Restrictive healthcare policies associated with delayed TB diagnosis and treatment

The introduction of policies that restrict healthcare access for visitors and migrants not entitled to free NHS care may be associated with delays in diagnosis and treatment for patients with tuberculosis (TB) who were not born in the UK, according to a study published in the open access journal BMC Public Health. Delays in diagnosis and treatment of an infectious disease like TB may increase morbidity and mortality for infected individuals, as well as transmission in the community.

In 2014, the UK government launched the NHS Visitor and Migrant Cost Recovery Programme (CRP) to recoup costs from 'chargeable' (largely non-UK born) patients not entitled to free NHS care. Researchers at Queen Mary University of London, UK investigated a possible association between the introduction of the CRP and diagnostic and treatment delays in subsequent years.

Jessica Potter, the corresponding author said: "This study provides novel data showing an association with delayed diagnosis and treatment of an infectious disease—tuberculosis—among people not born in the UK with the roll out of government policy designed to restrict healthcare access for some migrants. These findings are despite the fact that infectious diseases are exempt from charging."

The authors analysed data on 2,237 TB cases notified between 2011 and 2016 on the London TB Register across Barts Health NHS trust, which serves three East London boroughs and treats over 500 patients with TB each year, representing about 10% of cases in England.

They found that among non-UK born patients, median time to treatment—the average number of days between the date of symptom onset and the date of starting treatment—increased from 69 to 89 days following the introduction of CRP. Non-UK born patients were also more likely to experience a delay in diagnosis after introduction of the CRP. The number of years migrants had been living in the UK before diagnosis was found to increase from 10 years before to 14.8 years after the CRP was introduced.

A number of mechanisms may underlie the association between treatment and diagnostic delays and health policies, such as the CRP, which aim to restrict access to care based on migration status, according to the authors. Previous research has suggested that migrants in the UK are often not aware of their entitlement to care and patients' concerns about being charged for care may delay them seeking health advice, even before diagnosis.

The authors suggest that while the study area is small geographically, the findings may be applicable to other areas within England which have similar migrant populations and have been subject to similar policies as the East London boroughs examined in this study. They caution that the observational nature of the study does not allow for conclusions about cause and effect. Nevertheless, the findings show an important association that warrants further investigation.

Jessica Potter said: "Whilst we have demonstrated an association and not proven causality, we provide a convincing argument for more research in this area and contribute to the growing body of evidence that restricting healthcare access to some has public health implications for us all."