Healthcare professionals’ views and experiences of … professionals’ views and experiences of dealing ... issues in the first two groups in this ... providers such as SERCO and

MedactManchesterreport October2017

1

Healthcareprofessionals’viewsand

experiencesofdealingwithrefugees

andasylumseekers:asurveyofNorth-

Westpractitioners

AreportbyMedactManchester

October2017


2

TableofContents

Acknowledgements 4

Declarationofinterests 4

Terminology 5

Glossaryofterms,acronymsandabbreviations 5

1.ExecutiveSummary 6

2.Introduction 8

3.Aims 12

4.Methods 12

5.Results 14

5.1Surveyresponses 14

5.2HCPs’understandingofthedefinitionsofimmigrationstatus 15

5.3HCPs’understandingofmigrantgroups’eligibilityforNHScare 16

PrimaryCare 16

FreeEmergencyCare 18

Freenon-emergencycare 19

5.4Identifying,documentingandtreatingtorture 21

5.5HCPs’trainingneeds 24

6.Discussion 25

7.Limitations 29

8.Recommendations 31


3

AppendixA:SurveyQuestions 33

AppendixB:ResponderFeedback 34


4

Healthcareprofessionals’viewsand

experiencesofdealingwithrefugees

andasylumseekers:asurveyofNorth-

Westpractitioners

ThisreporthasbeenauthoredbymembersofMedactManchester:DrKatieLawton,DrAlice

Lee,DrNadiaMahmood,DrMayaTickell-Painter,DrPiyushPushkar,DrAmySquire,DrLouise

Tomkow,DrRuthWiggans,DrEmilyWhitehouseandDrRebeccaWilson.

MedactManchesterisagroupofdoctorsbasedintheNorthWestofEnglandwithaninterestin

thesocialdeterminantsofhealth.TheyareaffiliatedtothenationalcharityMedact.

AcknowledgementsDrDavidMcCoy

DrRebeccaFarrington

DrJoanneMiller

EstelleWorthington

DeclarationofinterestsMedact Manchester has received no specific funding for the writing of this report. Medact

Manchesterhasnoconflictofinterestwithregardtoanyissuesarisinginthisreport.


5

TerminologyThis report seeks toexaminehealthprofessionals’understandingofhealthneeds in refugees,

asylumseekers,andfailedasylumseekers.Asylumseekersareindividualswhohaveappliedfor

protectionasrefugees.Refugeesaredefinedbythe1951RefugeeConventionaspersonsfleeing

conflict or persecution, and are afforded special protection under international law. Failed

asylumseekersareindividualswhohavehadtheirasylumclaimrejected,orareundergoingan

appealsprocess.Theterms‘migrant’and‘refugee’aresometimesusedinterchangeably,andin

practice making a distinction between the two groups can be very difficult. Distinguishing

between people who are refugees and those who are migrants is a highly political and

controversial issue.Whilstwe recognise that refugees and asylum seekers sharemanyhealth

issueswithothermigrantgroups,wefocusonhealthissuesinthefirsttwogroupsinthisreport.

Glossaryofterms,acronymsandabbreviationsAS–Asylumseeker

AHP–AlliedHealthProfessional

COMPASS-CommercialandOperationalManagersProcuringAsylumSupportServices

FAS–Failedasylumseeker

GP–GeneralPractitioner

HCP–Healthcareprofessional

NHS–NationalHealthService

PTSD–PostTraumaticStressDisorder


6

1.ExecutiveSummary

1.1 Numbersofrefugeesandasylumseekersareincreasingacrosstheworld

Globally, levels of forcedmigration are at their highest on record. In the UK specifically, the

numberofasylumapplicationsincreasedby30%in2016comparedtopreviousyears.

1.2 Refugeesandasylumseekershavespecifichealthcareneeds

Individuals seeking asylum experience a range of healthcare problems related to the

circumstancesintheirhomecountry,thenatureoftheirjourneyandthesituationinwhichthey

findthemselvesintheUK.

1.3 LocalNHSservicesreceivenoextrasupportorfinancialhelptoprovidecarefor

refugeesorasylumseekers

ThereisnonationalcoordinationofhealthcareprovisionforasylumseekersintheUK.Assuch,

existingNHSservicesareexpectedtoprovidecareforasylumseekersintheirlocalareawithno

extrasupport.

1.4Atundergraduateandpostgraduatelevels,medicaltrainingonthespecifichealthissues

facedbyasylumseekersandrefugeesintheUKispatchyandinconsistent.

Confusion amongst healthcare professionals regarding eligibility for NHS healthcare has been

reportedbutneverquantified.Concernshavebeenvoicedthatthisconfusioniscontributingto

thepoorerhealthoutcomesseeninasylumseekersandrefugees.

1.5 We conducted a survey of 198 NHS healthcare professionals working in Greater

ManchesterandLancashire

We sought to examine North-West of England NHS healthcare professionals’ current

understanding of refugee and asylum seeker health issues, identify healthcare professionals’

trainingneedsonthesetopicsandexploreavenuesforfutureresearchonrefugeeandasylum

healthintheUK


7

Our sample included doctors, nurses, psychologists and non-clinical staff, working across a

broadrangeofspecialties.

