EBOLA WORKERS STATEMENT:
Why we are giving our Ebola medals back to the UK government
We were honoured with medals for crossing borders to treat patients overseas, representing the UK and the NHS. Now the charging regulations, introduced as part of the ‘hostile environment’ for migrants are creating borders between us and our patients at home, undermining the founding principles of the NHS and the right to health
Who are we?
In 2014, the global community was shaken by an unprecedented event, the rapidly spreading epidemic of Ebola. When cases started to appear on western shores, our government rightly decided to intervene, enabling volunteers and service personnel to travel abroad. This intervention was based on the simple fact that diseases don’t recognize borders and that restricting our view on political or economic lines whilst ignoring the global and interconnected world in which we now live will be detrimental to all.
Many of us who volunteered to address this unprecedented outbreak work in the NHS, we left family and friends behind and acknowledging the life-threatening nature of this illness, went to help nonetheless. Whilst this was not done for any recognition, it was with great pride that we were given a government issued medal for our service. This was not an individual achievement but a point of national pride, recognizing the role the UK can play on a global stage with a humanitarian approach.
It is therefore with great sorrow and shame, that we find ourselves writing this letter. Since we received our medals, the government that rewarded us for helping people in a different country increasingly want us to now reject those that seek our help at home, and have introduced the most regressive regulations in the history of the NHS, restricting care to vulnerable migrants in an unprecedented way. It is hard to believe how far our pride in our country’s humanity has been eroded. The core principles of the healthcare profession; to help those in need without judgement, are being undermined by an insidious legislative agenda, the purpose of which appears to be to stigmatise and assign blame to those without a political voice, while distracting from the real problems the modern NHS faces.
The ‘Hostile Environment’
The Windrush scandal has brought the injustices being faced by immigrants in the UK into focus, and brings shame upon this country, but is only the tip of the iceberg. We are deeply disturbed that healthcare is being denied not only to the Windrush generation, but by anybody struggling to ‘prove’ their immigration status. This is no accident, but an entirely predictable effect of the ‘hostile environment’, which has now been firmly embedded into our healthcare system.
In particular, the most recent regulations, enshrined in law in October 2017, and currently being rolled out in England, build upon the last few years of increasingly stringent charging legislation in the UK. Health workers are now obliged to refuse to treat patients who are unable to prove their immigration status or to pay upfront (at 150% of the actual cost) before treatment, for secondary care and various community services. There are even plans to extend this charging into A+E and GP services. Treatment is to be withheld for those who cannot pay (unless urgent or immediately necessary, in which case they pay later), and unpaid debts of over £500 can be used against patients by the Home Office to deny entry or leave to remain in the UK. The effect is clearly not only to deny healthcare to vulnerable people, but also to threaten them when they are sick.
A letter pleading for the regulations not to introduced was signed by 193 organisations, on the grounds that they will significantly worsen what is already severely restricted access to health for vulnerable groups, but the policy went ahead nonetheless. There was very little public debate or consultation, although a ‘regret motion’ in parliament, passed by Lord Hunt after the changes were put into law, described the legislation as ‘wretched and miserable policy’ which gives a ‘dreadful impression and reputation’ to our country, and the former chief executive of NHS England said the charging regulations were “nothing short of a national scandal based on fake evidence”. We naively thought that the Windrush scandal would lead to the regulations being withdrawn, but they have not been changed.
Vulnerable people are being denied life-saving care
Many of us have personally witnessed patients being denied or deterred from care with devastating consequences, including pregnant women, newborns and children, but many of the negative effects are unseen, as people are deterred from seeking treatment. Only recently have a few cases started to receive mainstream media attention, whether it be patients denied cancer care; refugees having their chemotherapy stopped; home office decisions preventing life saving treatments for asylum seekers; others dying at home due to fear of charges; or pregnant women deterred from maternity care with life long consequences for themselves and their babies. The unpublished case stories from our own experiences have in many cases been more devastating than those that have reached the media. We have seen patients discharged to die, but as is often the case, patients have been too sick or too frightened to share their stories, and confidentiality prevents us from sharing them in detail.
Furthermore, there is now widespread evidence that upfront immigration checks are resulting in people being denied care even when they are actually ‘entitled’ to it if they can’t find the right documents, and particularly if they belong to a minority ethnic group who are more likely to be ‘checked’. This is affecting asylum seekers and refugees, and particularly applies to groups which are intended to be exempt but are unlikely to be identified, such as victims of modern day slavery and those who have been trafficked into the U.K. Exemptions for certain infectious diseases are also equally or perhaps even more impractical, given that people see a doctor for symptoms, without necessarily knowing what disease they have, and in many cases infectious diseases such as TB and HIV are diagnosed in a range of secondary care services, which many patients are now deterred from accessing. It is for this reason that infectious disease specialists and organisations such as the National Aids Trust, and many others have been opposed to the regulations.
Flawed definitions of people’s ‘legality’
Beyond these arguments, it is now clear to everyone that we cannot trust the accuracy or motivations behind the rhetoric labelling people as ‘illegal’ when the system that defines people as such is so flawed that it wrongly detains and deports its own citizens. It is clear that if a person can be wrongly detained or deported, then they can easily be wrongly denied healthcare. Not only that, but as recent changes demonstrate, this system is deliberately designed such that the process of obtaining and maintaining a legal status has become increasingly insurmountable and un-affordable.
