st. P ro te cte d b y co p yrig h t. h ttp ://b m jp a e d so p e n .b m j.co m / b m jp o : first p u b lish e d a s 1 0 .1 1 3 6 /b m jp o -2 0 2 0 -0 0 0 7 0 5 o n 1 6 Ju ly 2 0 2 0 . D o w n lo a d e d fro m http://bmjpaedsopen.bmj.com/ 3Wood LCN, Devakumar D. BMJ Paediatrics Open 2020;4:e000705. doi:10.1136/bmjpo-2020-000705 Open access effect, in line with France, Italy, Norway, Portugal and Spain.26 Their healthcare access must be determined by their health or developmental needs, not by immi- gration status. ► All migrants must have access to NHS healthcare for ALL necessary treatments and preventative health- care without cost during the course of the COVID-19 pandemic and ongoing. Caregivers must feel safe to attend for their own, and their children’s healthcare needs without fear of debt and impoverishment. ► A firewall between the NHS, justice services and immigration must be urgently established. Migrant caregivers and children must be able to seek and receive healthcare, report violence and unsafe working and living conditions without any fear of being reported to immigration services, detained or deported. ► The healthcare surcharge for non- EEA migrants requires urgent review due to the risk of impover- ishment of low- paid workers and their dependents during a season of severe economic instability. ► Research into the risks of COVID-19, social deter- minants of health, systemic racism, hostile policies and hostile indifference towards migrant health outcomes must be ongoing and considered through a child rights framework. All barriers to healthcare access including language and physical barriers, legal, administrative and financial constraints should be removed. ► The principles of Universal Health Coverage must be clarified through the lens of international human rights law with a view to enhanced understanding of how legal avenues can be used to combat inadequa- cies in current healthcare access policy.27 The ongoing COVID-19 public health crisis presents an urgent, distinctive opportunity to enable the full rights of migrant children to health to be realised, recognising their situation within the wider picture of the enabled rights of their parents, carers and communities. Twitter Laura C N Wood @DrLauraCN Contributors LCNW took lead author role and provided main content. DD led key structural revisions and content review. Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not- for- profit sectors. Competing interests LCNW: (non- financial association) is the Child & Family Modern Slavery Lead for VITA, an organisation seeking to advance the public health response to modern slavery. Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. Patient consent for publication Not required. Provenance and peer review Commissioned; externally peer reviewed. Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non- commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/. ORCID iD Laura C N Wood http:// orcid. org/ 0000- 0001- 8947- 2677 REFERENCES 1 World Health Organisation. Address by DR Margaret Chan, Director- General, to the Sixty- Fifth World health assembly 2012. 2 United Nations Committee on the Rights of the Child. Concluding observations on the fifth periodic report of the United Kingdom of great britain and Northern Ireland 2016. 3 Murphy L, Broad J, Hopkinshaw B, et al. Healthcare access for children and families on the move and migrants 2020;4:588. 4 Mayor of London. London’s Children and Young People Who Are Not British Citizens: A Profile. Available: www. london. gov. uk [Accessed 28 Apr 2020]. 5 HM Government. Modern slavery strategy, 2014. Available: www. gov. uk/ government/ publications [Accessed 25 Jun 2020]. 6 Sturge G. BriefingBRIEFING paper number SN01403, asylum statistics. house of commons library 2020. 