Patients Not Passports: Challenging border controls in healthcare

In this interview, conducted over email between 10 June and 17 June 2020, Dr Kathryn Medièn, Lecturer in Sociology at The Open University, speaks to the authors of the recent Patients Not Passports: Migrants’ Access to Healthcare During the Coronavirus Crisis report. Patients Not Passports is a campaign led by Medact, Docs not Cops, Migrants Organise, and the New Economics Foundation, that seeks to challenge and organise against the imposition of border controls within healthcare institutions in England.
 

In the report, Akram Salhab (Migrants Organise), Aliya Yule (Migrants Organise), James Skinner (Medact) and Daniel Button (New Economics Foundation) present new vital research into the barriers to healthcare faced by migrants and BME populations in Britain during the Coronavirus pandemic. In the interview, Kathryn asks them about their key findings, how barriers to healthcare intersect with other social issues, and how we can all work to challenge internal border controls within healthcare institutions. Learn more about the work of Patients not Passports and view their toolkit designed to support people taking action to end immigration checks within the NHS.

You recently published a report – Patients Not Passports: Migrants’ Access to Healthcare During the Coronavirus Crisis - can you tell me why you decided to write the report and how you went about compiling the data?

We wrote the report for two main reasons. First, through the migrant groups and healthcare professionals we work with, it had become clear that an enormous problem - the exclusion of migrants from accessing healthcare - was taking place, unidentified, in the middle of the coronavirus pandemic. We had heard of numerous cases, one of which involved a man dying at home of coronavirus without calling a doctor, because he was so fearful of Hostile Environment immigration policies that exist in the NHS. He thought that he or his wife might be deported if they sought treatment. The damage to those we knew, and our concern for the  thousands of other people we didn’t know, all unable to access healthcare, motivated us to record these instances and make them public. We felt it was important to ensure the Government and health authorities had a crystal clear picture of the experiences detailed in our research and the recommendations arising from them, which are also reflected in reports by Doctors of the World and the Lancet. We wanted to be sure they could no longer say they didn’t know.  

Our second reason for writing the report was to deal with the apparent ‘mystery’ of BAME deaths from Covid-19. Through our work on the Patients Not Passports campaign, we knew we could identify at least one contributory factor of these deaths: Hostile Environment immigration policies. We thought it ludicrous that the Government should feign confusion as to the causes of the disparity when for years they have been telling migrants they are not welcome in the NHS, and racially profiling BAME communities. The public discourse, too, began from the premise that these deaths were inexplicable and required considerable research to determine their causes, or - even worse - that this had to do with bogus ‘race science’. We felt we could produce evidence very quickly that explained at least part of the story.

As we were working to a tight deadline, we collected information through a convenience sample of migrant caseworkers and community groups. Caseworkers could provide us with information anonymously, and without fear of potential repercussions for their immigration status, and because they often work with dozens of migrants, could give us a general sense of the situation as they saw it. Not only do they have an insight into the individual injustices faced daily by people targeted by the Hostile Environment, they are also able to identify the patterns of exclusion and discrimination that demonstrate the systematically racist nature of these policies. We sent them an online survey allowing for both qualitative and quantitative submissions and conducted follow up semi-structured interviews. We were keen to both collect data and identify general trends, as well as gather examples that could explain and personalise the nature of the tragedy we knew was happening. It is important to note, however, that many migrants, especially those whose status is most precarious, often do not want to make themselves known and thus do not receive any support from migrant caseworkers. As a result, our research is likely to understate the scale and depth of the issues highlighted. 

During the Coronavirus crisis there has been a lot of media and public attention focused on the Immigration Health Surcharge – whereby visa applicants pay a fee in order to access NHS services – particularly for these working within the NHS. This critical attention is welcome and has led to the government scrapping the surcharge for healthcare workers. However, we haven’t heard much about the NHS charges for overseas visitors. Why do you think this is?

Around migration, the Government’s policy-making procedure follows a now familiar course: first, introduce a policy whilst ignoring the moral and practical objections raised against it and with barely a modicum of legal due diligence; second, disregard all evidence of the policy’s harm as incidental; and finally, if pressure builds, to make minimal changes in the law to ameliorate the impact to one subsection of those affected by the policy. This, for example, is how the Government dealt with the Windrush Scandal, with only a few dozen of the tens of thousands affected getting compensation, and the Hostile Environment policy that created it remaining intact.

Similarly, the Government has completely ignored the negative impact of the Immigration Health Surcharge (IHS) both on individuals and on the healthcare system as a whole. It was evident that the surcharge constituted a double taxation, and that when applied to healthcare workers coming to the UK, was discouraging many from coming here and filling the many empty nursing and other healthcare jobs. Again, this was raised with the Government but it was only after the recent furore that they were forced to take action to address the problem for migrant healthcare workers. 

However the surcharge has not actually been scrapped yet, nor has it been scrapped for all healthcare workers, despite commitments from no.10. Further, the scope of the policy remains an open question - what will happen to outsourced NHS workers who in the social care workforce will be included, and will families and dependents of health and social care workers also no longer have to pay? 

