If there is a positive message to be drawn from the misery of the covid-19 pandemic, it is that of community. Of people in their thousands volunteering to support the NHS, of neighbours coming together to check on each other, of people taking measures to protect not just their own health, but the health of others. There has been a realisation that health is shared. Your health depends on my health—it is our health.
The health of every individual impacts the health of the whole population. Yet, over the past decade in the UK, this fundamental principle of public health has been undermined by policies that restrict access to healthcare for migrants living in the UK, threatening the health of all. These policies are politically motivated and in conflict with moral and financial logic.
The NHS charging regulations demand the full cost of care to be paid upfront for those unable to prove entitlement, at 150% of the NHS tariff, or treatment is refused. While exemptions exist, they are ineffective and inadequate. Since the introduction of the regulations, the fear of exorbitant costs or immigration enforcement has left some people in our communities wrongly refused treatment, led to unnecessary delays in vital care provision, and has caused preventable distress.
The Department of Health and Social Care (DHSC) have exempted treatment for covid-19 following a positive test result, but this exemption on paper is meaningless in practice. Firstly, patients and clinicians are largely unaware of the exemption, as the government has failed to run an effective public health campaign to ensure this information reaches migrant communities or NHS staff. Indeed, despite the importance of quick and accurate communication during a pandemic, concerns about “a significant gap in…public health information for individuals from ethnic minority populations, including those who are not online and those for whom English is not their first language” have been left unanswered. The charity Doctors of the World have stepped up to fill this role in translating the latest advice into 60 languages, but government communication remains woefully inadequate. Secondly, the exemption is too narrow to accommodate the novel nature of the virus or practicalities on the ground (for example the high false negative rate of the PCR test, or paediatric multisystem inflammatory syndrome which can be seen with a negative PCR result). The predictable, inexcusable end result is migrants have stayed away from health services and, in some cases reported in the media, died.
Covid-19 is disproportionately impacting ethnic minority communities, with the health and financial impacts significantly stratified by country of birth and ethnicity. When the contributing roles of healthcare access, comorbidities, occupation and housing in fuelling these disparities are examined, the thread that runs through them all is that of structural and institutional racism. Indeed, the government’s own equity analysis of the NHS charging regulations states: “non-white people or people for whom English is not their first language are, on some occasions, targeted in the application of the 2011 regulations due to speculation or assumption that they are not resident in the UK.” Nothing could be more plainly stated—the guidelines are increasing existing inequalities and discriminatory practices.
The consequences of the so-called “hostile environment” suite of policies have extended far beyond deterring people who are undocumented from accessing health services, as it has fostered racism and discrimination, and has erroneously affected people with the legal right to use NHS services, due to fear of charging and data sharing with the Home Office. We can no longer continue to ignore the impact of the charging policy on undocumented migrants, but also on the people who are mistakenly caught up in these restrictive policies; or the wider impact of the xenophobic rhetoric towards migrants and asylum seekers which has so pervaded political discourse over recent years.
Lancet Migration was created to address evidence gaps and drive policy change through multidisciplinary research, and to counter the xenophobic politics filtering into health. While migrants have been made the scapegoat for societal disruption, immigration enforcement has embedded into public services and generated a culture of exclusion over fairness and justice. As the charging regulations have not been shown to be effective at “recovering” money for the NHS, and evaluation work on their impact has been suppressed, it is hard to conclude that this policy is anything more than a perfomative exercise in xenophobic politics that further intensifies institutional and structural racism. Among the political weaponisation of this population, the lives and people behind the degrading and discriminatory terms used are often forgotten: no human is illegal.
The NHS charging regulations epitomise this—restricting access to and embedding immigration enforcement within healthcare services perpetuates the prioritisation of entitlement rules over service provision and human rights. These discriminatory and restrictive regulations are threatening the health of us all. That is why Doctors of the World UK, the Faculty of Public Health, and Lancet Migration are initiating a coalition of academics, non-governmental organisations, professional bodies and people with lived experience of exclusion from healthcare to launch the Hands Up for Our Health campaign, with three key asks for central government:
- To immediately suspend the NHS charging regulations, giving everyone the chance to see a doctor or nurse when they need to. This public health change is needed urgently as charging migrants for hospital services threatens the health of both individuals and the population as a whole during the covid-19 pandemic.
- To carry out research and investigations into the impact of charging regulations on individual and public health, including during the first wave of the covid-19 pandemic, and to invite coalition partners to take part in joint action to bring about long-term reform of the charging policy.
- To commit to improving access to all NHS services for everyone living in the UK as part of the government’s plan to “build back better”. This should include developing policy alternatives to the existing regulations.
This campaign is a public health necessity—we must insist on the right to health over xenophobic, scapegoating politics. In launching this campaign, we hope to use health to shape politics, rather than merely allowing politics to shape health. Covid-19 has shown us what we can achieve when we come together: join us in raising our Hands Up for Our Health.
Lucinda Hiam, Clinical Lead for UK Policy and Advocacy, Doctors of the World UK; Programme Officer, Lancet Migration; NHS GP
Parth Patel, Policy Officer, Lancet Migration; Junior doctor in the NHS
Rachel Burns, Research Associate, Institute of Health Informatics, Faculty of Population Health Sciences, UCL
Miriam Orcutt, Executive Director, Lancet Migration; Senior Research Fellow, UCL Institute for Global Health
Anna Miller, UK Policy and Advocacy Manager, Doctors of the World UK
Maggie Rae, President of the Faculty of Public Health
Competing interests: None declared