Kitty Worthing and Sophie Williams

Patients Not Passports- the struggle to end the ‘Hostile Environment’ in the NHS

The NHS is often spoken about as a source of pride in the UK. Pride in what is perceived to be a universal healthcare system: free and accessible to all those who need help. If only it were. 

Kitty’s experience

I first encountered NHS charges for migrants as a medical student, volunteering in East London with Doctors of the World, here I witnessed the far-reaching and devastating impacts of NHS charging, and its intersection with the effects of other Hostile Environment policies on health and well-being. 

When I started work as a Junior Doctor, I encountered patients experiencing barriers to accessing care due to their immigration or housing status, or who were experiencing significant psychological distress secondary to being charged. I stood aghast the first time I witnessed an Overseas Visitors Manager walk unannounced into a ward to see a patient carrying a chip and pin machine to ask for payment; it felt so at odds with the principles our NHS supports. Attempts to advocate for patients on an individual basis felt inadequate in the face of the wilful implementation of a policy that clearly caused harm by NHS trusts, and this led me to my first Docs Not Cops meeting.

Whilst thankfully General Practice remains free for all, many without formal documentation struggle to register with a GP. Research I’ve been conducting has found that restrictions in secondary care and ideas around who ‘deserves’ care may in some cases inform staff’s reluctance to register this patient group. For patients, many are unaware GP is free, there are concerns about their data being shared with the home office, and they may not be able to access secondary care services when referred by a GP. 

In the rest of this article, we will discuss the legal aspects of charging migrants for NHS treatment, outline the harm it causes and discuss Docs Not Cops & other campaigns active nationally to bring this practice of rationing healthcare based on immigration status to an end. 

NHS charging policy

Legislation to charge patients for NHS care, based on immigration status, has existed for some time: the first attempt to charge patients not deemed ‘ordinarily resident’ was made in 1982. However, this was largely abandoned in the face of resistance led by migrant centres, trade unions, law centres and healthcare workers. With the Immigration Act of 2014, and associated immigration policy subsequently dubbed as the ‘Hostile Environment’ we saw a reintroduction of charging based on immigration status. Further regulations in 2017 expanded ‘chargeable’ services into the community, introduced ‘upfront charging’ (patients required to pay full cost of care before receiving it) and increased legal pressure on NHS trusts to check eligibility and implement charging. In brief, those deemed not ‘ordinarily resident’ (a complex legal term that in 2014 came to exclude those not deemed to be living in the UK ‘lawfully’) are charged for NHS secondary care (including in the community, but excluding care received in A&E) at 150% the actual cost of care. If the care is deemed ‘urgent’ or ‘immediately necessary’ they should receive the care regardless of their ability to pay, but will still be asked to pay upfront and charged retrospectively if they cannot do so. If the care is deemed ‘non-urgent’ it can be refused if they are not able to pay the full amount upfront. 

Other important forms of immigration control outside of charging mechanisms include:

1) Data sharing – if you have a debt of over £500 to the NHS for over three months, the NHS can pass your demographic data to the Home Office, which can then be used to detain and deport you. Until recently patient data was shared with immigration officials by GP surgeries, but this is currently suspended. Many NHS trusts also employ private debt collectors to chase outstanding payments, who hound patients in their homes. 

2) International Health Surcharge – an additional visa fee of £625 that must be paid annually to access the NHS, which acts as double taxation.

The harm caused by the implementation of these policies expands beyond those ‘correctly’ charged, and we have seen many racialised as ‘foreign’ who have come to harm; one notable example being those affected by the Windrush Scandal. In addition, we have seen widespread fear and reluctance to access healthcare even amongst those who would be eligible for care either because they are ordinarily resident, or meet an exemption criteria.

The cases of Elfreda Spencer, Kelemua Mulat, Esayas Welday, Pauline Pennant, Beatrice, Bhavani Espathi, and Evette White are just some that have been made public, but of course the vast majority of experiences of harm have gone unheard. Whilst testing and treatment for COVID19 has been made exempt from charging, research suggests these exemptions do not work – we recently heard the devastating story of Elvis, who died at home with likely COVID19 too scared to seek help due to his immigration status.

We have witnessed the expansion of borders into our public services beyond the NHS – many left with no recourse to public funds, unable to rent housing or access free school meals; punishing those already facing precarity by cutting off vital lifelines. This has forced healthcare workers and others to be complicit in restricting services based on immigration status, and in some cases operationalising access to care as a means by which to collect demographic information then used for immigration purposes.

It is important to be clear that this policy is racist in its intention and implementation and forms part of a Government agenda to scapegoat migrants for deliberate underfunding of public services. Furthermore, implementing and refining charging mechanisms for one group of people, inevitably lays the groundwork for the expansion of charging to others.

Docs not Cops and the Patients not Passports campaign

Dops Not Cops are a grassroots group of activists, from many different backgrounds, who believe health is a right and not a privilege. The group fights for an end to all forms of immigration control in healthcare and the Hostile Environment more broadly and for a truly universal NHS.

Docs Not Cops is an example of a campaign which works to change public perception, and political mandate, on charging for NHS treatment. Examples of the group’s work includes street protests, vigils, publications, and online videos. Docs Not Cops uses the power in everyday people to challenge those with institutional power to make change happen. 

With the expansion of charging in 2017, Docs Not Cops has joined forces with groups across the country, including Migrants Organise and Medact, to form the Patients Not Passports (PnP) campaign. The work of PnP has included organising NHS staff and communities to resist charging and the creation of an online toolkit to support both individual advocacy and broader campaigning. Additionally, PnP has supported campaigns led by those directly affected by charging – one example of this is the Justice for Simba Campaign

The Justice for Simba Campaign 

In Sheffield, Simba Mujakachi’s campaign against NHS charging has brought together local MPs, health workers, students and community groups, as well as garnered support nationally. 

Simba has faced the worst consequences of immigration in healthcare and has been targeted by the cruel and unjust Hostile Environment. After suffering a life threatening stroke, Simba was presented with a bill of £93,000 because he is a failed asylum seeker. He struggled with access to long term rehabilitation and appropriate housing: an example of how the Hostile Environment extends into all aspects of welfare and support. Now, he is left with a debt to the NHS of over £100,000, and ongoing health problems as a result of the stroke. His story has been covered in the national press, including on Channel 4 news.

One tragedy is that Simba had been diagnosed with a blood clotting condition prior to his stroke, but had been denied specialist, secondary care because of the upfront costs which he could not afford. We can never know whether managing Simba’s underlying condition would have prevented the catastrophic stroke, if he had been able to access treatment for the blood clotting condition. However, we do know that the associated costs prevented him from accessing the healthcare he needed. This is not the face of a universal NHS, free and accessible at the point of need, but instead another border, obstructing a right to life lived without fear and in good health. 

Simba’s story is not unique – there are thousands like him, denied treatment or billed immense sums of money for care. By telling his story, Simba has sent a message to others facing similar charges, that they are not alone and that there is support and solidarity for them. 

How to take action 

  1. Make use of toolkits for supporting individual advocacy and community organising:
    1. Patients not Passports toolkit: 
    2. DOTW Migrant health toolkit:
    3. Safe surgeries toolkit:  
  1. Join your local Patients not Passports campaign group – please email to be put in touch
  2. Sign our letter to the Department of Health and Social Care calling for an immediate end to all NHS charging and data sharing
  3. Check out the Fairhealth migrant health wiki  

For more information feel free to contact or