Patients Not Passports-No borders in the NHS!

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PatientsNotPassports–NobordersintheNHS!
Author(s):JessicaPotterincollaborationwithDocsNotCops
Source:Justice,PowerandResistanceVolume2,Number2(August2018)pp.417‐429
PublishedbyEGPressLimitedonbehalfoftheEuropeanGroupfortheStudyofDeviancyandSocial
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27thSeptember2018.
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PatientsNotPassports–NobordersintheNHS!
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Authors:PotterJL1incollaborationwithDocsNotCops
1DoctoralResearchFellow,CentreforPrimaryCareandPublicHealth,QueenMaryUniversityofLondon

Contact:jessica.potter@qmul.ac.uk
Twitter:@DrJessPotter@DocsNotCops
Introduction
TheNHS,despitesignificantwearandtear,remainsthejewelinthecrownoftheBritishWelfareState
(Timmins,1998)attheripeoldageof70.Itmightbearguedthatitisthestrengthofitsideologythathas
madeitakeyvotingissueforsolong.Asalungdoctormyselfwhoundertakesresearchamongstoften
marginalisedpopulations,deliveryofcarefreeatthepointofservice,toallthoseinneed,irrespectiveof
background,isofcentralimportancenotonlytothepatientsIcareforbutmyownprofessionalidentity.
Thesevalues,however,arebeingeroded.ThatiswhymyselfandothermembersofDocsNotCops‐aUK
basedgroupofhealthcareworkers,NHScampaignersandpatients–areworkingtogetherwithlike‐
mindedorganisationsoncampaignstoresistsuchattacks.

NHSTrustsinEnglandarenowlegallyobligedtoidentifypeopleineligibleforfreecareandwithholdnon‐
urgenttreatmentfromthosewhocannotorwillnotpayupfront(DepartmentofHealth,2017b).Such
wasthecaseofSylvesterMarshall(originallygiventhepseudonymAlbertThompson)whocouldnotprove
hiseligibilityforfreeNHScareandconsequentlywasdeniedcancertreatmentbecausehecouldnotpay
the£54,000billpresentedtohim(Gentleman,2018).

Inthispaperwewillevidencetheimportanceoftimelyaccesstopreventative,aswellasacute,health
careandoutlinethechangesinpolicyandlegislationregardingNHSchargingwhichhaverestricted
healthcareaccessforsomemigrants1inEngland.Wesituatethesechangeswithinthespecificsocialand
politicalcontextinwhichtheyhaveevolved.WearguethatconflationoftheNHScrisisandtheso‐called
‘migrantcrisis’hasresultedintheconstructionofmigrantpatientsas‘undeserving’‘healthtourists’,
castingmigrantsas‘Other’andthereforeexcludablewhenitcomestohealthcareprovisionintheUK.We
examinethejustificationtochargemigrantsforNHScare,employedbysuccessivegovernments,that“in
orderfortheNHStobefinanciallysustainable,itisvitalthateveryonemakesafaircontribution”
(DepartmentofHealth,2017a).Weconcludebyoutliningtheroleofactivistgroups,includingourown–
DocsNotCops‐invoicingtheinjusticesandviolenceinherentintheseexclusionarypoliticsofcare,and
inchallengingabroadernarrativeof‘deservingness’.Usingthelanguageofrights,dutiesandobligations
weinterrogatetheimplementationofthesepoliciestocarveoutpathwaysofresistance.

Restrictinghealthcareaccess:‘Unwiseaswellasmean’
1Inthisarticleweusethetermmigranttomeananypersonresidingin(ratherthantemporarilyvisiting)acountry
theywerenotbornin.


