‘The Trust will pursue debt through all means necessary.’ This is the response that I received to a Freedom of Information Act (FOI) request that I submitted to a London-based NHS Trust. I had specifically asked the Trust to ‘provide details of the Cost Recovery Programme, specifically how outstanding charges are enforced and recuperated by the hospital’. Their response, in many ways, encapsulates the aggressive financialization of NHS secondary care for migrants in Britain. In 2015, later amended in 2017, the UK government introduced the National Health Service (Charges for Overseas Visitors) Regulations, which build on earlier legislation (1982, 2015) in order to place a statutory duty on secondary care NHS providers to establish whether a person is a lawful resident in the UK before providing them with treatment. Justified through narratives of ‘health tourism’ and austerity, hospitals now have a duty in law to check the immigration and residential status of all patients and make those who are deemed not ‘ordinary residents’ pay for their treatment at 150% of the cost to the NHS.

Figure 7.1 A copy of an NHS Pre-Attendance Form received in response to a Freedom of Information Request submitted to a London NHS trust.

The introduction of these charges has led to the attendant creation of Overseas Visitor Manager posts in NHS trusts and the implementation of an Overseas Visitor Cost Recovery Programme. Through a complex system of data gathering and sharing between the NHS and the Home Office, regulations stipulate that if any bills for NHS treatment over £500 are outstanding for two months, hospitals must pass on patient details to the Home Office. This will result in the likely refusal of any future visa applications and, in some cases, detention and deportation. Furthermore, in implementing the Cost Recovery Programme, NHS trusts employ third-party debt-collection agencies to recuperate healthcare debt ‘through all means necessary’. What does the Trust's response tell us about the deepening relationship between finance capital, digital surveillance and internal border controls in Britain? In what ways does this regime of hostility and cost recovery represent a continuation of Britain's colonial logics of population governance in the aftermaths of empire – logics which are discussed in relation to the administration of British empire by Abdul Rahman (Chapter 6)? And how might we understand the introduction of NHS charges as operating as a lethal deterrent for certain racialized migrants who seek access to healthcare in Britain? Indeed, during the COVID-19 epidemic we have seen just how lethal a deterrent this can be. ¹

Entanglements with empire: ‘making a fair contribution’

In order to fully understand the context within which the National Health Service (Charges for Overseas Visitors Regulations) (2015, 2017) came about, it is important to situate this policy within Britain's history of empire and colonialism, along with the racially exclusive development of Britain's welfare state. Against notions that Britain is a postcolonial nation-state, Nadine El-Enany (2020: 3) has argued for an understanding of Britain as ‘a racially and colonially configured space in which the racialized poor are subject to the operation of internal borders and are disproportionately vulnerable to street and state racial terror’. Within this geography of ‘colonial space’, El-Enany charts how successive nationality and immigration Acts, including the 1948 British Nationality Act, 1965 Immigration and Nationality Act, 1971 Immigration Act and 1981 British Nationality Act, have redefined post-empire Britain in order to preserve the financial ‘spoils of empire’ – the wealth derived from centuries of colonialism and enslavement – for Britain's white populace, using immigration law to keep such wealth out of the hands of racialized populations from whom it was derived (El-Enany 2020: 2).

While the creation of the NHS in 1948 is often heralded as creating a universal health system for all, racialized forms of entitlement and control have been present from its inception. In its early years the NHS benefited greatly from the labour of formally colonized populations, particularly through the overseas recruitment of nurses and ancillary workers from the Caribbean (Bryan, Dadzie and Scafe 2018). Yet the provision to charge NHS patients deemed not ‘ordinarily resident’ is an early and salient feature of the NHS. Arrangements for charging those deemed ‘not ordinarily resident’ for healthcare have existed since 1977, while notions that the NHS exists to serve and preserve white Britishness date back to its founding. As El-Enany has argued:

