Migration and NHS Entitlement Reform

by Jake Watson

Reforming Entitlements to the NHS

On the 25th of March Secretary of State for Health, Jeremy Hunt, announced Government intentions to reform entitlement to primary health care for overseas nationals. Hunt announced that this would be done through:

  1. Changing the criteria for free, unimpeded access to primary NHS services: principally, transitioning from ‘temporary residence’ to ‘permanent residence’ (Hunt 2013: Column 1291).
  2. Ending free primary care access for all visitors and tourists.
  3. Introducing health insurance to visitor visas.
  4. Improving mechanisms of identifying those liable to charges and collecting charges.

(Hunt 2013: Column 1291)

Health Tourism

These changes represent a proposed solution to the sustained moral-panic over “health tourism”; the idea that people come to the UK with the specific intention of accessing free health care from the NHS, costing the NHS roughly £28 million a year (see Dr. Huppert Column 1295).  Under the pervasive rationale of austerity, it is argued that this is an unfair burden on the resources of the NHS at a time when it is being asked to streamline and rationalize its spending while maintaining the quality of its care. As current regulations make primary care free to anyone in the UK, it is here that concerned commentators have seen the need for reform.

The argument is that attempts to identify those liable for charges at the secondary level, where eligibility is regulated by residency criteria, is being undermined by access through primary healthcare where services are not regulated by residence. Primary healthcare services are presented as a gate-way for health tourists, an argument supported by a recent Panorama special. Hence, so the argument goes, introducing residency criteria and charges for those seeking to access primary health services will prevent health tourism and allow the NHS to identify those liable for charges.

Challenging the Logic

If primary health care is a gate-way for health tourists, certain migrants in the UK clearly can’t find the entrance.  As migrant and refugee community organizations (MRCO) know all too well, accessing appropriate health services is a constant challenge. Research shows profound problems in accessing primary and secondary health services for vulnerable migrant groups.  Already, vulnerable migrants are being subject to a range of unjustified and illegitimate exclusions from health care which is leading to troubling policy implications. The current Governments’ proposals do not address these concerns. Instead, they threaten to escalate and accentuate problems.

Complicating the Solutions – Residency Criteria

Jeremy Hunt proposes ‘residency’ as the principle mechanism to control access to health services. It is, however, exactly the use of residency criteria that needs to be challenged as an effective mechanism for identifying those liable to charges. Arbitrary and misapplied criteria for proof of residency by front-line primary care staff is leading to unjustified and legally ambiguous, exclusions from health services. This is operated through requests for:

  1. Official proof of address documentation, most commonly utility bills.
  2. Official proof of address documentation to prove legal residency in the UK for a period longer than six months.

Those migrants unable to easily provide such information are being excluded from primary health care, increasing the vulnerability of an already vulnerable group.

It is a damning indictment that we already have the evidence to see the problems of policies that have not yet even been implemented. Far from only ethical arguments or individual health concerns, there are a number of important socio-economic policy issues. Here are three specific concerns:

1)     Costs Outweigh the Benefits – Capacity, Training and Bureaucracy:

Perhaps the biggest indictment of Governments plans is that it is unclear whether the introduction of proposed reforms will even save money. The fact that residency criteria are already being so grossly misapplied by front-line primary care staff testifies to the fact that, if reforms are enacted, there would need to be significant investment in capacity building and training. Research has suggested that the price of such capacity building would outweigh any benefits.

2)     Costs Outweigh the Benefits – Ineffective Primary Health Care:

As the US health system graphically attests to, a poorly functioning system of generalized primary health care leads to a more expensive health care system. This is because conditions that could be addressed through preventative care are allowed to manifest into more serious health complications, leading to hospitalizations, expensive surgery, costly palliative care, and increased strain on unemployment and disability benefits. Even for migrants ineligible for free secondary care, the UK has a legal obligation to treat conditions that are deemed “immediately necessary” or “urgent”. For example, for some failed asylum seekers, conditions of destitution coupled with the often protracted length of stay in the UK, can lead to serious health deterioration and the need for urgent and immediately necessary care. It is unlikely that the NHS will be able to recoup charges from this group.

3)     Profiling and Discrimination:

Government needs to think about the introduction of eligibility screening in frontline public services in terms of anti-discrimination and social cohesion policy. As stop-and-search practices in the police force have shown, mandating public sector staff to screen and profile their service users can have troubling implications. Without expensive capacity building and a costly, robust, and independent monitoring system in place, contemporary and historical example raise serious concerns around racialised, discriminatory and arbitrary mechanisms preventing certain groups in society from realising their right to health.

Who’s the Target Anyway?

More problematically, it is unclear who exactly the Government is targeting when they seek to regulate health tourism: EU-nationals have rights under EU-level complimentary measures; and non-EU transnational business elites will likely have access to private health providers. This leaves the principle object of policy concern as UK-citizens who become ineligible for certain secondary care due to leaving the UK for a period that forfeits their eligibility under residency criteria (this may be a large group), and non-EU nationals in the UK, i.e., students, tourists, family visitors, asylum seekers, and undocumented migrants.