Restrictinghealthcareaccessisharmfulforindividualsandpopulations.Formanyhealthconditions,the
greaterthedelaytodiagnosis(andconsequentlytreatment)themoreunwellanindividualmightbecome,
themorelikelytheyaretobeleftwithlongtermhealthissuesandsomemayevendie.Forthosewho
haveaninfectiouscondition,delayingdiagnosisalsoputsthewiderpopulationatrisk(Potter,2017).
Thus,healthcareprovision,includingaccess,isasocialdeterminantofhealth(Marmotetal.,2012).
Accesstohealthcareisnotsimplyapointintime,itisdynamic,contextualandnegotiated(DixonWoods
etal.,2005).Consequently,restrictingaccesstohealthcareisnotsimplyamatterofshuttingthedoor.
‘Operatingconditions’(DixonWoodsetal.,2005;Mackenzieetal.,2013)suchas,forexample,a‘hostile
environment’(Hiam,SteeleandMcKee,2018),alsoaffectdeterminationsof‘candidacy’(Dixon‐Woodset
al.,2006)inrelationtohealthcare.

Migrantsexperiencespecificchallengestotheirhealthbefore,duringandafterthemigrationprocess
(Bhopal,2007).Populationsonthemoveembodyamultitudeofgeo‐temporallysituatedsocial,
environmentalandpoliticalexperienceswhichdifferentiallyaffectdiseaseriskacrossthelifecourse
(Krieger,2008).Withoutwishingtoessentialisethemigrantexperience,atapopulationlevelmost
migrantsarriveattheirdestinationingoodhealth‐likelybecausetheprocessofmigrationitselfisaform
of‘survivalofthefittest’.Thishasbeencalledthehealthymigranteffect(Vissandjeeetal.,2004;Anikeeva
etal.,2010).However,thisadvantagedecreasesovertime(Abraído‐Lanza,ChaoandFlórez,2005).
Hypothesesforhowthishappensincludetheimpactofsocioeconomicandpsychosocialfactorswhich
accompanymigrationsuchasstressesassociatedwiththeacculturationprocess(Bhugra,2004),language
barriers,employmentandlackofsocialsupport(WilkinsonandMarmot,2003).

AstheInternationalOrganisationofMigrationstates:“Migrants’healthistoalargeextentdetermined
bytheavailability,accessibility,acceptabilityandqualityofservicesinthehostenvironment”(Davies,
BastenandFrattini,2009).Manycountrieshavemovedtowardssystemsthatadheretotheidealsof
universalhealthcoverage:thatpeoplecanaccessthecaretheyneedwithoutsufferingsignificantfinancial
hardship(Marmotetal.,2008).However,inEurope,includingtheUK,provisionofcareforsomemigrant
populations–inparticularundocumentedmigrants‐islimitedtoemergencycarewithcontested
definitionsofwhatthisconstitutes(Davies,BastenandFrattini,2009).Theserestrictionstocareconflict
withevidencethatsuggestsitiscost‐effectivetoprovidepreventativeaswellasemergencycareto
undocumentedmigrants(FRA(EuropeanUnionAgencyforFundamentalRights),2015).Considering
thesepoints,restrictinghealthcareaccessformigrantsmightarguablybeconsidered‘unwiseaswellas
mean’(Bevan,1952).

AhistoryofNHSchargingregulations

TheUKNationalHealthServicewasfirstestablishedin1948withtheaimofdeliveringcomprehensive
advice,treatmentandcaretoall,freeatthepointofaccess,“fromcradletograve”(GreatBritainand
Beveridge,1942).Inthatsameyear,healthwasformerlyrecognisedasacentralhumanconcernand
enshrinedintohumanrightslawasthe“righttotheenjoymentofthehighestattainablestandardof

physicalandmentalhealth”(UnitedNations,1948).Today,UniversalHealthCoverageremainshighon
theglobalhealthagenda(Sommerlad,2018).

