Following the 2014 Immigration Act, there was a broadening of pre-existing National Health Service charges for ‘overseas visitors.’ This expanded the group of people deemed chargeable for secondary health care, made provisions for charging at 150% of the cost to the NHS, and saw the introduction of the ‘immigration health surcharge’ for those applying for a visa to live and work in UK.
For residents with insecure immigration status, the entrenching of border controls within the NHS and the attendant financialisation of healthcare has functioned as deterrent, preventing migrants from accessing necessary medical treatment for fear of subsequent debt collector and Home Office involvement.
Indeed, not only do many NHS trusts outsource debt collection to private agencies but, through the stipulation that patient details can be passed on to the Home Office if healthcare debt is outstanding for more than two months, accessing vital medical care can now lead to visa refusal, detention and deportation.
These passport checks and charges, which form part of the broader hostile environment policies, have been fiercely critiqued and resisted by patients, medical practitioners, and other campaigns and organisations, where calls have centred on ending this policy and abolishing the hostile environment more broadly. However, less discussed is how current charges for NHS secondary care draw upon on an earlier iteration of NHS passport checks and charges for migrant health care, first introduced in October 1982.
activists framed their resistance such that it allows us to draw out the connections between internal bordering within the British welfare state and the ongoing legacies of empire and colonialism
This short article recovers this earlier policy and details how it was understood and resisted by migrant organisations and community activists. Drawing on archival research, I suggest that activists framed their resistance such that it allows us to draw out the connections between internal bordering within the British welfare state and the ongoing legacies of empire and colonialism, both here and elsewhere. Such understandings may help us better grapple with how passport checks and charges within the British welfare state today inherit their logics from colonial governance.
Health Charges for Overseas Visitors, 1982
In 1981, the UK Government announced their intention to introduce passport checks and charges for overseas visitors’ NHS treatment, with responsibility placed on healthcare providers to recuperate outstanding debt. This was to be done through an amendment to Section 121 of the NHS Act 1977 and, similar to current charging regulations, excluded various treatments including sexually transmitted and contagious diseases, treatment for those detained under the Mental Health Act, and treatment in accident and emergency departments. The announcement was justified through claims of alleged widespread abuse of the health service by foreign nationals. As a result, the government suggested that the policy would save the NHS £5 million a year.
While the introduction of NHS charges for overseas visitors was officially framed through discourses of health tourism, a discourse more recently described as a racist ‘baseless myth to support the supposed need to exclude people from accessing the NHS’, they were also situated within a broader context in which the rights of racialised migrants in Britain were being eroded through the Nationality Act 1981.
The 1981 Act built on previous immigration acts (1962, 1971) and sought to recreate British citizenship through abolishing birth right and making citizenship dependent on direct descended connection to the UK. In effect, the Act removed former citizens of British Empire from the category ‘British’, thus characterizing citizenship in Britain as racialized (Tyler, 2010). As a result, a number of restrictive policies were introduced that sought to make services conditional on citizenship and residency, introducing passport checks into healthcare, social security, housing, and elsewhere.
the move to restrict certain migrants from healthcare provision also functioned to deny them access to resources derived from colonial extraction
In the specific context of the NHS, which had and continues to benefit from the labour of Commonwealth migrant workers, the move to restrict certain migrants from healthcare provision also functioned to deny them access to resources derived from colonial extraction. Indeed, as Gurminder Bhambra has argued, ‘taxation in colonial dependencies and resource extraction and appropriation continue to be part of the explanation for the growth of the resources available for the establishment of the domestic welfare state’. The implementation of passport checks and charges for NHS care, both in the 1980s and now, should be situated within this broader colonial history, and understood as both instances of racist surveillance and restriction and as a policy that facilitates continued colonial dispossession (El-Enany, 2020).
The 1981 announcement of NHS passport checks and charges was met with widespread criticism from trade unions, medical practitioners, migrant organisations, and law centres. The National Union of Students (NUS) and the United Kingdom Council for Overseas Student Affairs (UKCOSA) called for international students to be treated as a ‘special case’ and exempted from NHS charges.
A report published by UKCOSA in December 1981, Overseas Students and the NHS: The Wrong Prescription, called for NHS charges for overseas students to be scrapped, claiming that they would be racially discriminatory in practise and that they would be ‘a first-step in an insurance-based health service for all’ (1981, 19). The report also noted that ‘the saving of £5m is calculated to be less than 0.04% of the health budget and the Health Authorities themselves have expressed scepticism as to whether any saving will be made’ (1981, 14).
The NUS International Students Campaign called a day of action against the charges, held on January 29th 1982. The day included picket lines outside hospitals, the lobbying of MPs, and evening gigs to raise awareness and campaign funds. In February 1982 Norman Foster, then Secretary of State for Social Services, announced an amendment to the original NHS charging proposal whereby all visitors, including international students, who had resided in the UK for over a year would exempt, as would international students already residing in the UK.
However, despite these concessions, on October 1st 1982 NHS charges for overseas visitors came into effect.
No Pass Laws to Health!
In response to the introduction of NHS charging regulations, a number of local campaigns arose that sought to resist them. One such group and the focus of this section, No Pass Laws to Health, formed as a coalition of law centres and migrant organisations in North London and sought to document and resist passport checks and charges.