Unfortunately the debate around the IHS was not completely helpful in the fight against other NHS charges as it reinforces the idea that people have to ‘earn’ their entitlement to NHS care - in this case by working for the NHS, and risking their lives. Not only is this an impossibly high bar to set for migrants to ‘earn’ entitlement to use the NHS, it undermines the central and founding principle of the NHS: that good health is a right that should be available to everyone via a publicly funded and universally available healthcare system. 

We haven’t yet been able to ignite popular opposition to secondary care charging in the same way, or in the way the Windrush scandal did, and there are many reasons for this. Often the policy operates silently and out of view of most people: the vast majority of people in the UK think that the NHS is simply free for everyone to use, and not that there are hundreds of thousands of people - many of whom have lived in the UK for most of their lives - who are unable to use the NHS. It is harder for people who face NHS charges to speak out, often due to their precarious immigration status and because they fear repercussions for them and their families.

However, with the onset of the coronavirus crisis, the problems of secondary care charging have become more apparent. During the pandemic, the Government has been hiding behind an ‘exemption’ that removes Covid-19 from charging, and halts immigration checks for people undergoing treatment for the virus. Our research shows that these measures are not doing enough to ensure people can get the healthcare they need, and demonstrates that the fear and deterrence generated by years of Hostile Environment policies cannot simply be undone by exemptions for certain conditions: people are too scared to attend in the first place for fear of being reported to immigration authorities. Further, we found that often both migrant support workers, and migrants themselves were not aware of the exemption. This speaks to the real disdain and lack of care the Government shows towards migrants, even during this unprecedented global crisis and public health emergency. The pandemic is exposing the true cruelty of secondary care charging. It demonstrates how limiting access to healthcare for huge numbers of people living here undermines the Government’s response to the crisis and poses a significant threat to the ability of the NHS to  protect everybody.

Throughout the report the connected issues of patient debt and data sharing between NHS Trusts and the Home Office arise as key barriers to healthcare access, both during the current pandemic and more broadly. Can you explain how this system works, and say a little about how the current pandemic is intensifying this barrier?

The key operating principle of the Hostile Environment is fear. Through a number of different policies the Government introduced immigration controls into public services and essential sectors, designed to exclude people who are undocumented from living any kind of normal life by blocking access to services and pushing people into poverty and destitution. With regard to the NHS, people are deterred from care for fear of their data - including their home address - being shared with the Home Office, who use this information to track, detain and deport people. Similarly, people are afraid of being asked for papers to prove eligibility for care, accompanied by the threat of being charged for their treatment at 150% of the cost. Many migrants are barred from working in the UK, and so people are fearful of receiving bills for treatment they cannot afford. Information about individuals debts to the NHS are also shared with the Home Office and used to deny visas. 

In our research we found just how corrosive these fears are. We found that the Government’s policy of hostility has been extremely effective with most migrants having received the message that they are not welcome. This has become so embedded in many migrants' understanding of the NHS that qualifications or exemptions from the policy that are supposed to protect particularly marginalised groups or provide free care for communicable diseases - like coronavirus or HIV - are often not known about and rarely believed to be true. As a result, migrants’ relationship with healthcare workers and basic trust in the system has completely eroded. 

The coronavirus crisis has exacerbated already existing problems. As above, fear overrides the exemption from charging that exists for communicable diseases. This means that people often don’t know that Covid-19 treatment is free, but even when they do, they are still too afraid to seek care, for fear of becoming known to immigration authorities, and putting themselves and their families at risk of immigration enforcement. Additionally, lockdown has meant that migrants as an ‘at-risk’ group have suffered the same challenges as others who are locked out of society by lack of access to the internet, enforced destitution, and other factors that we cover in the report.

It goes without saying that for people at risk of immigration enforcement from the Home Office, having your address passed on is equally if not more dangerous than being unwell. For many people accessing the NHS now means being exposed to increased risk of detention or deportation, or other punitive immigration controls. 

It becomes clear when reading the report that the lockdown has had untold effects on the lives of migrants and/or BME people in Britain, particularly those who are destitute. You make the case that overcrowded housing, lack of access to the internet and interpreters and the closure of public libraries and community centres are public health issues. Could you talk me through these findings?

We’ve long made the case that austerity in Britain is an inseparable part of the acceleration of anti-migrant policies spearheaded by the Hostile Environment. Much of our work in healthcare, for example, has identified how governments have introduced migrant charging into the NHS in order to lay the groundwork for a broader, as they describe it, ‘culture change’ away from a system of public health provision to one based on the ability to pay, creating much of the infrastructure needed to charge people for treatment. So what we are fighting for is not only migrant justice, but for the very heart of the NHS: our shared values of ensuring that healthcare is there for those who need it. 

Migrant communities have often been used as the testing ground for new draconian measures, and as such, are often the first and worst affected by these policies. With  public facilities closed, information is less available and the Hostile Environment has pushed many ‘underground’ - unable to work, rent property, fearful of sending their children to school, unable to access a driving licence, or open a bank account, and so on. This has made virtually every aspect of their lives more precarious, a precariousness which the Covid-19 pandemic has laid bare.