FounderoftheNHS,NyeBevan,addressedconcernsthattheNHSwouldbeopentoabusefromoverseas
visitorsemployingargumentsthatstillresonatetodayincluding:highlightingthecontributionvisitorsand
migrantsmaketotheeconomy;theinconvenienceofrequestingidentificationaspartofhealthcare
delivery;andthenegligibleimpactonfinancesduetotherelativegoodhealthoftourists(Bevan,1952).
ChargingregulationswerenotformerlyintroducedintotheNHSuntil19822(DepartmentofHealth,1982)
afterwhich“therewerethenthreedecadeswhenverylittlehappened”(HouseofCommonsCommittee
ofPublicAccounts,2017).Duringthisperiod,despitesuccessiveminoramendmentstoNHScharging
regulations,verylittlechangedinpractice:eligibilityforfreecarewasbasedonthetestof‘ordinary
residence’sothatstudentsandimmigrantswhohadmovedtotheUKtostudyorworkwereallentitled
tofreeNHScare(LockQC,2017).Thosewhowerechargeableincludedtouristsandundocumented
migrants(amongstothers–foramoredetailedreviewoftheperiod2000‐2010seeChimientiand
Solomos,2016).Agovernmentreviewin2012revealedthatasystemicfailuretochargethesegroupswas
likelybecausetherewas“noincentiveforNHSTruststoidentifyoverseasvisitors”(DepartmentofHealth,
2012).

Duringthisperiod,theimpactoftheglobalfinancialcrisisin2007,theaccompanyingausteritymeasures,
andincreasingprominenceofIslamicfundamentalismandISISinpublicdiscoursehadahugeimpacton
globalandlocalpoliticsandpolicies.TheUK,EuropeandtheUShaveseenariseinAlt‐rightpolitical
parties.Ideologues,mediaorganisations,politicalpartiesandmoreamorphousmovementshavestoked
fearofracialised‘others’(Fassin,2011).Governmentstoohaveutilisedfearinreactingtothesepressures
andindeepeningexistingsystemsofrepressionandcontrol‐tighteningnationalborders,increasing
surveillance,bothingeneraland,of‘foreigners’inparticular(Yuval‐Davis,WemyssandCassidy,2017),
anddevelopingarangeofanti‐immigrationpolicies(foracriticalreviewseeWallace,2018).Inrelationto
healthcare,‘fairness’hasbeenincreasinglydeployedtojustifypoliciesthatrestrictedtheuseofpublic
servicestoUKcitizens(Maughan,2010;DepartmentofHealth,2015b,2017a).Itisinthiscontextthat
thenHomeSecretaryTheresaMayannouncedheraim“tocreate,hereinBritain,areallyhostile
environment”foranyonelivingintheUKwithouttheappropriatedocumentation(KirkupandWinnett,
2012).

TheNHSincrisis

NyeBevanestimatedthatthecostoftreatingoverseasvisitorswouldbenegligible–atmost0.4%ofthe
NHSbudget.Yetin2013,priortotheroll‐outoftheVisitorandMigrantCostRecoveryPlan,deliberate
healthtourismwasstillestimatedatonlyafractionoftheoverallNHSbudget–0.3%(Prederi,2013).
2Thefirstlegislationthatallowedchargingthose“not‘ordinarilyresident’intheUKwasintroducedintheNational
HealthService(Amendment)Act1949,althoughthesepowerswerenotformallyenactedthroughregulationsuntil
1982”(Blundell,2014).

Followingnearlyhalfacenturyofcarebeingprovidedallbutfreeatthepointofservice,whathad
changed?

Thecry"TheNHSisanationalnotaninternationalhealthservice"isbutthemostconciseslogantohave
emergedfromabroadreactionaryperspectiveonpublicservicesthathasbeenstokedbyright‐wing
populistpoliticiansandmediaoutletsinanattempttoscapegoatandultimatelyexcludepeoplemaking
useofservices(Hope,2015).Thisperspectivehastheconvenientcorollarythatitavoidsandindeed
divertsattentionfromvoiceschallengingthenecessityofausterity,orpointingouttheunfairdistribution
ofwealthinsociety.

