Image: Authors Own

Describing the care his mother received in an NHS hospital Russell Brand recently wrote, “The NHS is the very best of us, it is a living, breathing, healing mother goddess born of war and sacrifice sustained by love and dedication.” I have worked on the frontline of healthcare for over ten years. I have rubbed the feet of babies until they took their first breath and sat with wrinkled hands pressed between mine to ensure the last breath was not spent alone.  My grandfather’s last days were featured on 24 hours in A&E, my cousin was cared for by the very trauma service Brand extols and my own life was saved in that same hospital following the birth of my child.

In 1948 the NHS was established with the central ambition of providing healthcare, free at the point of service for “everyone – rich, or poor, man, woman or child” to “relieve your money worries in times of illness”.  On its 70th birthday the NHS, once a bastion of universal healthcare, has now become a ‘hostile environment’ letting migrant ‘others’ die in order to ensure citizens live.

At the time of its inception, concerns that such an open access system would attract abuse by overseas visitors were headed off by Nye Bevan who argued that it was ‘unwise as well as mean’ to restrict access to usually healthy people who contributed to the economy the moment they stepped ashore.  Meanwhile the government at the time was actively recruiting nurses, midwives and other healthcare workers to come and staff the newly formed NHS.  With foundations built on migrant labour, including people from the so-called ‘Windrush generation’, today 12% of the NHS workforce were born overseas, rising to 35% amongst doctors.  This is truly an international health service.

It was not until the 1980s that NHS charging regulations were introduced for overseas visitors.  However, within a system characterised by a no-charging culture with financial mechanisms that created little incentive to recover costs from chargeable patients, decades went by during which the NHS was ostensibly open to all in need.  Bevan calculated the cost of health tourism at the time to be approximately 0.4% of the overall NHS budget.  Today that figure stands at 0.3%.  Despite little objective evidence its open access policy has been detrimental to the NHS or the populations it serves, successive governments have introduced increasingly restrictive legislation focused on excluding migrants.

What changed?

Whilst the capitalist economy demands cheap labour and relies on human mobility; globalisation and freedom of movement within Europe brought concerns that public services might become overwhelmed.  Reflecting this, recent governments have become increasingly occupied by ensuring rules governing access to welfare systems remain ‘fair’ to the tax payer.  Then came the global economic crisis.  Using taxpayer’s money, the government bailed out banks arguably responsible for the crash in the first place, and successive governments have chosen to impose austerity measures. This has led to an NHS in crisis. Waiting times are rising and staff are in short supply.

Framing the so-called ‘migrant crisis’ with media reports of deliberate health tourism conveniently distracts from government imposed budget restrictions and firmly places the blame for the NHS crisis at the feet of people not born in the UK. In 2012, then Home Secretary Theresa May demonstrated the government’s commitment to protecting taxpayers’ money from these ‘undeserving’ ‘others’ by announcing she was going to make the UK a ‘really hostile environment’ to those living here illegally.  There followed a suite of interventions designed to restrict access to a number of vital services including the NHS.

NHS Charging Regulations

Historically, eligibility for free NHS care was based on an individual being “ordinarily resident in the UK” such that if you moved here to live and work, or you came here to study, you would be entitled to free NHS care.  A series of amendments to the NHS regulations formally excluded a number of vulnerable groups including failed asylum-seekers, undocumented migrants and those who had overstayed their visa. Restrictions were further extended by the Immigration Act 2014 excluding everyone without indefinite leave to remain.

On 23rd October 2017, upfront charging for patients ineligible for free NHS care with non-urgent conditions became law.  Individuals paying for NHS treatment upfront or billed after treatment are charged at 150% of the actual cost.  For those who cannot pay their bill, the use of debt collectors has been reported as well as restrictions placed on future travel.  An outstanding debt of more than £500 is also likely to have a detrimental effect on any claim for asylum, further deterring this vulnerable group from accessing healthcare. There is clear evidence that even the threat of charges prevents people from seeking help when they are unwell. The longer diagnosis is delayed, the more likely an individual will suffer or even die.

To determine eligibility, everyone must be asked for ID – bringing concerns that the process would further exacerbate existing institutional racism.  Proving eligibility can also be problematic, particularly for those who may not have a passport such as the elderly or homeless. A recent article in the Evening Standard demonstrated that of nearly 9000 patients checked, just 50 were found to be ineligible for free care. Many, including the British Medical Association, have raised concerns that these reforms are “unlikely to produce enough revenue to cover the cost of setting up its own bureaucracy”.

In recent weeks reports of those caught in racialized determinations of eligibility have surfaced.  Most famously the case of Albert Thompson (pseudonym), a British citizen of the Windrush generation, made homeless because he could not prove his citizenship and then refused palliative chemotherapy unless he could pay the £54,000 bill upfront. One women was denied urgent treatment for her breast cancer, others avoid maternity services because of the charges they face, another died because she was too afraid her details might be passed onto the Home Office by the NHS.

Healthcare workers are also not immune to the ‘hostile environment’. As the UK government has undertaken during previous staffing crises, it is currently actively recruiting from former colonies.  All the while the Home Office rejects visa applications from both those already offered a job in the health service as well as those already working here, hoping to continue their much-needed care work.

Difficult to measure are the impacts of these policies on staff morale.  For those, like me, whose professional identity is defined by NHS principles of universal, non-discriminatory healthcare, determining eligibility based on immigration status conflicts with the way many of us wish to provide care – based on need, not politicised notions of ‘deservingness’.  If we do not comply and attempt to provide NHS care to those deemed ineligible, we could be prosecuted for fraud.  The implementation guidance of the charging regulations stand at a whopping 117 pages. It is filled with complex lists of exemptions and hazy guidance on how to determine urgency, therefore ‘doing no harm’ becomes an impossibility.  Making such harms visible outside of institutional structures is further challenged by our commitment to the principle of confidential healthcare and stories like those highlighted in this article too often go unheard.

About the Author: Dr Jessica Potter (@DrJessPotter) is a lung doctor and public health researcher at Queen Mary University London.  She campaigns for migrants’ rights to healthcare as part of ‘Docs Not Cops‘ (@DocsNotCops)and Medact Refugee Solidarity Group.