Immigration White Paper: We treat #PatientsNotPassports

The government published its delayed Immigration White Paper yesterday, outlining its plans drastically to decrease the number of EU citizens able to migrate to the UK. This comes just after the NHS surcharge has been increased by 100% for visa applicants – now this will apply to EU citizens too. We spoke to Stacey Willliams, a doctor active in DocsNotCops about the damage the government’s immigration policies is already causing for her patients.

First of all, can you give us a brief timeline of how charging for access to NHS care has been introduced?

The roots of this go back a long way, but the current framework is governed by the 2014 Immigration Act. This came into force in 2015, with the introduction of the Health Surcharge to be paid by overseas visitors, initially set at £200 per year for temporary migrants and £150 for students. Payment of the surcharge, which was obligatory, provided access to basic services, but additional treatment would bring further costs to the individual. NHS trusts started hiring Overseas Officers, and a statutory obligation to collect payment retrospectively from eligible patients was imposed on health workers.

In 2016, a number of trusts started running pilot schemes for up-front charging on non-exempt treatment. Data released from these schemes suggested very little money was actually raised, and exposed the discriminatory way in which the system was being applied. However, the Department of Health rolled out the scheme on a national basis starting from 23 October 2017, and also started sharing patient data with the Home Office.

Campaigns by groups such as DocsNotCops, MedAct and Doctors of the World helped to suspend the Memorandum of Understanding allowing data sharing between the Department of Health and the Home Office in 2018, and stopped charging for healthcare in schools. Pending wider consultation and the findings of a report by a parliamentary select committee, chaired by Tory MP Margot James, data sharing remains suspended – although it still happens de facto if a patient gets into debt because of failure to pay a charge.  So you can still end up getting deported as a consequence of using NHS services. Meanwhile, the cost of the Health Surcharge was doubled from £200 to £400 (and £150 to £300 for students).

In all of this, the health unions and professional organisations haven’t been silent. In 2016, the BMA passed a motion denouncing the Immigration Act, and recently the medical union Doctors in Unite has pledged to support health workers who refuse to check patients’ eligibility for care.

How do you respond to government claims that charging non-UK residents for NHS healthcare is necessary because of the drain that “health tourism” puts on NHS resources?

The government tries to make out that there are large numbers of people who purposefully travel to the UK to receive NHS treatment, costing the NHS up to £500 million per year. This argument is often repeated, including by some doctors, unfortunately.

The basis for this claim is very shaky: much of the spending covered by this figure is on people who are here for other reasons, have family here, and long-standing connections to this country. But there is also a more fundamental ideological issue here: the idea that some people contribute more and that they deserve healthcare more.

In DocsNotCops, we’d argue, firstly, that everyone has a right to healthcare, and no-one should be afraid to access NHS services because they cannot afford it, or because they worry that their immigration status will be reported to the Home Office.

Secondly, as health workers, it’s not our job to assess our patients’ immigration status or their ability to pay for treatment. Our job is to treat the people in front of us.

Thirdly, the data we have suggests that more is being spent on implementing the policy than is collected from those liable to pay. Currently, the Department of Health’s own statistics suggest that only 0.3% of the NHS budget is spent on “health tourism”. Only a fraction of this is ever actually recouped.

So the policy works more as a deterrent: scaring people away, many of whom may actually have a right to free treatment under the legislation, so they never come to hospital in the first place.

Can you talk about some of the ways in which the charging regime reinforces other forms of oppression?

Let me give you three examples.

First, let’s take maternity care. Although considered emergency care, you can now be charged retrospectively for accessing maternity services at 150% of the rate of the NHS calculated tariff. You can also be charged for abortion (the charging exemptions for family planning do not cover termination of pregnancy).

Of course, if you’re in a stable marital relationship with a partner with residency rights, you might be able to access the services you need. But what if you’re not? Or what if that changes? The UK is now unusually regressive on this: many European countries do have provisions to ensure undocumented migrants can access maternity services free of charge. The system here leaves many women in a very dangerous situation.

Secondly, the charging system around mental health. You are exempt from charging if you are sectioned – that is, if you are given treatment against your will. But there are patients with very severe mental health needs who may consent to treatment, and they can be charged. The system starts from the potential danger that patients with mental health issues pose to society, not with the patients’ own needs. This reinforces the worst kinds of stigma.

Thirdly, there is the Windrush scandal that you will already be familiar with. It demonstrates so clearly how this whole system is racialized. What does it take to be believed that you are British if you are a person of colour? The cases of people who have lived their whole lives here being rejected care stand in sharp contrast to white ex-pats who return for treatment, which they are often given without question, even though they are technically ineligible. I’ve got no problem with them getting treatment – the point is it should be available for everyone.

What is DocsNotCops doing to try to reverse these policies?

Initially, our work was about raising awareness among healthcare workers and the public, and providing support to health care workers trying to get their unions and professional organisations to come out against the charges.

But over time, we’ve started to develop a couple of models for organising more directly against the charges.

In Brighton, we have a group that works through the local staff unions to give workers the confidence to challenge unfair charging. The strength of the local union organising is sometimes enough to persuade the Overseas Officers not to pursue patients.

We have a very exciting campaign in East London, at Bart’s Hospital. There, a lot of working behind the scenes with health workers at the hospital, as well as with community-based campaigns, such as the local Keep Our NHS Public group, and NGOs like MedAct and Migrants Organise, led to a big health worker meeting in July 2018. Over fifty people associated with the trust were there. Now both health workers and the local community have drawn up an Open Letter, calling on the trust to refuse to comply with the charging regime. We’re planning another meeting to further involve community groups.

There are useful lessons from the Bart’s campaign. First, of all, we worked out that this was somewhere where we could really influence the conversation locally, as we had strength both inside the hospital, and in the local community organisations. Then, we found a weakness. Bart’s had been piloting a scheme, where patients were asked to bring two forms of ID to every check-up. This really annoyed everyone, and of course discriminated against those without papers. But we found out that out of 8,900 people who did produce papers, only 50 were eligible for charging. So we could easily say this was a waste of money. Bart’s has now scrapped the pilot scheme.

There are other things health workers are doing to make the charging regime unworkable. Some GPs have deliberately been registering migrant patients as having No Fixed Abode to get round data-sharing with the Home Office. Sajid Javid renamed the “Hostile Environment” the “Compliant Environment”. We are trying to build a non-compliant environment.

The people we treat are #PatientsNotPassports, because we are #DocsNotCops. We need to share experiences of working round the legislation, and build more campaigns like the one at Bart’s that combine strength inside and outside the hospital, as we fight to bring an end to charging in the NHS altogether.


See the DocsNotCops website, and the toolkits for workplace and community activism on the PatientsNotPassports website (developed by DocsNotCops, MedAct and Migrants Organise).


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