No one should avoid healthcare because they are scared of the debt they’ll incur, or that they’ll be deported, especially not during a public health crisis like Covid-19. The nature of coronavirus means that we are only as protected as the least protected amongst us. But many migrants face life threatening exclusions and racial profiling when accessing NHS.
The NHS was founded on the principle of universal healthcare, that everyone could access for free, regardless of background, nationality, or ability to pay. The Hostile Environment means this is no longer the case.
A man, known only as Elvis, who had lived in the UK for 10 years and worked as a cleaner, died at home of coronavirus, after having severe symptoms for two weeks. He did not seek help from the NHS because he was scared he’d be landed with a huge, unaffordable bill for his treatment, or that he would be reported to immigration authorities.
In response to the coronavirus crisis, the Government has made a number of minor changes and adaptations to the NHS Charging and Covid-19 was added to the list of conditions exempt. But the report we produced with Medact and the New Economics Foundation and with colleagues in 53 migrant organisations from across the UK shows the devastating impact of NHS charging on the most vulnerable people who are afraid to seek care or speak out.
We need you to take action now and urge the government to immedietly end the Hostile Environment and make the the NHS safe and free for everyone, by:
1. Stopping all NHS charges for migrants, so no one is left to pay unaffordable fees for medical care.
2. Ending all data sharing between the NHS and the Home Office, meaning that patient data will no longer be used for immigration enforcement.
3. Launching a public health campaign to ensure NHS staff and the public are aware of these changes.
These measures are urgently needed. They echo the recommendations made by: the Lancet Commission on Migration and Health, 60 MPs, the Mayor of London, the BMA, six Royal Colleges that represent doctors and midwives, and over 100 civil society organisations. They can and should be implemented now to end the Hostile Environment in the NHS and ensure genuinely universal access to healthcare
We received 70 responses from representatives of 53 different organisations, spanning London and the South East, West Midlands, East Midlands, Yorkshire and Humber, North East, North West and Wales. Each of these respondents supports numerous migrants at one time. So, while the sample of case workers is relatively small, each respondent is able to speak from their experience of supporting dozens of individuals each year.
It is clear from these responses that migrants are facing a multitude of barriers to accessing healthcare during the pandemic.
The result is that migrants are less willing and able to seek care. Over 70% of survey respondents report that the coronavirus crisis has negatively impacted on migrants’ willingness to access healthcare
Jamal (not his real name), based at a migrant centre, works to ensure that asylum seekers and refugees have access to mainstream health services. While the centre is closed during the lockdown, support continues over the phone.
Those supported by Jamal face a range of barriers to healthcare. GP surgeries frequently require specific forms of ID and/or proof of address, which newly arrived asylum seekers often don’t yet have. Some have improved their access requirements in recent months, but many have not. This means that asylum seekers have to register for a GP far from where they live, which is hard for many who cannot afford to travel. These barriers have worsened as a result of the coronavirus lockdown.
With many services and NHS facilities now physically inaccessible, Jamal and colleagues are spending a lot of time supporting clients to register for services electronically, and some GP surgeries have said that they are not registering asylum seekers.
Yeah, a lot of places the door is locked or the building is locked. You can’t even come in to register.”
In Jamal’s experience, there are signs that charging legislation has begun to introduce a culture of discrimination in the health service. For instance, whilst charging does not apply to primary care, ‘it still filters down’. Jamal has experienced receptionists not registering people because they are told that they ‘could be an illegal immigrant’, and GPs not referring patients to secondary care because they are ‘not eligible for it’.
They shouldn’t be making those decisions, obviously.
That language of the Hostile Environment is coming through in the GP surgeries.”
Another man with severe mental health issues was asked why he doesn’t ‘go back home’ by a nurse.
Ultimately the practice and perceptions of NHS charging and data-sharing, and the resultant denial of care, is leading people to delay seeking care, avoid it all together or seek informal support and medical advice.
This is causing serious and long-lasting health consequences.
One man we supported had previously been homeless and his asylum claim had been refused. He had diabetes and did not know, he did not think he could go to the doctors as he did not have status. Because he did not receive treatment, he went blind for 6 months.”
One [client] had a miscarriage and had not seen any doctor because she had no immigration document. She is scared she will be taken away.”
The charging regulations place stringent requirements on people to prove that they are in one of the exempt categories, particularly for survivors of trafficking, torture, or domestic abuse. The institutional disbelief in people’s circumstances, combined with language barriers and the difficulty in obtaining the right documentation, has the effect of deterring people from seeking care altogether.
Accessing health services is a last resort when people are desperately ill. Usually people suffer in silence and use home remedies or if possible over counter medications. People want to limit the scrutiny they have to go through in qualifying for medical exemption.”
Based on our experience, initially, clients would not be overly aware of NHS charging at all, let alone categories that are exempt. They would come to realise it once charges are imposed on them or their family/friends, but then they would not be aware of certain exceptions.”
Although Hostile Environment policies primarily target secondary care, they are having a knock-on effect on other services. Respondents cite instances of GPs unwilling to refer patients to secondary care:
Client in [Yorkshire] was not referred to secondary care by his GP as the GP knew he wouldn’t be able to pay. The GP should not be making this decision. The person should be referred to the specialist to assess if the treatment is immediate and necessary.”
Clients with no immigration status are barred from accessing secondary care. GPs either do not refer such individuals, or the referrals are turned down.”
There are examples of people being asked to ‘prove their entitlement to care’ at the door of A&E or GP practices, in contravention of NHS guidance. One survey respondent clearly identified discrimination from staff as a factor deterring people from seeking care. Another details her experience of having to prove her entitlement to care:
When I was pregnant, they didn’t believe me that I was Polish and entitled to health care as an EU citizen. I had to send a copy of my passport to the hospital and was taken to a different room for questioning. It was stressful because I didn’t know what was going on. Everything was a new system for me. … I left that visit in tears and thought about filing a complaint. It felt like discrimination.”
One of the concomitant effects of the Hostile Environment is the proliferation of a culture in the NHS that prioritises the questioning of a persons’ entitlement to care, over and above their clinical need. In practice this often leads to racial profiling, with increasing reports of assumptions about a person’s entitlement or immigration status based on how they look, how they sound, or their name.
For more information and to keep up to date check out Patients Not Passports Campaign Toolkit