No compliance with ‘hostile environment’ in NHS
James Linney looks at the impact of Theresa May’s immigration policy on asylum-seekers
There has been plenty written over the past few months about the effects of the Tory’s ‘hostile environment’ on the Windrush generation, and the mainstream media have been pretty unanimous in their criticism of a policy that resulted in people, who have the legal right to live in Britain, being wrongly threatened with deportation, refused entry back into the UK and denied free treatment in the national health service.
The case of Sarah O’Connor, who died this year at the age of 57, was one of the more publicised examples, but it was typical of hundreds of other cases. She was wrongly accused of being in Britain illegally, subsequently lost her job and her house, was refused benefits and was facing bankruptcy when she died.
Despite such heart-breaking stories, Theresa May, who was responsible for implementing and enforcing the ‘hostile environment’ in her role as home secretary, could not quite bring herself to apologise during an Andrew Marr interview in September.1 She did her best to appear regretful that people’s lives have been ruined, but the result was the - by now familiar - spectacle of her not just failing to appear empathetic and caring, but failing to convince us (and possibly herself) that she is even recognisably human. But, putting her existential crisis aside, what she was clear about was her continued faith in the principle behind the ‘hostile environment’ policy. In other words, had the Windrush generation fallen the wrong side of the home office’s ‘right to remain’ categorisation, then the cruel treatment meted out to them would in fact have been morally justified (a sentiment about which the mainstream media are noticeably more silent in their criticism). And a fact that, strangely, puts the Windrush generation in a more privileged position than the thousands of people whom the British state deems it is morally justified to abuse because of their less privileged visa status.
One such group are asylum-seekers, who in the UK are people deemed to have fled their country of origin due to a “well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion”, as defined by the 1951 UN Refugee Convention.2 On arriving in the UK, they begin the process of applying for the ‘right to remain’; if successful they are categorised as refugees and can benefit from the same rights to work, welfare support and NHS care as other UK citizens (for a minimum of five years at least). If their application to remain is not successful, they have the right to appeal, but if the decision is upheld then they will be forcibly returned to their home country. The whole process is only supposed to take six months,3 but in reality can last several years. The UK interprets the above UNHCR definition in a notoriously strict manner, resulting in the rejection of most cases. In 2016, of 33,000 such applications, 21,000 were rejected.4
Asylum-seekers (often young children and teenagers arriving alone), have already been through unimaginable horrors. They come from the poorest countries, where often they have been imprisoned, tortured, raped and/or are fleeing war. Their journey to the UK commonly involves further abuse at the hands of transit countries, where many are locked up for months, or they have had to risk perilous journeys on death-trap boats at the mercy of smugglers. A list of deaths of migrants travelling to Europe since the early 1990s has been compiled by a Dutch NGO - United for Intercultural Action.5 As of May 2018, it has recorded 34,361 deaths. This list is in itself an indescribably sad record of the human cost of policing borders, but it is only the tip of the iceberg: these are only the reported deaths; the real number is certainly far higher.
On reaching the UK, their suffering continues - but now at the hands of the British state. Most are processed in one of the nine privately run ‘detention centres’ - a 21st century term for concentration camps. In 2017, 27,300 people were held in one of these centres, 42 of whom were children.6 The decision to detain someone is made solely by immigration police. There is no recourse to the judiciary and the UK is the only country in Europe that can detain asylum-seekers indefinitely in this way.
The lucky ones are released, whilst the home office starts the lengthy process of deciding whether they can stay. The realities of this process are a bureaucratic tragedy that makes Kafka’s The trial look like a frivolous sitcom. People are firstly given accommodation, but the home office ensures that they are moved outside London (where they might have some sort of support network) to distant cities, usually in northern England. They are accommodated in often dilapidated, overcrowded houses or hostels. Throughout their asylum processing - something that can last years - they are not allowed to work and each person (each adult and child) is given a weekly allowance of just £36.95, forcing them to live in destitution. They must report regularly to the home office and are subject to repeated, lengthy interviews, where they are interrogated about their past sufferings. They are also subject to ‘house rules’, which can often mean curfews or asking permission to come and go where they are housed.
One small mercy during their processing is that they have access to the majority of NHS care. True, there are some NHS services that are denied: for example, pregnant women, or children under four years old from families earning below a certain threshold, are normally given ‘Healthy Start’ vouchers. These can be spent on milk, fruit and vegetables and free daily multivitamins. However, children of asylum-seekers are not deemed worthy of these basics, despite their need being greater than most: often they are nutritionally deficient, which puts them at risk of infections, stunted growth, becoming anaemic from iron deficiency or developing rickets because of severe vitamin D deficiency. This situation is exacerbated by the exclusion of these children from the free school dinner scheme.
