Correspondence
Forced displacement due to conflict, violence, and human rights violations is at record levels, with the UN High Commissioner for Refugees predicting that the number of people displaced will exceed 60 million in 2016. Medical practitioners need to address the challenge of providing equitable care for this vulnerable group. Application for asylum in the UK is complex. Asylum seekers often experience long periods when their application is classed as “failed”, but 42% of appeals were allowed in January to March, 2016. At present, asylum seekers are legally entitled to primary and emergency health care, including the right to register with a general practitioner and to access emergency services. However, a UK Government proposal plans to introduce charges for people whose asylum appeal is refused, including for emergency, ambulance, and maternity services. These individuals do not have the permission to work or financial support. Although the proposal includes exemptions from charging, groups that will be exempt are ill defined. Although we acknowledge the finite resources of the UK National Health Service (NHS), we think that the introduction of such charges will not save money and will lead to increased long-term spending. Opportunities for cost-effective preventive care and early intervention will be missed. Restriction of access to primary care is harmful to vulnerable individuals, detrimental to public health, unfeasible, and ethically unsound. Health care is a fundamental human right.1 A central principle of the NHS Constitution is that health care should be available to all, based on clinical need and not the ability to pay. The proposal to introduce charges for asylum seekers risks these rights for people who are highly susceptible to ill www.thelancet.com Vol 388 July 30, 2016
health but are not entitled to the full democratic rights of citizens. The proposal will have the greatest impact on the most disadvantaged.2 For example, pregnant women seeking asylum are seven times more likely to develop intrapartum complications and three times more likely to die than women in the general population.3 Introduction of charges adds to health-care barriers by compounding existing confusion among health-care professionals around eligibility. 4 The requisite checking of all people perceived as foreigners risks delays in their diagnosis and treatment. Anxiety about accruing unmanageable debt deters potentially vulnerable people from seeking care5 and adds to their mental health burden.6 Population health inequalities widen, adding to public health concerns. An impact assessment accompanying the consultation showed the financial risk for the NHS presented by the proposal. New information systems, and extra administrative and interpretation costs, are substantial. People who are refused asylum are usually unable to pay for health care, making costs unrecoverable and creating a net economic loss to the system. Already overworked clinicians are unlikely to welcome the responsibility for gatekeeping, and potential conflicts of this proposal with the duties of a doctor are pertinent. Most NHS clinicians consider it unethical to withhold care solely on the grounds of the ability to pay. Management of destitute asylum seekers under these proposals would create moral dilemmas: how should doctors act in patients’ best interests? Is it ethical to wait for the patient’s condition to deteriorate to a state where they require emergency care? We declare no competing interests.
Rebecca Farrington, *Sepeedeh Saleh, Sam Campbell, Ayman Jundi, Estelle Worthington
[email protected]
University of Manchester, Manchester, UK (RF, SC); School of Public Health, Health Education North West, Liverpool L3 4BL, UK (SS); Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK (AJ); Syrian British Medical Society, UK (AJ); and Regional Asylum Activism Project, Refugee Action, Manchester, UK (EW) 1
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UN General Assembly. International covenant on economic, social and cultural rights. United Nations, 1966. Nyiri J, Eling P. A specialist clinic for destitute asylum seekers and refugees in London. Br J Gen Pract 2012; 62: 599–600. The confidential enquiry into maternal and child health. Saving mothers’ lives: reviewing maternal deaths to make motherhood safer—2003–2005. London: Confidential Enquiries into Maternal Deaths in the United Kingdom, 2007. NHS England. Patient registration: standard operating principles for primary medical care (general practice). Leeds: Primary Care Commissioning, 2015. https://www.england. nhs.uk/commissioning/wp-content/uploads/ sites/12/2015/11/pat-reg-sop-pmc-gp.pdf (accessed July 5, 2016). Doctors of the World briefing: Department of Health consultation on further NHS charging— “Making a fair contribution”. London: Doctors of the World, 2016. https://www. doctorsoftheworld.org.uk/files/DOTW_ briefing_DH_consultation_on_further_NHS_ Charging_Feb_2016_FINAL.pdf (accessed July 5, 2016). Vostanis P. Meeting the mental health needs of refugees and asylum seekers. Br J Psychiatry 2014; 204: 176–77.
