Xenophobia in the UK Health System

By Guest writers at Doctors of the World

In 2020, the Faculty of Public Health, Lancet Migration and Doctors of the World UK launched the Hands Up for Our Health campaign calling for everyone in the UK to have access to NHS services during the COVID-19 pandemic regardless of immigration status. Since then over 60 non-governmental organisations (NGOs), unions, medical organisations and academic research teams have joined the campaign*. The campaign’s aim has little to do with changing entitlement to NHS COVID-19 treatment and services (which are freely available to everyone) and is much more concerned with the circumstances under which we entered the pandemic, where refugees, asylum seekers and migrants without status were unlikely to reach NHS COVID-19 services in the first place. Most refugees and migrants without formal immig

ration status are not registered with a GP and therefore do not have an NHS number. Before the pandemic, not being registered with a GP meant limited access to primary care services. Once COVID-19 arrived in the UK, it became clear that the lack of an NHS number meant a person was outside of the healthcare system altogether and was therefore unable to book vaccination appointments or get proof of vaccination status. At times we have seen people struggle to even get a COVID-19 test because they did not have a bank account and financial footprint in the UK. A cruel and complex NHS charging policy, introduced in 2015 as part of the UK’s hostile environment, also ensures that people without immigration status or with refused asylum claims cannot receive most NHS secondary care services free of charge. Those in need of hospital treatment or an appointment with a specialist are forced to pay huge and inflated medical bills in advance. Anyone who does receive NHS treatment they are not entitled to – either through luck or as an emergency – and cannot pay is reported to Home Office and put at risk of being deported. At the Doctors of the World’s clinic we see patients who are denied medical care or who are too afraid to access NHS services going to extreme measures to manage health conditions alone, buying medication online, avoiding antenatal appointments with a midwife and taking paracetamol in substitute for palliative care.

This NHS charging policy is not only deeply unfair and dangerous during a pandemic, it also disproportionately impacts Black, Asian and minority ethnic (BAME) patients. BAME patients are more likely to be targeted for immigration status checks in hospitals and are less likely to be able to pass an immigration check, even if they are fully entitled to all NHS services. In this way, the policy is a classic example of structural racism - a policy and series of accompanying laws that result in and supports the continued unfair treatment (poor access to NHS services in this case) for some people based on race. An equality analysis by the Department of Health and Social Care found evidence that immigration checks in NHS services are sometimes targeted at “non-white people or people for whom English is not their first language…. due to speculation or assumption that they are not resident in the UK”. But the Department concluded that any indirect discrimination caused by the policy was “justifiable as a proportionate means of achieving the legitimate aim of the policy”. Time has shown this equality analysis to be correct, with NHS trusts continuing to use racial profiling to determine who is and isn’t eligible for free NHS care. There are well evidenced reasons why BAME patients are less likely to be able to pass NHS immigration checks, even if they are British citizens or fully entitled to NHS services. NHS immigration checks are complex, requiring a patient to demonstrate legal immigration status and residency by providing a combination of documents including photo ID. Electoral Commission data shows that of the 3.5 million British citizens who do not have any form of photo ID, lack of ID is highest amongst people who are unemployed or renting from a local authority or housing association. BAME people are overrepresented in both of these groups. And whilst 26% of adults in England do not have a full driving licence, this rises to 49% for Black people and 39% for people of Asian ethnicity. The case of Albert Thompson, a member of the Windrush generation in need of cancer treatment, is an example of how lack of paperwork leads to healthcare being withheld and delayed. The harrowing impact of the Windrush scandal, which saw Black Britons denied access to a range of essential public services including NHS care is now well documented. Less well documented is the everyday experiences of BAME patients who do not have a passport or driving licence and face extended delays whilst they persuade their hospital that they are entitled to free treatment. A third way in which the NHS charging policy contributes to unequal access to NHS services for BAME patients is in eroding of trust in the NHS. A recent review into ethnic inequalities in healthcare commissioned by the NHS Race and Health Observatory identified a deep distrust of NHS services by many different ethnic minority groups as a key factor that deterred people from seeking help from NHS services. Under the charging policy, NHS trusts send letters to patients they suspect are not eligible for free NHS care telling them they will be reported to the Home Office unless they prove their entitlement. In the Doctors of the World clinic, we see how these letters instill fear of the NHS in patients. Clinicians are also picking up cases of people who have lived in the UK since they were young children now avoiding medical care fearing it will lead to immigration problems with the Home Office. This fear and erosion of trust in the NHS amongst BAME communities is perhaps the most far reaching and insidious impact of the NHS charging policy. In response to COVID-19 vaccine hesitancy amongst Black Britons, Dr Wanda Wyporska explained "there’s a distrust… of authorities which is hardly surprising when the authorities have tried to send our grandparents back to the Caribbean”. This captures how mistrust of the NHS undermines our response to the COVID-19 pandemic and extends well beyond those without immigration papers. As attention turns to addressing racial inequalities in health and we seek to identify the structures that uphold race disparities within the NHS and then dismantle them, the role of the NHS charging policy must be considered. Data on the ethnicity of those affected by the policy is not collected and the government has long resisted calls for an independent evaluation of the policy. But a wealth of evidence from patients, community groups, voluntary sector organisations and clinicians shows the harmful impact the policy has on patients and the urgent need for action. Recognising this urgency, the Hands Up for Our Health campaign seeks to act on this evidence and push for an end to all policies that cut people out of the NHS, either intentionally or as an unintended (but accepted) consequence. *Race & Health is a member of this collaboration