Refused asylum-seekers however, are even less fortunate: at the point that their asylum claim is denied, their access to NHS care is drastically rationed. Restricting essential healthcare is one of the weapons the Tories devised in the creation of their ‘hostile environment’. Hence the repellent National Health Service (Charges to Overseas Visitors) Regulations 2015, and the 2017 amendment. These were an extensive expansion of the 2011 regulations and created a situation where people not “normally resident” in the UK (including refused asylum-seekers) could only access a narrowly prescribed list of healthcare services. Exempt from the exclusions were GP visits, accident and emergency care, family planning, treatment for some infectious diseases and for a physical or mental condition caused by torture, female genital mutilation, domestic violence or sexual violence. But all other care is withheld unless the person first pays for its cost upfront. This is obviously an impossibility for almost all failed asylum-seekers, the majority of whom can barely afford to feed themselves, being no longer entitled to the £36 per week that applied during the processing of their case.
People coming to the UK as asylum-seekers have a host of complex mental and physical health conditions, linked to either the lack of healthcare in their home countries, the abuse they have suffered at home or at the hands of the UK government - as well as all the other acute and chronic conditions that anyone can suffer from. Their need for healthcare is therefore greater than the average person’s. Mental health conditions are predictably their most commonly experienced illnesses - what they have witnessed often leaves them with severe depression, anxiety or post-traumatic stress disorder, all of which require regular and intensive input from specialist psychiatric and psychological services. If by chance they are not suffering from a mental illness on arriving in the UK, then the psychological stress produced by years of being constantly threatened with an early-hours visit from the immigration police for immediate deportation may well create one. Yet, at the point where their asylum case is unsuccessful, whatever care they were receiving is then withdrawn. The results are predictably tragic, with suicide rates - already very high, compared to the rest of the population - rising sharply after their cases are rejected.7
If a refused asylum-seeker suffers a life-threatening illness or accident, they will be taken to A&E and receive care, but, as soon as they are stable and transferred to a ward, charges will apply. So the rest of their essential treatment (further operations, blood tests, nursing care, x-rays, rehab, etc) can be withheld unless payment is made. The regulations also create a statutory responsibility for the NHS staff to establish if someone in entitled to free NHS care - if not they must ensure that the money is received before care is given. It is the home office which decides what is medically necessary, not the doctors caring for these patients - and not surprisingly they interpret ‘immediately necessary’ and ‘life-saving’ very narrowly indeed. One case highlighting the reality of the suffering which has resulted is that of Kelemua Mulat, a 38-year-old refused asylum-seeker who fled Ethiopia, where her partner - the father of her daughter - was killed by pro-government forces after he took part in protests. Her treatment for advanced breast cancer was withheld by the home office, forcing her doctors to delay her treatment for six weeks, while they appealed.8
This is just one example, and a short article cannot possibly come close to illustrating the full extent of the misery that the ‘hostile environment’ policy has caused.
It is a policy that is explicitly not about economics. After all, the amount of money spent on asylum-seekers’ healthcare (or recouped through NHS charges) is inconsequential. And, if it was about saving money, why not allow asylum-seekers to work whilst their case is being processed? And, despite what some may claim, the policy cannot be about deterring people from seeking asylum. They leave their home country because they have to, usually because not leaving immediately would mean death for themselves and their family. They usually do not have detailed knowledge of the UK’s immigration policy and, even if they did, it would not matter: they do not have a choice. But presumably the government hopes that eventually its cruel restrictions will become common knowledge and they will flee to a different destination.
Theresa May’s implementation and recent enthusiastic defence of the ‘hostile environment’ is partly a (futile) attempt to placate the rightwing of her party, which is becoming increasingly emboldened by the divisions that Brexit has catalysed. It is also obviously pandering to reactionary and lumpen voters (including amongst the working class) who are not able to see through the oldest trick in the book: namely distraction via scapegoating. That is why the Tory narrative has consistently been: ‘Immigrants are to blame for your dissatisfaction with life. No need to do anything silly like question our austerity policies.’ There is also clearly something deeper at play. While borders and nationalism are not capitalist inventions, these are concepts it enthusiastically embraced. Immigration controls were created and then broadened in the late 19th and 20th centuries as a consequence of colonisation and imperialist wars.
So what does this mean for the left in Britain? It goes without saying that we must support movements fighting for full political and other rights for migrants. We should call on NHS staff to do all they can not to comply with the home office regulations on charging for care, and for their unions to coordinate and fully support such acts of solidarity. Yet we must also be clear that this is not enough to end the suffering.
And, at the same time as fighting to transform the Labour Party, we must be clear in our criticism: borders and immigration controls are inconsistent with socialism. We are internationalist as a principle and should have no part in any process that categorises another human being, who happens to move from one locality to another, as ‘illegal’. Until this ends, the suffering will continue l