How the ‘hostile environment’ and online-only services stop the vulnerable from using the NHS

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Trying to access public services without an internet connection is increasingly difficult. Getting care without secure immigration status is even harder. Matteo Besana (Doctors of the World) Laurence Lessard-Phillips, Lin Fu, Antje Lindenmeyer and Jenny Phillimore (University of Birmingham) explain the findings of a study into people who struggled to obtain healthcare during the pandemic.

When Joseph Ndau, an asylum seeker and one of Doctors of the World’s National Health Advisors, had severe symptoms of COVID-19 in March 2020, he called 111 and was told to go to A&E. As he arrived, he found signs warning that migrants need to pay the Immigration Health Surcharge. While emergency medical care and COVID services are free to everyone, the attitude and culture of some NHS trusts has not changed. Had he been undocumented, Ndau fears he would have been turned away.

The notion that the pandemic has been a great leveller, with the power to erode the social, racial and economic divisions in our societies, has always been a myth. Ndau’s experience confirms that the reality is very different.

Doctors of the World’s Rapid Needs Assessment, conducted during the first wave of the pandemic, highlighted how socially excluded some populations are. They are at higher risk of being exposed to COVID, more likely to have poorly managed chronic health problems, less likely to access timely healthcare if they become unwell with the virus, and less able to self-isolate and protect themselves and others from further transmission.

These socially excluded populations, therefore, should have been among the groups to have received more protection and support. Unfortunately, undocumented migrants and refused asylum seekers, people experiencing homelessness, Gypsy, Roma and Traveller communities and sex workers are among the populations who find it most difficult to access mainstream healthcare provision. For many of these people, basic rights such as visiting a local GP or getting the COVID jab are a challenging and stressful experience, mainly because ‘hostile environment’ policies are embedded within healthcare settings.

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Photo: Lydia via a CC BY 2.0 licence

They are the key service users of Doctors of the World (DOTW) UK, a non-governmental organisation which runs clinic and advocacy programmes to provide medical care, information, and practical support to socially excluded people. When the pandemic struck, they had to reorganise their services, switching from face to face provision to telephone help and a free advice line. Researchers at the Institute for Research into Superdiversity at the University of Birmingham, with the support of the Nuffield Foundation and Economic and Social Research Council, conducted a study about the people using their services at the beginning of the first lockdown and in the six months afterwards. They compared user questionnaire data and handwritten notes collected by DOTW’s volunteers.

The analysis offers a unique insight into the experience of excluded populations at the onset of the pandemic, when most public services, including health, were either reduced or switched to online/phone delivery. It suggests that not enough effort was made to provide an alternative to digital services to people who are not online.

  • The average number of consultations per month dropped drastically, from approximately 170 before the pandemic to 50 during it
  • Service users were much more likely to find themselves in inadequate housing
  • The percentage of undocumented service users decreased, while the percentage of asylum seekers increased
  • There was a significant increase in service users reporting ‘bad’ or ‘very bad’ health.

The increase in the number of asylum seekers calling the advice line suggests that hotels housing them did not have processes in place to register people with their local GP, and asylum seekers therefore had to rely on DOTW or other services.

The government may have now realised the extent of the problem. Announcing of “Operation Warm Welcome” for recently arrived Afghans, they specifically allocated  £3 million to the NHS so that Afghans arriving under the Afghanistan Relocations and Assistance Policy (ARAP) scheme can access healthcare and register with a GP once they leave quarantine.

The drop in the number of consultations and a changing demographic among the service users could relate to a switch to telephone consultations, which demand both digital skills and financial means. This will have been reflected in the experience of many migrants when trying to access their local GP, where remote consultations gradually became, and in some cases remain, the dominant way that clinicians and patients communicate.

Many service users mentioned administrative barriers, especially being asked for proof of ID and address when trying to register with a GP. This is despite clear and longstanding NHS and government policies that state that everybody in England is entitled to register with and see a GP, regardless of their immigration status or personal circumstances.

What are the long-term lessons of our findings? One is that reducing health inequalities needs to be a priority for policy makers and health leaders alike. Ensuring that excluded populations can access mainstream healthcare means understanding the key role that primary care plays in keeping people well and managing health conditions in the community, relieving pressure on hospital and A&E services. It also plays an important role in vaccination and management of communicable diseases. People who don’t have good access to a GP are forced to use A&E services when they may not need them.

Persistent barriers to GP registration also mean that opportunities for illness prevention and early diagnosis are lost, and increases the likelihood of patients resorting to unscheduled or emergency care. Another important lesson is the need to maintain face to face provision, even during a crisis, as well as offering alternatives to registering with a GP by using an online tool.

The pandemic has given us a deeper understanding of the essential nature of an internet connection. Many GPs were providing their services mainly through the web during the pandemic. This means that people living in poverty or who are destitute need to be given wifi or data packages so they can access essential services. Once the crisis is over, we cannot simply reinstate and reinforce the same barriers to healthcare. Instead, we should look at the inequalities it brought to the fore and use the experience to do a better job of reaching the vulnerable.

This post represents the views of the authors and not those of the COVID-19 blog, nor LSE.