How to end the hostile environment in the NHS

New research has found that migrants who need NHS care in England are denied treatment for an average of 37 weeks as a result of the government’s hostile environment policies. Just last week, Priti Patel promised to lead an ​“unprecedented programme of change to build a Home Office fit for the future”, while arguing that steps had already been taken to ensure that injustices like the Windrush scandal will ​“never happen again”. Yet the suite of policies that caused the scandal in the first place – the hostile environment – has not gone away. The government’s response even suggests that these measures will be extended to 2022.

Nowhere is the hostile environment more prominent than in the NHS, where migrants’ access to care has been restricted and border enforcement has been brought into the health system. Patients unable to prove their eligibility for care are charged up to 150% of the cost prices for some services. Behind this, NHS Trusts share patient data and report patient debt to the Home Office, which has used by immigration teams to track, detain and deport people.

These practices are still ongoing, and are having devastating consequences. The hostile environment means that many – including those entitled to care under current policy – are deterred from seeking care, face greater delays in accessing treatment or have care denied outright. In April, a Filipino migrant known as Elvis died at home with suspected coronavirus. He had lived and worked in the UK with his wife for more than 10 years, but was so scared by the hostility of government policies that he did not seek any help from the NHS.

A new report from the New Economics Foundation, Medact and Migrants Organise for the Patients Not Passports campaign demonstrates the scale of damage caused by policies that restrict migrants’ access to healthcare in this way. It shows that many countries across Europe have implemented similar policies to varying degrees over the last decade. Where these restrictions have been implemented, the evidence consistently shows that they both harm health and cost health systems more – thus failing on their own terms.

In Spain, for instance, restrictive healthcare policies were responsible for a 15% increase in mortality amongst the migrant population over a three-year period – corresponding to over 70 additional deaths per year on average. In Germany, restrictions on asylum seekers’ access to health care displaced demand for care towards more costly acute emergency settings, which cost the health system billions of euros.

But does this evidence mean the hostile environment’s days are numbered? Unlikely – because the Home Office bases policy on ​“anecdote, assumption and prejudice”, according to the Public Accounts Committee. If decisions were based on credible evidence, hostile environment policies would never have been introduced to begin with.

What is clear from our research however, is that where restrictions have been implemented, they are invariably met with public outcry and resistance. Similarly, where policy has progressed, this has not been because of national governments voluntarily responding to evidence, but because of pressure from healthcare workers, city and regional governments, civil society and members of the public.

When the Spanish government passed restrictions by Royal Decree in 2012, healthcare workers conscientiously objected to the policy and continued to treat migrants without charge, while regional governments chose not to implement the national policy, passing more inclusive policies locally. There were public demonstrations that spread across the country and over 300 civil society organisations signed up to publicly denounce the restrictions. This multifaceted resistance was instrumental in the government’s eventual decision to overturn the Royal Decree and expand migrants’ rights to healthcare. Similar successes have been achieved using similar tactics across the continent, from Italy to Sweden.

In the UK, where universal healthcare is a cherished principle, resistance is already gaining ground through networks of locally organised groups of healthcare workers joining forces with migrant community groups and NHS campaigning organisations. This is accompanied by public opposition from civil society and healthcare organisations. The BMA has called for a full and independent review of the hostile environment in the NHS, while the Academy of Medical Royal Colleges and the Royal College of Midwives have called for an immediate suspension. Since the coronavirus pandemic, there have been repeated calls for an end to the hostile environment in the NHS in letters signed by 60 MPs, the Mayor of London, the BMA, six Royal Colleges and over 100 civil society organisations.

Campaigns from across Europe demonstrate the potential that pressure of this kind can have.

Despite mounting evidence of the harm caused by the hostile environment, we should not expect this government to make amends of its own accord. The Home Secretary’s announcements last week underscore this. But pressure can force their hand, ceasing further damages to health, the healthcare system and beyond.

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