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“I just try as much as possible not to get sick, I know you can’t prevent it, but if I had pain, I would never go [to the doctor], I can’t call the ambulance or anything, I would never have done that because of the fear.”                               

Joseph*, recently regularised

Government policies deter migrants from accessing healthcare

At the onset of the pandemic, the Government was warned that its Hostile or Compliant Environment policies in the NHS would hamper public health efforts by making migrants afraid to access healthcare even if they were entitled to do so. JCWI’s new research confirms that this is the case.

Almost half of all the migrants surveyed (43%) said they would be scared to access healthcare if they got sick during this pandemic. We did not ask for ethnicity information but 60% of migrants from Africa and the Caribbean report being fearful of seeking healthcare. 56% of Asian respondents said they would be scared. This is compared to just 16% of respondents originating from North America, Australasia and Europe. Given that there is evidence that BME populations are being vaccinated at far lower rates than the rest of the population, these findings are extremely concerning. We have also seen that BME populations are dying of the disease at higher rates, and that this cannot be explained by underlying health conditions [see Williamson, E.J., Walker, A.J., Bhaskaran, K. et al. Factors associated with COVID-19-related death using OpenSAFELY. Nature 584, 430–436 (2020)]. 

Those eligible for free care are deterred

Undocumented migrants have reason to fear seeking medical care as their data may be passed from NHS trusts to the Home Office which could result in them being targeted by immigration enforcement. Some temporary migrants are also liable to be charged up to 150% of costs for secondary healthcare interventions. But most migrants are entitled to free NHS care and yet many of these still reported feeling afraid of the repercussions of doing so. Among migrants who do have a visa and are in the UK lawfully, 30% still reported being fearful of seeking healthcare.

The government’s Hostile Environment for migrants has produced a culture of fear that is preventing the NHS from being able to do its job and putting our communities’ health at risk. Policies that force some communities to avoid seeking healthcare are bad for public health at the best of times, but during a global pandemic they are reckless in the extreme. The NHS charging regime and data-sharing with the Home Office must be scrapped.

“It’s like walking through thick dark unending tunnels. It’s dehumanising, lacking dignity, mentally exhausting, no hope in future, not likely to visit GP or hospital if I contracted Covid-19.”

Edward*, undocumented cleaner

Public health must come first

JCWI wrote to the Home Secretary on 16 March 2020 requesting the immediate suspension of NHS charging and data-sharing with the Home Office for the purposes of immigration enforcement. It was also highlighted that the Government must mount a public information campaign reassuring migrant communities that it will be safe for them to access care. This request was repeated in letter sent on 20 January 2021. The British Medical Association, Royal College of Physicians, UK Faculty of Public Health and Doctors of the World UK also wrote along with other major medical bodies to the Home Secretary on 13 April 2020 calling for the suspension of the same measures.

The Government added COVID-19 testing and treatment to the list of NHS treatments exempt from charging on 10 February 2020 but the wider charging regime and data-sharing policies remain in place. Sufficient steps have not been taken to inform communities of the exemption.

There is significant evidence that these policies stop migrants, refugees and asylum seekers from accessing healthcare, even where exemptions exist and in cases where they are not the targeted group. For example, there is clear evidence the Hostile Environment deters individuals with tuberculosis from accessing care and that migrants are deterred from accessing healthcare advice for fear that they will be charged for treatment, or that interaction with the NHS could lead to them being targeted by immigration enforcement. Many organisations are reporting that this will interfere with vaccine take-up.

Our research adds to this evidence that exemptions do not prevent migrants from being deterred from accessing healthcare. The NHS charging system and data sharing system were designed from the ground up to deter migrants from accessing healthcare as part of the Hostile Environment strategy by:

1. Charging some migrants 150% of the cost of the treatment, according to a set of complex rules and exemptions;
2. Sharing data with the Home Office about debts accrued due to healthcare as a means to deny future visas to those with unpaid debts;
3. Sharing data between hospitals and the Home Office to assist with immigration enforcement.

The policies are complex and often have unintended but serious effects. For example, all migrants have access to primary care, regardless of  immigration status yet there is a significant impact on GP registrations. Reminding people that all migrants are able to register with a GP is an important step, but it cannot prevent migrants from being deterred by charging and data sharing policies.

Health professionals have raised the alarm about the comparatively low rate of vaccine take-up among black, brown and minority ethnic populations in the UK and the government’s advisory SAGE group has called for the barriers to access to healthcare for these groups to be understood and addressed. The Hostile Environment for migrants in healthcare is one of the major barriers that has consistently been proven to contribute to acceptable and uneven health outcomes.

The solution is to suspend the Hostile Environment

The UK’s COVID strategy relies on people being registered with  GPs to access vaccinations and relies on everyone being willing and comfortable to access treatment, to go to hospital when sick, and to share key personal information with hospital staff without fear of reprisal or future punishment. This cannot occur while the health system is designed to discourage migrants from interacting with it.

As we, and many other organisations, including the BMA, have previously raised, the only way to ensure that no one in the UK is prevented from accessing essential healthcare including vaccinations during the pandemic is to:

1. Suspend the entirety of the NHS charging regulations;
2. Suspend all information sharing between the NHS and the Home Office and ensure that no data collected at this time is subject to sharing in future.

This needs to be followed by a well-funded public outreach campaign that clearly states that there is no risk of someone being charged for healthcare, having their data shared with the Home Office, and that every single person in the UK is eligible to be registered with a GP.

But such a campaign cannot happen unless that assurance is watertight. As our research below shows, the fear of the Hostile Environment is too embedded and, in too many cases, justified.