It is extremely unlikely that migrants under the undocumented and asylum-seeker category come to the UK for the explicit reason of using NHS services. Such individuals are fleeing persecution or looking for better economic opportunities. Of the latter group most are young, male, economically active, and least likely to use health services. That leaves non-EU students, tourists and those visiting family members. For all the problems highlighted above, access to NHS services for these categories can and should be regulated through controls outside of the NHS. These controls could include: health insurance attached to visas; development of expenditure recoupment methods under complimentary agreements with non-EU states; or, perhaps a small increase in the price of non-EU visas, the revenue of which can be directed into the NHS.

Migration and NHS Reform: Alternatives

It seems the Government has two principle choices. It can continue in its fear-driven control agenda, a path destined to fail.  In this choice migration is rendered an object of threat to the NHS, and seen as in need of restriction and exclusion. This is counter-productive as economic and social policy, and most importantly for this Government, it will cost more. Alternatively, the Government could accept migration as an inevitable, and indeed in many ways, beneficial reality of contemporary life in the UK and begin constructing positive narratives and positive policy responses.

This choice raises a number of interesting and potentially productive policy opportunities. Instead of being an object of control, perhaps migration can become a subject-position from which to think about NHS reform. Thinking about migration and the NHS in such a way could revitalize the NHS in this country, lead to more efficient spending, and produce a more efficient form of service provision.

An example:

My own research on this subject for the Migrants’ Rights Network uncovered that domestic workers (eligible for free and unimpeded access to the NHS) make extensive use of walk-in centers in A&E’s during weekends. This is due to a variety of reasons: they struggle to provide the six month proof of residence arbitrarily required in many GP surgeries; their conditions of employment mean that they are unable to attend normal GP hours; and they struggle to negotiate the administrative aspects of GP surgeries, finding the walk-in aspect of A&E’s easier to navigate. In terms of personal health outcomes, this results in interrupted care, poor follow-up, and an increased likelihood of health deterioration and development of more acute health complications. In terms of the health system, it leads to increased costs- as A&E walk-in centers are more expensive than GPs, and improper primary care coverage can lead to far more costly health concerns- and an unnecessary clogging up of A&Es. Looking at NHS reform in this way, treating migrants as legitimate, claim-making users of NHS services, we can suggest that increasing the availability of flexible, on-demand, primary care providers in hospital facilities during week-ends could lead to reductions in expenditure and improvements in health provision.

This is just one example from a small-scale research project. However, the general idea of including migrants in user-led service provision reforms may be a far more effective, and certainly far more positive, way of solving contemporary issues within the NHS.


It is essential that the Government reevaluate its proposals for addressing health tourism through the introduction of residency criteria at the primary health care level.

  1. It is far from clear how the proposals will save money. The sheer cost of developing administrative, human resource, and monitoring capacities may outweigh any cost-benefits.
  2. Good, inclusive, and appropriate primary health care is the foundation of a cost- and result- efficient health economy. Evidence already points to widespread misapplication of residency criteria checks at primary care level. As it is probable that this will continue, unnecessary expenses at secondary care level are likely to be incurred.
  3. It is not convincing that the planned reforms to combat health tourism are effective or fair. Combatting health tourism through introducing screening mechanism within the NHS will unfairly impact on vulnerable migrants who are not health tourists. The Government is urged to explore alternative approaches outside of the NHS. Above all, these plans introduce elements into the NHS which undermine its very essence as a human service.

In Conclusion

It is essential to place this prosed reform within wider governmental strategy. It is in order to cultivate the support for, and justify a savaging of substantive citizenship and institutions of social justice that the Government has committed to reducing net migration to the tens of thousands. This is the twin discourse of austerity and immigration control -essential to this Government- where the latter recurrently justifies, obscures and gains popular support for the former. It is exactly in this way that the disproportionate and misleading focus on health tourism must be understood. It is a strategic attempt to invoke racist and xenophobic social cleavages to create an ambivalence and ambiguity in damaging NHS restructuring.

From a social democratic perspective this discourse must be rejected. A space must be cleared for a critique of Government austerity and the proposal of alternative responses to current crises. Far from migrants using NHS services, what is threatening is state legislated tax evasion, off-shore banking, high finance, the commodification of citizenship, and the tacit acceptance of vast swathes of UK society excluded from ‘growth’, and living on subsistence wages from either the public or private sphere. And most importantly it is the appropriation of ‘common sense’ by the economic right. Any attempts to blame migrants must be rejected, not simply because of the control agenda which flows from this, but also because it is exactly through this that the economic right cultivate populist support for its attacks on substantive citizenship and social justice.

Jake holds an MA in Migration Studies from the University of Sussex, and a BA in Sociology from the University of Warwick. He recently completed a project with Migrants’ Right Network looking at migrants’ access to NHS services in the context of proposals for reform. His principal research interest involves the potential of the postcolonial critique for thinking through alternatives to the dominant political economy of citizenship.

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