Quantifying the health needs of migrants in vulnerable circumstances registered with a nurse-led primary care service

Abstract

Background

As of the end of 2019, at least 79.5 million people worldwide have been forced to flee their homes. Those seeking asylum face adversity before, during and after arrival in the UK, resulting in complex health and social needs. The study setting was a nurse-led asylum seeker service in a dispersal city, commissioned to provide an initial health assessment, immunisations and support to register with a general practitioner.

Aims

The aim was to quantify the health needs of migrants in vulnerable circumstances registered with a nurse-led primary care service by clinical audit.

Methods

In June 2018, 80 electronic records were reviewed by seven auditors to analyse documentation of demographics, asylum status, service use, barriers to care, physical and mental health.

Results

Where data were available, 86% migrated due to persecution or trafficking, 59% had a chronic physical illness, 51% had a mental health condition and 49% experienced barriers to accessing a mainstream general practitioner.

Conclusions

Although a small sample, this survey demonstrated high physical and mental health needs that are often unmet in mainstream services. There was a high level of unknown need, for example of torture rates. These findings informed quality improvement in documentation and health assessments, and further research.

Introduction

The UK gave protection – in the form of grants of asylum, humanitarian protection, alternative forms of leave and resettlement – to 18,519 people in the year ending June 2019 (UK Home Office, 2019). Determining the total number of undocumented migrants in the UK is challenging given that the Office of National Statistics (ONS) does not routinely publish data on this (ONS, 2019). In this study we use the term ‘vulnerable migrants’ as a collective label for all asylum seekers, refugees and undocumented migrants, although there are differences between these groups in terms of the challenges they may face. The term ‘vulnerable’ refers to those adversely affected by circumstances leading to or resulting from migration, rather than an attribute of people themselves (The Faculty of Inclusion Health, 2018; Refugee Council, 2020) (Supplementary Material S1).

Vulnerable migrants frequently face adversity before, during and after arrival in the UK, resulting in complex health and social needs (Centre for Health Services Studies, 2014). Refugees and asylum seekers have poorer health than the general population, reporting high rates of physical and mental health problems (UK Border Agency, 2010). The evidence base demonstrates that there are some key barriers in accessing primary care for this cohort. Services are often ignorant of the rights of vulnerable migrants to access primary care: they may request documentation that migrants cannot provide, or refuse registration altogether (Nellums et al., 2018). If they are able to see a clinician, vulnerable migrants often find standard appointments too short and face language barriers to communicating their needs. They also report concerns regarding interpreter confidentiality (Kang et al., 2019). Other barriers include hostility, stigma and discrimination from staff lack of knowledge regarding the availability of services or how to use them; (O’Donnell et al., 2007), and financial concerns (Nellums et al., 2018).

Evidence regarding the best model of primary care for this cohort is lacking and there is no consistent model used across the UK. Models used include nurse-led services and charities providing care. Some evidence suggests that vulnerable migrants benefit from specialist services (Poduval et al., 2015) and are best served by clinicians who are able to advocate on their behalf (Nellums et al., 2018).

It is important to analyse and capture the needs of this group in order to improve the quality of specialist and non-specialist services, and to justify ongoing commissioning of specialist services.

The aim of this study was to quantitatively analyse the health needs and service use of vulnerable migrants registered with a nurse-led primary care service.

Methodology

The study setting was a nurse-led adult ‘Vulnerable Migrant Service’ in a UK city, which has home office accommodation for around 150 asylum seekers. The service was commissioned to provide 4 hours of a single Band 6 practice nurse to provide an initial health assessment, catch-up immunisations and infectious disease screening for patients who were registered with local practices. There was an additional 60 hours of Band 5 support worker time to help adult asylum seekers to register and access mainstream general practice as well as allied health services such as dental care and opticians.

A rapid clinical audit of the health needs of this group was needed to assess the current service provision. The service had changed significantly in the 15 years since inception and there was no up-to-date information for re-commissioning, although it was known that the numbers of patients had increased. Due to time limitations, data was captured pragmatically from the electronic patient record, rather than from a more extensive assessment by patient survey or other forms of primary data collection.

