Refugee Health

Question 1

Define who qualifies as a refugee under the Geneva Refugee Convention.

Answer 1

Someone whose asylum application has been successful; the Government recognises they are unable to return to their country of origin owing to a well-founded fear of being persecuted for reasons provided for in the Refugee Convection 1951 or European Convention on Human Rights.

Question 2

List common barriers to healthcare faced by this group in the UK. (7)

Answer 2

52% didn’t even try (believed they were not entitled to access the NHS)
29% had administrative difficulties (didn’t have proof of address/ID so were refused registration)
17% didn’t understand how to access NHS/that you have to be registered with a GP
14% language barrier
12% tried but were refused
11% feared arrest
2% were asked to pay in advance and couldn’t afford it

Question 3

What is MÉDECINS DU MONDE?

Answer 3

International organisation providing healthcare for excluded people all over the world.

Question 4

Doctors of the World in the UK - what do they do?

Who attends?

Answer 4

Drop in clinics in London and Brighton that provide short-term medical care (volunteer GPs and nurses) and a GP registration advocacy service.

Mainly undocumented migrants (55%) and asylum seekers (14%).

Question 5

What is the average time patient have been living in the UK before they access these services?

Answer 5

Six years

Question 6

What is the top country of origin of the people that access these services?

Answer 6

Philippines (then India and Bangladesh)

Question 7

Define asylum seeker.

Answer 7

A person who has left their country of origin and applied for asylum in another country but whose application has not yet been concluded.

Question 8

Define refused asylum seeker.

Answer 8

A person whose asylum application has been unsuccessful.

Question 9

Define undocumented migrant.

Answer 9

Someone who enters or stays in the UK without the documents required under immigration regulations.

Question 10

Why might migrants be undocumented? (6)

Answer 10

• They are trafficked into the UK
• Don’t make an asylum claim because they don’t receive legal advice
• Those who come to the UK to work without a visa
• Domestic workers on a visa sponsored by employer who then leave their employer/employer does not renew the visa
• Those on a spousal visa and the relationship then breaks down
• Those on a student or working visa and are then unable to return home because of conflict

Question 11

Are undocumented migrants entitled to free primary care?

Answer 11

“Everyone in England is entitled to free primary care regardless of nationality or immigration status.”

“Inability by a patient to provide proof of address/ ID would not be considered reasonable grounds to refuse to register a patient or withhold appointments”

Question 12

What could a GP do to support an undocumented migrant? (5)

Answer 12

• Use an interpreter
• Flag up in patient notes that she is vulnerable
• Think about how she will get referral letters/results
• Holistic approach to healthcare
• Consider mental health needs

Question 13

What is the general rule for entitlement to secondary care? What is the exception?

Answer 13

Refused asylum seekers and undocumented migrants are charged for secondary care (charged 150% NHS tariff and must be paid before treatment)
BUT “Urgent or immediately necessary” treatment will be provided regardless of ability to pay (they don’t have to pay upfront, doesn’t mean it is free).

Question 14

Who is always exempt from charges for secondary care? (7)

Answer 14

• Refugees and asylum seekers
• Refused asylum seekers receiving ‘destitute families/destitute and unable to return to country of origin’ support or accommodation support under the Care Act 2014
• Victims of trafficking
• Victims of sexual or domestic violence, FGM and torture (only for treatment cased by experience of violence)
• Children looked after by a local authority
• Those receiving treatment under the Mental Health Act
• Those held in immigration detention

Question 15

What secondary care services are exempt from charges? (3)

Answer 15

A&E
Some communicable diseases
Family planning (not maternity or termination)

Question 16

What counts as ‘immediately necessary’ treatment?

Answer 16

Life saving treatment that will prevent a condition becoming life-threatening or will prevent permanent serious damage.
E.g. maternity services/antenatal check-up.

Question 17

What counts as ‘urgent’ treatment?

Answer 17

Cannot wait until they can return to their country of residence.
Should take into account pain, disability, and the risk of the delay exacerbating their condition.