7 Refugee Council. Information - Children in the Asylum System, 2019. Available: https://www. refugeecouncil. org. uk/ wp- content/ uploads/ 2019/ 06/ Children- in- the- Asylum- System- May- 2019. pdf 8 United Nations High Commissioner for Refugees. Asylum in the UK. Available: https://www. unhcr. org/ uk/ asylum- in- the- uk. html [Accessed 24 Jun 2020]. 9 University of Oxford. The health of migrants in the UK, the migration Observatory, 2020. Available: www. migrationobservatory. ox. ac. uk [Accessed 1 May 2020]. 10 Abubakar I, Aldridge RW, Devakumar D, et al. The UCL- Lancet Commission on migration and health: the health of a world on the move. Lancet 2018;392:2606–54. 11 Van Lancker W, Parolin Z. COVID-19, school closures, and child poverty: a social crisis in the making. Lancet Public Health 2020;5:e243–4. 12 Douglas M, Katikireddi SV, Taulbut M, et al. Mitigating the wider health effects of covid-19 pandemic response. BMJ 2020;369:m1557. 13 Helen Bamber Foundation. Urgent call for the UK government to protect and safeguard survivors of modern slavery, 2020. Available: http://www. helenbamber. org/ our- services/ legal/ medico- legal- reports/ [Accessed 1 May 2020]. 14 Public Health England. Beyond the data: understanding the impact of COVID-19 on BamE communities. PHE publications (gateway number: GW-130), 2020. 15 Toubiana J, Poirault C, Corsia A, et al. Kawasaki- like multisystem inflammatory syndrome in children during the covid-19 pandemic in Paris, France: prospective observational study. BMJ 2020;369:m2094. 16 Nursing Times. RCN keeps pressure on PM over pledge to scrap immigration surcharge, 2020. Available: https://www. nursingtimes. net/ news/ policies- and- guidance/ rcn- keeps- pressure- on- pm- over- pledge- to- scrap- immigration- surcharge- 10- 06- 2020/ [Accessed 25 Jun 2020]. 17 National Health Service, England. The National health service (charges to overseas visitors) regulations, 2015. Available: http:// www. legislation. gov. uk/ uksi/ 2015/ 238/ contents/ made [Accessed 3 May 2020]. 18 National Health Service, England. The National health service (charges to overseas visitors) (Amendment) regulations, 2017. Available: http://www. legislation. gov. uk/ uksi/ 2017/ 756/ contents/ made [Accessed 1 May 2020]. 19 Lewis A, Potter J, Bola G, et al. Challenging healthcare charging in the NHS challenging healthcare charging in the NHS patients not Passports: challenging healthcare charging in the NHS. Available: https://www. medact. org [Accessed 1 May 2020]. 20 Gower M. Briefing paper Number CBP 8779. Windrush generation: Government action to ‘right the wrongs.’ House of Commons Library 2020. 21 Burrell K, Hopkins P, Isakjee A, et al. Brexit, race and migration. Environ Plan C Polit Sp 2019;37:3–40. 22 Devakumar D, Shannon G, Bhopal SS, et al. Racism and discrimination in COVID-19 responses. Lancet 2020;395:1194. 23 UK Government. Coronavirus (COVID-19): get support if you’re a migrant living in the UK, 2020. Available: https://www. gov. uk/ guidance/ coronavirus- covid- 19- get- support- if- youre- a- migrant- living- in- the- uk [Accessed 1 May 2020]. 24 Doctors of the World. Open letter to the Secretary of state for the home office and Secretary of state for health and social care, 2020. Available: https://www. doctorsoftheworld. org. uk/ wp- content/ uploads/ 2020/ 04/ Letter- to- HS- and- SSHSC_ 13. 04. 