Last week the Patients Not Passports campaign published new research on the impact of the coronavirus crisis on migrant access to healthcare. It is the latest addition to a compelling and growing body of evidence demonstrating the devastating harm and complete unworkability of NHS charging policies implemented under the Hostile Environment.

In this new blog series we will publish work from a range of authors that explore some of the impacts of the Hostile Environment that were not covered in our report and that look at the impact of anti-migrant policy and border militarisation outside of the UK.

In part 1, Darran Martin, a paediatric intensive care and ED nurse, explores the long term psychological impact of the Hostile Environment and the way in which these policies affect much more than a person’s ability to access public services.

To keep updated about the next issue in the series sign up to Medact’s Patients Not Passports mailing list.

Akram, Aliya, Daniel and James

Migrants Organise, New Economics Foundation & Medact

The Psychological Impacts of the Hostile Environment

by Darran Martin, Paediatric Intensive Care and ED Nurse

We accept psychological needs as being the requirements we need to feel at home in the world. From our basic food, health and shelter necessities, to a feeling of safety, love and belonging, all the way to more complex needs such as esteem, respect, status, recognition, freedom and ultimately self-actualisation. If met, these manifest positively as attachment to a place or society, feeling in control and orientated, and being able to have pleasure and achieve self-enhancement.

In this short piece I look at how exclusion from healthcare, facilitated by the Hostile Environment, can negatively impact a person’s psychological well-being and ability to engage in society.

Oppression and marginalisation through the restriction of access to healthcare influences a person’s sociological imagination. It connects societal structures to individual agency and links institutional and economic persecution, the social determinants of health, and the impact of social exclusion and poverty on different groups. There is now ample evidence that the legislation and procedures brought in under the Hostile Environment leave migrants deterred from or delaying seeking healthcare and that Black and Asian Minority Ethnic (BAME) communities are more likely to be asked for proof of entitlement to services compared to a white British person. This is seen in evidence produced prior to the coronavirus pandemic by the BMA, the RCPCH and Medact’s Migrant Solidarity Group, Doctors of the World, Maternity Action, and many others; while the latest research from the Patients Not Passports campaign shows how the effect of the Hostile Environment has been compounded by the crisis.

These Government policies are exacerbating multiple negative psychological markers, promoting social exclusion, creating structural barriers to services, and generating health poverty for those who require healthcare interventions the most.

Whilst the environment in which people work, attend school, socialise or access healthcare is variable, so too is how those affected by these hostilities react and interact with their environment. Rejection, discrimination, ostracism, betrayal and stigmatisation all form part of the psychological impact of hostility and often become the motivating factors for how an individual responds. Those responses could include prosocial, antisocial, and socially avoidant behaviours that can further impact how people feel able to engage with healthcare services or the wider society in which they live.

The wider public perception of migration in general, alongside the treatment of people targeted by Hostile Environment policies, has a substantial impact on physical and psychological well-being (Richman, 2009). Actual or perceived rejection not only impacts physical and mental well-being directly, but it also provokes negative behaviour towards health overall, compounding the negative health impact of the Hostile Environment. Examples of this include individuals who experience reoccurring discrimination having above average rates of smoking and drug and alcohol use.

In short, not only does the Hostile Environment serve to directly prevent people accessing healthcare services, the longer term psychological impact pushes people into a cycle that further marginalises them from society and their community, and increases their likelihood of suffering ill health.

Often migrants begin to face barriers at their initial contact and engagement with health services. Such an early rejection in their health journey impacts their confidence that the services provided are for everyone, including themselves; jeopardising future attempts to access healthcare and other public services. The further a person progresses in the health system the increasing number of services, healthcare professionals and locations they are likely to engage with mean they are equally likely to be faced with additional barriers deeper within the health service that could amplify this psychological impact.

It is also important to note that these policies have a particular and profound effect on migrant children, compounding the diverse physical and psychological challenges arising from the discrimination and racism they already face daily. Alongside this, children themselves can become exposed to the components of this environment, reacting with aggression, hostility and conflict.

In the short term, practitioners wanting to improve care delivery and patient outcomes must look at how their services could be made easier to engage with and navigate for people affected by Hostile Environment. Taking the time to understand  the complex range of barriers people face when accessing care will help in creating more appropriate and engaging local services that are capable of meeting the future needs of an increasingly excluded patient group. Recommendations to help make this a reality include training for staff in rights and entitlements, increasing the availability of interpreters, and reviewing health journeys, including understanding the impact of limited access on the deterioration of people’s health.

In the long term however, if we are to challenge the existing psychological, cultural and structural oppressive systems faced by migrants and BAME communities we need to challenge Hostile Environment policies at their root. This will require not only ending the policies themselves, but undoing the years of psychological harm and systematic marginalisation that has accompanied their implementation.

You can contact Darran at darranjmartin@gmail.com

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