Primary care for survivors of trafficking

The Global Slavery Index 2023 estimates that approximately 122 000 people in the UK are living in modern slavery (1.8 for every 1000).¹ Survivors of trafficking have often experienced multiple, repeated, and prolonged physical and psychological violence, and may therefore present in primary care with significant and enduring symptoms. However, in line with the inverse care law, utilisation of primary care in these groups is often poor.² Barriers to disclosure of abuse are plentiful in busy and overstretched NHS practices.

Identifying those who have experienced such abuses in primary care can facilitate swift assessment of their physical and psychological symptoms, thereby preventing further deterioration and distress. However, the PROTECT study reported in 2015 that 86% of NHS professionals lacked the knowledge to identify victims of slavery and 71% were not confident in making referrals for victims to receive additional support.³ Frontline health workers such as GPs may well be the only public sector workers to interact with those who have experienced this ill-treatment. However, there are challenges in providing primary care to those marginalised through trafficking and overcoming the barriers they face in accessing care.

What is modern slavery and human trafficking (MSHT)?

Modern slavery encompasses human trafficking, servitude, and forced or compulsory labour. Forms of exploitation range from sexual exploitation, domestic servitude, forced marriage, and forced crime. It is a highly lucrative, global business that is often hidden in plain sight and embedded in day-to-day life with multiple providers of everyday services such as nail salons, car washes, hospitality, and agricultural labour all implicated. Forms of exploitation can overlap, and victims can be abused in multiple ways simultaneously or sequentially.

Who is at risk and why? Pre-and post-trafficking vulnerability

Zimmerman et al have conceptualised MSHT as a cycle during which harm accumulates before, during, and after exploitation has ended.⁴ In the context of MSHT, vulnerability refers to intrinsic contextual and environmental factors that increase vulnerability to trafficking. These vulnerabilities include, but are not limited to, a disruption of childhood attachments and loss of community through conflict, poverty, domestic violence, or pre-existing physical or mental disability.⁵

Thus, there may be cumulative harm accrued by injuries and ill-health caused by situations pre-trafficking as well as the harm caused as a direct result of the trafficking experience. Victims of MSHT often have poor or sporadic access to healthcare services and present in advanced states of illness or with untreated injuries. Situations of adversity and hardship after leaving the control of traffickers are common, and further impact survivors’ mental and physical health. These include complex and punitive immigration systems, barriers in accessing legal representation, separation from family, and destitution.⁶ MSHT has traditionally been examined through the lens of law enforcement, but an increasing body of research calls for viewing it through a clinical and public health lens. Victims and survivors carry a heavy disease burden, with implications for both public health and health services.⁷

Barriers to health care for survivors of ill-treatment

Language barriers and lack of interpreters may hamper disclosure and relationship-building. Time-limited appointments with varying clinicians in busy NHS practices inhibit individuals from volunteering traumatic histories. The shame experienced by survivors of abuse, particularly if this abuse transgressed sexual or gender identity boundaries, will further impede volitional disclosure of past traumas. Enforced, habitual secrecy adopted by traffickers instils a fear of authority and a lack of trust in statutory services that prevents the disclosure of abuse. Survivors have sometimes witnessed healthcare workers as complicit actors in trafficking. A culture of disbelief embedded within the UK asylum process may engender a feeling of hopelessness in survivors, with disclosure to a professional seen as not worth pursuing.

Victims of trafficking are often moved frequently, causing loss to follow-up and preventing the establishment of trusting relationships with professionals. In many cases, GPs may suspect a history of exploitation, but are reluctant to probe for fear of re-traumatisation as well as a lack of confidence in managing these complex disclosures.⁸

GP records as medical evidence

The Nationality and Borders Act 2022 heralded an increasingly stringent standard of proof required by those seeking asylum, increasing reliance on medical evidence to support their claim. Cuts to legal aid means many cannot access detailed medico-legal reports (legal documents that provide evidence of physical and psychological abuse) by trained clinicians. GP records in their entirety are now routinely being used as evidence in immigration tribunals. While these records can be useful where a therapeutic relationship has been established between clinician and patient, medical records are written for the purposes of recording interactions, interventions, and for clinician-to-clinician communication. They are not written with a view to being relied on for the documentation of ill-treatment in asylum and trafficking legal cases. If patients are not asked directly about a history of ill-treatment through trafficking, GP records will not contain this crucial documentation, the absence of which may later be used as evidence.⁹ Ardens have created an Open Access template, ‘Suspected Human Rights Abuses’, which aims to provide prompting to enquire about a history of ill-treatment as well as the opportunity to code this into medical records for SystmOne users.¹⁰ An EMIS template is currently being designed.

Trauma-informed survivor care

Trauma-informed methods of working are based on an understanding of the harmful effects of traumatic experiences together with fundamental principles of compassion and respect. This approach requires the clinician to build trusting relationships with patients who have experienced adversity, providing informed choices and promoting safety to prevent re-traumatisation.¹¹ The Trauma-Informed Code of Conduct is a practical, ‘best practice guide’ for professionals working with survivors of trafficking.¹²

Adopting a trauma-informed approach, fostering a stable therapeutic relationship, and showing respect for survivors’ lived experiences are crucial. This work requires a holistic, multi-agency outlook and consideration of the Modern Slavery Core Outcome Set that was co-created with survivors and outlines the essential pillars of survivor recovery and reintegration.¹³

Beyond this, a holistic approach in primary care is crucial in identifying and documenting incidences of such trauma. VITA Safeguarding Training (https://www.vita-training.com) for clinicians improves identification, support, and care for victims who present in healthcare settings. The National Referral Mechanism is a framework for identifying and referring potential victims of trafficking and ensuring they receive the appropriate support.¹⁴ This will enable clinicians to act on any safeguarding alerts, and to refer onwards to the relevant statutory services, or to specialist organisations such as the Salvation Army or the Helen Bamber Foundation.

Provenance

Commissioned; externally peer reviewed.

Competing interests

The author has declared no competing interests.