1.6Our resultsdemonstrate significantgaps in theknowledgeandconfidenceofhealthcare

professionals when dealing with asylum seekers and refugees, across all specialties and

grades.

• Only 21% of responders felt confident defining the terms “asylum seeker”, “failed

asylum seeker”, “economic migrant” and “refugee”, with only a quarter correctly

identifyingwhichgroupswereeligibleforfreeprimarycare.

• 32%failedtoidentifyfailedasylumseekersaseligibleforfreeemergencycare.

• Although55% said they had treated a patient sufferingwith psychological or physical

effectsoftorture,only12%feltconfidentaskingapatientaboutprevioustorture.23%

feltthattheywerenotcompetenttoenquireaboutexperiencesoftorture.

• 88% felt that they would benefit from further training on issues surrounding asylum

seeker and refugeehealth,with79% saying that theywouldprefer training ledby an

expertinthefield.53%alsosaidtheywouldlikeonlinetraining.

1.7 ThereisanurgentneedfortrainingforfrontlineNHSstaffonthehealthneedsofrefugees

andasylumseekersandtheireligibilityforNHScare.

Thistrainingshouldcoverfivekeyareas:

a. Understanding thecomplexhealthneedsof refugeesandasylumseekers,and

howtheymaydiffertotheordinarilyresidentpopulation.

b. Understanding terminology used to describe refugees and asylum seekers,

including how this may change over time. This would require a basic

understandingoftheasylumprocess.

c. Exploring the moral, ethical, and legal responsibility healthcare professionals

haveinassessingindividuals’rightstohealthcareintheUK.Thismustbedone

inkeepingwithprofessionalcodesofpracticesuchas‘GoodMedicalPractice’.

d. Identifying and appropriately documenting evidence of torture. This should

include information on signposting to groups experienced in dealing with

refugeesandasylumseekerhealth.


8

e. Wesuggest this trainingbeprovidedby individualswithexperience indealing

withthecomplexitiesofrefugeesandasylumseekerhealth.Thisshouldinclude

allstakeholders,andcouldincludeNHSprofessionals,thirdsectororganisations,

andmembersoftherefugeeandasylumseekercommunity.

1.8 Refugeeandasylumhealthshouldbeintroducedasacoretopicinmedicaleducation

fromundergraduateleveltoseniorcontinuingprofessionaldevelopmentprograms.

1.9 ThereisaneedforfurtherresearchonHCPsandrefugeeandasylumhealthintheUK.

Avenuesforfurtherresearchinclude:

a. expandingtolookatHCPsinotherregionsoftheUK;

b. greater inclusionofHCPsotherthandoctorse.g.nursing,midwifery,dentistryand

otherAHPs;

a. exploringthe impactof thenew legislationonHCPsunderstandingof refugeeand

asylumhealth.

1.10 Refugees and asylum seekers must continue to receive healthcare in line with their

humanrightsandthecodesofpracticethatgoverntheprovisionofhealthcareintheUK.

2.Introduction2.1AsylumissuesworldwideandintheUK

Complexhumanitariancrisesareincreasinginfrequency.Levelsofforcedmigrationareattheir

highestonrecord;onein113peoplegloballywereforciblydisplacedfromtheirhomesdueto

conflictorpersecutionin20161.IntheUKasylumapplicationsareincreasing,withapplications

madefor44,323peopleintheyearendingJune2106,up34%fromthepreviousyear.In2016,

thelargestnumberofapplicationsforasylumcamefromIran(4,910),followedbyIraq(3,199),

1http://www.unhcr.org/uk/news/latest/2016/6/5763b65a4/global-forced-displacement-hits-record-high.html


9

Pakistan (2,992), Eritrea (2,790), Afghanistan (2,690) and Syria (2,563).2 In addition to these

numbers, theUKgovernmenthaspledged to resettleanadditional20,000Syrian refugeesby

2020, a commitment that would require the resettlement of 10 times asmany refugees per

monththaniscurrentlyhappening,3aswellasayetundeterminednumberofunaccompanied

asylumseekingchildrenfromEuropeundertheDubsamendmenttothe2016ImmigrationAct.4

2.2AsylumissuesinGreaterManchester

Asylum seekers are unevenly distributed across the UK. Greater Manchester has one of the

highestnumbersofasylumseekersintheUK,anumberthathasincreasedsignificantlyoverthe

last threeyears.5Approximately5000asylumseekerswere living inGreaterManchesterasof

June 2015, with uneven dispersal throughout the region.5 Under the Commercial and

