This guest post by Sarah Steele from the Centre for Primary Care and Public Health, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, builds on Ana Aliverti’s account of the immigration bill, focusing on its implications for access to healthcare. Sarah is on Twitter @DrSarahSteele.
‘We're not tough enough right now about people who come from the other side of the world who decide to use the health service: they haven't contributed…' ‒ Prime Minister David Cameron, February 2013
‘We have been clear that we are a national health service not an international health service… The NHS is a national treasure and we need to work with the entire health system to develop plans and make sure it is sustainable for years to come.' ‒ Health Secretary Jeremy Hunt, July 2013
At the heart of the National Health Service (NHS) is the principle that healthcare is available for everyone in the UK, free at the point of use
. Established in 1948, this principle is now coming increasingly under attack, first by the Health and Social Care Act 2012 and now by the latest immigration bill
. This bill, which will receive its final reading in the House of Lords in May, permits the Secretary of State to extend charging for visitors and non-EEA migrants for NHS services, and allows for a NHS levy on visas, proposed to be around £200. No longer will services be free-at-the-point-of-use for all in the UK.
The government argues the bill is essential, suggesting it will ‘wipe out abuse,’ making sure the NHS ‘is sustainable for years to come.’ Identifying migrants as the cause of overwhelmed emergency departments, missed four-hour wait targets, and growing waitlists
in the NHS more broadly, the Government suggests immigrants are costing the NHS millions of pounds―a cost that can only be met by a levy on visas as a ‘contribution,’ and expanded charging
. Alongside the ‘go home’ vans
, such policies seek to encourage migrants to leave in order to reduce their ‘constant drain’
on public services.
In contrast to government claims, recent research has identified that migrants are net contributors to the UK, putting in 2% more than they take out
. Meanwhile, 36% of doctors registered
with the General Medical Council are foreign trained, coming from either the EEA (10%) or rest of the world (26%). They are essential to the running of the NHS, especially in areas facing recruitment shortages, including emergency departments. The idea that migrants drain the NHS is flawed
So how does this rhetoric continue to prevail?
Hostility to immigrants occurs when individuals are rhetorically positioned as a ‘threat
’ to the country. Foreigners, we are told, ‘cheat the system’ and drain it dry, even when they access services legally. As citizens become increasingly concerned about immigration, immigrants are marginalised and repeatedly stated to be inferior, driving inequalities in access; in turn, this often makes their inferiority appear natural and threatening to social cohesion and values
. As a result, dehumanising beliefs and negative attitudes, spread by both policy makers and the public at large, become further entrenched.
Such behaviour has been acknowledged around the immigration bill, and contemporary UK politics more broadly. Former Coalition Minister, Sarah Teather, was recently scathing in her review
of her own government’s policies, suggesting current popular political rhetoric ‘links immigrants to criminals in the public eye,’
about setting up political dividing lines, and trying to create and define an enemy. … It's stifling the rest of the debate, making people afraid to speak. If you get to a stage where there is no alternative voice, eventually democracy's just going to break down.
Presenting immigrants as enemies, Teather observes, has injurious results both to them and the values of equality and human rights.
Healthcare sector professional organisations have opposed the bill and suggested it's unfeasible. The British Medical Association (BMA) and Royal College of General Practitioners (RCGP), for example, both contend the bill is deeply troubling, isolating immigrant communities and threatening public health, while also distracting practitioners from their primary concern: patient care
. The proposed bill will cost more to implement and administer than it saves, they point out
, while transforming healthcare workers into law enforcement agents. As, Clare Gerada, Chair of the Council of the RCGP, put it
I don't think we should be turning the GP surgery into a border agency. I think we should be making sure that people who do feel that they are ill can come and access us because we certainly don't want… anybody that believes themselves to be ill, to be frightened of seeing a GP for fear of being charged…
Meanwhile, the BMA has found that the reforms are directly contrary to their motion from 29 June 2005 that it's inappropriate for medical staff to act as proxy immigration officers when providing healthcare and treatment. The BMA has also expressed fears that the administrative burden involved in ascertaining immigration status would detract from patient care. Citing the first do no harm principle, many practitioners have indicated they will maintain a focus on care not migrant status.
Despite such concerns, the bill looks set to become law later this year. With an increasing focus on targets and penalties in commissioning, practitioners may not be able to resist implementing the changes. Who will be exempt has yet to be determined.
What's clear from the reforms is that the boundaries of membership and inclusion are ever-changing. People who are safe today—afforded free healthcare—may not be tomorrow. The diffuse logic of differential exclusion has become part of the healthcare sector. Who will be targeted is always changing, and while it's often along predictably racialised and gendered lines, it's hard to know who will be excluded next. It's integral to explore the various systems of control and exclusion interacting also within the healthcare space, understanding how the NHS is a crucial site through which the government is redrawing the meaning of citizenship in the twenty-first century.
How do we distinguish a visitor from anybody else? Are British citizens to carry means of identification everywhere to prove that they are not visitors? What began as an attempt to keep the Health Service for ourselves would end by being a nuisance to everybody. The whole agitation has a nasty taste. Instead of rejoicing at the opportunity to practice a civilized principle, Conservatives have tried to exploit the most disreputable emotions...
His observations are no less true today. We must contest the reforms and the language they promote, taking a stand with migrant workers and patients to defend the NHS.
How to cite this blog post (Harvard style):
Steele, S. (2014) ‘Getting Tough’ through Reforming Migrant Access to the NHS. Available at: http://bordercriminologies.law.ox.ac.uk/getting-tough-nhs/ (accessed [date]).