The results of the recent Pulse survey of GP views on health provision for migrants and asylum seekers were not surprising to me.
A large majority of GPs were confused about regulations regarding the entitlement to NHS care of different groups of migrants and asylum seekers. They fear being caught between anti-discrimination regulations and the threat of investigation if they register ineligible patients. And faced with ever increasing workload in the context of major threats to practice funding, many practices were reluctant to take on groups of patients that could create very significant extra workload for little or no financial reward.
This is not a new problem. When Bradford first experienced a significant influx of asylum seekers in 1999, it was noted that many of them experienced difficulty in getting registered with a GP. Homeless people in the city had faced similar problems for a number of years, leading to the development of a specialist Homeless Health Team. In response to these difficulties a bid was developed for a PCT-managed third-wave PMS practice specifically to register homeless people, people in temporary or unstable accommodation, asylum seekers and refugees. The bid was successful and in October 2003 the new practice opened its doors.
Almost 10 years on, our practice has developed beyond recognition. We left PCT control in September 2011 and now run as an independent Social Enterprise – Bevan Healthcare (named after the founding father of the NHS, Aneurin Bevan). We have around 2,000 registered patients funded through a 5 year APMS contract with the PCT. Health care is provided by a committed team of sessional clinicians who have actively chosen to work with these vulnerable groups, and who have developed considerable specialist expertise in dealing with the complex problems they face. We work closely with other health care providers such as mental and sexual health services as well as with social care, housing, benefits advice and interpreting services providing easy access to services on site whenever possible.
The age-sex and morbidity profile of the practice is unusual. There are very low levels of many of the chronic diseases incentivised by the national QOF. For that reason a practice specific QOF was developed, focusing on areas such as mental health, sexual health and substance misuse. Points from clinical domains in which the practice had very few patients are transferred to targets in these more relevant areas. This has encouraged us to improve quality of care for our patients, rather than penalising us financially for registering these unusual groups. Our contract also allows 15-minute appointments, recognising the increased complexity of our caseload and the extra time needed when using interpreting services.
We have been able to develop innovative services responding to the particular needs of our patients, such as on-site HIV testing and providing easy access to counselling for victims of sexual violence. We have also had the capacity to provide medical input for refugees arriving in Bradford through the Gateway Protection Programme. This is a scheme run by UKBA in partnership with the UNHCR to resettle some of the world’s most vulnerable and deprived refugees. This has included groups of Iraqis from camps in Syria, Burmese Rohingyans from camps in Bangladesh, Somalis from camps in Kenya and Congolese from camps in Tanzania. All this relieves strain on already overworked mainstream city practices.
It’s not down to us
I don’t believe that tightening the rules about eligibility for NHS care will reduce the difficulties caused for GPs by migration. Inevitably stricter rules will lead to more trouble for people at the sharp end, such as receptionists. The BMA’s view is that GPs shouldn’t be forced into making decisions about eligibility. I fully support that. We also need to think about the effect that even tighter rules will have on the health of many vulnerable migrants living in poverty or destitution. It’s a complex issue, not one that will be resolved by superficial political soundbites.
Our model is a specialist one that ‘mops up’ problems that neighbouring practices find it hard to cope with. Doctors are compassionate by vocation but I know local GPs in Bradford have at times felt overwhelmed by the needs of migrants, especially some of the unanticipated waves of migration from the EU. Our own situation at the practice is not without its difficulties. Like many GPs we are grappling with increasing demand, high A&E usage and hospital appointment DNA rates. We will also face huge risk when our contract comes up for renewal in 2016.
However our experience has shown that with personal commitment alongside proper strategic planning and investment, it is possible to mount an organised and effective response to the specialist health problems posed by homelessness, migration and the need for asylum. The PMS model was key to the development of Bevan Healthcare – I still believe in the power of developing unique local solutions to local problems, but I know we were lucky to get access to sources of funding when we set the practice up.
As doctors it is our responsibility to show compassion and provide the best medical care possible for those most in need. But without planning, funding, support and training there is a risk that clinicians become overwhelmed and demoralised and that care for the most vulnerable ends up haphazard and of poor quality. We need to make care for all vulnerable migrants a commissioning priority as a key part of wider strategy on health inequality.
Dr Les Goldman is the chair and acting medical director of Bevan Healthcare CIC, and a GP in Bradford.