Eighty sets of medical records of a total of 86 registered patients (as of June 2018) held as electronic medical records were reviewed by seven auditors by using a standardised Excel spreadsheet. This spreadsheet collated details of demographics, asylum process, service use, barriers to care, physical and mental health as documented on the medical record. Some data were quantitative measures (for example, number of attendances) taken directly from the health record. Other data were recorded narratively in the health record but quantified for the purposes of the data collection, for example, mental health diagnosis. The auditors were clinicians working within the service with full access to and understanding of the medical record. The data collection tool was piloted with four cases performed as a group, to check consistency between auditors and refined by the investigators. Where auditors were uncertain with how to record information, they queried it with the lead investigator and author.

Results

Results are presented in Table 1.

Table 1.

Results of patient record audit, summarising data extracted from case notes.

Patient characteristics, adult asylum seeker patients in June 2018 (n = 86)
Mean age of patient (excluding paediatric)	33 years (range 18–70)
Sex
Male	52 (60%)
Female	34 (40%)
Country of origin
Iran	25 (30%)
Iraq	16 (19%)
Other – Sub Saharan Africa	22 (26%)
Other – Middle Eastern	10 (12%)
Other – Asia	8 (9%)
Other – Central/South American	3 (4%)
Missing dataa	2
Documented need for interpreter
Yes	63 (80%)
No	15 (20%)
Missing dataa	8
Asylum process
Asylum seeker	48 (69%)
Asylum granted/leave to remain	19 (27%)
Refused asylum/undocumented migrant	3 (4%)
Missing data	16
Mean length of time in the UK	4.7 years (interquartile  range 2.3 years)
Missing data for length of time in the UK	26 (30%)
Came to UK alone	39 (49%)
Came to UK with family	41 (51%)
Missing dataa	6
Reason for migration
Forced – modern slavery/sex trafficked	10 (19%)
Persecution	35 (67%)
War	4 (8%)
Marriage	1 (2%)
Educational	2 (4%)
Missing data	34
History of torture and/or imprisonment	12 (14%)
Missing data	74 (85%)
History of traumab	49 (92%)
No documented history of trauma	4 (8%)
Missing dataa	33
Service use
Mean number of clinician contacts in last   12 months (June 2017–2018)	13 (range 0–71)
Mean number of support worker contacts in last   12 months (June 2017–June 2018)	9 (range 1–34)
Referrals at initial health checkc
Dentist	59 (74%)
Optician	31 (39%)
Genitourinary medicine (GUM) clinic	5 (6%)
Tuberculosis (TB) screening	44 (55%)
Drug and alcohol services	0
Charity referral	37 (46%)
Health visitor	10 (12%)
School nurse	1 (1%)
Smoking cessation	5 (6%)
Missing dataa	6
Access to mainstream General Practitioner (GP)
Not accessing mainstream	12 (16%)
Accessing	26 (35%)
Accessing with difficulties	36 (49%)
Missing dataa	12
Physical healthc
Any long-term physical health problem	40 (59%)
No known physical health problem	27 (41%)
Missing dataa	19
Asthma	4 (6%)
Musculoskeletal (e.g. chronic back pain)	12 (18%)
Chronic dental problems	3 (4%)
Epilepsy	1 (1%)
Gastroenterological	4 (6%)
Gynaecological	4 (5%)
Ischaemic Heart Disease (IHD)	6 (9%)
Endocrine (e.g. hypothyroid, diabetes)	7 (10%)
Other (e.g. chronic migraine)	11 (16%)
Any infectious disease	17 (22%)
Latent TB	13 (16%)
Other (e.g. hepatitis)	4 (6%)
No infectious disease	62
Missing dataa	7
Women’s healthc
Pregnant at initial health check	2 (2.5%)
Female Genital Mutilation (FGM)	4 (5%)
No issues documented	74 (92.5%)
Missing dataa	6
Mental healthc
Any mental health diagnosis	31 (51%)
Symptoms of mental distress and no diagnosis	17(28%)
No mental health diagnosis	13 (21%)
Missing dataa	25
Depressionc	35 (57%)
Post-traumatic Stress Disorder (PTSD)c	10 (16%)
Medication
Regular medication	35 (60%)
None	23 (40%)
Missing dataa	28

^aMissing data was due to six case notes not being audited by the assigned auditor, or due to incomplete information on the clinical record, the seven auditors not completing the audit tool completely or due to the incomplete sharing of the electronic record i.e. the mainstream practice not using System 1.

^b‘Trauma’ was any history of distressing, stressful or frightening event documented on the medical record.

^cNot mutually exclusive.