SuccessiveBritishgovernmentshaveselectedausterityasaresponsetotheglobalfinancialcrashof2007
(Karanikolosetal.,2013).Globalisation,theexpansionoftheEUtoincludecountriesinCentraland
EasternEuropein2004and2007,climatechange,inequalityandwarhaveallcontributedtoa"migrant
crisis"withincreasingandmorediversepatternsofmigrationtotheUK(Vertovec,2007).Whilecapitalist
economies’demandforlabourreliesonflexible,mobile,andthereforeoftenmigrantworkers,nation
statesinsisttheirresourcesarelimited‐andprioritisecitizensinordertobuildasenseofpatriotismeven
astheywithdrawprovision.Itisinthisambiguoussettingthatafierceimmigrationdebaterages
(Phillimore,2011).WithintheNHSthisisexemplifiedthroughactiverecruitmentofstaffoverseas,often
fromformerBritishcolonies(Crew,2017),whilstthegovernmentplacecapsonearningandenact‘hostile
environment’policiesthatforcepeopleoutoftheUK(Borland,2015;WeaverandCampbell,2018).

Understaffedandunderfunded(SpendingontheNHSinEngland,2017),intheyearofits70thanniversary,
theNHSisincrisis.Asthegovernmentimpose“efficiencysavings”ofover£20billionpounds(arounda
sixthofthewould‐beNHSbudget),theNHScreaksundertheweightof£70billionofpaymentsassociated
withtheconstructionofover100newhospitalsbuiltbetween1997and2008undercostly“Private
FinanceInitiative”arrangements(PollockandPrice,2013)andbillionsarewastedonprivateprofitsand
tenderinginamarketisedNHS(Molloy,2014).AKingsFundreportin2014concludedthat“thequestion
wasnotwhethertheNHSwouldrunoutofmoneybutwhen”addingtheriskof“reachingatippingpoint
whereonlyaminorityoforganisationsareabletosustainacceptablelevelsofperformance–isaclear
andpresentdanger,accentuatedbythepressuresfacingsocialcare”(Applebyetal.,2014).Earlyin2018,
asignificantriseindeathswasreportedcomparedtopreviousyearsandthousandsofroutineoperations
werecancelledsignallyasHiamandDorlingargue,theNHSwas“asystemstrugglingtocope”(Hiamand
Dorling,2018).

Thesuccessivemeasurestorestrictaccesstohealthcareformigrantsandvisitorssincethenhaveformed
partofabarrageofpoliciesdesignedtomakeremainingintheUKuntenableforindividualscaughtinthis
racialisednetof‘others’,whetherwithoutdocumentationorsimplyuncertainoftheirrights.These
policiesinclude,butarenotlimitedto:ariseinimmigrationraids;theprospectofunlimiteddetention;
thethreattohealthandevenlifethatimmigrationdetentionposes(Canning,2017);schoolmeals
withheldbecauseofparents’immigrationstatus(Weale,2018),restrictionstothehousingrentalmarket,
drivinglicensesandbankaccountsinsimilarwaystotherestrictionsappliedtotheNHS(Removalsand
Instructions,2018).Citizens,repeatedlytoldtheirsecurityisthreatenedbyaconstructedmigrant‘other’,

becomeeverydayborderguards(Yuval‐Davis,WemyssandCassidy,2017)‐unwittinglyifnotwillingly‐as
theyenforceconditionalaccesstoservices,andareencouragedtomakereportstotheHomeOffice.All
thesestrategiesrepresentdiscriminatoryattacksonthesocialdeterminantsofhealthformigrants
(DahlgrenandWhitehead,1993).Byscapegoatingmigrantsas‘healthtourists’whoabuse‘ourNHS’,the
governmentisabletodrawattentionawayfromtheirdecisiontorestrictNHSfunding(Tilford,2015)
whilstfirmlysituatingtheblameamongst‘undeserving’(Willen,2012)‘others’.

Hostileenvironmentorcostrecovery?

