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Coronavirus and the hostile environment

Originally published Tribune Magazine.

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.


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