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Recent waves of immigration from Afghanistan and Ukraine have highlighted the importance of primary care in looking after vulnerable migrants.
Dr Ishraga Awad, Dr Emily Clark, Dr Adam Harvey-Sullivan and Dr Nina Amedzro from the Faculty of Public Health special interest group for primary care and public health outline the actions required to care for this patient population
The role of primary care as the first point of access for healthcare in the UK is indisputable in meeting the initial and continuing health needs of vulnerable migrants. However, despite primary care being exempt from charging, many patients – and staff – are unaware of this healthcare entitlement and fears around costs, detention and deportation mean migrants do not always access services.
Added to this primary care services are not uniform across the country for this group, which clearly shows inequity of quality and quantity. In some areas there is reliance upon the charitable sector to provide care, in others there are contracts for locally enhanced services for certain practices in dispersal areas or with initial accommodation sites. However, in some places there is no access to care for some groups placed in initial and contingency accommodation.
There needs to be better training of health professionals around caring for this cohort. While there are many supporting resources available, and highlighted in this article, there needs to be mandatory training for frontline NHS clinical and administrative groups and inclusion of care for vulnerable migrants within undergraduate and postgraduate medical/allied health professional courses.
To provide holistic and appropriate care, more is needed than a reactive 10-minute consultation focused on acute health needs. This can be done using a population health management (PHM) approach, as advocated by integrated care systems (ICSs), to address health inequalities facing vulnerable population groups.
PHM is an approach that uses data to help health and care systems to improve health and wellbeing at population level. Data is used to: assess the needs of a particular population, such as vulnerable migrants; understand the make up (age, sex, ethnicity) of the population; identify unique health morbidities and risks; identify challenges in access to relevant, effective healthcare; and to carry out surveillance activities to monitor health morbidity and outcomes of care.
Using a PHM approach, PCNs could chart out the number and demographic make up of their vulnerable migrants and the impact of the wider determinants of health on them. Social prescriber teams could potentially engage with community organisations, housing providers and social service teams working with migrants to get information on their living and functional conditions. Migrants themselves could be encouraged to have a voice through their advocacy groups or directly via action research that could be accessed through partnerships with local universities and public health departments. The impact of the wider determinants of health on migrants’ physical and mental health can be assessed in this way. Key determinants are things like good housing and energy affordability, healthy nutrition, access to education and employment, income generating activities and opportunities for integration with the host area. These are factors that impact physical and mental health.
PCNs could also use primary care registration data to identify vulnerable migrants and invite them for initial health assessments to determine if they need early investigation to determine further treatment for conditions like tuberculosis and communicable diseases as well as mental health conditions like post-traumatic stress disorder that may have resulted from being in war zones, witnessing violence and the impact of their often hazardous journeys to safety. Some PCNs have already commissioned initial health checks for unaccompanied asylum-seeking children but this is by no means uniform or accessible to all vulnerable migrants. One of the main challenges of this PHM approach is the lack of ‘visibility’ of vulnerable migrants in the datasets used to inform commissioners. The coding of vulnerability in a primary care dataset often does not identify migrants/asylum seekers/refugees or their health conditions adequately. This leads to their unique, and often challenging, health needs being missed in the information on the majority population. So inequality continues and health needs remain unmet.
Also, ethnicity remains poorly coded within medical IT systems and data quality problems affect records for minority ethnic patients disproportionately.
We urge clinicians and policy makers at every level to adopt the ethos that “coding is caring”.
In order for marginalised groups not to be “missed” by population health approaches, we must ensure accurate coding of vulnerabilities such as torture history, history of FGM, requiring a translator or immigration status.
Challenges in access to healthcare for migrants
Healthcare charging, and the wider hostile environment, act as significant deterrents to migrants engaging with NHS services. Despite primary care being exempt from charging, many patients – and staff – are unaware of this healthcare entitlement. Migrant fears include that accessing healthcare will result in incurring unaffordable charges and that data shared with the Home Office could lead to detention, deportation or refusal of future asylum applications.
Staff can exacerbate this by incorrectly refusing care on account of immigration status or GP registration on the basis of not having access to proof of address or identification. Perceptions of discrimination because of immigration status and ethnicity further deter healthcare seeking.
Language barriers are particularly challenging to migrants and this is associated with poorer patient experience and worse patient outcomes. Despite availability of interpreting services, logistical barriers and time constraints mean they are often underused.
Vulnerable migrants also experience healthcare challenges associated with deprivation including indirect costs that limit access such as transportation fees and affording time off work. While policies related to asylum accommodation and dispersal further inhibit continuity of care.
Finally, Covid highlighted and exacerbated health inequalities for vulnerable migrants. Migrants were particularly at high risk of exposure to and infection from COVID-19. They had worse access to Covid vaccines. And access to healthcare was made harder due to worsening digital exclusion as health services moved to greater use of online and telephone consultations. This resulted in reduced utilisation of primary care among migrants relative to non-migrants, highlighting further inequity.
Good practice: The Ukraine war and the Afghanistan crisis
The Afghanistan crisis of 2021 and the Ukraine war in 2022 have brought the needs of migrants in vulnerable circumstances further forward in the minds of the public, NHS and policymakers. Many examples of good practice have been created including policy and advocacy documents, translated health, information communication cards and tool kits.
These good practice points may serve only a self-selecting interested group so as stated earlier there should be mandatory training for frontline NHS staff on this issue. In conclusion one of the main problems in a population health management approach is the lack of ‘visibility’ of vulnerable migrants in the datasets used to inform commissioners. This combined with ethnicity being poorly coded leads to health needs of this population being unmet. We call upon clinicians and policy makers at every level to adopt the ethos that “coding is caring” so that marginalised groups are not “missed” by population health approaches.
This article was written by: Dr Ishraga Awad, GP and Public Health Specialist; Dr Emily Clark, GP and NIHR In-practice fellow; Dr Adam Harvey-Sullivan GP and Academic Clinical Fellow in Primary Care, Wolfson Institute of Population Health, Queen Mary University of London; Dr Nina Amedzro, GP and Public Health Registrar, Yorkshire and Humber Region.
The authors have written on behalf of the Faculty of Public Health Special Interest Group for Primary Care and Public Health. More information is available here The next Building back better in primary care and public health webinar is at 12pm to 1.30pm on Wednesday, September 7.