32 Reproducing differential racialisation: social triage in forced migrant mental health services in England

Background In England, the provision of treatment for post-traumatic stress disorder (PTSD), a health condition that significantly impacts forced migrants, is theoretically universal. It can be offered to all, including undocumented migrants who are excluded from most other types of secondary and tertiary care. Nevertheless, numerous access barriers lead to implicit systems of rationing. This study, utilizing an intersectional approach, investigates the political and moral frames that underpin implicit rationing within the National Health Service (NHS). It asks why a universal health service may perpetuate differential racialization, wherein various coexisting populations are stratified and ranked in terms of their belonging to the nation. Methods Fieldwork was conducted in two phases, in 2015-2016 and 2019-2021. The research involved six months of participant observation within an NGO, 21 semi-structured interviews with healthcare professionals across 16 different NHS and NGO service providers, purposively selected until saturation was achieved, as well as six interviews with mental health commissioners and national policymakers. Additionally, grey literature was analyzed. Transcripts and fieldnotes were analyzed using NvivoR1 to identify themes, with results validated by interviewees. Results Despite the NHS offering coverage, undocumented migrants and asylum seekers were systematically excluded from PTSD services, as a result of social triage. People with refugee status were prioritised. Mental health care professionals consciously and subconsciously reinforced the social construction of 'undocumented migrants' as victims without rights. This exclusionary process was facilitated by austerity, biolegitimacy, securitization of mental health services and disconnected activism that bifurcated the forced migrant sector from established efforts to combat racism in mental health care. Conclusions Rationalities of care form part of a wider global health coverage assemblage. Reframing mental health policies through the lens of racial justice and decolonization may hold the potential to address forced migrants' exclusion from care.