Release arrangements for immigration detainees are medically unsafe
BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m15 (Published 13 January 2020) Cite this as: BMJ 2020;368:m15
- F W Arnold, independent forensic physician1,
- J Chisholm, chair of medical ethics committee2,
- J Cohen, independent forensic physician3,
- C Katona, medical and research director4,
- J Payne-James, consultant forensic physician5
- 1Medact, London, UK
- 2British Medical Association, London, UK
- 3Oxford, UK
- 4Helen Bamber Foundation, London, UK
- 5Queen Mary University of London, London, UK
- Correspondence to: F Arnold arnold_frank{at}hotmail.com
NHS England now requires that prisoners must be registered with a general practitioner before their release. It says this is because “release from custody can be a crisis situation for some and can result in the reversal of previous health improvements. Furthermore, it [pre-registration] is vital in helping to support better health outcomes and maintain continuity of care for these individuals.”1 The new policy also requires prison healthcare services to organise follow-up medical care for prisoners “up to one month” before the date of their release.
Some 69 622 people were released from prison in England and Wales in 2018.2 If successfully implemented, this commendable development should make a major difference to their health since problems are high in this patient group3 and may affect rehabilitation.
The positive commitment to aftercare for people released from prison is in marked contrast to current arrangements for the 13 992 people who were released into the community from UK immigration removal centres (IRCs) in 2018.4 The difference arises because release dates for prisoners are well defined and predictable, unlike those for detainees in removal centres. The UK has no limit on duration of detention for people detained under immigration powers5 and detains more than other European countries.67 Discharges are ordered by the Home Office or the courts, usually without warning, making access to medical care after release more precarious than for discharged prisoners.
An inquiry conducted for NHS England identified three removal centres that required detainees leave within a “two hour window” once the Home Office or courts order a release, and be given “a minimum of two days’ supply of medication.”8 The actual contract between the Home Office and removal centre management, however, requires that released detainees depart within four hours. Centres that breach this contract risk a substantial fine.9
We are unaware of any provision to help released detainees identify a general practice that will register them, although this patient group is known to have particular difficulty in accessing community care.10 The NHS England inquiry recommends that discharge arrangements should be audited to give a clearer indication of the numbers of detainees unable to access care after discharge and to guide improvements. A recent report by Her Majesty’s Inspector of Prisons about Brook House immigration removal centre also recommends an audit of discharge arrangements.11
Unsafe discharge
Current discharge requirements are clearly unsafe since they can result in detainees leaving removal centres without adequate medication, arrangements for GP registration, copies of medical notes, or provision for continuity of care. These and other serious problems in the healthcare of detainees have also been documented in expert reports.6121314 Complaints from former detainees about unduly hasty or dangerous discharge have elicited dismissive written responses insisting that clinicians must adhere to Home Office requirements for rapid discharge (personal communications, available on request from FWA).
The discharge practice is particularly concerning because many detainees need prescribed drugs such as psychotropic, anti-epileptic, or antiretroviral agents and are at risk of relapse or deterioration if treatment is discontinued. Released detainees may be vulnerable because of language difficulties, ignorance of UK healthcare systems, or traumatisation by their experiences before or during detention.
Medically unsafe discharge may be a consequence of the Home Office’s desire to avoid accusations of unlawfully prolonging detention. From 2012 to 2017 over £4m (€4.7m; $5.3m) was paid each year in compensating people who were wrongfully detained in England.14 Despite the concern to avoid such payments, the Home Office and removal centre GPs have an enduring duty of care which does not end at release.
Immigration detainees have a right to timely liberty when this is ordered but also a right to medically safe release. Similarly, the authorities should not be subject to unreasonable claims for wrongful detention. These requirements may seem conflicting but they can and should be reconciled without detriment to either party.
It is NHS England policy to audit performance indicators for immigration removal centres, and these indicators should include measures of safe discharge, as recommended by the Faculty of Forensic and Legal Medicine.15
New contracts for healthcare services in immigration removal centres are due from June 2020, providing an opportunity for a rethink. The Home Office, NHS England, and all providers should ensure that existing contracts do not prevent or obstruct clinicians working in these centres from complying with their professional duties as defined by the General Medical Council when discharging detainees or transferring responsibility for their ongoing care.16
Footnotes
Competing interests: We have read and understood BMJ policy on declaration of interests and declare that FWA, JCo, CK, and JP-J are sometimes paid to examine and write medicolegal reports about immigration detainees and former detainees. JCh chairs the BMA medical ethics committee.
Provenance and peer review: Not commissioned; externally peer reviewed.