Healthcare professionals and street-level bureaucracy: immigration healthcare in England and Wales

This proposal focuses on the emotional and moral dilemmas faced by healthcare professionals when caring for undocumented immigrants within England and Wales, amid restrictive policies designed to limit immigrant access to public services. The focus will be on healthcare professionals in their capacity as street-level bureaucrats. The project will seek to understand moral dilemmas faced and how discretionary power is used by bringing together several elements of discussion: borders, immigration, street-level bureaucrats and healthcare.

Through researching these elements in conjunction, the research seeks to understand the first-hand experiences of healthcare professionals as it pertains to their interactions with immigrants. There is a vast body of literature on the work of street-level bureaucrats, and on immigrant access to healthcare respectively. As such, this research will combine the topics whilst drawing on broader frames such as concepts of healthcare deservingness and medical humanitarianism.

A qualitative interview study has been designed, in which healthcare professionals within a range of settings will be interviewed. These settings are hospitals, clinics, non-governmental organisations (NGOs) and immigration removal centres. The research questions that will guide this project are as follows:

1. What are the emotional/moral dilemmas faced by healthcare professionals when caring for undocumented immigrants? 2. How do healthcare professionals use their discretionary power and how does this shape policy on the ground? 3. What coping mechanisms do healthcare professionals use to deal with these dilemmas?

Research contribution

This research sets out to engage in discussions around health, borders and street-level bureaucrats. Whilst these topics have been studied in great length individually, this research hopes to contribute to existing literature by discussing these topics in conjunction. Through the use of concepts/theories such as healthcare deservingness, medical humanitarianism and street-level bureaucracy, the research will make an original contribution to these areas of study, particularly as it pertains to immigrant-healthcare professional relationships and the moral tensions that arise as a result of these interactions.

Methods A qualitative interview study will be designed to answer the research questions.

It is proposed that I enter healthcare facilities that offer secondary care (undocumented immigrants do not have automatic access to this care). Healthcare professionals who work in hospital, clinic, NGO and IRC environments would be the core sample of this project - specifically, doctors and nurses. I will aim to interview thirty participants whose identities cut across gender and ethnicity.

NHS Trusts, Doctors of the World (NGO) and Medical Justice are organisations that will be contacted as part of this research to observe and interview medical professionals. However, it is important to note the possible difficulty in obtaining permission from organisations to conduct this type of field research. I believe that my successful experience gaining permission from an organisation to conduct research will be beneficial here.

Data collection will be through semi-structured interviews with healthcare professionals. These interviews would be an opportunity to discuss their experiences of caring for undocumented immigrants, as well as understanding in what ways they use their discretion and the coping mechanisms they employ. All research would be conducted in accordance with the University of Warwick's ethical guidelines and will require ethical scrutiny, from myself as the researcher and from Warwick University's ethics committee.