The fact that so many migrants do not have the right to work means that many are forced into highly exploitative situations, or are reliant on the Government for the incredibly minimal support it provides. Asylum seekers, for example, are expected to live on just over £37 a week, housed in accommodation provided by the Home Office, which is often overcrowded (entire families are expected to share single rooms), dirty and unclean, and - during the pandemic - have had the minimal communal spaces closed. Not only is there an ignored and forgotten mental health crisis that exists amongst the migrant population due to their dehumanising treatment, during the pandemic migrants  are far-more at risk of contracting the virus, and of being unable to afford masks and cleaning products to protect themselves and their families. Further, WiFi is not provided in accommodation provided by the Home Office, or is extortionately expensive, so many people are unable to find out the public health information they need through the internet. Nor do they have the mobile data to spend hours on video-calls, which is increasingly how doctors’ appointments are operating. 

Interpretation is one of the many services that has fallen victim to austerity with cuts leading to limited supply of and reluctance to use interpreters. We found that many individuals were denied interpreters by penny pinching managers, confused and discriminatory frontline staff or simply by an inability to relay the need for an interpreter over the phone. Many of the avenues for seeking support have closed down due to cuts in funding, with community organisations, overwhelmed and under resourced, trying but struggling to step in.

Something that struck me when reading the report was the presence of what you describe as a ‘culture of discrimination’ within the health service, which is both exacerbated by and extends beyond the NHS charges. You write about how, in the context of Coronavirus, this weakens trust in the NHS and is incompatible with the delivery of appropriate care. Why is trust such an important issue in this context?

The Hostile Environment legislation, along with other recent Government initiatives such as the anti-terror Prevent laws, should be considered as novel and alarming approaches to creating and implementing policy. Their particular innovation, and therefore their danger, is that they recruit individuals employed by public bodies to work as extensions of the security state. Healthcare workers who chose careers to provide care and support to ill people, are being drawn into acting as border guards - checking a person’s immigration status and even, on occasion, being forced to provide substandard care because of that status. 

This recruitment involves a whole host of training and internal procedures that encourage healthcare workers to no longer see people as only patients. Under the Prevent legislation, healthcare workers are asked to look at relatively normal behaviour amongst Muslims as an indicators of terrorism. Under the Hostile Environment, they are told that individuals with foreign names or those from a BAME background are potentially ineligible for free NHS care,  and need to be challenged and checked. This invitation to treat people differently on the basis of race, religion or country of origin gives license for individuals to act with impunity in who they suspect, and from whom they demand proof of entitlement of innocence. In a country with the colonial mentality that Britain has, this opens the door to a worrying and increased trend in racist attitudes now reinforced by the power of the law and disseminated via training and policy. 

Taken together, these phenomena have completely undermined trust between migrants and healthcare workers. This relationship of trust, always important in a healthcare setting, is ever greater in the context of a pandemic: a point that the WHO has made repeatedly and which we highlight at the end of the report. If migrants and BAME communities in Britain believe that healthcare workers are only interested in the colour of their skin or passports, then they will not come forward for care to the detriment of their health and public health more generally. Our report uncovered many cases of people believing they would receive worse treatment if they came forward with Covid-19 symptoms because of years of discriminatory treatment in our public services: a fact that, for many, seemed to be confirmed by the disproportionate number of migrant and BAME people who have died of coronavirus.

In the context of a pandemic, this mistrust is nothing short of disastrous for those affected and detrimental to any attempts to combat the infection. Track and trace will also not work in a system where people think they are likely to be targeted because of their race or immigration status. 

You end the report with a number of concrete recommendations for change. Could you outline these and elaborate on what steps individuals and organisations can take?

Our recommendations reflect the urgent need to end the hostile environment to enable a return to truly universal public services, which anyone can access without fear of discriminatory treatment. In the NHS, this means the end to all secondary care charging for migrants, and the creation of a firewall between health services and the Home Office, to ensure that patient data will never be used for immigration enforcement. To this we have also added the need for an awareness campaign, to alert migrants that they can access healthcare without fear once these policies have been reversed.

The only way change will come about is through large scale, mass resistance to the Hostile Environment from those public sector workers who are being tasked with implementing it. This includes healthcare workers, but also extends to other sectors of society in which the Hostile Environment is implemented, including in universities, schools, housing, employers and elsewhere. For example, primary school teachers and parents successfully refused to comply with a requirement to hand over information such as race and nationality of their pupils - information which was being shared with the Home Office. Collective action works when all sections of the community come together to resist unjust policies.

Hospitals and universities are the most promising site for the kind of large-scale, collective actions that will be required to bring about a change in the law. Whilst individual actions are always important, it is only through mass action - particularly by healthcare workers, lecturers, and more refusing to allow the Government to turn them into border guards - that we can affect the policy changes needed to preserve and grow the universality of our public services. 

We are organising alongside a vast movement of healthcare workers, migrant communities, NHS campaigners, and trade unions to achieve this, and to create the legal and political resources to make this form of collective non-compliance possible. The UCU has done some great work around Prevent in the past and expect that they will also need to play an important role in helping create legally sound and viable ways of protecting their members wanting to take action.