Dr Jess Potter: ‘I am your Doctor First’
@DrJessPotter is a respiratory doctor and recently completed her MRC-funded PhD at Queen Mary University of London. She also campaigns for the healthcare rights of migrants with Docs Not Cops and Medact. This year, for her campaigning work she won Champion of the Year at Woman on the Move Awards. You can hear Dr Jess on BBC radio making an argument for her right to be your doctor first. On the NHS’ 71st birthday in her guest blog she bring back some of the the spirit of its visionary founder Nye Bevan
In 2015 I stepped away from my work on the frontline of the NHS as a junior doctor to start my PhD. My aim was to explore how people who had moved to the UK experienced accessing healthcare when they became unwell. What I found was shocking and totally undermined the NHS principles I hold so dear.
I also gave birth to my son in 2015. After an emergency caesarean section I went into septic shock. Without access to healthcare, I might not be here today. I cannot imagine how I would have acted if I had known deportation, immigration detention, or destitution might be the outcome of accessing antenatal services. I cannot imagine how frightened I would have been to be confronted with a bill of thousands and thousands of pounds after giving birth to my baby. I cannot imagine turning up at health services and having my right to be there questioned. But that is what 2015 meant for so many of the people I have met through my research and campaign work.
Access to healthcare for migrants has become increasingly restrictive. In 2015 legislation was introduced that increased the amount people could be charged to 150% of the cost of treatment, and excluded people who had come to work or study in the UK, including healthcare staff, from free NHS secondary care. Instead, an immigration health surcharge – now £400 per person per year – was levied as part of the visa application process. This fee does not change relative to your earnings and it is not waived if you work in the NHS or if you pay UK taxes. It does not even give you the same access as British citizens – fertility treatment is withheld. One man told me of how his child would not be here now had they been born just a year later, as IVF had been the only option for him and his partner who was born overseas.
Alongside these increased charges for care, 2015 also saw an expansion of the sharing of patient data between the NHS and the Home Office. Whilst GP appointments and A&E treatment remain free to all, one of the people I interviewed as part of my research made clear the impact of data sharing , “Do you think that I risk going to the hospital who will inform the Home Office?” This fear is not unfounded. Despite concerns raised by the Health Select Committee, the patient data that is shared is used for immigration enforcement, often without the person’s consent. One overseas visitor manager I interviewed told me of a patient arrested on hospital grounds after their clinic appointment.
This increased surveillance within the healthcare service extended to frontline staff who are encouraged to pass details of patients they suspect should be charged for NHS care onto Overseas Visitor Manager teams. These teams were deployed to educate healthcare staff in their duty to report patients who were not eligible for care, a job the overseas visitor manager told me was easier for clinical staff who were “closer” to the patient’s details.
The identifying of individuals perceived to be ‘foreign’ often involved discriminatory profiling. I was emailed a while ago by an individual who expressed concern they had been racially profiled in this way and was asking for support to access the care they needed. According to the Department of Health implementation guidance for the NHS charging regulations everyone should be asked the question, “Where have you lived in the last 6 months?” If the answer is the UK, no further action should be taken. This individual was the only person in the queue booking into a clinic to be asked that question. Even if they were not profiled, they felt discriminated against and this still causes harm and undermines people’s trust in the NHS.
In 2017 restrictions were extended. Eligibility for care must now be determined up front and treatment withheld in lieu of payment if an individuals’ condition was considered non urgent. Eligibility is difficult to determine for a number of reasons, simply asking for a passport is insufficient and leads to discrimination, as a consultant pointed out to me recently when deciding on the follow-up of a patient retiring to Europe – so long as they’re white and have a UK address people are unlikely to be billed.
The NHS was created to be a universal service, available for all who needed it, with care never withheld based on someone’s ability to pay. Any charges for care undermine the foundational principles of the NHS, and the upfront charging system introduced in 2017 is a huge step in the wrong direction. Now healthcare workers are tasked with determining patients’ immigration status; forced to make complex decisions about how urgent treatment is versus how able someone is to seek care somewhere else; and having to negotiate substandard treatment plans with people that can’t afford the medication they really need.