In2013thegovernmentlaunchedaconsultationon“migrantcontributiontohealthcare”stating,“The
nextstepincross‐governmentplanstomakeitmoredifficultforillegalmigrantstoliveintheUK
unlawfully,andtoensurelegalmigrantsmakeafaircontributiontoourkeypublicservices,hasbeen
launchedtoday”(DepartmentofHealth,2013).Wide‐reachingreformsfollowed:TheVisitorandMigrant
CostRecoveryProgramme2014‐2016setoutaseriesofmeasuresdesignedtomorereadilyidentifyand
chargethosenoteligibleforfreeNHScare(Health,2014).In2014,theImmigrationActchangedthe
definitionof“ordinarilyresident”,increasingthenumberofpeoplenoteligibleforfreeNHScare,by
effectivelyexcludinganyonewithoutindefiniteleavetoremain(Blundell,2014).The2015NHScharging
regulationsfollowedintroducingtheImmigrationHealthSurcharge(IHS)andraisingtheamountanNHS
Trustcouldchargeineligiblepatientsto150%ofcostprice(DepartmentofHealth,2015a).

TheIHSisafixed(thereforenotprogressive),mandatory,insurance‐likeschemeassociatedwiththevisa
applicationprocessfornon‐EEAmigrants.Itisnow£400peryear(£150peryearforstudents)meaning
forafamilyoffouronafive‐yearvisathiswouldadd£8,000tovisacosts(UKVisasandImmigration,
2016).Thegovernmentclaimedthisistoensurethateveryone‘makesafaircontribution’tothe
(DepartmentofHealth,2015b).Butisitfair?PeopleoftenmovetotheUKbecausethereisademandfor
theirlabour,drawnoftenfromformercoloniesbythepromiseofrelativelyhigherwages.Whilstworking
intheUK,theypayincometaxandNationalInsurance,aswellasVATandconsumptivetaxesevenifnot
workingandintheirprecariousstatusasnon‐citizensaremorevulnerabletoabuse.Inaddition,concerns
havebeenraisedthattheIHSwilldeterhighly‐skilledmigrantsfromenteringandstayingintheUK.A
furthercritiquecentresaroundhistoricalinjusticeintheformofcolonialismthatpersiststhroughneo‐
colonialmechanisms.Forexample,activerecruitmentofhealthcareprofessionalsfromformercolonies
totheUKcontributetowideninginequalitiesthroughbraindrainfromcountrieswhoalreadylack
sufficientnumbersofhealthcareworkerstosupporttheirownhealthneeds.Theperceivedbenefitsfor
individualsofworkinadevelopedcountrymakethemvulnerabletolowerwageswhilsttheUKbenefits
fromavoidingthehighcostoftheirtraining.

OnceintheUK,thosemigrantsandvisitorswhohavenotpaidtheImmigrationHealthSurchargemaybe
chargeableforNHScare.Aninitialconsultationidentifieda:“fundamentalfinancialdisincentive”for
hospitalstoidentifyandchargethesegroups(DepartmentofHealth,2013).Thiswasbecausethe
momentanindividualwasidentifiedasineligibleforfreeNHScare,theNHSTrustcouldnotclaimthecost
ofthatcarefromthecommissioner.Ifthedebtwentunpaid,theNHSTrustfootedthebill(Creative
Research,2013).ToincentiviseNHSTruststoidentifyandchargepatients,the2015amendmenttoNHS

chargingregulationsincreasedtheamountnon‐EEApatientscouldbechargedto150%ofcost
(DepartmentofHealth,2015c).AsaDepartmentofHealthrepresentativehintedat,thiseffectively
positionsnon‐EEApatientsasasourceofrevenueincomparisonwiththosefromwithintheEEA(Public
AccountsCommitte,2016).Sanctionswerealsointroducedforthosethatfailedtoidentifychargeable
patientsandthecostofanytreatmentofpatientsidentifiedaschargeablewhodonotpaytheirbill,is
splitequallybetweentheNHSTrustandtheirlocalClinicalCommissioningGroup(Health,2014).Tohelp
identifyineligiblepatients,knowledgeoftheirIHSpaymentissharedwithNHSTrustsinanonline
interactivesystem(DepartmentofHealth,2017b).Forfurtherqueries,theHomeOfficehaveestablished
ahotlineforoverseasteamstocontacttheminrelationtoeligibilityqueries,chargingtheNHS80pence
perminuteforitsuse(BeckfordandKempsell,2017).

