Caring for the health of migrants

The current migration crisis is one of the most urgent global challenges that we face. More people have been forced to leave their homes and countries due to war, violence, exploitation or persecution than at any time in the 70 years that the UNHCR has been in existence.

Many migrants have complex health and social care needs. Health professionals face significant hurdles in addressing these needs, which impact on their ability to provide the same quality of care that the population in general enjoys.

Charges in relation to NHS services

Research evidence indicates that restricting access to healthcare leads to delayed care and higher per person health expenditures. In addition, it reinforces exclusion as a root cause of ill health among migrants.

The rules in relation to overseas visitors generally are complex. There are a number of categories of people who may or may not be able to access NHS care, may or may not have to pay for that care and payment may need to be up front or after the care has been provided.

Since 23 October 2017, NHS trusts have been required to charge overseas visitors upfront for non-urgent care. From this date, non-exempt patients can be charged by non-NHS providers for NHS-funded care and secondary and community care that is delivered outside a hospital setting. More information is available here. Bevan Brittan can advise in relation to specific queries.

Immigration centres

Healthcare professionals working in immigration detention owe the same ethical and legal obligations to their patients as they would in any other setting. The UK has one of the largest immigration detention estates in Europe, with 11 immigration removal centres across the country which can hold up to 3,500 individuals at any one time. The UK is only one of a handful of European countries where no time limits are imposed on detention.

In December 2017, the BMA published a report "on health and human rights in immigration detention entitled "Locked up, locked out”, which provides guidance on a range of ethical issues. The BMA argues that a fundamental rethink of current UK policies in relation to immigration centres in the UK is required, including phasing out immigration detention, and replacing it with more humane means of monitoring individuals who are facing removal from the UK. However, while detention continues, detainees' healthcare rights should not be infringed.

Young people under 18

A young person who is under 18 and who is without an adult to look after them is entitled to the same rights as looked-after children and young people. This will include assistance with accommodation, finance, education and health assessments. The application for asylum will be processed in a different way to that of an adult.

Disputes about age are common. They tend to arise if an asylum seeker does not know his or her own age, does not have any documentation or where immigration officers believe that the documentation is false or does not belong to the applicant.

Social workers are charged with carrying out formal age assessments, and do this by interviewing the person and gathering other background information. The Home Office has described physical interventions such as dental x-rays as "inaccurate, inappropriate and unethical". Medical experts say that physical intervention tests are unreliable and that stress and trauma can cause the human body to age faster.

UK practice is not to use any physical intervention tests and the Royal College of Paediatrics and Child Health and the British Dental Association have advised that x-rays should not be used to assess a migrant child's age unless the x-ray has been taken for a therapeutic or medical reason.

Immunisation

New migrant patients should always be asked about their vaccine history. It is important to assume that patients are not immunised, unless they can give a reliable history of vaccination. Individuals who arrive in the UK part way through their immunisation schedule should be transferred onto the UK schedule and immunised as appropriate for their age. If a course of immunisation has been started but not completed, it should be continued from when it was interrupted. The PHE immunisation algorithm is useful for advice on immunising individuals with uncertain or incomplete immunisation status.

Mental Health

Most migrants do not have mental health problems. However, some may be at increased risk due to their experiences prior to, during, or after migration to the UK. Mental health problems may present in different ways in people from different cultures, for example with physical rather than emotional symptoms. A professional interpreter should be used to explore mental health issues rather than a family member or friend where possible.

Women's health

Health professionals should be aware of possible religious and cultural sensitivities when discussing sexual and reproductive matters. Where language is a problem in discussing sexual or reproductive matters it is good practice to offer a female professional interpreter. It is inappropriate to use children as interpreters for adults, particularly when discussing intimate concerns. If there are concerns that a patient may be a victim of trafficking then the UK Human Trafficking Centre can be contacted.

Female Genital Mutilation

Female Genital Mutilation is illegal in the UK. Children born in the UK may be at risk of FGM when they travel with their families to visit friends and relatives in countries where this practice is common. It is illegal to take girls who are UK nationals or UK residents abroad for FGM whether or not it is lawful in that country. FGM has long term implications for physical, sexual, and psychological health, and girls and women who have been affected may need referral to specialist services. If FGM is identified through the delivery of healthcare services, it is mandatory to record FGM in the patient’s healthcare record.

Factors impacting on healthcare and how health professionals can be supported

Research indicates that five key factors impact on healthcare of refugees or asylum seekers:

• Trusting relationships - considerable attention needs to be paid to building trust with a group who may be apprehensive about engagement with healthcare systems;
• Communication - language barriers can compromise good healthcare. There are concerns about the quality and availability of professional interpreters and it is important that this is addressed locally;
• Cultural understanding - appropriate training for staff needs to be available in order that healthcare practice can be adjusted accordingly;
• Health and social conditions - engaging with service users can be emotionally difficult and appropriate training and support needs to be available;
• Time - in view of the various challenges, more time needs to be allocated to allow health professionals to deal with complex conditions; and
• Partners - work needs to be done with partners (communities, organisations and services) to understand mental health issues better.

How Bevan Brittan can help

Advice - Bevan Brittan has substantial experience in advising healthcare professionals and organisations (both NHS and Local Authority) in connection with issues relating to migrant patients. 

Training – Bevan Brittan can provide training on best practice that impact on the role of the healthcare professional.

Policy - Bevan Brittan can help draft up to date policies reflecting recent relevant guidance.

If you would like to discuss any of the issues raised in this article, please contact Claire Bentley, Associate and Jane Bennett, Associate.

Useful links

Other relevant Bevan Brittan articles

• Identifying modern slavery – The role of the healthcare professional – Claire Bentley
• Female Genital Mutilation and Children – Claire Bentley

Department of Health

• Migrant Health Guide
• Guidance on overseas visitors hospital charging regulations.
• Help for NHS to recover costs of care from visitors and migrants

BMA

• Locked up, locked out: health and human rights in immigration detention

RCPCH

• Refugee and unaccompanied asylum seeking children and young people: current UK asylum process and access to healthcare.

NRPF

• NHS healthcare for migrants with NRPF

Kent

Kent has developed a website containing key documents, templates, tools and clinical guidance used to support the health needs of unaccompanied asylum-seeking children. Many of these resources have been developed by subject matter experts and are published for use within Kent and to share learning across the UK.