In addition, the UK has, for example, one of the lowest asylum application acceptance rates in Europe, and we accepted legal pathways for only a woefully minute fraction of our fair share of migrants and refugees in Europe’s ‘refugee crisis’. Indeed, research on child refugees by the cross-parliamentary Human Trafficking Foundation has shown that restricting legal routes to migration actually encourages irregular migration and trafficking.
More importantly though, documents or not, human beings have a right to health and to be treated with dignity. Our system is hostile enough already, makes catastrophic misjudements, and we as health workers cannot accept that such an unsafe system can now be used in a hospital to decide whether our patient gets to live or die.
It’s not worth it economically, and it may be costing more
Importantly, apart from the obvious cruelty of such an approach, the economic arguments for the charging regulations are seriously flawed, and this is well recognised. The grossly exaggerated and misleading concept of ‘health tourism’ is often quoted, however even the government’s own estimates of the size of this issue are far lower than what would be predicted from the portrayal of this issue in some media (between 0.00016% and 0.3% of the NHS budget according to government estimates, and up to 0.07% according to the independent King’s Fund). In practice, even when targeted pilots were carried out in the hospitals which were felt to have the highest numbers of ‘health tourists’, only 1 in 180 patients were found to be chargeable for care under the regulations. This suggestion is also supported by some Freedom of Information requests to trusts revealing higher expenditures on bureaucracy than the charging actually generates (in some cases more than 4 times higher costs). This is unsurprising given that trusts are even known to be spending money on court proceedings to recoup money from destitute women after giving birth who are unable to pay for their pregnancy care.
Therefore it seems that the regulations may even cost more than they save, not only due to bureaucracy, but also due to missed opportunities for preventive care leading to more expensive emergency care (particularly higher A+E use) later, and the public health risk to all of us from communicable diseases remaining un-diagnosed. Indeed, published research supports the assertion that restricting access to health care for vulnerable groups does increase overall costs when these other factors are considered.
For perhaps obvious reasons, a full economic analysis of the charging regulations, including secondary costs mentioned above, has not been published. This has lead some to argue that the real purpose of the regulations is to create a convenient distraction from NHS underfunding by scapegoating migrants, while simultaneously justifying the introduction of a charging infrastructure which can be applied to other groups later.
In addition, far from targeting ‘health tourists’, research shows that many of the people being charged have actually been living in the UK for several years in poverty and difficult circumstances, are more likely to under-use health services, and are the least able to pay. This was even conceded by the government’s own briefing, which acknowledged that many of the people targeted for cost recovery don’t actually have the resources to pay, meaning the regulations are in many cases more about denial of treatment than actual cost savings.
Other comparable countries cover the healthcare of undocumented migrants
A widely accepted myth is that other European countries have similar laws to charge undocumented migrants. This is simply not the case in comparable countries. France for example, perhaps the most similar country in terms of population, economy, colonial history and undocumented migrant population, has a specific program called ‘State Medical Aid’, which is designed to give full and free access to primary and secondary care for undocumented migrants. Analysis across Europe also reveals for example that most countries’ laws respect the right of pregnant women to access free care, as opposed to the UK which now charges undocumented pregnant women a starting price of approximately £6700, and often much more (non-EEA category), and pursues them in court if charges are not paid. The situation of an undocumented migrant is simply not comparable to that of a tourist on holiday in Europe that may be significantly wealthier and may be insured or have a reciprocal agreement for reimbursement by states.
Migrants in general are actually the ‘lifeblood of the NHS’
Furthermore, we know that far from being a burden, migrants are actually the lifeblood of the NHS. More than a third of doctors in the UK, are graduates from other countries, with similar figures for nurses and other healthworkers. This saves the UK billions in training and means that the National Health Service truly is an International Health Service. Perversely, many of our colleagues who come to the UK to work in the NHS are now faced with an additional tax towards the NHS, in the form of the ‘health surcharge’. This means that migrant workers actually pay more into the NHS, even when they are working within it. Indeed in the absence of any appreciable cost savings from the charging regulations already described, the majority of the government’s quoted cost savings from the overall changes come from this regressive migrant tax. Despite calls for the removal of this surcharge on the grounds it causes significant hardship, in particular to nurses and their families, it was doubled this year. To add insult to injury, many of our colleagues have suffered discrimination and have become victims of the hostile environment themselves, even facing detention and deportation, and finding themselves in the position where even they would be denied healthcare in the service that they have worked in.
The anti-immigration agenda has gone too far
Lastly, it is now becoming clear that introducing the ‘hostile environment’ into the NHS is harming not only our patients but also undermining our professional integrity and caring role, eroding trust and encouraging xenophobia and racism, and ultimately damaging our society. The hostile environment serves a political agenda but costs lives, and is not based on an economic or moral justification.
It was with the greatest pride that we represented the humanitarian values we believed were core to this country, but it is precisely because of those values that we feel compelled to return our medals. We want to send a strong message that no government, not now nor in the future, should ever treat migrants in this way, especially when it comes to their health. We are calling on the government to abandon the hostile environment measures in the NHS, starting most urgently by removing immigration checks and upfront charging before treatment, removing charging for pregnant women and children, and suspension of the NHS charging regulations, given their clear evidence of harm, while a public health impact assessment is carried out, particularly focusing on vulnerable groups.