2020. pdf [Accessed 1 May 2020]. o n A p ril 5 , 2 0 2 1 b y g u e st. P ro te cte d b y co p yrig h t. h ttp ://b m jp a e d so p e n .b m j.co m / b m jp o : first p u b lish e d a s 1 0 .1 1 3 6 /b m jp o -2 0 2 0 -0 0 0 7 0 5 o n 1 6 Ju ly 2 0 2 0 . D o w n lo a d e d fro m https://twitter.com/DrLauraCN http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ http://orcid.org/0000-0001-8947-2677 www.london.gov.uk www.gov.uk/government/publications www.gov.uk/government/publications https://www.refugeecouncil.org.uk/wp-content/uploads/2019/06/Children-in-the-Asylum-System-May-2019.pdf https://www.refugeecouncil.org.uk/wp-content/uploads/2019/06/Children-in-the-Asylum-System-May-2019.pdf https://www.unhcr.org/uk/asylum-in-the-uk.html www.migrationobservatory.ox.ac.uk http://dx.doi.org/10.1016/S0140-6736(18)32114-7 http://dx.doi.org/10.1016/S2468-2667(20)30084-0 http://dx.doi.org/10.1136/bmj.m1557 http://www.helenbamber.org/our-services/legal/medico-legal-reports/ http://www.helenbamber.org/our-services/legal/medico-legal-reports/ http://dx.doi.org/10.1136/bmj.m2094 https://www.nursingtimes.net/news/policies-and-guidance/rcn-keeps-pressure-on-pm-over-pledge-to-scrap-immigration-surcharge-10-06-2020/ https://www.nursingtimes.net/news/policies-and-guidance/rcn-keeps-pressure-on-pm-over-pledge-to-scrap-immigration-surcharge-10-06-2020/ https://www.nursingtimes.net/news/policies-and-guidance/rcn-keeps-pressure-on-pm-over-pledge-to-scrap-immigration-surcharge-10-06-2020/ http://www.legislation.gov.uk/uksi/2015/238/contents/made http://www.legislation.gov.uk/uksi/2015/238/contents/made http://www.legislation.gov.uk/uksi/2017/756/contents/made http://www.legislation.gov.uk/uksi/2017/756/contents/made https://www.medact.org http://dx.doi.org/10.1016/S0140-6736(20)30792-3 https://www.gov.uk/guidance/coronavirus-covid-19-get-support-if-youre-a-migrant-living-in-the-uk https://www.gov.uk/guidance/coronavirus-covid-19-get-support-if-youre-a-migrant-living-in-the-uk https://www.gov.uk/guidance/coronavirus-covid-19-get-support-if-youre-a-migrant-living-in-the-uk https://www.doctorsoftheworld.org.uk/wp-content/uploads/2020/04/Letter-to-HS-and-SSHSC_13.04.2020.pdf https://www.doctorsoftheworld.org.uk/wp-content/uploads/2020/04/Letter-to-HS-and-SSHSC_13.04.2020.pdf http://bmjpaedsopen.bmj.com/ 4 Wood LCN, Devakumar D. BMJ Paediatrics Open 2020;4:e000705. doi:10.1136/bmjpo-2020-000705 Open access 25 Qiu H, Wu J, Hong L, et al. Clinical and epidemiological features of 36 children with coronavirus disease 2019 (COVID-19) in Zhejiang, China: an observational cohort study. Lancet Infect Dis 2020. 26 Stubbe Østergaard L, Norredam M, Mock- Munoz de Luna C, et al. Restricted health care entitlements for child migrants in Europe and Australia. Eur J Public Health 2017;27:869–73. 27 Health and Human Rights Journal. Using the Right to Health to Promote Universal Health Coverage: A Better Tool for Protecting Non- Nationals’ Access to Affordable Health Care? Available: https://www. hhrjournal. org/ 2016/ 12/ using- the- right- to- health- to- promote- universal- health- coverage- a- better- tool- for- protecting- non- nationals- access- to- affordable- health- care/#_ edn2 [Accessed 25 Jun 2020]. o n A p ril 5 , 2 0 2 1 b y g u e st. P ro te cte d b y co p yrig h t. h ttp ://b m jp a e d so p e n .b m j.co m / b m jp o : first p u b lish e d a s 1 0 .1 1 3 6 /b m jp o -2 0 2 0 -0 0 0 7 0 5 o n 1 6 Ju ly 2 0 2 0 . D o w n lo a d e d fro m http://dx.doi.org/10.1093/eurpub/ckx083 https://www.hhrjournal.org/2016/12/using-the-right-to-health-to-promote-universal-health-coverage-a-better-tool-for-protecting-non-nationals-access-to-affordable-health-care/#_edn2 https://www.hhrjournal.org/2016/12/using-the-right-to-health-to-promote-universal-health-coverage-a-better-tool-for-protecting-non-nationals-access-to-affordable-health-care/#_edn2 https://www.hhrjournal.org/2016/12/using-the-right-to-health-to-promote-universal-health-coverage-a-better-tool-for-protecting-non-nationals-access-to-affordable-health-care/#_edn2 http://bmjpaedsopen.bmj.com/ Healthcare access for migrant children in England during the COVID-19 pandemic Healthcare access—a child right Migrants in the UK Eligibility for National Health Service (NHS) healthcare Barriers to healthcare access for migrant children Moving forward—enabling migrant children to access healthcare References