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Coronavirus and the Hostile Environment

For weeks, the public has clapped the migrant workers who keep the NHS running — while the Tory government remains intent on treating them like criminals.

The NHS was conceived as a universal service based on the principle that everyone should have the right to healthcare, regardless of their ability to pay. But for many years this principle has been degraded, not only by privatisation but by the xenophobic ‘hostile environment’. As Covid-19 has exposed the reliance of our health system on migrant workers, it has brought the inhumanity of these policies into stark relief.

The policy of charging migrants for NHS healthcare was first introduced under Gordon Brown in 2009. But since 2014, we’ve witnessed an escalation in restrictions as the government has waged its attack on migrant rights. Under the Tories’ hostile environment, immigration enforcement was outsourced to our public services and a raft of measures were introduced to prevent people from accessing healthcare alongside other essential services. Hospital bills, ID checks, and patient data sharing with the Home Office has now become commonplace in our NHS.

The 2014 Immigration Act enforced a statutory duty onto the NHS to identify and charge patients who are deemed ‘not to be ordinary residents.’ All hospital treatment for those not resident — except what is immediately necessary to save a person’s life — was subject to charges. In 2018, this was extended to include community services such as mental health and abortion services. In fact, these charges were used to prop up cuts elsewhere: those deemed ineligible for care were charged 150 per cent the cost of their treatment.

To put this into context, a ‘non-resident’ woman who dares to give birth can be charged anywhere between a few thousand pounds to tens of thousands if she has complications during labour. This is, of course, completely unaffordable for the majority of undocumented migrants, who, under the hostile environment are unable to work legally. These are people whose circumstances mean they are forced into precarious work or the illegal economy — and therefore are the least likely to be able to afford exorbitant medical bills.

The charity Maternity Action documents many cases of women ending up destitute and prostitution trying to pay hospital bills. When it launched a legal challenge to the charges last year, the organisation’s director described the reality facing many migrants:

We hear from women who are pursued by debt collectors during their pregnancy. They are commencing care late, skipping appointments and in some cases giving birth at home unattended. There’s also the real fear of having the Home Office informed of their insecure immigration status if they do seek care.

In 2017 upfront charging was introduced, meaning healthcare can be denied to those who can’t afford to pay prior to treatment. A 71-year-old grandmother from Jamaica, Elfreda Spencer, became unwell while visiting her daughter in London. She was diagnosed with blood cancer. The London hospital refused to provide her with chemotherapy because her family were unable to pay upfront the £30,000 charge.

The hospital even refused the family’s desperate offer to pay £500 a month to enable treatment to begin. She died after a year without treatment. In the words of Elfreda’s daughter she, ‘died without dignity.’ Again and again, we see xenophobic policies leading directly to preventable deaths. This is the reality facing many migrants in our NHS — even as migrant workers are celebrated across the country for their contributions to the health service.

Outsourcing Immigration Control

But charges are not even the most pernicious intrusion of the hostile environment into the NHS. Recent years have also seen substantial data sharing with the Home Office. People who should be a sanctuary for help and care — not only doctors but also teachers and the police — are instead forced to become an arm of immigration enforcement. NHS hospitals have been mandated to refer people to the Home Office for bills not paid within three months.

Even in primary care, where there is currently no charging, the Home Office was still accessing patient records of suspected migrants often without the knowledge of the doctors. There have also been many reports of women who have gone to the police escaping violence or abuse being referred to the Home Office. In one particularly gross case a woman sought care at a sexual assault clinic after being raped and was taken into detention after the clinic called the Home Office. The result: some of the most disadvantaged people in our society are made the most vulnerable to abuse.

For many NHS patients, producing your passport at maternity checks is the new normal. Unsurprisingly, this requirement tends to be waived if you’re white or middle class. And of course, not everyone has the privilege of a passport. Therefore, as the Windrush scandal demonstrated, it’s a double burden if you’re both BAME without documentation. If you’re black or brown and ‘sound foreign’ or ‘look foreign’, you can, like Albert Thompson, be refused cancer treatment.

Pregnant mothers dying because they’re too scared to see a doctor. Black Britons being racially profiled as they enter hospitals. Any one of these scandals should have been enough to end these inhumane policies. But we didn’t see a shift until Covid-19. The outbreak of a pandemic has exposed our interconnectivity, and shown us that denying healthcare to the marginalised puts the health of everyone else at risk.

Long before Covid-19, the Faculty of Public Health had raised concerns about under-diagnosis and under-treatment of infectious diseases as a consequence of racist policies. There are no racial boundaries when it comes to pandemics. Belated realisation of this fact forced the Tory government to change course and declare that those requiring testing and treatment for coronavirus would be exempt from NHS charging.

But this won’t be enough. There is plenty of research to show that migrants suffering from other infectious diseases, such as tuberculosis, are still deterred from seeking care due to fear of being referred to the Home Office. Furthermore, mass testing and contact tracing can’t be carried out effectively when you have a section of the population who have been marginalised and forced to live outside the healthcare system. Racism and xenophobia are not just moral failings — they are considerable obstacles to sound public health policy.


Unfortunately, many of these policies were supported by Labour’s own MPs. In the New Labour years and beyond ‘our NHS cannot be the World Health service’ became a common refrain. But so-called ‘health tourism’ is estimated at 0.1–0.3% of the NHS budget, less than what the NHS spends on stationery. Despite the reality, politicians and the media have used the dehumanising ‘health tourist’ narrative as a useful scapegoat for the underfunding of our public health services.

The white British population would not be expected to justify their economic contribution to this country before receiving healthcare — and nor should they be. So why is this expected for migrants or people of colour? In Ireland, a firewall has been set up so migrants can access healthcare and other essential services without fear during this crisis, and visas have been automatically extended.

In Portugal, all asylum seekers and undocumented migrants who have pending residence applications can automatically access state support. Undocumented immigrants and asylum seekers in Portugal have been granted the same rights as residents, including access to medical care, in the current state of emergency. In South Korea, undocumented immigrants can be tested without the risk of deportation. But in the UK, the government has not followed suit.

Covid-19 alone does not have the power to unpick xenophobic and anti-immigrant sentiment. It has, however highlighted, the question of society and humanity. Those in power, who marginalised and dehumanised the vulnerable, are now as dependent on their migrant and ethnic minority workforces as they were in the aftermath of the Second World War.

Despite only accounting for 13% of the population in England and Wales, 44% of NHS doctors and 24% of nurses are from BAME backgrounds. Add to that a further 18% of frontline careworkers. And, according to the Health Foundation, many of them are migrants: ‘in June 2019, 13.3% of NHS staff in hospitals and community services in England reported a non-British nationality. Among doctors, the proportion is 28.4%.’

These are people who have received a weekly applause for keeping this country alive and yet they and their families are targeted with hostility and charges as if they weren’t instrumental to our public health system. Covid-19 has demonstrated worldwide that illness doesn’t discriminate and to best survive a crisis we must rely on our interdependency. In the discussions about the future of our health services, it’s time to bring marginalised voices to the forefront and ensure the truths exposed by this pandemic are not buried again.