WithchargingmechanismsestablishedandteamsofOverseasVisitorManagersstrengthened,thenext
stepwastointroduceupfrontchargingofnon‐eligiblepatientsforallnon‐urgentcare.InFebruary2017
thegovernmentissuedastatementofintenttochangethelawinApril2017inorderto“requireNHS
organisationstoidentifywhethersomeoneischargeablebeforenon‐urgenttreatmentisgivenandto
encourageaculturechangesothatapatient'seligibilityforfreeNHScareischeckedmoreregularlythan
iscurrentlythecase”(DepartmentofHealth,2017a).ThiswasdelayedduetoaGeneralElectioninMay
2017butcameintofulleffecton23rdOctoberofthesameyear(Departm,2017).NHSbodiesarenow
requiredbylawtoidentifyapatient’schargeablestatusatthefirstandeachsubsequenthealthservice
encounter.JeremyHunt,SecretaryofStateforHealthstates,“Weshouldallexpecttobeaskedquestions
thatconfirmoureligibilityforfreehealthcarefromtimetotime”(DepartmentofHealth,2017a).

TheNHSseesoveramillionpatientsevery36hours(NHSstatistics,factsandfigures,2017),thevast
majorityofwhomareeligibleforfreecare,itseemsunlikelythatitwillbecost‐effectivetocheck
everyone’sID.Thisraisesthequestionsofthemethodsclericalstaffwillusetodeterminewhichpatients
shouldbesubjecttochecks,andwhichpatientscanbeassumedtobeeligiblewithoutacheck?Ofthose
whoforgetorsimplydonothaveID,whowillbeblockedandwhowillbeallowedthrough?Oneinfour
Britsadmittobeingraciallyprejudiced(Kelley,KhanandSharrock,2017).Earlyevaluationalready
identifiedtheinformalmechanismsbywhichstaffused“signsof‘foreignness’toidentifypotentially
chargeablepatients(CreativeResearch,2013).TheintroductionofIDchecksgrantslicensetoracist
practiceswheretangibleidentifiersofdifference,suchasskincolour,‘foreign’soundingaccentsornames
orthewearingofnon‐Christianreligioussymbols,arethemeansthroughwhichstaffdeterminewhose
eligibilityischecked.AsEmmaBondandSimonHallsworthtestifyintheiranalysisofyoungpeople’s
experiencesseekingwelfare,determinationsoflegitimacyforhealthcareisyetanother‘degradationritual
designedtofurtherhumiliateandalienate’(BondandHallsworth,2017).

Giventhegovernment’sownconsultationhighlightsthat“costrecoveryisalsocompromisedbythefact
thatundocumentedmigrantsmakeupthelargestgroupofchargeableoverseasvisitors–approx.
500,000,manyofwhomhavefewresourcestopaychargesincurred”and“thesepeoplewouldbe
exposed“tosignificantfinancialrisk”(DepartmentofHealth,2013),wecontestthatratherthanthetitle
suggests,theOverseasVisitorandMigrantCostRecoveryProgrammeismerelyapunitivetoolofthe
‘hostileenvironment’throughwhichthegovernmentcanpublicallydemonstratetheirintentiontocontrol

immigration.ExcludingmoneyraisedbytheImmigrationHealthSurcharge,thereisnorobustevidence
todemonstratethatNHSchargingmechanismshaveraisedenoughtocoverthecostsofitsown
bureaucracy,letaloneuncalculatedcostsofdelayedcareorthepotentialadditionalpressureplacedon
GeneralPracticeandAccidentandEmergency,bothofwhichremainfreelyaccessibletoall.

