The NHS visitor and migrant cost recovery programme \u2013 a threat to health?

J L Potter,C D Tweed,D Swinglehurst,C J Griffiths,H Kunst,M Burman,D Vaghela

doi:10.1186/s12889-020-08524-9

J L Potter, C D Tweed + Show 5 more

Open Access

https://doi.org/10.1186/s12889-020-08524-9

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Abstract

BackgroundIn April 2014 the UK government launched the ‘NHS Visitor and Migrant Cost Recovery Programme Implementation Plan’ which set out a series of policy changes to recoup costs from ‘chargeable’ (largely non-UK born) patients. In England, approximately 75% of tuberculosis (TB) cases occur in people born abroad. Delays in TB treatment increase risk of morbidity, mortality and transmission in the community. We investigated whether diagnostic delay has increased since the Cost Recovery Programme (CRP) was introduced.MethodsThere were 3342 adult TB cases notified on the London TB Register across Barts Health NHS Trust between 1st January 2011 and 31st December 2016. Cases with missing relevant information were excluded. The median time between symptom onset and treatment initiation before and after the CRP was calculated according to birthplace and compared using the Mann Whitney test. Delayed diagnosis was considered greater or equal to median time to treatment for all patients (79 days). Univariable logistic regression was used to manually select exposure variables for inclusion in a multivariable model to test the association between diagnostic delay and the implementation of the CRP.ResultsWe included 2237 TB cases. Among non-UK born patients, median time-to-treatment increased from 69 days to 89 days following introduction of CRP (p < 0.001). Median time-to-treatment also increased for the UK-born population from 75.5 days to 89.5 days (p = 0.307). The multivariable logistic regression model showed non-UK born patients were more likely to have a delay in diagnosis after the CRP (adjOR 1.37, 95% CI 1.13–1.66, p value 0.001).ConclusionSince the introduction of the CRP there has been a significant delay for TB treatment among non-UK born patients. Further research exploring the effect of policies restricting access to healthcare for migrants is urgently needed if we wish to eliminate TB nationally.

Highlights

In April 2014 the UK government launched the ‘National Health Service (NHS) Visitor and Migrant Cost Recovery Programme Implementation Plan’ which set out a series of policy changes to recoup costs from ‘chargeable’ patients
The NHS Visitor and Migrant Cost Recovery Programme (CRP), introduced in April 2014, was designed to ensure migrants in England who are otherwise ineligible for free NHS care make a ‘fair contribution’ [14] to the cost of running the NHS
We collected patient data from the London TB Register (LTBR) for TB cases notified across Barts Health NHS Trust between 2011 and 2016 inclusive

Summary

Methods

The London TB Register (LTBR) is an online database for the statutory recording of notified cases of TB, as entered by clinical staff. In 59 cases, there was no data on treatment start date recorded in the LTBR database. For these cases we used the date the patient was first seen in TB clinic as a proxy measure. Variables were manually selected based on significance level in a univariable model (p value < 0.10) with the exposure (treatment before or after the CRP) and outcome variables (delay in diagnosis). These were included, along with sex and age, in a final multivariable logistic regression model testing the association between delay in diagnosis and introduction of the CRP to account for potential confounding. The regression model was tested using the Hosmer-Lemeshow test, and the minimum number of measurements was thought to have been reached in each of the two patient groups based on the number of variables being tested

Results

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Background

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