Healthcare workers are trapped by these policies, forced to undermine their duty of care to patients and threatened with fraud if they do not uphold the regulations. Knowingly or unknowingly, we are now complicit in the detention and deportation of the people we are supposed to be caring for. This is distressing to say the least and as the NHS becomes increasingly linked with immigration control, many healthcare workers have nowhere else to turn for advice on how to support their patients. I have spent hours on the phone to doctors who want to advocate for their patients. One told me they were pressurised by hospital management and senior colleagues to discharge someone so unwell they would die without treatment, simply because they could not prove their legal entitlement to care.
With a massive staffing crisis we can little afford to drive even more doctors away by making the NHS an untenable place to work. This is a very real threat revealed through my work with EveryDoctor – a grassroots organisation campaigning for the working rights of doctors. We work with large online communities which allows us to listen to the concerns NHS staff raise about their everyday working lives. Many doctors have expressed concerns about unaffordable visa and health fees, been made to feel unwelcome because they were originally born outside the UK, and still others who experience the broader effects of institutional racism.
The impact on us as healthcare workers is nothing compared to the harm these policies are causing patients. Last week, the British Medical Association (BMA) revealed evidence of what we as healthcare workers already knew; that charging migrants for NHS care is discouraging them from seeking the care they need. The clear evidence up and down the country is that NHS charging does not save money, is dangerous for patients, a threat to public health, and must be scrapped. This is supported by evidence from the Equality and Human Rights Commission that the policy is negatively impacting asylum seekers, and from Spain where the introduction of a similar system led to a 15% increase in mortality for undocumented migrants. Recent research carried out by healthcare charity Medact revealed that no NHS Trust in England has a system in place to monitor the impact of the policy, meaning we must rely on healthcare workers and patients coming forward and telling their stories so we can understand the true harm the policy is causing. The research also revealed that the majority of Trusts provide little to no training to the healthcare workers required to enforce the policy, leaving staff confused about how to ensure people get the care they need.
Increasingly we are being supported by the bodies that represent us, starting in December last year with a statement from a coalition of Royal Colleges representing over 70,000 doctors and followed in March 2019 by the Academy of Medical RoyalColleges, with both demanding the DHSC suspend the policy and immediately commission an independent review of its impact. We welcome the BMA joining us and adding to the mounting pressure on the DHSC to listen to the concerns of healthcare workers. Unfortunately the DHSC still refuse to publish the findings from their internal review of the policy, despite the fact they admit it was being applied incorrectly and causing harm to patients.
So, in the face of overwhelming evidence, why is the Department of Health and Social Care still forcing NHS Trusts to charge patients? With a government more intent on looking strong on immigration than upholding our international obligations to human rights and universal health care, it is down to us to act. Across the country, healthcare workers are calling on NHS Trusts to join them in standing up for the rights of the communities they serve with campaigns now running in London, Liverpool, Birmingham, Brighton, and Manchester. There is still much more we need to do in order to ensure the NHS stays true to the universal values on which it was founded.
My commitment to the values of universality and equity is why I joined the campaign for a health service that sees #PatientsNotPassports. As a member of Docs Not Cops and Medact, working alongside Migrants Organise and many other organisations I have tried to make these stories of harm visible. The intrusion of the hostile environment into the NHS is widespread, constructed through government legislation and propped up by a wider xeno-racism that permeates our society.
On Tuesday, April 30, hundreds of healthcare workers, patients, campaigners and ordinary members of the public met in central London to declare their opposition to this abhorrent policy and their intention to fight it until it is scrapped. Now is the time to organise and stand up together for everyone’s right to health. All those who believe in a free NHS, the central, shared institution in our public life, are invited to join us in calling for an NHS that is for Patients Not Passports.
Dr Jess Potter
NHS is 71 today! As we continue the struggle to protect this essential service and ensure access to universal healthcare, decades ago, as he founded it, Nye Bevan has given us the best argument for why NHS must be free for all of us. Here is the quote from his book In Place of Fear