While much recent Home Office rhetoric and the current immigration debate within the UK election campaign has been around ‘stopping the boats’, another element of the Conservative government’s immigration policy continues to affect thousands of migrants already residing in the UK.
The Hostile Environment is designed to make it impossible for undocumented migrants in the UK to access basic necessities such as housing, health care and employment. This intention was formally declared in 2012 by then Home Secretary, Theresa May, who stated: “The aim is to create, here in Britain, a really hostile environment for illegal immigrants”. This policy has since been translated into various pieces of legislation, and caused widespread harm, including triggering the Windrush Scandal, in which hundreds of people who had arrived from the Caribbean between the late 1940s and early 1970s were wrongly denied their legal rights because of difficulty in proving their entitlement to remain in the UK, as required by these new laws.
In the NHS, the Hostile Environment has required healthcare professionals to deny treatment to those unable to prove their immigration status if asked. There have been high-profile cases of harm caused to migrants denied care, or too afraid to seek it, including 38-year-old Nasar Ullah Khan, who died in 2019 after being refused treatment for his heart condition, and Elfreda Spencer, who died in 2018 from cancer, after having been unable to access treatment and then denied even palliative care. Many more thousands have received unaffordable bills, often for five- or six-figure sums, after receiving urgent treatment.
Yet health care is a devolved policy area, and the NHS in Wales is currently under the control of a Labour government. So, with a likely change of government imminent, can the Welsh case help predict the likely trajectory of this policy under a potential future Labour government in Westminster?
In 2017, as healthcare professionals, patients and concerned citizens setting up a Welsh branch of the Patients Not Passports campaign, which resists the Hostile Environment in healthcare settings, we had heard nothing about a Welsh version of the policy. Given the country’s aspirations to be a Nation of Sanctuary and its more progressive approach to immigration policy compared to the rest of the UK (for example, the continued eligibility of refused asylum seekers to access NHS secondary care), our assumption was that the Hostile Environment was not being implemented in the NHS in Wales.
To test this, we submitted a series of requests to all the health boards in Wales under the Freedom of Information Act. These found that, between 2017 and 2023, at least 1,182 patients were charged a total of £4,361,653.19 for NHS care in Wales after being identified as ‘overseas visitors’, the category into which undocumented migrants fall. This constitutes an average of £3,690 per patient, and £726,942 per year: the equivalent of 0.01 per cent of the £7,619 million annual NHS Wales budget. These included at least 73 children and 94 pregnant patients.
Our research also suggested that many of these patients are struggling to pay for their treatment. Of the total £4.3m billed to patients during the six years covered by our research, the health boards reported that around one third (£1,450,324.81) was outstanding at the time of our requests, and in the last five years of this period, £248,301.79 (7.6 per cent of the total amount invoiced in that period) was written off due to patients’ inability to pay. A further £575,547.27 (17.5 per cent) was passed to debt collectors, again suggesting that these patients were unable to pay. A further 36 patients (3 per cent of the total number invoiced) had repayment plans, of which 20 charged £50 or less per month. Once again, the existence of repayment plans, particularly at relatively low amounts per month, would suggest that patients were struggling to pay these invoices since such plans tend to be based on an assessment of household income.
Worryingly, our research also uncovered that £326,737.44 (10 per cent of the total amount billed to patients) was credited after it was identified that these patients should not have been billed for care. It is unclear why such a large number of patients are being incorrectly billed, but it raises the possibility that other patients are paying these invoices because they are unaware that they should not have been billed, or are unable to successfully challenge such invoices when they do receive them. In addition, there appears to be a risk that other patients may be declining or fearful of trying to access the treatment that they need because they are threatened with the possibility of being invoiced, even if they are in fact entitled to free treatment.
Taken in its totality, our research paints a worrying picture of access to health care for an already marginalised population. It also suggests that, if the actions of Welsh Labour in the Senedd relating to the implementation of charging migrants for health care in the NHS are any kind of signifier, there is little appetite within the Labour Party to dismantle the Hostile Environment if it gains power on 4 July. And indeed, while the election campaign has seen a welcome statement from shadow Home Secretary Yvette Cooper that, if elected, Labour will act to address the injustices of the Windrush Scandal, the party’s manifesto is silent on the Hostile Environment itself. As so often, change will most likely come from sustained public pressure and visibility – which is why the work of the Patients Not Passports campaign and migrant groups across the UK remains so vital.
Christine Haigh is a junior doctor living in Swansea with an interest in social justice, and access to healthcare, housing and food for marginalised communities in particular. Holly Mogford is a member of Patient’s not Passports Wales and a PhD candidate at Swansea University.
Hostile healthcare? Initial insights into the landscape of charging policies in the NHS in Wales by Christine E. Haigh and Holly Mogford in Justice, Power and Resistance and is available on Bristol University Press Digital here.
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