Photo: Hostile Environment from Ged Carroll Flickr photo stream

As usual I was running late. Walking away from patients or relatives at the end of the day working as a doctor in the NHS is never an easy task. But it is something that has become increasingly difficult since I left medical school well over a decade ago. There are fewer staff, more to do and less to do it with. We are stretched far too thin – held together by a commitment to care for anyone in need, no matter who they are.

I was on my way to give a speech as part of the #StopTheCoup rallies with colleagues from Docs Not Cops, a grassroots organisation of healthcare workers and patients who campaign for free healthcare for all. The tube was closed and so I flagged down a taxi. Tony, the driver, was a Black man in his 50s. We got chatting about why I was on my way to the Home Office. He had not heard of the ‘hostile environment’. He had heard of the Windrush scandal.

Access to the NHS is based upon the idea of usual residency. At its inception, people who considered the UK their home were able to access the NHS free at the point of service. Over the years, legislation has become increasingly restrictive. Now, only people with indefinite leave to remain are entitled to free NHS care. With frightening speed charging mechanisms have infiltrated the NHS, teams of border guards permeate spaces of care they have no right to occupy and fences have been erected, placed between people seen to ‘deserve’ healthcare and those who supposedly do not. The NHS is now a hostile environment where anyone positioned as foreign is asked not ‘how are you’ but ‘who are you’.

Evidencing harm

There is good evidence that fear – of deportation or being burdened with a crippling bill for example – deters people from seeking help when they are unwell. Delayed care has an number of effects. It increases a person’s risk of illness and even death, it can increase the risk of transmission in the case of infectious diseases and it costs more in the long run. For these reasons, healthcare has long been considered a public good. Yet the government continues to turn a blind eye to campaigner’s concerns that a hostile environment in the NHS is causing harm and is bad for the population at large.

Sylvester Marshall was one of many Black British people caught in the wake of policies designed to make the UK a “really hostile” place for anyone living here without the legal documentation to do so. People were made homeless, deported, denied care and some even died as a result. Sylvester was denied cancer treatment unless he could pay £54,000 up front. Like many others from the ‘Windrush Generation’ although he did not have the papers to prove he was British, Sylvester was born a citizen of colonial Britain.  As Tony pointed out to me in the taxi, these ‘hostile’ policies and practices are embedded in a racialised global hierarchy of deservingness within which whiteness reigns supreme. It is no accident that it is British people of colour who continue to find themselves at the sharp end of immigration enforcement.

Exposing lies

Identifying people who can be charged for NHS care and/or deported is an expensive business. Recently the government announced a further £1 million investment into the overseas visitor manager teams responsible for recovering debt.  Digital information systems are being used to make the task more efficient. Whilst the implementation guide speaks of non-discrimination and the importance of asking everyone the same questions, this is not the case in practice. As a campaigner on this issue, I know that individuals have contacted myself and others concerned they were racially profiled when accessing NHS care. There is a concern these discriminatory practices are becoming digitised. A traffic light system on a person’s central NHS record alerts clerical staff as to who is eligible for free care (green) and who might not be (amber or red). During an interview for my PhD research, an Overseas Visitor Manager described searching for new NHS numbers among other proxy identifiers which might suggest a patient is not eligible for free NHS care. Similarly, the Victoria Derbyshire Show heard from another Overseas Visitor Manager who routinely screened admissions for ‘foreign-sounding’ names. These practices are clearly discriminatory.

Other, worrying developments include recent reports in the  Health Service Journal that an NHS Trust was employing a credit agency to run checks on all patients referred into their service. Patients’ information was passed, without their knowledge, to Experian to check their credit footprint in the UK as a proxy for eligibility for NHS care.  Ruha Benjamin describes how such seemingly more objective uses of technology not only reflect but reproduce and even amplify existing inequities.  In this case, the ‘New Jim Code’, as Benjamin terms it, fundamentally encodes a link between foreignness and poverty. In a society where people from minority ethnic populations are disproportionately affected by poverty, this code is racist.

Unveiling the ideology

There is increasing evidence of harm caused by the government’s “hostile environment” policies. Yet calls to scrap the NHS charging regulations and undertake an independent evaluation of harm from professional bodies, academics, advocacy organisations and people affected continue to fall on deaf ears. And there is little public outcry on the matter.  How has the government convinced us to allow these borders to creep into the NHS – once a bastion of universality and non-discrimination?

Looking across policy documents from successive governments two themes stand out: cost recovery and fairness to the British taxpayer. Emphasising fairness to taxpayers positions them as perhaps more important and deserving of health services than people who do not pay tax. This fundamentally undermines any notion of healthcare as a human right or that healthcare should be based on need and not ability to pay.

In terms of cost recovery, there is no evidence to suggest the NHS charging regulations are cost effective. Whilst significant sums have been collected through the Immigration Health Surcharge, the majority of people who are chargeable for NHS care in the UK are the least able to pay even according to the government’s own evaluation.  This is not to mention the increased cost of delayed care which is very difficult to measure.

Despite the policy narrative, the NHS charging regulations are nothing to do with cost saving, they are nothing to do with fairness and they are nothing to do with saving the NHS. They are everything to do with successive governments wishing to look strong on immigration at the ballot box.

Speaking truth to power

It is said we are living in a post truth world. If this is the case, as academics, we might be forgiven for feeling somewhat lacklustre in our efforts to push the boundaries of knowledge. After all, who will be interested in our attempts to “approach the truth” when facts can so easily be constructed to achieve particular aims. However, in the current climate of rising xenophobia and racism, it has perhaps never been more important to remember the responsibility of intellectuals. As Noam Chomsky argued over 50 years ago, we must stand up and speak truth to power, uncover lies, lift the veil of ideology and in so doing, provide a foundation for action.


What can you do? If you would like to advocate for a person affected by the charging or start a local campaign please go to  To ACT NOW sign this letter to the Health Secretary demanding an end to NHS Charging –  Join us on 23rd October in London, Bristol, Birmingham and Manchester for a day of action to mark the two year anniversary of the expansion of NHS charging policies and commemorate the extensive harm already done by these brutal, racist policies and demand an end to immigration controls and charging in the NHS. More info here:

About the author: Dr Jessica Potter is a lung doctor and public health researcher.  She campaigns for migrants’ rights to healthcare as part of ‘Docs Not Cops‘ (@DocsNotCops)and Medact Refugee Solidarity Group. She is also on twitter (@DrJessPotter).