Question 18

What are the barriers to accessing secondary care? (5)

Answer 18

• Patients fear bills they cannot pay
• Immigration status checks make patients fear immigration enforcement
• Hospitals refusing ‘urgent or immediately necessary treatment’ until patient pays in advance
• Hospitals and debt collection agencies aggressively chasing destitute patients for money.
• Hospitals billing or denying care to exempt groups.

Question 19

Does the NHS share information with the Home Office?

Answer 19

Yes! Hospital bills often threaten to report patients to the Home Office. Hospitals notify the Home Office of bills £500+ and outstanding for over 2 months.
2017: A Memorandum- requires NHS Digital to share non-clinical patient information (i.e. address) for immigration enforcement.

Question 20

As a doctor what can you do to support undocumented migrants? (6)

Answer 20

• Encourage them to engage with treatment
• Know which services are exempt from charges
• Know what services are ‘immediately necessary’
• Understand barriers e.g. fear of bills and the Home Office
• Always ask about violence
• If you suspect patients falls into ‘exempt’ group, raise this with your team

Question 21

What did the Immigration Act 2014 do?

Answer 21

To make it ‘more difficult for ‘illegal’ immigrants to live in the UK’. It changed the definition of ordinarily resident to indefinite leave to remain.

Question 22

What did the 2014 Department of Health Cost Recovery Programme do?

Answer 22

Set charges at 150% of NHS tariff

Pilot programmes in hospitals to carry out routine ID checks

Question 23

What did the DH announce in 2017? (3)

Answer 23

Legal obligation on NHS trusts to charge upfront
Extension of charges into community care
Phased approach to charging in primary care

Question 24

What is human trafficking/modern day slavery?

Answer 24

Recruiting, harbouring, transporting, providing, or obtaining a person for the purposes of commercial exploitation, forced labour or a modern-day form of slavery through the use of force, fraud, or coercion.

Question 25

How many human trafficking/modern day slavery victims were there estimated to be in 2014?

Answer 25

10,000 - 13,000

Question 26

What reasons are there for trafficking?

Answer 26

Sexual exploitation (31%)
Forced labour (22%)
Criminal activity (17%)
Domestic servitude (11%)

Question 27

How many % of victims of trafficking that encountered a healthcare professional were not identified as a victim?

Answer 27

> 50%

Question 28

What are red flags for trafficking? (12)

Answer 28

• Element of control (presence of a minder, someone speaking on behalf of patient)
• Inconsistent or scripted history
• Unable to give address or doesn’t know current city
• Poor English considering length of time in UK
• Lack of documents
• Late presentation
• Appearance younger/older than stated age
• General physical neglect
• Unusually high number of sexual partners
• Drug/Alcohol addiction, especially in children
• Children who express interest in, or may already be in, relationships with adults
• Child with unclear relationship with the accompanying adult

Question 29

What questions could you ask if you suspect your patient is a trafficking victim? (5)

Answer 29

Are you paid for your work?
Do you have control of all of the money that you earn?
Are you able to move around / come and go freely?
Do you feel you could leave the situation you are in if you wanted to?
How many meals a day do you have?

Question 30

Why is access to healthcare for this group important?

Answer 30

Public health - communicable disease and vaccination
Financial cost to NHS - health Inequalities, delayed access to treatment and charging patients costs the NHS more in the long run.

Question 31

How much do migrants cost the NHS?

Answer 31

1.83% of NHS budget

Question 32

How does healthcare charges impact staff? (4)

Answer 32

Increased pressure on clinical staff - time and denying care to those who cant pay

Conflict with medical ethics and duty to patient - responsibility to protect and promote the health of patients, including vulnerable groups

Changing role of staff – supporting Home Office with immigration enforcement

Departure from NHS founding principle – treatment based on clinical need not ability to pay

Question 33

What are the DOTW’S policy recommendations? (4)

Answer 33

• Full access to free primary, emergency and essential care for everyone living in the UK.
• Exemptions from healthcare charges for children and pregnant women living in the UK.
• NHS information should not be shared with the Home Office
• Health professionals should be supported to take care of all patients regardless of their administrative status.