Halt harmful “hostile environment” policies – open staff letter to the Board of University Hospitals Bristol NHS Trust

The government is implementing new charging regulations for migrants. These deny vulnerable people healthcare, deter those eligible for care from seeking it, and establish mechanisms to roll out further charging in the future NHS. 2019 has seen the BMA, Faculty of Public Health and the Academy of Medical Royal Colleges demand the policies be withdrawn on clinical grounds.

Bristol is one of the UK’s most diverse, forward thinking cities, with migration embedded in its history. The following is a letter to University Hospitals Bristol NHS Trust asking them to also reject these policies. It is for open sign on for all staff within the trust – if you work at the trust, please add your name below.

If you work at North Bristol Trust, please sign the open letter aimed at this Trust: https://www.medact.org/NBTletter

If you don’t work in the trusts, please sign our open petition to UHB: https://www.thepetitionsite.com/en-gb/800/572/221/say-no-to-racist-migrant-charges-an-attack-on-our-communities-an-attack-on-our-nhs/

To: Robert Woolley, Chief Executive, and Trust Board Members – University Hospitals Bristol

We the undersigned call on University Hospitals Bristol NHS Trust to reject the government’s “Hostile Environment” NHS Overseas Visitor Charging Regulations.

As you know, these policies include upfront ID checks for secondary care services, potential withholding of care that is not “immediately necessary”, charges being levied after care is carried out, and sharing of information with the Home Office for migration enforcement purposes.

Evidence is mounting both nationally and from within Bristol’s Trusts that these policies are causing some of the most vulnerable in our society to be denied care they need. Cases are increasingly reaching the media of misapplication of rules which have had desperate consequences for individuals1,2. They act as a deterrent for migrants seeking care, impacting our public health3. Patients are being approached at their sickest & being asked about eligibility. Bailiffs are being sent to collect fees from those who will never be able to pay them4. The policies rely on racial profiling to identify those who might be deemed ineligible for care and demand staff to weigh clinical need for treatment against a patient’s origin. In doing so they have contributed to a climate of racism, fear & uncertainty in your Trust that affects both patients and staff, who are no longer sure of who can be treated and for what. Ultimately, they are embedding mechanisms to change NHS care into a paid for service, furthering the covert disintegration of the NHS that your staff and patients rely on and trust.

Nationally, our leading healthcare bodies are coming out in force calling for these policies to be scrapped. In December 2018 The Faculty for Public Health highlighted evidence that the policies will have an unacceptable negative impact on our health with no evidence for financial savings5. In February 2019 The BMA released its report “Delayed, deterred, and distressed” which also highlighted the impact on doctors and their time with patients6. Since then, the Academy of Medical Royal Colleges and the Royal College of Midwives have joined the call highlighting the damage caused by the policies7,8.

We as clinicians, researchers and providers of healthcare know that our future health outcomes, and our future NHS staffing will be reliant on policies that include rather than exclude migrants9. The Hostile Environment policies breach international human rights laws, and will prevent the UK contributing to the WHO’s Sustainable Development Goal of universal health coverage. They contradict the founding principles of the NHS, the 2011 NHS constitution and the ethical principles of your workforce.

Bristol is one of the UK’s largest, most forward-thinking and diverse cities, and migration is a key part of its history and life. Bristol’s NHS Trusts, acting together, are in a unique position to stand against the government’s Hostile Environment policies – as harmful to the hospitals and the population they serve. Although the government’s Hostile Environment policies regulations have been mandated as legal obligations on our NHS Trusts, it is not acceptable for the Trust to claim to be unable to take a stand against them. These policies conflict with your other institutional obligations – to healthcare outcomes, patients, staff and financial governance.

In Spain in 2012 clinicians refused to enact national policies to restrict healthcare provision to migrants – despite the threat of losing their registrations – until regional Spanish governments reversed the policies10. We call on you to share this bravery, and that of our city’s migrants. Bristol’s migrants have come here as asylum seekers fleeing violence, they have resettled here to work in our hospitals, and they are here to contribute to Bristol’s vibrant future despite these uncertain times. We call on you to:

  1. Suspend upfront charging in your Trust
  2. Suspend ID checks in the Trust
  3. Properly evaluate the impact of charging on patient care – Undertake detailed research into the impact of charging and ID checks on your Trust’s patients’ health,  on your Trust’s ability to meet its legal obligations to its population, staff body, and equality, and on your Trust’s finances
  4. Call on the Government to suspend charging in the NHS nationally


  1. ‘Migrants wrongly told to pay for NHS care upfront, minister admits’, The Guardian, 17/02/19: https://www.theguardian.com/society/2019/feb/17/migrants-wrongly-told-to-pay-for-nhs-care-upfront-minister-says
  2. E.g. ‘Cancer patient died after NHS demanded £30,000 for treatment’, The Guardian, 13/11/18: https://www.theguardian.com/society/2018/nov/13/cancer-patient-died-after-nhs-demanded-30000-for-treatment
  3. E.g. ‘Deterrence, delay and distress: the impact of charging in NHS hospitals on migrants in vulnerable circumstances’, Doctors of the World, 2017: https://www.doctorsoftheworld.org.uk/wp-content/uploads/import-from-old-site/files/Research_brief_KCL_upfront_charging_research_2310.pdf
  4. ‘Revealed: NHS under fire for steep increase in charging migrants for healthcare’, Bristol Cable, 22/07/19: https://thebristolcable.org/2019/07/revealed-nhs-under-fire-for-steep-increase-in-charging-migrants-for-healthcare/
  5. ‘FPH briefing on the NHS Charging regulations for overseas visitors in England’, Faculty of Public Health, 11/12/18: https://www.fph.org.uk/media/2202/final-fph_briefing_nhschargingregs_4.pdf
  6. ‘Delayed, deterred, and distressed: The impact of NHS overseas charging regulations on patients and the doctors who care for them’, BMA, 11/02/19: https://www.bma.org.uk/-/media/files/pdfs/employment%20advice/ethics/20190211%20overseas%20charging%20paper.pdf
  7. ‘NHS charges to overseas visitors regulations’ Academy of Medical Royal Colleges, 14/03/19: https://www.aomrc.org.uk/wp-content/uploads/2019/03/2019-03-14_NHS_charges_overseas_visitors_regulations.pdf
  8. ‘Duty of Care? The impact on midwives of NHS charging for maternity care’, Maternity Action (supported by RCM), September 2019: http://maternityaction.org.uk/wp-content/uploads/DUTY-OF-CARE-with-cover-for-upload.pdf
  9. Abubakar, I., Aldridge, R.W., Devakumar, D. et al, ‘The UCL-Lancet Commission on Migration and Health: the health of a world on the move’, Lancet, 2018; 392: 2606-2654
  10. Urtaran-Laresgoiti, M., Fonseca Peso, J. & Nuño-Solinís, R., ‘Solidarity against healthcare access restrictions on undocumented immigrants in Spain: the REDER case study’, Int J Equity Health, 2019; 18: 82. https://doi.org/10.1186/s12939-019-0971-9