In 2017 there was a global population of 244 million international migrants, including 22 million refugees. With the inevitable implications for healthcare as a result of mass population movements, Abubakar and Zumla (2018:1) are clear that ‘national governments and international bodies have a responsibility to ensure that, in keeping with their pledged obligations to the United Nations' Sustainable Development Goals, no migrant or refugee is “left behind.”’
When Cross-Sudworth and Williams (2015: 734) investigated the high rate of adverse outcomes in pregnancies of migrant mothers in the West Midlands, they found that many had ‘medical and social risks that are currently not recognised or acted on, which can result in perinatal deaths that are potentially avoidable.’
It is significant that in the same year that Cross-Sudworth and Williams (2015) reported their findings, the immigration health surcharge was introduced in the UK. Feldman (2018: 4) wrote in a report for the charity Maternity Action that, ‘[o]verseas visitors are charged 150% of the normal tariff and Clinical Commissioning Groups and hospitals have a duty to report to the Home Office any patients who owe £500 or more for two months […] Holders of visitor visas and undocumented migrants are the main chargeable groups under current rules.’ This means that, according to the overseas patient upfront price list 2019/2020, a prenatal package can cost £1475–2212, a birth £3024–4536; and a postnatal package £415–623 (NHS Improvement, 2019).
Examining trends in perinatal outcomes among migrant mothers in the UK, Puthussery (2016: 39) reported that ‘ethnic minority grouping, regardless of migrant status, is a significant risk factor for unfavourable outcomes.’ Hackney GP Dr Hannah Fox (2016: 32) feared that the immigration health surcharge would not only ‘have a detrimental impact on vulnerable patients [but also that] charging poor and vulnerable patients also raises medical ethics issues. GPs will have to make clinical decisions based on a patient's ability to pay.’
On the one hand —and in the context of Dr Fox's medical ethics concerns—it is tempting to argue that measures such as the immigration health surcharge have contributed to former prime minister Theresa May's declared aim to create ‘a really hostile environment for illegal immigration’ (Kirkup and Winnett, 2012).
On the other hand, while one can argue that migrants, undocumented or otherwise, have a moral right to free NHS maternity services, let us consider what a right could mean. Warnock (1996: 148) argued that a right is essentially a legal concept and that asserting a ‘moral right’ may just indicate indignation against the way one has been treated, ‘giving the claim to a right a spurious and borrowed certainty or legitimacy.’ Perhaps this approach might have contributed to the finding from a UK survey that over three-quarters of GPs favoured charging migrants for accessing primary care (Lind, 2015), and one might speculate that at a time of stretched health resources, the Department of Health has an obligation—or even a duty—to consider charging overseas visitors and undocumented migrants who wish to access primary care.
However, Shahvisi and Finnerty (2019: 7) are robust in their assertion that it is morally unjustified to exclude migrants from accessing NHS healthcare of any sort ‘especially within a healthcare service that has always been critically dependent on migrant workers. Yet, it is particularly morally troubling to leave pregnant women and neonates without free medical care.’ Their citation of a founding tenet of the NHS—that healthcare should be free at the point of delivery and based on clinical need, not ability to pay—is particularly relevant in this context.