Kathryn Medien
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‘The trust will pursue debt through all means necessary’
in The entangled legacies of empire

‘The Trust will pursue debt through all means necessary.’ This is part of a response to a Freedom of Information Act (FOI) request submitted to a London-based National Health Service (NHS) Trust, regarding the cost-recovery programme being used to collect outstanding debts from migrant women who have been charged for maternity and post-natal care in NHS institutions. Since 2015, migrants in England classed as undocumented, failed asylum seekers and overseas visitors, among others, are required to pay for secondary NHS services. The regulations stipulate that the certain migrants charged for care can be reported to the Home Office after two months of non-payment, a measure that directly affects their immigration status and the outcome of future immigration applications. In addition, outstanding debts are often passed on to third-party international debt-collection agencies. Narrating this complex and unfolding extension of the British debt economy to encompass migrant healthcare in Britain, the chapter links the production of indebted migrants to the afterlives of British empire. In so doing, it outlines how the Commonwealth Immigration Acts, which stripped citizenship rights away from colonial British subjects on the basis of race, form the precursor to the aggressive forms of racialized capitalism and immigrant incarceration being brought to bear against migrants in Britain today.

‘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:

The British welfare state has always embodied the assertion of white entitlement to the spoils of colonial conquest. The 1942 Beveridge Report perhaps captured this spirit best when it declared that ‘housewives as Mothers have vital work to do in ensuring the adequate continuance of the British Race and British ideals in the world.’ Britain has always been an internally bordered, hostile environment for migrants, with access to welfare made contingent on legal status.

(El-Enany 2020: 69)

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:

I am afraid that if I go to the hospital, they will charge me and I'm so afraid what's gonna happen to me if I say that I don't have money to pay for that. If they will detain me, or if after I have delivered the baby if I'm gonna stay at the hospital or in a detention centre or something like that.

(Helena, Maternity Action 2018: 46)

It is not just a bill to me, or not even the bill, the harassment I had to endure all those months because I couldn't pay. So I was very stressed, and that affected the way I look after my children, it affected how confident I was to be able to have a different role in society, like work or study and other things, I basically stopped for a year or so, so I could pay this debt. I felt like I was in debt with the whole country!

(Isabella, Maternity Action 2018: 30)

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.

Further resources

Bhambra, G. K. (2017) ‘Brexit, Trump, and “methodological whiteness”: On the misrecognition of race and class’. The British Journal of Sociology, 68: 214–S232. https://doi.org/10.1111/1468–4446.12317 (accessed 9 August 2021).

Button, D. , Salhab, A. , Skinner, J. , Yule, A. and Medien, K. (2020) ‘Patients not passports: Challenging border controls in healthcare’. https://fass.open.ac.uk/school-social-sciences-global-studies-sociology/news/patients-not-passports-challenging-border (accessed 9 August 2021).

Corporate Watch (2018) The UK Border Regime: A Critical Guide. London: Freedom Press for Corporate Watch.

Okolosie, L. (2020) ‘A reignited spirit: Black women's lives in Britain’. Verso Blog. www.versobooks.com/blogs/3949-a-reignited-spirit-black-women-s-lives-in-britain (accessed 6 September 2022).

Works cited

Bryan, B. , Dadzie, S. and Scafe, S. (2018) The Heart of the Race: Black Women's Lives in Britain. London: Verso Books.

Department of Health (2013) Sustaining Services, Ensuring Fairness. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/268630/Sustaining_services__ensuring_fairness_-_Government_response_to_consultation.pdf (accessed 6 September 2022).

Department of Health (2017) Making a Fair Contribution: Government Response to the Consultation on the Extension of Charging Overseas Visitors and Migrants Using the NHS in England. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/590027/Cons_Response_cost_recovery.pdf (accessed 6 September 2022).

El-Enany, N. (2020) (B)ordering Britain: Law, Race and Empire. Manchester: Manchester University Press.

