Dr Durga Sivasathiaseelan: ‘Charging migrants for NHS services needs to stop’

Dr Durga Sivasathiaseelan runs a mobile clinic bringing healthcare to people in deprived parts of London unable to access the NHS. When Covid-19 arrived and the small enclosed space in her van became too risky, she donned PPE and took to the streets.

“Most of our clients do not have a GP,” says Sivasathiaseelan who works for Doctors of the World (UK) (DotW, a charity supporting the health of marginalised people. Reasons include the belief that they are not entitled to one (everyone is), fear of charging or of data sharing (with the Home Office) , past experience of stigma or discrimination, or simply being unable to register.

“A lot of surgeries suspended registration at the start of the pandemic,” says Sivasathiaseelan. “NHS England eventually told them they shouldn’t, but it took a long time, and most practices still required you to register in person and that wasn’t possible.”

Even before Covid-19, DotW found that one in five attempts by its volunteers to register clients was refused. “It is often because they do not have photo ID or proof of address, but NHS guidance is clear that lack of these is not grounds for refusal,” she says.

DotW runs a nationwide project, Safe Surgeries, to train GP practices to make registration easier and to be more inclusive of people like DotW’s clients, who include homeless people, asylum seekers and undocumented migrants.

Many have “traumatic pasts and chaotic lifestyles,” says Sivasathiaseelan, “and immediate priorities like finding food and queueing for a shelter bed may make them late for appointments”. There are 341 Safe Surgeries across the UK.

DotW supports more than 2,000 individuals a year at its mobile clinic and walk-in centre in Stratford, east London. These clients have not seen a doctor for an average of five and a half years. Closure of the formal face-to-face programmes sent Sivasathiaseelan trudging through what she describes as the “post-apocalypic emptiness” of lockdown London.

DotW had been providing outreach to rough sleepers in the City of London for six months and she adapted the service for those still on the streets to provide not only the usual healthcare but also food she sourced from one of the hotels accommodating other homeless people, as well as screening for symptoms of Covid-19.

While the nation was in lockdown, DotW carried out a rapid needs assessment (in April and early May) for the groups it works with. A qualitative study drawing on the experience of doctors, NGOs and affected individuals in England, it details a healthcare gap that is rapidly widening in the pandemic.

It found people becoming newly destitute and homeless after losing work and being unable to access benefits. Many lacked basic information about Covid-19 or were unable to follow guidance because of their living conditions. It is impossible to self-isolate, for instance, if you share kitchen and toilet facilities with several families, as many in temporary accommodation and refuges do.

The findings came as no surprise to Sivasathiaseelan. “It shows the risk to these vulnerable people, and to public health,” she says.

On the plus side, Covid-19 has provided a unique opportunity to engage with hard-to-reach homeless people who were allocated beds in hotels, thanks to the government’s Everyone In campaign.

Sivasathiaseelan says this “remarkable project” has allowed DotW, other agencies and NGOs to build trust, treat previously undiagnosed physical and mental health problems , and link people to drug and alcohol services. Crucially, she adds, “with safe accommodation and three meals a day provided people have had the headspace to think about their health.”

Some homeless people are too afraid of the authorities or habituated to sleeping outside to take advantage. These are the ones she has been looking after no the streets.

As most do not have smartphones and can’t access information or remote support, she says: “They may know nothing of the virus – or nothing but myths.” They often have underlying health conditions putting them at greater risk of Covid-19 and even once they know the symptoms, “may have particular difficulty identifying them because so many have chronic coughs”. They move around, too, including on public transport, “so they pose a risk to others as well as to themselves”.

Together with a nurse colleague, Sivasathiaseelan has picked up several Covid-19 cases, getting one admitted to hospital and others to Covid hotels, part of the Everyone In provision.

A hotel in London that the charity St Mungo’s was running for homeless people during the pandemic.
A hotel in London that the charity St Mungo’s was running for homeless people during the pandemic. Photograph: Sean Smith/The Guardian

Sivasathiaseelan, 36, combines her DotW work with two days a week as a GP in Lewisham, south London. She always wanted to work in humanitarian medicine, but assumed this meant working abroad.

She has volunteered in a refugee camp in Greece and in rural Namibia, but when her mother was diagnosed with cancer (she has since recovered), Sivasathiaseelan wanted to be back in London with her, and as a stop-gap applied for a role at DotW.

She started as manager of its women’s service where she discovered what she calls the “terrible barrier that is NHS charging”. Undocumented migrants, of whom there are an unknown number estimated between the low hundreds of thousands and 1.2 million, can be charged for hospital care including maternity services.

“At a cost of £6,000 upwards, this means many women go without antenatal care,” says Sivasathiaseelan, “I had a woman on our helpline this morning who had refused antenatal appointments while she waited for her visa. These women present for the first time in labour, which makes delivery higher risk.

“Our clients have a 40% caesarean rate, as opposed to 26% for the general population. Shockingly, one woman was advised by a hospital overseas team – who are non-medical – to have an elective C-section because [in her case] it would be cheaper!”

“Lots of people contact our advice line because of charging,” Sivasathiaseelan continues, “They don’t know Covid-19 is exempt, and even when they do, they fear going to hospital. If it turns out they don’t have Covid-19, they could get a bill. For all our sakes, charging needs to stop, not just for the pandemic, for ever.”

Her current role has just taken Sivasathiaseelan (in full PPE) to a Traveller encampment in north London. Travellers, along with Gypsy and Roma people, have a life expectancy a decade shorter than average as well as well-documented difficulties accessing healthcare .

The DotW identified high levels of misinformation and mistrust in these communities too, and a growing sense of exclusion as Covid-19 advice failed to take account of their communal lifestyle.

Sivasathiaseelan expected to face suspicion at first but says “women and children at least were happy to see me”. It shows what can be done, she adds, when a dedicated outreach worker has built trust and prepared the way.

Sivasathiaseelan hopes the DotW needs assessment will help provide the evidence needed for MPs and the government to support its campaign for truly universal healthcare in Britain. “Covid-19 has shown that healthcare for the most vulnerable is a public health issue,” she says, “and that is true beyond Covid-19”.

Curriculum vitae

Age: 36.

Family: Single.

Lives: Lewisham, south London.

Education: Watford grammar school for girls; University of Nottingham Medical School (BMedSci BMBS). Postgraduate qualifications in tropical medicine and hygiene; palliative care, obstetrics and gynaecology.

Career: 2019-present: mobile clinic coordinator, Doctors of the World UK and GP, Lewisham medical centre; 2018: women and children’s clinic coordinator, Doctors of the World UK and GP, The Family Practice, Islington; 2016-17: GP, Orkney; 2013-16: GP, Stenhouse medical centre, Arnold, Nottingham: 2011-13: maternity locum GP, Leen View surgery, Bulwell, Nottingham; 2008-11: GP training posts, Nottingham; 2006- 08: foundation medical training, Chesterfield Royal hospital, Derby Royal infirmary and Derby City general hospital.

Public life: 2018-19: volunteer medical doctor, N/a’ankusê Lifeline clinic, Namibia; 2018: volunteer primary care doctor, Syrian American Medical Society, Vial refugee camp, Chios, Greece.

Interests: Running, yoga, meditation, wild swimming, hiking, climate and biodiversity activism.