The government’s repeated reforms of rules governing migrants’ access to NHS services have caused confusion among healthcare staff with “tragic consequences”, a new report has found.

Inclusive Practice, by the Department of Health national inclusion health board, examined access to primary care and “hospital admission risk” for vulnerable groups.

“Charging regulations for secondary care for asylum seekers and overseas visitors have undergone a number of changes over the last decade and have been the subject of much confusion and misunderstanding by healthcare staff and managers, sometimes with tragic consequences,” it said.

“Frequent changes to eligibility for access to free secondary care for overseas visitors… present barriers to good access for these groups, and training for primary and secondary staff on eligibility issues is needed.”

The report, published on 30 April, points out that the rules on charging are likely to change again: “On 3 July 2013 the Department of Health launched an open consultation on charging migrants and overseas visitors access to use the NHS.”

The changes were confirmed on 30 December.

It also found “strong evidence that some GP practices refuse to register vulnerable populations’ needs”. It points to wide gaps in evidence, information and in spreading good practice on services for migrants, Gypsies and Irish travellers, homeless people and sex workers. The report was published alongside a document highlighting examples of good services.

Bobbie Jacobson, chair of the DH inclusion health data and research working group, said: “We still haven’t learned [how to] roll out good practice. Good examples are hidden from view, particularly models which serve populations that don’t have a voice.”

A DH spokeswoman said: “We know variation exists [in access] which is why the [inclusion] board looked into this and has discussed with NHS England how we can ensure eligibility for NHS primary care services is understood.”