These assertions of white entitlement to Britain and its welfare state, and the attendant construction of racialized populations as underserving of access to it, have become pronounced through the politics of austerity, the 2016 Leave Campaign that preceded Brexit and the hostile environment policies that have emerged out of the 2014 and 2016 Immigration Acts. Arising out of all of these sites is a notion that it is simply not fair for migrants to come to Britain and access the benefits, services and jobs that ought to be the sole preserve of British subjects, who here are constructed as white (Shilliam 2018). In the specific context of the National Health Service (Charges for Overseas Visitors) Regulations (2015), the Department of Health has articulated these regulations as a request for migrants to make a fair contribution to health services. Indeed, ‘ensuring fairness’ and ‘making a fair contribution’ have been the titles and language used throughout public consultation and in policy documents (Department of Health 2013, 2017). As Sir Keith Pearson, Chair of Health Education England, remarked in a video on the NHS Cost Recovery Programme, ‘the NHS is a national health service, not an international one’. ²

It is within this context of ‘fairness’ that certain migrants from outside of the European Economic Area, including those with no recourse to public funds (NRPF) and those who have yet to apply for asylum or whose asylum applications have been refused, are now require to pay an upfront charge of 150% of the value of the treatment (Shahvisi 2019). Covering all secondary care services, including maternity and post-natal care, cancer treatment, cardiology, among others, the charges entwine border controls with healthcare and situate vulnerable racialized populations as materially and figuratively indebted to the British state. Through the introduction of these charges, Britain's borders move from airport terminals and ports of entry into healthcare institutions, operating as a lethal ‘apparatus that facilitates, regulates, stigmatizes, and criminalizes movements in space and time’ (Mitropoulos 2017). The charges install a regime of racial profiling within healthcare institutions, turning healthcare workers into border guards and positioning all of those who appear or sound ‘foreign’ vulnerable to profiling and questioning. The implications of being categorized as a person with NRPF for school-age children is explored in more detail by Dickson and colleagues (Chapter 8).

Carceral healthcare debt

Since the coming into effect of upfront charging in October 2017, there is significant evidence that the NHS charges operate as deterrent to healthcare access, with migrant women seeking to access maternity and post-natal care being disproportionately affected (Maternity Action 2017, 2018). Everyone seeking to access secondary NHS care is required to fill in a pre-attendance form on visiting a hospital, such as the one shown in Figure 7.1.

This form, which I received in response to an FOI request to an NHS trust, states that the details of patients may be passed on to the Home Office and other law enforcement authorities, and that any outstanding debt may be passed on to debt-recovery agencies for recuperation. The use of third-party debt-collection agencies by NHS trusts has been a recurring theme in my research, with a large number of trusts contracting CCI Credit Management, a debt-collection agency who list ‘collecting NHS debt from overseas patients’ with the help of their ‘90 offices servicing 130 countries’ as one of their core competencies.

Jackie Wang (2018) has called on us to extend our definition of the carceral – a term that is characterized as anything related to prisons and prison infrastructure – to encompass the various racialized systems of financialization and debt and technologies of surveillance and control that are central to capitalism. The relation between carceral regimes and racialized systems of indebtedness is examined further in the chapters by Rossipal (Chapter 9) on immigration bonds in the US and by Stork (Chapter 17) on predatory lending and Black access to higher education, also in the US. In arguing that instruments of credit are carceral instruments of unfreedom, Wang examines the US practice of debt-financed government, whereby local municipalities increasingly rely on private credit which is then offloaded to their constituents in the form of a fine-and-fee regime for traffic violations, court fees and a privatized court and prison system. Together, for Wang, these modes of ‘predatory lending’ and ‘parasitic governance’ form the ‘two main modalities of contemporary racial capitalism’ (Wang 2018: 69). For the undocumented migrants, ‘failed’ asylum seekers and other groups who are met with charges under the NHS/Home Office regime, their existence in Britain is already coded by the carceral logic of ‘illegality’. The extension of healthcare debt into their lives, tied to an expansive carceral surveillance and border regime, represents a tactic of predatory carceral capitalism that positions certain racialized populations as vulnerable to ‘premature death’ (Gilmore 2007: 28).

