This is a guest blog for the Patients Not Passports No Borders in the NHS Week of Action by Kirit, a nurse in the NHS.

As a nurse working for a specialist team that improves access to healthcare for marginalised people through outreach in the community, we have a role that is vitally important, yet often frustrating, as we consistently come up against systemic challenges.

Seeing people in this setting we understand how restricted their lives are, and this includes restrictions to accessing the very organisation I work for: an organisation whose core value should, like the rest of the NHS, be ensuring access to healthcare for all. The hostile environment in the NHS endangers people’s health and well-being.

“Everyone In”

The start of the pandemic looked like an opportunity to really give attention to health inequalities, with the Government’s ‘Everyone In’ initiative launched in March 2020. Under the scheme they even provided temporary accommodation to people with uncertain or insecure immigration status, ensuring that everyone was off the street and supported to protect their own and their communities health.

Our team couldn’t believe it, given the hostility with which the Government usually treats migrant communities—particularly people who are homeless. Previously, the majority of migrants have been completely shut out of accessing any benefits or state support, with No Recourse to Public Funds (NRPF) conditions attached to their visas and the threat of the Hostile Environment for those living with a precarious immigration status. The scheme saw positive outcomes, and for my team it meant being able to do some meaningful work with clients who prior to this were often more transient and therefore, harder to do consistent work with.

Worse, Not Better

Despite positive interventions like the Everyone In scheme, it quickly became apparent how the pandemic has exacerbated health inequalities. Many primary care and other health services have moved to telephone or virtual appointments which has exposed digital poverty. People living in Home Office-provided hotel accommodation faced frequent re-location, which left them disoriented and without support networks in the middle of lockdown, struggling with re-registering with new GPs, and sometimes disrupting ongoing hospital investigations.

GP services are still refusing to register people without documents or de-registering those who have temporarily moved out of area into a hotel, and we continue to see hospitals charging people for treatment (including cancer care). More recently, we’ve seen an end to the ‘Everyone In’ scheme for our NRPF clients who are being turned out onto the streets again—often with nowhere to go.

This has presented our clients with unique challenges. How can we address a person’s poorly-controlled diabetes when they have no choice over what they eat because the Home Office provides totally inadequate meals or refuses to give people enough money to buy their own food? How can we begin to unpick the memories and trauma that led to a person’s current state when their accommodation keeps changing, leaving them feeling unsafe in unfamiliar environments? How can we expect someone to self-isolate when they don’t have job security and can’t rely on any Government support? How can we expect people to engage with a healthcare system that threatens to charge them for necessary treatment or share their personal data with Home Office Immigration Enforcement teams? Simply put, it is difficult for people to attend to their health the way they may want to when their basic needs are unmet and they are excluded from the services they need.

As a healthcare worker, you want to assist people to make choices that better their health. Instead, we’re frustrated at the structural challenges that make it difficult to do our job. By expecting health workers to implement Hostile Environment policies, some would say the Government are making working in the NHS untenable, as the policies and outlook mirror the very societal problems we are trying to improve.

Public health for all

These policies are not in line with the NHS’s original values, nor with the motivations that drive many NHS workers to join the service. This imbalance leads to healthcare workers spending time disagreeing with various departments and their NHS colleagues, challenging Home Office dispersals, advocating for clients to access gate-kept services, which often lead to us feeling deflated at not being able to affect tangible change for our clients. 

The NHS’s hostile environment is real, and along with Home Office practices, is damaging not just the patient-clinician relationship but the health and well-being of those who are part of our community. There is no public health without everyone’s health.