UK surgical trainees will continue to support European research collaboration Trainees (equivalent to residents in the USA) are committed to continuously improve patient care. In the past 10 years, trainee-led surgical research collaboratives in the UK1 have developed a track record in running high-quality randomised controlled trials.2,3 As our experience has grown, so has our collaboration with our European colleagues. We recognise that international collaboration is essential to running efficient, rapid trials that are generalisable across health systems and able to change practice. We have actively worked with trainees across Europe to develop international research networks. Building grassroot engagement and
Steve Percival/Science Photo Library
Impact of proposal to extend charging for NHS in England
For the UN High Commissioner for Refugees report see http:// www.unhcr.org/uk/statistics/ unhcrstats/56701b969/midyear-trends-june-2015.html For more on asylum appeals see http://www.refugeecouncil.org. uk/latest/news/4648_latest_ asylum_facts_and_trends For the UK Government proposal see https://www.gov. uk/government/consultations/ overseas-visitors-and-migrantsextending-charges-for-nhsservices For the NHS Constitution see https://www.gov.uk/ government/publications/thenhs-constitution-for-england/ the-nhs-constitution-forengland For the impact assessment see https://www.gov.uk/ government/uploads/system/ uploads/attachment_data/ file/482648/Impact_ Assessment.pdf For the duties of a doctor registered with the UK General Medical Council see http://www. gmc-uk.org/guidance/good_ medical_practice/duties_of_a_ doctor.asp
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
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For the EuroSurg collaborative network see http://eurosurg.org For the R&D Blueprint Initiative see http://www.who.int/csr/ research-and-development/en See Online for appendix
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collaboration in more than 160 local surgical centres in the UK, trainee groups have helped to run panEuropean cohort studies through the European Society of Coloproctology and launched the student-driven EuroSurg collaborative network. We have built on these foundations by running multinational randomised controlled trials, such as the Reinforcement of Closure of Stoma Site trial.4 The European Union (EU) has supported the development of research networks across the continent through the Erasmus and Marie Curie exchange programmes, Horizon 2020 funding, and harmonisation of regulation. We accept that diverse and complex arguments exist for modifying the UK’s political and financial relationship with the EU. However, there is considerable uncertainty regarding the full impact of Brexit on pan-European medical research. We are concerned that future UK access to EU initiatives and funding sources might be limited, and that the referendum result risks sending a negative message to our European collaborators. Trainees belong to a younger generation that overwhelmingly voted to remain in the EU, a generation that has embraced the globalisation of medical research and the attendant opportunities for advancing medical science and patient care.5 Science transcends national boundaries, and the very best research has always relied on the free exchange of information and ideas. For this reason, it is now more important than ever to ensure that incentives for international collaboration—such as research funding, training fellowships, and reciprocal exchanges—between the UK and EU continue to advance scientific and medical research for the benefit of patients across borders. As a group of early-career researchers and trainees, we are the future of surgical research in the UK. We remain as committed as ever to leading and
enhancing high-impact research collaboration with our colleagues across Europe. DN declares no competing interests. Several contributors currently hold or have previously held research funding awarded by the European Union.
Dmitri Nepogodiev, on behalf of the National Surgical Research Collaborative members listed in the appendix
[email protected] Academic Department of Surgery, University of Birmingham, Birmingham B15 2TH, UK 1
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Bhangu A, Kolias AG, Pinkney T, Hall NJ, Fitzgerald JE. Surgical research collaboratives in the UK. Lancet 2013; 382: 1091–92. Pinkney TD, Calvert M, Bartlett DC, et al. Impact of wound edge protection devices on surgical site infection after laparotomy: multicentre randomised controlled trial (ROSSINI Trial). BMJ 2013; 347: f4305. Hutchinson P, Kolias A. Protocol 14PRT/6944: randomised evaluation of surgery with craniectomy for patients undergoing evacuation of acute subdural haematoma (RESCUE-ASDH). http://www.thelancet.com/ doi/story/10.1016/html.2015.08.14.2280 (accessed June 26, 2016). Reinforcement of Closure of Stoma Site (ROCSS) Trial Management Group. Feasibility study from a randomised controlled trial of standard closure of stoma site versus biologic mesh reinforcement. Colorectal Dis 2016; published online Feb 29. DOI:10.1111/codi.13310. GlobalSurg Collaborative. Mortality of emergency abdominal surgery in high-, middle- and low-income countries. Br J Surg 2016; 103: 971–88.
The need for global R&D coordination for infectious diseases with epidemic potential The relentless increase of public health crises caused by emergent, often life-threatening infectious diseases—eg, Nipah virus infection, severe acute respiratory syndrome, avian influenza, Middle East respiratory syndrome, Ebola virus disease, chikungunya, Zika virus infection, and now yellow fever— needs no introduction. In an increasingly globalised world, a coherent global response is needed, not only in the immediate care of patients and countermeasures to transmission but also in the prompt initiation of research efforts.
The timely establishment of the Global Research Collaboration for Infectious Disease Preparedness (GloPID-R) network (May 28, p 2197)1 of research funding organisations in 2013 is an exciting development and fits neatly with the research and development (R&D) Blueprint Initiative of WHO. In May, 2015, the 68th World Health Assembly “welcomed the development of a blueprint, in consultation with Member States and relevant stakeholders, for accelerating research and development in epidemics or health emergency situations where there are no, or insufficient, preventive, and curative solutions, taking into account other relevant work streams within WHO”.2 The R&D Blueprint aims to reduce the time between the declaration of an international public health emergency and the availability of effective tests, vaccines, antivirals, and other treatments that can save lives and avert a public health crisis. WHO expert teams, an international scientific advisory group, and several partners engaged via global forums have been collaborating to articulate this novel R&D model. Several activities have been developed, experiences from the R&D efforts during the west African Ebola outbreak have provided a starting point, and the Zika virus outbreak in the Americas has served as an important testing ground. The WHO R&D Blueprint is both a convening mechanism for public health officials, scientists, and product developers, and an instrument to articulate technical guidance for R&D preparedness and response, especially in the area of coordination (ie, addressing priorities and avoiding unnecessary duplication), that can be effectively implemented through norm setting, appropriate incentives, and other measures. WHO collaborates and works in partnership with several initiatives www.thelancet.com Vol 388 July 30, 2016