Emerging research has found that undocumented migrants are failing to seek medical attention for fear of Home Office involvement. A report found that three pregnant women had died after being reluctant to access care over fears of costs and immigration enforcement (MBRRACE-UK, 2019), while a study produced by charity Maternity Action (2018) found that new mothers were receiving threating phone calls and letters from debt collectors just weeks after giving birth. In their interviews with women targeted by the charging regime for maternity and post-natal care, they described the kinds of fears and anxieties that shape their lives:

The carceral logics of the state interweave debt, healthcare and border controls, creating a hostile environment for already subjugated populations. If the welfare state is designed to promote and secure the health and vitality of the British populace, then the NHS charging regime places these women and many others on its necropolitical ³ underside, figuratively and materially indebting those deemed ‘not ordinarily resident’ to the British state.

Financial belonging

The use of credit and debt instruments extends beyond NHS debt and the use of credit agencies and bailiffs. In September 2019 it emerged that Lewisham and Greenwich NHS Trust, who run two hospitals in south-east London, had since 2015 been passing patients’ confidential information, including name, date of birth and residential address, to private credit check agency Experian in order to conduct credit footprint checks. As part of an NHS pilot scheme, the algorithmic credit footprint checks work to ‘confirm residency by matching an individual to an address using a patient's digital footprint and then analysing credit bureaus for other aspects which could “disprove” residency against economic activity’ (Lintern 2019). In other words, the footprint checks work to assess the likelihood of lawful residency in Britain through the examination of one's digital economic activity, with the absence of such activity deeming a patient potentially an unlawful resident and thus chargeable for treatment. Taking place without the knowledge of the patients concerned, the credit footprint checks assisted Lewisham and Greenwich NHS Trust in generating £4.2 million in invoices in 2017–18 (Lintern 2019). After coming under public scrutiny, the Trust announced in 2019 that they were suspending their data-sharing agreement with Experian while an independent review was conducted (Lewisham and Greenwich NHS Trust 2019).

The Trust argued that Experian's services acted as a ‘non-discriminatory way of potentially identifying patients that are not entitled to free NHS treatment’ (Lintern 2019). However, this use of algorithms and big data to detect economic activity arguably ushers in new forms of racialized bordering and surveillance. In their work on smart border technologies, Tamara Vukov argues that the increasing technologization of the border using data-driven, algorithmic technologies, rather than ‘postracial’, allows ‘race [to be] monitored and produced through the tracking of nonnormative movements’ (Vukov 2016: 87). Through the algorithmic predicting of immigration status via economic activity, the credit-footprint checks equate those who are not economically active in the UK with the racialized marker of ‘health tourism’. As such, they function as a digital mode of surveillance that codes those whose economic activity is deemed ‘abnormal’ – lacking in direct debits, credit cards, a bank account and so forth – as subjectable to racialized border controls. These checks work in concert with the broader hostile environment policies, which until 2018 required UK banks and building societies to check the identity of every bank account holder against a Home Office database and gave banks the power to close the bank accounts of those deemed ‘illegal’.

This chapter has sought to illustrate the role that debt and indebtedness play within NHS migrant care, tied to Britain's expansive carceral border regime. Here the border violently emerges in hospitals, birthing centres and bailiff visits and retains a constant presence in the lives of those targeted by the charging regime and border apparatus. While they are framed as a request for vulnerable migrant populations to make a ‘fair contribution’ to British society, I have argued that NHS charges and the pursuit of debt through all means necessary should be situated within the afterlives of British empire, whereby immigration controls operate to secure the ‘spoils of empire’ for Britain's white populace (El-Enany, 2020).

At the same time, I have sought to elaborate on the important role that digital technologies play in surveilling migrant populations and expanding the frontiers and possibilities of debt through the creation of new technological instruments that can be used in the service of state racism and internal bordering. Here, seemingly banal financial products – credit cards, direct debits, a bank account – are utilized as proof of economic activity, which in turn generates data on residency and entitlement to welfare services. Tracing and understanding these deepening and profitable relations between welfare, debt, debt-collection agencies, credit footprint technologies and immigration and border controls is vital both in tracking state racism, border infrastructures and the expanding frontiers of capitalism and in calling for their abolition.