#PatientsNotPassports

Fromtheperspectiveofmanyhealthcareworkers,themovementawayfromahealthservicefreeatthe
pointofaccessandavailabletoallisintolerable.DoctorsworkingintheNHS,unlikeprivatisedor
insurance‐basedsystems,arelargelyabletoconsiderandtreattheindividualinfrontofthemwithout
considerationofthatindividual’sabilitytoaffordcare.Spendingvaluabletimetryingtodecidewhether
torequestatestbecauseitistherightthingtodoaccordingtobestmedicalpractice,ortoorderacheaper
butlesseffectiveoneisnotsomethingwearetrainedtodoandismorallyunacceptabletomanyofus.
AlsounacceptableandcontrarytotheprincipleslaidoutintheNHSconstitution3isanyformof
discrimination.Inthisarticlewehaveoutlinedthewaysinwhichpoliciesthatrestrictaccesstohealthcare
undermineNHSvalues.ItisfromthisconcernthatgrassrootsmovementssuchasDocsNotCopsand
MedactRefugeeSolidaryGrouphaverisenup.

Inassociationwithbroaderrights‐basedorganisationssuchasMigrantsRightsNetworkandMedical
Justiceamongstothers,wehaveemployedthecall,‘healthcareisaright,notaprivilege!’AsMilena
ChimientiandJohnSolomosdetail,therealisationofhumanrightsfornon‐citizenscanbeproblematic.
Theyargue“itisthetaskofsociologists(andotherscholarsinthesocialsciences)todistinguishbetween
thediscrepanciesandtheidealsandtomakesenseofthem”(ChimientiandSolomos,2016).Thepotential
spacesandambiguitiesbetweenmoralstandards‐suchasthosethatunderpinhumanrightslawsor
professionalcodesofconduct(forexampleseeGoodMedicalPractice,2013)‐andgovernmentpolicies
andlegislationcanprovidefruitfulgroundforresistance.

ThistensionwasemployedparticularlyeffectivelyinacampaignleadbyDoctorsoftheWorldtogetNHS
Digitalto#StopSharingdataaspartofaformalisedprocessthatallowstheNHStopassindividual
demographicdata,includingaperson’slastknownaddress,totheHomeOfficeImmigrationEnforcement
Team(madepublicinJanuary2017butactivebeforethen;GOV.UK,2016).UnderthisMemorandumof
Understanding(MoU),theHomeOfficemade8,127requestsfordatainthefirst11monthsof2016alone,
leadingto5,854peoplebeingtracedbyimmigrationteams(Travis,2017).Thethreatofdeportation
deterspeoplefromseekinghelpwhentheyareunwell(Seedat,HargreavesandFriedland,2014;Poduval
etal.,2015).Evenwhendataiskeptconfidential,thesimpleprocessofhavingtoprovideidentification
documentscandeterpeoplefromaccessinghealthcare(Hackeretal.,2015).Inahearingonthisissueby
thecross‐partyhealthcommitteechairedbySarahWollastonMP,thefundamentalissueatdebatewasa
publicinterestinprovidingaconfidentialhealthservice–confidentialityasoutlinedbyprofessional
medicalbodiessuchastheGMCandtheBritishMedicalAssociation–versusthepublicinterestin
3Inparticular“TheNHSprovidesacomprehensiveservice,availabletoall”and“AccesstoNHSservicesisbasedon
clinicalneed,notanindividual’sabilitytopay”

immigrationcontrolwhichsawfittobreakconfidentialitysimplybecauseanindividualcommitsan
immigrationoffence(Wollaston,2018).Combiningvoicesandexpertiseacrossmultipleorganisations
includingbutnotlimitedto:DoctorsoftheWorld,MigrantsRightsNetwork(currentlyinvolvedinajudicial
reviewonthisissue),NationalAidsTrust,andVoicesofDomesticWorkers–inasmallbutsignificant
campaignwinthegovernmentfinallyagreedtolimitdata‐sharingtoseriouscrime.Whatthismeansin
practiceremainstobeseen.