Summary of key results

Overall, details of asylum status, reason for migration, length of journey, history of torture and journey were poorly documented. For example, there was missing data on 40% (34/86) of cases on the reason for migration and missing data on length of time in the UK in 30% (26/86). From the cases where information was known about their reason for migration, 86% (45/52) had migrated due to persecution or trafficking. The majority of patients (48/70 or 69%) who had data recorded on migration status were those seeking asylum rather than refused asylum seekers or had leave to remain. There was missing data on 85% (74/86) of case notes on torture. Where documented, over 90% had a history of trauma (49/53). Of those surveyed, 80% of patients (63/86) required an interpreter for consultations.

Where data were available 59% (40/67) had a long-term physical health problem, with the greatest category being musculoskeletal problems. Twenty-two per cent (17/79) were known to have an infectious disease, with the majority of these being latent TB. Fifty-one per cent (31/61) had a formal mental health diagnosis and a further 28% (17/61) had symptoms of mental distress without a formal diagnosis. Of those with data recorded on the need for an interpreter, 80% (63/78) required one. In 49% (36/74) of cases there was documentation about difficulties accessing mainstream primary healthcare, despite support worker input. Barriers included being unable to access an interpreter or not understanding how to navigate the health system.

Discussion

Comparison of data to national statistics

In the UK, most of those seeking asylum are men under the age of 40 years (Burnett and Peel, 2001b) and this is reflected in the current study group. The majority of registered patients in this service were from the Middle East (61% or 51/84) with a diverse spread across the other countries (Figure 1). In 2016 37% of UK asylum applicants were nationals of Asian countries, 29% from the Middle East, 23% from Africa and 7% from Europe (House of Commons Library, 2018). This is important as torture occurs in Iran and Iraq (Freedom from Torture, 2019). Torture rates were comparatively low in this study, with 12/86 patients (14%) known to have experienced torture. Although there was missing data on 74/86 patients (85%) which would suggest under-reporting or lack of documentation of this important data.

Figure 1.

Country of origin of patients registered as of June 2018, with nurse-led vulnerable migrant primary care service, demonstrating a diverse spread of countries of origin.

The mean length of time patients had been in the UK was 4.7 years, and we know that 68% of asylum seekers wait more than 6 months for a decision (Refugee Council, 2020). Many can move in and out of the asylum process for years.

Of the registered patients 51% (31/61) had a diagnosed mental health condition and a further 28% (17/61) had mental distress without a mental health diagnosis. This correlates well with national research which suggests that asylum seekers are five times more likely to have mental health needs than the general population and more than 61% will experience serious mental distress (Fazel et al., 2005). This includes higher levels of depression, anxiety and post-traumatic stress disorder (PTSD) (McColl et al., 2008).

The data shows that patients required 13 contacts with a clinician within the nurse-led service (in addition to their general practitioner (GP) appointments) in one year, although this was not tested for statistical significance. It is difficult to draw conclusions on service usage from this small sample, but nationally the average number of contacts for the general population is a lot less, at 4.91 per year (Kings Fund, 2014).

In terms of barriers faced by vulnerable migrant patients accessing mainstream GP services across the dispersal city, 49% (36/74) were known to have experienced difficulties with access (and had these difficulties documented on their medical record). A study by the Doctors of the World UK (2019) clinic (a specialist primary care service for marginalised groups) showed that one-fifth of their patients are denied registration by GP surgeries in England, despite being fully entitled to access NHS primary care. The common barriers experienced by marginalised patients when trying to access services were: administrative barriers (i.e. being refused access for not having proof of address or ID; 22%); lack of understanding of the healthcare system (16%) and language barriers (14%) (Hiam, 2018).

Limitations of study

This study aimed to gauge needs simply from secondary data, which provides only limited details. However, it offers a useful platform for further exploration. For example, data extracted were only as reliable as the information recorded on the electronic patient record and were also reliant upon the quality of the auditor extracting information. There were data missing and data absent from the system due to other practices not using System 1 (these patients are all dual-registered with the nurse-led service and with their local mainstream GP practice). This information includes details of regular medication and mental health diagnoses.

There are many other characteristics of our population that are likely to affect their ability to access care but were not captured by this audit such as literacy. Further data that would shed light on service usage which were not able to be captured from this exercise due to time limitations include appointment length.

