Sitting side by side in the chilly basement of an east London church, Victoria and her mother Shelly* are telling a doctor how grateful they are for something most women in the UK take for granted: free, safe and effective contraception.
Originally from Vietnam, the two women have never seen a British GP before. They are not sure which health services are open to them — and which it would be safe for them to access.
When Shelly heard about a free drop-in clinic that did not require proof of address or share patients’ details with immigration enforcement, she quickly persuaded her 29-year-old daughter to go with her. Victoria has just been prescribed the contraceptive pill and she says it’s going to change her life: she feels “confident and safe” now.
Upstairs, 18 people were already waiting to access the clinic, run by charity Doctors of the World (DOTW), when I arrived at 11am — an hour before the service opened. Many had been queuing since 9am.
Appointments with the clinic’s two volunteer doctors are allotted on a first come, first served basis and on most days staff are forced to turn people away. The clinic is open to anyone who is struggling to access healthcare on the NHS, but the majority of patients are migrants who have become desperate to see a doctor.
“So many times I’ve heard patients tell us they’ve taken three buses to get here because it’s the only place in London they can access healthcare,” clinic support worker Natalie Pedersen tells me.
Although the drop-in has been running since 2006, Victoria is the first person to have been given contraception as part of a new service. The staff and volunteers – all women on the day I visit – are incredibly excited about being able to offer something so crucial to their clients. But there is also a sense that it shouldn’t be necessary for a charity drop-in, already operating at capacity, to offer such a basic necessity to women in Britain in 2018.
GP and DOTW health advisor Dr. Lucinda Hiam explains that since Theresa May made it her mission to create a "hostile environment" for migrants, it’s become harder and harder for thousands of vulnerable people living in the UK to access healthcare. Women are often the worst affected.
Many of the migrants DOTW sees are undocumented, Hiam explains, although refugees and other people with papers sometimes struggle to see a doctor, too. Some don’t know how to make an asylum claim or have done so and been rejected; others have been trafficked here to work in the sex trade or as domestic slaves. Many have experienced torture or sexual violence and some have serious mental health problems.
Pedersen recently returned from working in Sierra Leone on the Ebola outbreak, but she tells me she regularly sees people here – particularly women – who are more vulnerable, in many respects, than the people she worked with in Africa.
The rules around who is entitled to free healthcare in the UK are complicated, poorly understood and seem to be constantly changing. In the past few years, passport checks and upfront fees have been introduced across sections of the NHS, while little effort has been made to ensure vulnerable people continue to be able to access the services that do remain open to everyone, like GP clinics. Doctors are often confused, for example, about who they should register; they turn away people who don’t have the ‘correct’ paperwork, even though they are not supposed to.
Since last January, the NHS has also been forced to share patient records with the Home Office, which means undocumented migrants now have the very valid fear that a trip to the doctor could result in detention or deportation. DOTW says this has had a massive deterrent effect, and it’s one of the reasons for launching the new family planning service.
“Most women get their contraception from their GP – about 60%,” Hiam explained. “But because of the data sharing, our patients are too scared to see a GP. In 2016, 89% of the people we saw weren't registered with a GP when they came to us.”
Dr. An Vanthuyne, a consultant in sexual and reproductive health, specialises in helping vulnerable women access family planning services. She’s passionate about her work: "It's about giving women control and empowering them, it's a basic human right,” she says. When I ask, she reels off a list of barriers migrant women face to accessing contraceptives. “These women are frightened," she says, "they're worried people will find out about it. It's difficult with language. It’s difficult stepping through a door in a country that you're not sure about."
The stakes are also extremely high: becoming pregnant – accidentally or not – can be incredibly difficult to navigate for migrant women.
DOTW runs a women-only clinic twice a month, where they regularly see people who have never been to a doctor before presenting with extremely late-stage pregnancies. “We had a pregnant woman who was turned away [by GPs] four or five times before she was registered,” Hiam said. “We get people presenting really late, not being seen until 20 weeks plus, which is really dangerous for mum and baby.”
Last year, I interviewed Jeremy, who was already six months pregnant by the time she first saw a doctor. Born in the Philippines, the 38-year-old had been living in the UK for almost 10 years when she conceived her son, Ethan, but she had never registered with a GP surgery.
When she did try and see a doctor, she was repeatedly turned away; surgery after surgery said she didn’t have the right documents.
“We were so desperate,” Jeremy said. “We felt hopeless because I hadn’t had a proper check-up and we kept getting turned away.”
Although pregnant women are never supposed to be denied maternal healthcare on the NHS, undocumented migrants are always charged for having a baby, receiving a bill for between £5,000 and £6,500 following an uncomplicated birth.
The government justifies NHS charges like these as a response to ‘health tourism’, but there is little evidence this exists on a large scale, aside from in rightwing tabloids. The government estimates that health tourism costs the NHS a tiny 0.3% of its annual budget each year, and even this is speculative.
Hiam says she has never encountered a ‘health tourist’ at the DOTW clinic. Instead the migrants the charity sees have been living in the UK for six years on average before they have even tried to access healthcare. They also tend to be incredibly poor — Hiam tells me the clinic is increasingly seeing women who cannot afford to eat properly while pregnant. Most will never be able to pay off a £6,500 bill.
Things are getting worse all the time. In October, one of the latest restrictions on healthcare seemed to specifically target women: abortion services became chargeable and even charities like Marie Stopes were told they could no longer provide free terminations without checking immigration status.
The impact of this new restriction is not clear yet, but DOTW says it was already helping women struggling to access terminations, even before the rules changed.
Last winter, Helen, a 28-year-old Eritrean refugee arrived at the clinic in distress. She had been to A&E with stomach cramps, only to be told she was five weeks pregnant. She had just been made homeless and after being discharged from hospital she spent three nights sleeping in a bus station.
“I was sleeping outside, I was hungry and I had no food. I was so worried that I couldn’t even sleep,” she told staff. “How could I handle a pregnancy when I had no plan?”
She decided to have an abortion but when she tried to visit a doctor, four different GP surgeries turned her away because she didn’t have proof of address. “The whole experience was tiring and scary. I really didn’t know what to do,” she said.
It took DOTW caseworkers seven weeks to get Helen the help she needed and was entitled to.
I asked Hiam what the government intends for destitute migrant women to do if they find themselves in a situation like Helen’s, especially now terminations are chargeable. “There are no really good options for these women,” she said. “Contraception is difficult to access, you can’t get a termination, and you can’t pay for your pregnancy, so they’re really left quite stuck.”
Although the charity hopes its new contraceptive service will help a lot of women, DOTW is far from being able to meet the family planning needs of all undocumented migrants in the UK. “We’re not trying to run a parallel health service,” Hiam says. “We can’t – we don’t have the resources to.” And they wouldn’t want to anyway, she adds; the NHS offers extensive family planning services, which everyone should be able to access. “GPs are fantastic at providing contraception and family planning services remain free of charge, but we need to break down the fear people have of going to their GP.”
The charity is asking doctors to make their clinics ‘safe surgeries’ by not uploading patient records to an online database the Home Office can access, and by anonymising addresses. But ultimately they want bigger changes: an end to data sharing, passport checks in hospitals, and charges for people who are destitute.
Hiam finds it particularly absurd that women are struggling to access contraception. “For the NHS, it’s cheap, it’s easy and it’s safe, so not giving it doesn’t make sense,” she says.
“As a woman and a feminist I just feel women need to be able to access contraception. It’s a human right. It’s just unacceptable not to have access to it in Britain in 2018.”
*Names and countries of origin have been changed