ResistanceagainsttheMoUstrengthenedwhen,despitedatasharingalreadyoccurring,thepracticewas
maderealintheformofpublishedpolicy(HomeOffice,DepartmentofHealthandNHSDigital,2016).In
asimilarway,thecomplexitiesoftheimplementationguidancerelatingtoupfrontchargingregulations
providessomething‘toshoot’at(HaywardaandLukesb,2008).Thisallowsadefenseofvalues,thatcan
perhapsbedeflectedaswoolly,tobegroundedinreal‐worldpracticesandmaterialharms.Organisations
suchasDocsNotCopsandMedactRefugeeSolidarityGrouparoseduetoconcernsregardingthewaysin
whichsuchpoliciesattackvaluesimportanttothoseworkingin,andinneedof,healthcare.Itisthe
experiencesofthoseonthegroundthatrevealwhoisharmed,when,howandbywhatmechanisms,
arguablyprovidingamoredirectlinkbetweenpolicyandthoseaccountableforit.

DocsNotCopshaveraisedconcernsoftheracialisationofpoliciesthatrestrictaccessmostoftentonon‐
white‘others’(foranexampleseeDexter,2017).WiththerecentrevelationoftheWindrushscandal,
suchconcernshavebeenrealisedaspeoplewhoareinfactBritishCitizensarerefusedhealthcarebecause
theycannotproveit.Whilstthishasprovidedaplatformfromwhichtoraiseourconcerns,thenarrative
of‘deservingness’hasagaincomeintoplayacrossbothsidesofthepoliticaldivide.SylvesterMarshall
waspresentedasdeservingevenbeforehisstatusasBritishhadbeenacceptedbyvirtueofthefacthe
hadpaidtaxesandhismotherhaddedicatedherlifetoworkingfortheNHS(Gentleman,2018).
Increasingly,careisrationed–themost‘feckless’(Foges,2018)placedatthebackofthequeue.Whether
itisnon‐citizensorsimplytheoverweight,wewillcontinuetochallengethesenarrativeswhichundermine
amoralpositionthathealthcareisahumanright,feedjustificationsforexclusionandconvenientlyignore
thestructuraldeterminantsofhealth.

Conclusion

Workingwithotherorganisationscampaigningagainstthewidereffectsofthe‘hostileenvironment’
(includingbutnotlimitedtoMedicalJustice,AsylumMatters,Migrants’RightsNetwork,JointCouncilfor
theWelfareofImmigrants,AgainstBordersforChildrenandMigrantsOrganise)hasensuredabroad
appealandanevidencingofthewide‐reachingharmsthesepoliciescontinuetoinflict.Thestrengthof
thisresistanceisitsdiversemembershipwithnonethelessacollectivevoice,underpinnedbybroadly
sharedvaluesofsolidarityandsocialjustice.

In2014theWorldHealthOrganisationandRockerfellerFoundation,representingmorethan500different
organisationslaunchedthe“GlobalCoalitiontoAccelerateAccesstoUniversalHealthCoverage”.
Historically,theNHShasbeenanexemplarymodelofUHCbut,throughtheintroductionofmarketforces
andchronicunderfunding,successivegovernmentshavemadepoliticaldecisionsthatsetitsfuture

hanginginthebalance.Byconflatingaglobalfinancialcrisiscausedbytheneoliberalagendaoftherich
intheglobalNorthandthemigrantcrisisfueledbyinequality,warandclimatechange,thecurrent
governmenthavedrawnalinearoundhealthallowingdeservingcitizensinandkeepingundeserving
‘others’out.Thesepoliciesarepoliticallydriven.Thefactsareclear:restrictingaccesstohealthcareis
badforindividualsandbadforpopulations.Healthcaremustbearightandnotaprivilegeanduntilthis
rightisrealisedwewillcontinuetodemandtosee#PatientsNotPassports.

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