Conclusion

Although data were missing on reasons for migration, it is still clear that there is a great diversity in experience. Sadly, the most universal experience is that of trauma with over 90% having this documented in their notes. It is therefore unsurprising that, like national data, our study shows that migrants have a high burden of complex physical and mental health needs, which need to be understood in the context of their background history. With 80% needing an interpreter, it also demonstrates that competence using interpreters is vital for clinicians so that shared understanding in the consultation is achieved, particularly in more complex areas such as mental illness. Thus, having clinicians with experience and training is most likely to meet these needs.

We know that over half of this group were forced to migrate because of persecution or trafficking. A history of torture is significant, impacting on mental and physical health (Burnett and Peel, 2001a). Studies have shown torture rates can be as high as 84% in asylum seekers (Kalt et al., 2013), so this is an unknown and unmet need of the patient group in this study. Anecdotally this was thought to be under-reporting as the nurse was not asking about this. Patients rarely volunteer this unless asked. In response, training was provided for the nurse on how to sensitively ask about torture, and to routinely document findings. This training was carried out via peer support with experienced clinicians in this area and attending relevant conferences.

The format of the initial health assessment template for this service was also revised to address data gaps identified in this study and to ensure it is in line with national standards (Public Health England, 2019). The higher number of contacts with a clinician than the general population demonstrates perhaps that holistic and thorough assessment often requires a number of appointments, in order to build rapport, gain a good understanding of the patient’s background and address all the patient’s medical and psychosocial needs. It is clear to see that in order for health needs to be met, a specialist service or an enhanced service within mainstream primary care is necessary. At the time of writing, the nurse hours had been increased from 4 hours weekly to 23 hours a week and the service was due for re-commissioning.

Most asylum seekers face post-migration adversities and stressors including social isolation, poverty and cultural alienation, and we know their health deteriorates in the asylum system because of this (McColl et al., 2008, UNHCR: The UN Refugee Agency, 2019). Poor access to primary care compounds post-migration stressors, and this study unfortunately shows that even with the extra input of support workers barriers to care are faced. Improved access to mainstream primary healthcare should be an important agenda item for the NHS, focusing on breaking down administrative barriers and improving access to interpreters. NHS England guidelines clarify that registration should never be refused due to immigration status, permanent address or lack of paperwork (NHS England, 2015). ‘Doctors of the World’ has a ‘Safe Surgeries’ programme to help with practice education and improve access for vulnerable groups (Doctors of the World, 2019). Furthermore, tackling these adversities requires nurses to work closely with all health and social care professionals, including third-sector agencies.

Further qualitative exploration research is needed to assess the barriers and enablers to accessing mainstream primary care services, in order to shed light on how services can be developed and improved. Furthermore, exploration of the barriers and enablers to asking about torture and severe trauma are needed in this group.

Key points for policy, practice, and/or research

• Migrants in vulnerable circumstances have diverse backgrounds and face much adversity. An holistic initial assessment is essential for understanding an individual’s social, medical and psychological needs and may require multiple visits.

• The needs of migrants are not always adequately recorded, even in specialist services. Torture was not routinely asked about. Asking sensitive questions can identify those survivors and need for further support, as can the initial health assessments with standardised questions.

• Migrants in vulnerable circumstances face considerable barriers to accessing mainstream primary care services due to service configuration, registration difficulties and language barriers. Further research on how to tackle these barriers is needed.

• This study adds to the body of evidence that specialist knowledge and expertise are required to meet complex health needs of vulnerable migrants and further research is needed on what is the most effective model of primary care for this group.

Biography

Emily Clark is a GP in Norwich with a specialist interest in health inequalities. She recently completed an NIHR (ARC E of E ) Applied Heath Research Fellowship evaluating primary care services for vulnerable adults.

Hannah Fox is a GP based in Norwich with an interest in migrant health and global health. She volunteers for “Doctors of the World” in their London clinic.

Tara Gillam is an academic public health trainee who works between Cambridge and Peterborough Clinical Commissioning Group (CCG) and Norwich Medical School. Her interests include heath service evaluation and re-orientating health systems to serve population health.

Clodagh Clarry is a registered nurse and clinical educator. She works for the Workforce Transformation team at the Integrated Care System (ICS). She is passionate about health inequalities, having worked as a specialist nurse for the vulnerable migrant service.

ORCID iD

Emily Clark https://orcid.org/0000-0002-8543-3010