Refugees and primary care: tackling the inequalities

As the 20th century draws to a close, outbreaks of hatred between human population groups show no sign of abating and conflicts continue to erupt. Families across the world find themselves forced to leave their homes and seek refuge where it can be found.

Globally, there are 18 million refugees with 230 000 living in the United Kingdom (see box 1).¹ Almost half of these live in London, where 100 000 people are refugees or awaiting confirmation of refugee status.² Asylum seekers come from several countries around the world (see box 2). Many refugees have health problems but experience difficulty having their needs met by the NHS.³ This article explores the challenges that refugees pose for primary care and suggests alternative strategies to address inequalities in the care of refugees.

Summary points

• The refugee population in Britain is highly diverse and is likely to remain large as conflicts continue to occur throughout the world

• Refugees, unlike other migrants, have had to flee to escape oppression

• The refugee population is concentrated in the greater London area, but new legislation will result in dispersal throughout the United Kingdom

• Refugees may be vulnerable to mental health problems yet have difficulty communicating their needs because of language barriers

• All refugees are entitled to the full range of NHS services free of charge, including registration with a general practitioner

• A strategic approach is needed to address the inequalities in primary care

What happens to refugees?

In Britain the geographical distribution of refugees has been influenced by many factors, including local authorities’ housing policies.⁴ The refugee population is not evenly spread but concentrated in areas where local authorities have given refugee housing a higher priority.⁵ Recent legislation will result in greater dispersal of refugees,⁶ which will make the provision of specialist services more difficult.

“Cultural bereavement”⁷ and coping with “deeply disruptive change”⁸ are widely shared experiences of migration. But refugees are distinguished from other migrants by their lack of choice. Refugees have had to leave their countries of origin to escape persecution, imprisonment, torture, or even death. Families may have been physically separated, causing much grief. Refugees are often preoccupied by worry about relatives left behind in their country of origin. Many refugees, including children, have no other relatives in the United Kingdom. Poverty and dissatisfaction with housing is widespread.⁴

Health problems

Some health problems, especially parasitic and nutritional diseases, are determined by the country of origin and vary between refugee groups.⁹ Mental health problems have been found to be influenced by various factors including language difficulties, family separation, hostility from the host population, and traumatic experiences before displacement.¹⁰ Some of these factors may be found in non-refugee migrants, but refugees are especially vulnerable. A recent UK study of Iraqi refugees found that all had been separated involuntarily from some close family members, 65% had a history of systematic torture during detention, and 29% were unable to speak any English. Over half of this group had significant psychological morbidity when tested.¹¹ There is evidence that refugees who have not yet been granted the right to remain are under particular stress.¹² Karmi has highlighted the importance of early recognition and treatment of psychological problems.¹³

Deficiencies of primary care

Although all refugees are entitled to the full range of NHS treatment free of charge, including the right to register with a general practitioner, there is evidence that some general practitioners are confused about this.³ A study in Islington found that 38% of refugees encountered problems registering with a general practitioner.¹⁴ Some patients are asked for passports when trying to register,¹⁵ which raises a number of questions. What happens to patients unable to produce a valid passport? Are they sent away? Who makes these decisions? General practices differ in their attitude. Some practices are, perhaps reluctantly, open for refugees whereas others are effectively closed, creating neighbouring practices with very different demographic profiles and unequal needs.

Information on general practitioners’ perceptions of refugees’ health needs is limited. Perhaps reflecting the low level priority that refugees receive on the national agenda, most studies are local and small scale, but they suggest that problems exist. Ramsey and Turner found that 50 general practitioners identified a diverse range of problems and five practitioners reported their own anxiety in dealing with patients “with special needs who seemed to take up a disproportionate amount of time.”¹⁶ Seventeen general practitioners in this study identified language difficulties as the reason for their associating refugee status with lengthy and time consuming consultations.