Gardner, Z. (2021) ‘Migrants deterred from healthcare during the COVID-19 pandemic’. London: The Joint Council for the Welfare of Immigrants.

Gilmore, R. W. (2007) Golden Gulag: Prisons, Surplus, Crisis, and Opposition in Globalizing California. Berkeley: University of California Press.

Lewisham and Greenwich NHS Trust (2019) ‘Statement on agreement with Experian for identifying overseas visitors’. www.lewishamandgreenwich.nhs.uk/latest-news/statement-on-agreement-with-experian-for-identifying-overseas-visitors-1944/ (accessed 17 November 2021).

Lintern, S. (2019) ‘Mass use of credit check firm to find NHS patients to charge’. Health Service Journal, 30 September. www.hsj.co.uk/policy-and-regulation/revealed-mass-use-of-credit-check-firm-to-find-nhs-patients-to-charge/7026012.article (accessed 17 November 2021).

Maternity Action (2017) ‘The impact on health inequalities of charging migrant women for NHS maternity care’. London: Maternity Action.

Maternity Action (2018) ‘What price safe motherhood? Charging for NHS maternity care in England and its impact on migrant women’. London: Maternity Action.

MBRRACE-UK (2019) ‘Saving lives, improving mothers’ care – lessons learned to inform maternity care from the UK and Ireland confidential enquiries into maternal deaths and morbidity 2015–17’. National Perinatal Epidemiology Unit, University of Oxford.

Mitropoulos, A. (2017) ‘Bordering colonial uncertainty’. PoLAR: Political and Legal Anthropology Review. https://polarjournal.org/bordering-colonial-uncertainty/ (accessed 9 August 2021).

Patients not Passports (2020) ‘Migrants’ access to healthcare during the coronavirus crisis’. Patients-Not-Passports-Migrants-Access-to-Healthcare-During-the-Coronavirus-Crisis.pdf (medact.org) (accessed 17 November 2021).

Shahvisi, A. (2019) ‘Austerity or xenophobia? The causes and costs of the “hostile environment” in the NHS’. Health Care Analysis 27(3): 202–219.

Shilliam, R. (2018) Race and the Undeserving Poor: From Abolition to Brexit. Newcastle, UK: Agenda Publishing.

Vukov, T. (2016) ‘Target practice: The algorithmics and biopolitics of race in emerging smart border practices and technologies’. Transfers 6(1): 80–97. https://doi.org/10.3167/TRANS.2016.060107 (accessed 6 September 2021).

Wang, J. (2018) Carceral Capitalism. Cambridge MA: MIT Press.


1 Although the British government made COVID-19 testing and treatment exempt from the charges normally levied on migrants seeking NHS treatment in February 2020, the wider regime of charges, and liaison with the Home Office for the purposes of immigration enforcement, has persisted throughout the pandemic. Despite exemptions, fear of Home Office involvement has nonetheless deterred migrants from seeking treatment for COVID-19 (see Patients not Passports 2020; Gardner 2021).
2 This phrase was also used by Health Secretary Jeremy Hunt when he called for ‘action to ensure the NHS is a national health service – not an international one’. Department of Health and Social Care and Home Office (2013) ‘New report shows the NHS could raise up to £500 million from better charging of overseas visitors’. Press release, 22 October. www.gov.uk/government/news/new-report-shows-the-nhs-could-raise-up-to-500-million-from-better-charging-of-overseas-visitors (accessed 12 September 2022).
3 Necropolitics is a term that comes to us from Achille Mbembe. Mbembe developed the term to describe the kinds of deathly sovereign violence exercised against colonized populations and others experiencing racist violence. It has come to be used as a description of how authorities might exercise the right to expose people to death, or the risk of death – for instance, by putting them in a situation where they must choose between ill health, indebtedness and encounters with hostile, racialized border regimes. The chapter by Bhattacharyya (Chapter 22) contains an extended discussion on necropolitics (or the ‘necropolis’) and racial capitalism.
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The entangled legacies of empire

Race, finance and inequality


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