Charging migrants more for NHS care isn’t just bad for migrants – it’s bad for all of us

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This article was written by Dr Piyush Pushkar and first appeared on the Doctors’ Broadsheet, the website for the Broad Left in the BMA. Dr Pushkar writes in a personal capacity and his views do not necessarily represent those of the BMA.

Piyush Pushkar is a Junior Doctor in the NHS and a member of Medact and Manchester KONP. 

The government has made a new pay offer for public sector workers. Prime Minister Rishi Sunak says he accepts the recommendations of the public sector pay review bodies in full. Great! Except that a Conservative backbencher already admitted what every public sector worker has known for years: the pay review bodies are rigged.

But the thing I want to talk about in this article is where Sunak says the money will come from. Sunak says the government will fund pay increases by charging migrants more for healthcare.

Pitting migrants against workers already resident in this country is not a new tactic. Nor is using the NHS as a national icon around which to wrap your divisive rhetoric. We all remember the Brexit bus, but Dominic Cummings didn’t invent racism. In 1952, Nye Bevan railed against the potential concern that foreign people might avail of free healthcare in the UK. He wrote:

The whole agitation has a nasty taste. Instead of rejoicing at the opportunity to practice a civilised principle, Conservatives have tried to exploit the most disreputable emotions in this among many other attempts to discredit socialised medicine.

Aneurin Bevan, 1952

While we certainly ought to valorise Bevan’s arguments, we must also recognise the embrocation of colonialism in the origins of the welfare state. How did the UK come to have enough wealth to be able to fund a welfare state? Who has worked in the NHS over the course of it’s 75 year history? Who works in the NHS now? Which governments pay for the training of NHS staff? Who pays taxes to those governments? Who provides healthcare for those taxpayers in India, Jamaica, Nigeria?

Fine. But what do we do now? Claps won’t pay the bills. Nor will recalling the historical origins of the current political conjuncture. Understanding that the NHS was built on the backs of migrants is necessary, but not sufficient. The BMA – and others – have already pointed out that it is not ethical to pay for (still way below inflation) pay increases for UK workers by punishing migrants (including migrant workers who work in the UK public sector). Good on the BMA. But I want to add one more point. It is not just migrants who lose out when a Conservative government attempts to divide and rule working people. We all lose out.

The cost-benefit calculations of the migrant cost recovery programme[1] have always been suspect. (See herehere and here for critiques of earlier iterations of the programme). Looking at it now, it still makes little sense. If you charge migrants even more to come to the UK then you reduce the amount of migrants who want to come and the amount of migrants who want to stay (since working people may want or need to bring family members over to help with care, particularly in a country where childcare often costs more than a middle-class salary).

One of the key motivations underlying the strikes is to improve pay in order to address the recruitment and retention crises in the healthcare workforce. A very high proportion of recruitment of clinicians is from abroad. For nurses, those trained overseas accounted for nine tenths of growth in nursing numbers in the past year. So encouraging current migrant workers to leave and disincentivising future migrants from coming may not be the best idea. That is, if this government really gives a f*** about the NHS and the care it provides.[2]

So what have been the real effects of the migrant cost recovery programme? Apart from consolidating anti-migrant arguments in public discourse, the key material change brought forth by the migrant cost recovery programme has been the creation of an administrative bureaucracy within the NHS – within most NHS trusts – whose purpose is to recoup costs from people. They are called overseas visitors managers (OVMs). This is a bureaucracy that we all pay for.[3] These are administrators and managers whose express purpose is to track people down who they think are meant to pay for NHS care, and then to make them cough up.

The people who they think are meant to pay for NHS care are “overseas visitors”. The Windrush scandal has already demonstrated that, in practice, OVMs can come for any UK residents, including UK citizens. But even if the overseas visitors managers (OVMs) managed to do what they were theoretically meant to do, do you really think that the institutional mechanisms used to extract funds from “foreigners” will stop at charging them? Once this bureaucracy exists, a future portends in which we are all in its crosshairs. It’s only a matter of time before the bureaucracy widens its remit. You are next. That is why the only way to view the migrant cost recovery programme is through the frame of solidarity with our fellow workers, wherever they are from: “an injury to one is an injury to all”.

When Rishi Sunak comes for migrants, it’s not just migrants who lose out. It’s everyone. Let’s fight to keep the NHS universal, free and comprehensive. Let’s fight together for better pay and better healthcare for all of us.

[1] There are two main components to the programme. The first is the health surcharge added on to the cost of a UK visa. The second is the requirement for NHS trusts to identify people who are not eligible for free NHS care and to charge them.

[2] There is also a separate argument regarding whether increasing pay by increasing government funding would actually incur the kinds of costs Sunak implies. The government would recoup a significant amount of the pay in the form of tax anyway: not just income tax but all the other taxes that working people pay as well, such as VAT. Healthcare workers would also be able to use that money to buy things that they are currently unable to afford, thus stimulating a lagging economy. Would that be inflationary? Well, the NHS isn’t going to increase its customer costs to cover the pay increase, is it? It’s free at the point of use. Oh wait, that is exactly what Sunak is proposing, for the one group who does pay for NHS care. His hypocrisy is galling.

[3] To charge people for something, you have to create a system. Until the creation of the migrant cost recovery programme under New Labour (for a decent account, read this), and its advance under David Cameron’s Conservative governments, the NHS did not have a system for charging people. Why would it? The NHS is meant to be free at the point of use. A cost recovery mechanism takes time and money to devise. And then more time and more money to continue to administer. People have to be trained. Administrators have to be employed. They need offices and equipment. And then you realise it would have been cheaper never to have created the system in the first place.

July 22, 2023 Piyush Pushkar

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