This Is Not Part of the Deal: Refugees, Migrants and Access to the NHS

One thing I’ve noticed as a migrant in Britain is that you’re told to be grateful for whatever you have been given by the Government. Paying taxes alone is not enough: you have to follow the rules (of which there are very many for migrants), and only if you behave will you be given more rights and entitlements, and you really need to appreciate them because no one asked you to come here. 

I have paid the Immigration Health Surcharge three times – the double-tax that migrants have to pay to get to use the NHS – costing about £2,000 in total. Since I moved here, I have been to the GP probably four times, one of which I paid for privately. But that is the deal, which I guess I struck with the UK Government by virtue of living here, and I am lucky enough to be afford it and not have to think too much about the cost of going to the doctor.

But my recent experience assisting one of our members to obtain an exemption to her NHS charges, however, radically changed my perspective on access to healthcare. Our member, known as Elizabeth, is a single mother from Nigeria. I worked with her for a few years initially to help her with her asylum claim. Like many others in her situation, she has been through much more than anyone should. After years struggling with the Home Office, she finally obtained her refugee status in 2019. I remember her coming to the Migrants Organise office, with her newly minted pink biometric card with “refugee” written on it, her face beaming with excitement. As an adviser in the migrants and refugee sector, you don’t get a lot of big wins, so you really do cherish moments like this one.

Along with her brand-new biometric card, however, she also brought a huge invoice that she had just received from the NHS. She asked me what the letter was about, and with a heavy heart, I had to explain it to her as I watched her smile disappear: since 2015, many migrants have to pay – sometimes upfront – to use the NHS, up to 150% of the cost of their care. Elizabeth had received treatment from the NHS in the past and had been identified as a so-called ‘overseas visitor’: someone who should be paying for their treatment. 

“But don’t worry, it must just be a mistake” I said very confidently, “you are a refugee now, and the Government’s policy is explicit that all NHS services, including past ones, provided to a refugee are free, so we should be able to sort it out in no time.” 

This is what the Department of Health’s guidance says:

Anyone granted asylum, temporary protection or humanitarian protection under the Immigration Rules made under section 3(2) of the Immigration Act 1971 is recognised as a refugee and is exempt from charges… 

…charges incurred prior to a person being recognised as a refugee must be refunded or, if not yet paid, cancelled… 

I sent a letter to the relevant NHS Trust in August 2019. I referred precisely to the relevant part of the guidance and regulation, included a clear copy of the Home Office’s issued biometric card, and politely asked them to cancel all of the charges. 

To my surprise, they refused. 

Instead of simply cancelling the charge, they demanded answers to intrusive and entirely unnecessary questions about Elizabeth’s asylum claim, such as when did she arrive in the UK, when exactly did she start her claim and, what was the reason for her claim – questions which the Home Office had already gone through in great details in the asylum process. 

I wish I could publish here the entirety of the correspondence: a back and forth of more than 20 lengthy emails over the course of a year, of me trying to understand why Elizabeth would need to re-traumatise herself by telling her story all over again, and practically pleading with the Overseas Visitor Manager team in the NHS to indicate under which legal provision, or guidance, or any kind of published, unpublished, or yet-to-be written policy, is such an investigation required. If there was such a requirement, I would have happily complied, because that would be part of the deal. 

Alas, this was the explanation I received:

Thank you for your patience regarding this matter.

I have liaised with my line manager and have been asked to obtain further information/documentation. I must again request supporting documentation to confirm [the client’s] circumstances so I can request my management team to make an informed decision regarding the case.

While I completely understand the sensitive nature of the documentation requested it is because it is vital for me to be able to present a clear explanation with evidence to be reviewed and considered for [the client’s] case.

In summary, the information was needed because her manager asked her.

I escalated the issue through a formal complaint process, spending hours writing it up, gathering and collating all the evidence. They replied requesting a conference call to discuss the issue. We were meant to meet at the end of July 2020 – nearly a year after Elizabeth had received a bill she should never have been issued with in the first place. But just one day before the meeting, the Trust emailed to say that having reviewed the case again, they would finally cancel Elizabeth’s NHS charges. The meeting was summarily cancelled without the courtesy of waiting for a response, as they had deemed the matter closed.  

So now I am angry: firstly, for the absolute waste of my and our member’s time, fighting over something which should not have been an issue in the first place. I am also angry thinking about what people in Elizabeth’s position would have done if they had no support from organisations such as ours. I have a bachelor and master’s degree in law, and it took me one full year to sort this out. Elizabeth is also not the first of our members to have been incorrectly charged, and it’s not the first time that an NHS Trust refused to withdraw the bill, and it certainly won’t be the last. 

Mostly, however, I am angry because this is not part of the deal. Elizabeth followed the rules: she answered questions from the Home Office, she told and retold the story of her past trauma and why she cannot go back safely to her home country, she endured living in squalid asylum support accommodation and living on £37 a week for many years. Yet it seems that for an entire year, they have been trying to cheat her from what should have been given to her as part of the deal.

Are we still supposed to be grateful?

Brian Dikoff is the Legal Organiser at Migrants Organise.

To find out more about NHS charging, the Hostile Environment in the NHS, and its impact during coronavirus, read our report with Medact and the New Economics Foundation, and make sure to sign the petition to end all Hostile Environment policies in healthcare. 

If you have been affected by similar issues, please get in touch with Aliya, our Access to Healthcare Organiser at