When refugees join a general practitioner’s list they are often registered on a temporary rather than a permanent basis. This prevents access to past records, if there are any, and removes financial incentives to undertake immunisation and cervical smear tests. Why do general practitioners avoid giving refugees permanent registration status? Some have justified this on the grounds that refugees move around and that this mobility makes it inappropriate to offer permanent registration. This reputation for high mobility may be exaggerated, as a 1995 Home Office study found that 70% of refugees had been living in their current home for more than a year.⁴

Refugee families are not likely to have enjoyed good quality primary care in their countries of origin. Immunisation rates may be low,¹⁷ and medical records are usually not available. Language barriers at the reception desk and in the consultation are common. Health authorities lack knowledge about the languages spoken in their districts and of the extent of the need for interpreter services. These are generally not available outside working hours¹⁸ and for acute consultations. Telephone interpreting using “hands free” technology may offer a solution to the practical problems in providing interpreting services for many different language groups dispersed between practices, but this remains underdeveloped.¹⁹

Effective communication improves health outcomes,²⁰ and Meryn has argued that doctors have responsibilities to their patients that can be fully met only by effective communication.²¹ Lack of adequate professional interpreting services presents a barrier for all non-English speaking patients, but this barrier is larger for those with psychological and emotional difficulties that can only be explored verbally. If tragic mistakes are made as a result of communication failure does moral responsibility rest with the doctor or with a medical system which expects doctors to communicate well but fails to provide adequate resources?

Increasing spending on refugee primary care

We consider increased spending on refugee health to be fully justified on clinical and ethical grounds but recognise that it requires considerable political courage to prioritise refugees at a time when other groups in the population, such as elderly people and the mentally ill, have been identified as in need of greater resources. It is important to remember that many refugees who settle in Britain have made valuable contributions to society.²²

The General Medical Services Committee has successfully negotiated extra resources for those general practitioners whose work is thought to contain additional elements not presently properly rewarded.²³ The care of refugees generates an additional workload for general practitioners, and there is evidence that current deprivation payments are not adequate.²⁴ We believe that some of the £60m negotiated by the committee should be used to reward doctors caring for such patients. Financial audit would need to be robust.

What can be done to improve primary care for refugees?

A strategic approach is required, which should include providing refugees with intensive courses in spoken English. The Department of Health needs to commission an information pack that includes a certificate of entitlement to NHS treatment and to develop patient held medical records for refugees. The development of a national telephone interpreting service in a range of languages is a priority. A separate capitation payment for refugee patients, together with a new item of service payment linked to the duration of each professionally interpreted consultation, should be introduced.

Health authorities need to provide all practices with detailed guidelines for the process of registration and to introduce a mechanism to ensure ethical standards are being adhered to. Healthcare facilitators should be recruited from each specific refugee population and could help to provide patient held records with an accurate and detailed medical history and support health promotion and screening.

Primary care groups are being introduced²⁵ and should be given the resources to address the distortions created by different practice policies towards the registration and care of refugees and other marginalised patients.

Conclusion

The refugee population is likely to remain large. High needs, especially psychological distress, combined with language barriers require a great deal of additional time in consultations. General practitioners in inner cities need adequate resources, especially interpreting services, and should be properly rewarded. We have outlined some ideas for dealing with this. A truly effective solution requires the political will to develop a comprehensive strategy at national level.

Box 1.

—Definition of refugees

• Those applying for asylum (refugee) status in the United Kingdom
• Those who have been given temporary admission by the immigration service while their applications are considered
• Those who have been given exceptional leave to remain in or enter the country
• Those who are required to renew their status at the Home Office at regular intervals
• Those given refugee status
• Those who gain the right to stay in this country indefinitely
• Those who have had their application refused and are going through the appeals process
• Dependants of the above groups
• Other individuals or groups who may fall outside the legal definition but who face similar problems—such as those entering the country under family reunion rules, policy, or discretion

Box 2.

—Top 12 countries of origin of refugees in Britain (1997)*

•Afghanistan	• Pakistan
• China	• Somalia
• Colombia	• Sri Lanka
• Ecuador	• Turkey
• India	• Former Soviet Union
• Nigeria	• Former Yugoslavia

 *Data from Home Department⁶