It’s hard to keep an official count of the number of NHS patients that have died due to the impact of the government’s ‘hostile environment’ for migrants – partly for reasons of confidentiality, partly due to the complex nature of defining causes of death. In recent years we’ve seen delayed presentations of cerebral tuberculosis due to fear of detention, premature babies who have struggled to survive due to lack of prenatal care, delayed cancer treatment – need I continue?
I wonder if as doctors we should start writing ‘the hostile environment’ in part II of a death certificate (where ‘other significant conditions contributions to the death but not related to the disease or condition causing it’ are noted). Thanks to the updated government guidance on the ‘implementation of charging for overseas visitors’ brought in last October – aggressive charging at inflated prices and an ever-increasing exchange of information between the Home Office and the NHS – patients from overseas are discouraged from seeking care, leading to preventable deaths and diseases. But despite the promotion of these anti-immigration policies, the NHS continues to function because of its international workforce. Is it fair that only British nationals feel the benefit of this?
Many NHS executives rejoiced when visa restrictions for overseas doctors were scrapped last week. “It is fantastic news that the government has listened to our calls and scrapped the cap on tier 2 visas for doctors”, they said. “It is vital the NHS is able to employ doctors from overseas, and we hope this change means it is no longer prevented from doing so by arbitrary immigration rules.”
Currently one in three UK doctors are from overseas, and one in four from outside Europe. The second most common country for NHS staff to come from (after Britain) is India, with Nigeria, Zimbabwe and Pakistan also contributing significantly. Evidently, postcolonial countries continue to support our island. But scrolling through both Jeremy Hunt and Sajid Javid’s Twitter feeds, there is a strange silence over the scrapping of visa cap – perhaps they are ashamed of the hypocrisy surrounding the government’s migration policy.
Let’s have a closer look at how some of Britain’s former colonies are faring against this country. Nigeria has a doctor patient ratio of four to 10,000. The UK’s is almost seven times higher at 27.1 per 10,000. Life expectancy here is 71, in Nigeria it’s only 48. Around 50% of doctors registered to work in Nigeria work abroad. There are currently over 5,000 Nigerian-trained doctors working in the NHS, yet if a Nigerian comes to hospital in the UK they will be charged vast sums of money and in some cases turned away.
Of the 36% of NHS doctors that come from abroad, 12% are from Asia – of which half are from India (life expectancy 59) and Pakistan (life expectancy 57). Both are former colonies and overseas visitors from these countries are charged some of the highest rates when seeking healthcare here. It seems the NHS is only international when it suits the government.
The idea that this is the fault of footloose migrating doctors who could choose to practice in their home country doesn’t stand. Countries in the Global North offer superior remuneration and working conditions for doctors, and if your choice is between being able to provide a better life for your family or not, it’s not much of a choice.
The structural violence inflicted on these nationalities doesn’t stop here. British citizens who are descendants of immigrants from former commonwealth countries see greater barriers to accessing healthcare and worse health outcomes than their white British counterparts. As the Windrush scandal so violently demonstrated, British citizens who came here legally before 1971 from former commonwealth countries including Nigeria, India and Pakistan have been racially profiled and denied healthcare, housing, work, and in some cases even detained.
What’s more, structural racism affects the staff working tirelessly in our underfunded and understaffed system. Take the case of Dr Bawa-Garba – a British-trained paediatrician of Nigerian descent who was struck off amid high controversy and dismay from the medical profession. The decision, taken by the General Medical Council (GMC) – the professional regulatory body of doctors in the UK – highlighted discrimination against black and ethnic minority British doctors. These doctors are more likely to have complaints made against them, more likely to have those complaints investigated, more likely to have them upheld, and then more likely to be struck off. If one thing is clear, it’s that the hostile environment will only continue to ingrain these prejudices against both staff and patients.
Nye Bevan founded the NHS 70 years ago in 1948 – the same year the Empire Windrush first came to Britain. His idea was for free healthcare for all, and at the time the question of health tourism and charging overseas patients was dismissed as “unwise as well as mean”. In his words: “Not even the apparently enlightened principle of the ‘greatest good for the greatest number’ can excuse indifference to individual suffering.”
As healthcare workers, we are at risk of losing the moral high ground. Without remaining vigilant, and fighting for the founding principles of the NHS, we will end up with a two-tier system where the right to healthcare is based on biased notions of ‘deservedness’ rather than genuine clinical need. For me, it’s a question of morality: how can we deny treatment to somebody who requires it? If it’s true as Bevan said that “there is no test for progress other than its impact on the individual”, right now we seem to be moving backwards.