Methodology

Between December 2020 and January 2021, JCWI conducted an online survey recording the experiences of migrants of all different kinds during the pandemic and subsequent lockdown restrictions throughout 2020. The survey asked questions about access to healthcare, housing, and experiences of work during this time. It was shared via social media channels, by organisations providing support to migrant communities and through trade unions. The survey received 310 responses. This data was supplemented by 10 interviews carried out with migrants, and two interviews with union officials about the general experiences of their migrant members. This report focusses on the questions asked about healthcare.

Findings

A substantial proportion of migrants are deterred from accessing healthcare

We surveyed migrants with a broad spectrum of immigration status and those without documentation. 43% said that they would be scared to access healthcare for fear of being charged or having their data shared with the Home Office (11% fear being charged, 25% fear their data would be shared, 7% fear both). This shows that there is a real risk these policies pose a serious impediment to our pandemic response.

The deterrent effect is likely to be higher for BME groups

Migrants from countries with populations that tend to be minoritised in the UK report a fear of accessing healthcare at particularly high rates. In the context of new data showing much lower rates of vaccination among BME groups than their white counterparts, the rate of fear of accessing healthcare in these communities is particularly alarming. In both cases, for migrants surveyed from African or Caribbean countries and from Asian countries, 60% and 56% respectively said they would fear accessing healthcare. This is compared to just 16% of respondents originating from North America, Australasia and Europe. We did not ask for people’s ethnicity, so these assumptions are based on the likely races or ethnicity of people coming from majority non-white vs majority white countries. However, given the well-established health disparities for BME people and the wide evidence of the disproportionate impact of Hostile Environment policies on ethnic minorities, this finding is unsurprising.

Refugees are deterred despite being exempt from charging

Of those with surveyed who hold refugee status, over half (56%) would be scared to access healthcare, citing the risk of the NHS sharing data with the Home Office. This is the case despite refugees being entitled to access all healthcare free at the point of use.

Fear of using the NHS increases with precarity of status

Apart from refugees, the more precarious a migrant’s status the more likely they are to fear accessing healthcare. While 17% of people with Indefinite Leave to Remain would be fearful, 24% of those with a temporary visa such as a work or spouse visa would be fearful, and 82% of those without any form of status would be fearful.

Those subject to no recourse to public funds  are deterred at higher rates

Having No Recourse to Public Funds (NRPF) is associated with an increased fear of accessing healthcare, despite the fact that NRPF does not in itself exclude people from NHS care. 58% of respondents with NRPF would fear accessing healthcare.

Survey questions asked and results

If you need to see a doctor, or go to hospital, would you be scared because you are a migrant?
No, I would not be scared	177
Yes, I would be scared, because I think I would be asked to pay and I cannot afford it	33
Yes, I would be scared they will give my information to the Home Office	78
Both	22
Total	310

 

Do you have Indefinite Leave to Remain in the UK?
Yes, Indefinite Leave to Remain or Settled Status	81
No, I have time limited visa (work, spouse, family, student, other)	78
No, I have Refugee status	25
No, I have Pre-Settled Status	22
No, I have no visa	79
I don’t know	21
Blank	4
Total	310

 

Fear of seeing a doctor among migrants with a lawful immigration status in the UK
No, I would not be scared	162
Yes, I would be scared, because I think I would be asked to pay and I cannot afford it	21
Yes, I would be scared they will give my information to the Home Office	45
Both	3
Total	231

 

Are you allowed to claim all benefits in the UK (NRPF)
I am allowed to claim all benefits	96
I am not allowed to claim all benefits (NRPF, undocumented, asylum seeker, other)	175
I don’t know	38
Blank	1
Total	310

 

Fear of accessing healthcare for those unable to claim benefits (NRPF)
No, I would not be scared	73
Yes, I would be scared, because I think I would be asked to pay and I cannot afford it	21
Yes, I would be scared they will give my information to the Home Office	61
Both	20
Total	175

 

Fear of accessing healthcare by region of origin	Africa & Caribbean	Asia	North America, Australasia & Europe
No, I would not be scared	46	39	82
Yes, I would be scared, because I think I would be asked to pay and I cannot afford it	16	10	7
Yes, I would be scared they will give my information to the Home Office	45	25	8
Both	7	15	1
Total	114	89	98

 

Fear of accessing healthcare among respondents with Refugee Status
No, I would not be scared	11
Yes, I would be scared, because I think I would be asked to pay and I cannot afford it	0
Yes, I would be scared they will give my information to the Home Office	14
Both	0
Total	25

 

Fear of accessing healthcare among respondents with Indefinite Leave to Remain
No, I would not be scared	67
Yes, I would be scared, because I think I would be asked to pay and I cannot afford it	7
Yes, I would be scared they will give my information to the Home Office	6
Both	1
Total	81

 

Fear of accessing healthcare among respondents with a temporary immigration status (work visa, spouse visa, student visa, etc.)
No, I would not be scared	59
Yes, I would be scared, because I think I would be asked to pay and I cannot afford it	6
Yes, I would be scared they will give my information to the Home Office	11
Both	2
Total	78

 

Fear of accessing healthcare among respondents with no lawful immigration status
No, I would not be scared	15
Yes, I would be scared, because I think I would be asked to pay and I cannot afford it	12
Yes, I would be scared they will give my information to the Home Office	33
Both	19
Total	79

 

Fear of accessing healthcare among respondents working the field of health or care provision
No, I would not be scared	17
Yes, I would be scared, because I think I would be asked to pay and I cannot afford it	2
Yes, I would be scared they will give my information to the Home Office	1
Both	2
Total	22

 

For more information please contact: Zoe Gardner, Policy Advisor, JCWI
[email protected] - 0207 553 7463

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