‘Women forced to show passports.’ ‘Photo ID to access care’. The media reported with interest on St George’s NHS Trust’s October board papers,[1] which propose that all women should show their passports at their first midwife appointment in order to prove their eligibility to receive care. Condemned by Labour leader Jeremy Corbyn in Prime Minister’s Questions, the proposal received support from Theresa May, who stated: ‘Where there are people who come to this country to use our health service – and who should be paying for it – the health service identifies those people and makes sure it gets the money from them. I would have thought that would be an uncontroversial view.’ Accompanying editorials and articles argued for the need to ‘crackdown’ on ‘health tourism’ to limit the NHS’ growing debt. The financial crisis in the NHS is not the fault of people needing care. Measures such as those proposed by St George’s Trust will be harmful to the people who do need care, and will ultimately cost more. Even more importantly, they strengthen racist arguments about who should be cared for and who should not, and begin to normalise the NHS charging for care.
Documents from the south London NHS Trust explain that this is about money – about its growing ‘overseas debt’ (money it spends on care for overseas patients, but does not get back), which stands at £4.6 million. The Trust, like others across the country, already charges women who are ‘visiting’ the UK for maternity care, in the form of a bill given after the birth. They currently get back only 20% of the money they try to collect, working with debt collection ‘partners’ LRC, who have proudly clawed back £380 million for their clients, including the NHS and universities. The Trust proposes to remedy the shortfall by a more concentrated effort to identify women deemed ineligible early in their care and bill them sooner. The board papers claim that the hospital has become an ‘easy target’ for women not ‘eligible’ to receive free care, and goes so far as to argue that they are facing ‘organised illegal activity’, with women from Nigeria paying an agent to organise the trip to Tooting to have their babies for ‘free’ on the NHS. This claim – without any apparent evidence – is reminiscent of comments in 2013 from a central London hospital about a ‘Lagos shuttle’, apparently a flow of women coming from west Africa to give birth.
Strengthening checks and charges
The proposal is not new, but is an attempt to advance the process of charging for care. 2011 saw the introduction by the ConDem government of charges passed on to women classed as temporary migrants or ‘visitors’ – around 50,000 pregnant women each year, one in 14 births, costing approximately £180 million a year. ‘Visitors’ include women who have been trying to make their way through the immigration system for years, whilst provided with devastatingly small benefits and inadequate housing. Unable to work because of restrictive immigration laws, women are then burdened with a heavy debt they simply will not be able to pay. The costs stand at around £6,000 per birth, with additional costs for a caesarean or more complex care. FRFI has campaigned alongside women who have been charged over £10,000. This system of charges has already seen horrendous results – two women aggressively pursued for thousands of pounds following the deaths of their babies, of women avoiding care resulting in the loss of their babies and of women having to borrow money from friends, families and churches each month to try to come up with a plan to ease the constant pressure – phone calls, letters and emails – from debt collectors. These bills not only cause constant stress, worry and poverty, but are finally used to deny future immigration applications.
An impossible proposal
Healthcare bodies and charities have explained that charging women is likely to ultimately cost the NHS more. If early, regular and quality care is not provided it increases the potential need for complex care around birth and specialist care postnatally.[2] Women will avoid or delay accessing care, as the current system of charging has already proven. Doctors of the World, a charity providing clinics and support for refugees and migrants, has reported that 75% of women relying on their clinic had not accessed antenatal care from the NHS when they needed it. The proposal can only make this situation worse.
So if the money will be difficult to collect and the proposal costly and harmful, why has it come about now? We are seeing yet another intensification of racist checks and charges which make the country ever more hostile for migrants and refugees. St George’s is candid – its overseas patient team will work ‘in liaison with the UK Border Agency and the Home Office’, to ‘further screen’ women. Health service staff are increasingly being expected to play the role of border guards. Despite attempts to suggest this will not impact on access to care, the board report is littered with phrases such as ‘overseas visitors who are accessing NHS who are not entitled to treatment’. This is simply false; all patients are entitled to treatment. Some have to pay – but this distinction is too often left out, leaving repeated suggestions that pregnant women and patients are not entitled to be seen. The Department of Health and the Cabinet office are already developing national guidance that is ‘likely to advocate routine presentation of proof of identity and eligibility’ for NHS care more generally, including A&E and ambulance services. The 2014 and 2016 Immigration Acts have set the legal framework for the further charging of migrants and expanded the category of those who may face charges. The Department of Health supported the 2016 Act by encouraging more aggressive pursuit of charges, and a spokesperson has said they are looking ‘forward to the results’ of St George’s ‘pilot’.
This is at a time when further cuts are being forced on an NHS in dire financial straits. FRFI has reported on the savage cutbacks, creeping privatisation, bursary cuts and dangerous contracts for junior doctors. The sums raised by those talking about overseas eligibility are negligible in comparison to the payments made to the private finance initiative (PFI) schemes – private debt schemes – which cost the NHS £3,700 every minute, about £2 billion a year. The endless media stories blaming everyone but the system itself distract attention from the real issues while charges and changes are pushed through. UK director for The White Ribbon Alliance for Safe Motherhood, Brigid McConville, said of maternity charges: ‘It’s the perfect storm for the NHS totally undermining preventive care […] One of the biggest fears is that this is test to get mechanisms in place for charging through the backdoor. Currently it’s for migrants, but who next?’
The intensification of state racism is not confined to health care. The proposal comes at a time when schools are sending letters to parents asking for identification documents. The week following the release of the board papers saw small numbers of refugee children arriving in Britain, only for their ages to be questioned in a torrent of racist media coverage. Conservative MP David Davies was ridiculed by health professionals when he called for their teeth to be checked to determine their age, but the idea of refugees divided into those who need support and those less deserving remained. Just as charging for health care has been shown to be a bad solution even in cost terms, the idea of ‘eligibility’, of those who deserve care and those who are trying to cheat the system, is being strengthened. We argue against these false distinctions and against racism in all forms. Health and education staff are increasingly being expected to play the role of border guards, which must be opposed by those giving and accessing care, whether we are affected or not.
Rachel Francis
[1] www.stgeorges.nhs.uk/wp-content/uploads/2016/10/Trust-Board-Public-PDF-Oct-16-1.pdf
[2] Royal College of Midwives, Doctors of the World