The campaign took their name – No Pass Laws to Health – from the pass law regime of Apartheid South Africa, a system of governance that has its roots in British colonialism. Requiring Black and other racialised workers to carry pass books with them at all times in order to access employment and land, the pass law regime sought to maintain racial segregation and dispossession within a white supremacist state, while also securing the provision of cheap Black labor. In other words, pass laws functioned to produce and maintain a system of racial capitalism.
The use of pass laws as a frame to apprehend internal border controls within 1980s Britain, in my view, allowed important connections to be drawn between tactics of racialising and colonial governance in post-colonial Britain and elsewhere. This is an important framing in the context of the Nationality Act 1981. Indeed, if we understand NHS charging regulations to be part of a larger state project functioning to deny citizenship and rights to certain formerly colonised populations and to prevent those populations from accessing resources derived from colonial extraction, then colonialism, racial capitalism and anti-colonial resistance are vital frameworks within which to situate and resist internal border controls in post-colonial Britain.
the No Pass Laws to Health campaign argued that passport checks and charges within the NHS were racist and anti-working class
In their public facing materials, the No Pass Laws to Health campaign argued that passport checks and charges within the NHS were racist and anti-working class; they functioned to divide the workforce along lines of race, resulting in the creation of a colour bar within the health service. They raised concerns that the policy functioned to turn health workers into agents of the Hone Office, ushing in a in a regime of racial profiling. The group also noted the disproportionate impact that the policy would have on migrant women because of the gendered nature of reproductive labour; women ‘have to go to the hospital more often then men, not only for reasons of their own health but the responsibility for ensuring that sick and injured children generally falls on their shoulders’.
Working with trade unions, migrant organisations and individuals effected by the policy, the campaign’s work was varied. On December 12th 1982 they held a conference at City Hall, London, which brought together trade unions medical professionals and community organisations. Through law centres they collated instances of charging and supported cases. The campaign also created information and advice leaflets, which were translated into Arabic, Bengali, Greek, Spanish, Tagalog, Turkish, Urdu, among other languages.
As the campaign continually argued, the NHS charges for overseas visitors were unlikely to generate significant revenue. And unlike todays hostile envionment, this earlier iteration of NHS charges were not a statutory duty. Thus, burdened with the signifcant costs of administering the passport checks and charges, along with continued resistance from unions, healthcare workers, and the affected pateients, by 1984 many hospitals had dropped the charging regime having made a fianncial loss.
While the 1980s fight against border controls within the NHS wasn’t ‘won’ in any spectacular way, the support that campaign groups provided undoubtably played a role in helping those affected navigate the charges. Moreover, in the context of the No Pass Laws to Health campaign, the framing of passport checks and racialised welfare restriction as akin to colonial and apartheid systems of governance offers us fertile ground through which to connect and analyse struggles against border controls and racialised surveillance globally. Indeed, while South Africa’s pass law regime officially ended in 1986, scholars have traced its many afterlives to a variety of systems of racialised governance that seek to control movement such that exploitation and appropriation are facilitated – from the Israeli ID card regime used to classify and control Palestinian movement, to the US guest worker visa programme and European visa regimes (Clarno, 2017; Hahamovitch, 2013).
it is vital that we frame our demands for universal healthcare outside of a nationalist frame
At a time when ‘NHS nationalism’ – the widespread public supporting and celebrating of the NHS as a patriotic symbol of modern Britain – is prevalent, it is vital that we frame our demands for universal healthcare outside of a nationalist frame, recognising the active role that British empire played in determining the very existence of the NHS, who is excluded from healthcare and where those tactics of exclusion inherit their logics from. In recovering this 1980s history of health charges for overseas visitors, we are reminded that current internal border controls are not new, but rather that they build on earlier restrictions and Britain’s colonial legacies. Moreover, in connecting Britain’s internal borders to other forms of racist restriction and control, we must remain vigilant that the fight against racist governance is not a nationalist fight, but rather one in common with subjugated populations globally.
Bhambra, G.K. (2021). Colonial global economy: towards a theoretical reorientation of political economy. Review of International Political Economy, 28(2): 307-322. DOI: https://doi.org/10.1080/09692290.2020.1830831
Clarno, A. (2017) Neoliberal Apartheid: Palestine/Israel and South Africa after 1994. University of Chicago Press. DOI: 10.7208/chicago/9780226430126.001.0001
El-Enany, N. (2020). (B)ordering Britain: law, race and empire. Manchester University Press. DOI: https://doi.org/10.7765/9781526145437
Hahamovitch, C. (2013) No Man’s Land: Jamaican guestworkers in America and the global history of deportable labor. Princeton University Press. DOI: 10.23943/princeton/9780691102689.001.0001
Tyler, I. (2010) Designed to fail: A biopolitics of British citizenship. Citizenship Studies, 14(1): 61-74. DOI: https://doi.org/10.1080/13621020903466357
Kathryn Medien is a Lecturer in Sociology at The Open University.
Header Image Credit: Joint Council for the Welfare of Immigrants
TO CITE THIS ARTICLE:
Medien, Kathryn 2021. ‘NHS Apartheid: On resisting NHS charges for overseas visitor healthcare’ Discover Society: New Series 1 (4): https://doi.org/10.51428/dsoc.2021.04.0004