Operational Managers Procuring Asylum Support Services (COMPASS) programme, the UK

government has awarded private providers such as SERCO and G4S contracts for providing

asylum seekers with accommodation. The desire to provide this accommodation in a cost-

effectivemannerhasledtomanyasylumseekersbeinghousedinareaswhereaccommodation

ischeap.However,notonlyisthestandardofhousingprovidedoftenunacceptablypoor,6but

alsolarge-scaleresettlementofasylumseekersinareasofsignificantsocioeconomicdeprivation

has exacerbated existing social tensions in some of the most deprived areas of Greater

Manchester.9,7

2https://www.gov.uk/government/publications/immigration-statistics-april-to-june-2016/asylum3ManchesterCityCouncilCommunitiesScrutinyCommittee-28thOctober2015.SupportAvailabletoAsylumSeekersandRefugeesinManchester.StrategicDirector,AdultSocialServices.4https://www.gov.uk/government/news/unaccompanied-asylum-seeking-children-to-be-resettled-from-europe5http://www.manchestereveningnews.co.uk/news/greater-manchester-news/rochdale-mp-simon-danczuk-attacks-99578366http://www.parliament.uk/business/committees/committees-a-z/commons-select/public-accounts-committee/news/asylum-accommodation-substantive/7http://www.manchestereveningnews.co.uk/news/greater-manchester-news/asylum-seekers-greater-manchester-cost-10874865


10

2.3Asylumandhealth

Individuals seeking asylum experience a range of healthcare problems that may differ from

those of local populations.8 Prior to arrival in the UK, asylum seekers may have endured

imprisonment,tortureorsexualassault,andmayexperienceongoingphysicalorpsychological

effectsofthese.9Poornutritionandsubstandardsanitationcanplaceasylumseekersathigher

risk of communicable diseases. Many asylum seekers come from areas where existing

healthcareinfrastructureispoor,meaningchronicdiseasecangoundetectedandmanagement

isneglected.10Inadditionthereisevidencethatthehealthandwellbeingofasylumseekersand

refugeesdeteriorateonarrival to theUK,owing to separation, stigmatisation, social isolation,

lossofstatusandlackofaccesstoservices.11Aprolongedasylumapplication,withitslegaland

financialcomplexities,hasbeenshowntocausephysicalcomplaints,lowself-reportedqualityof

lifeandfunctionaldisabilities.12Furthermore,mentalhealthdisorderssuchasmooddisorders,

anxiety,somatoformdisordersandPTSDaremorecommoninasylumseekers.13

However, despite this population having specific health needs, medical professionals are not

currently being provided with training on these issues. In ‘Tomorrow’s Doctors’, the GMC

stipulatesthatUKmedicalschoolgraduatesshouldbeabletodiscussthewiderdeterminantsof

healthandhealthinequalities.14Despitethis,notallmedicalschoolsprovidespecifictrainingto

medical students on the health of asylum seekers and, where it is provided, training for

undergraduates is fragmented. Many specialties including general practice, paediatrics and

psychiatry require their trainees to appreciate some of the global health issues that they

encounter during their practice. However, there is no uniform programme of postgraduate

8Burnett,A.,&Peel,M.(2001).Healthneedsofasylumseekersandrefugees.BritishMedicalJournal,322(7285),544.9Carlsson,J.M.,Mortensen,E.L.,&Kastrup,M.(2005).Afollow-upstudyofmentalhealthandhealth-relatedqualityoflifeintorturedrefugeesinmultidisciplinarytreatment.TheJournalofnervousandmentaldisease,193(10),651-657.10http://www.fph.org.uk/uploads/bs_aslym_seeker_health.pdf11Woodhead,D.(2000).Thehealthandwell-beingofasylumseekersandrefugees.King'sFund.12Laban,C.J.,Komproe,I.H.,Gernaat,H.B.,&deJong,J.T.(2008).Theimpactofalongasylumprocedureonqualityoflife,disabilityandphysicalhealthinIraqiasylumseekersintheNetherlands.Socialpsychiatryandpsychiatricepidemiology,43(7),507-515.13http://www.rcpsych.ac.uk/pdf/Appendix%201_EPA%20statement%20on%20Refugees%2020151023_sent.pdf14http://www.gmc-uk.org/Tomorrow_s_Doctors_1214.pdf_48905759.pdf


11

education for traineedoctorsonmanaging the specific health issues facedbyasylum seekers

withintheUK.

2.4AsylumandaccesstoNHShealthcare

Inadditiontothelackoftrainingonthespecifichealthneedsoftheasylumseekerpopulation,

therehasbeenconsiderableconfusionamonghealthcareprofessionalsaboutwhichgroupsare

eligible to access NHS care.15 Lack of training, confusion about definitions, lack of clarity on

HomeOfficedecisionsandmultiple changes in legislationhavemade it extremelydifficult for

healthcareprofessionalstokeepuptodateoneligibilityforhealthcare.Thereisevidencethat

asylumseekersandrefugeesdeferseekinghealthcarebecauseofconcernsabout immigration

status,possiblechargesandpoortreatment,allleadingtopoorerhealthoutcomesforpatients

andraisingconcernamongdoctorsabouttheirroleinassessingimmigrationstatus.16Doctorsof

theWorldrecentlyfoundthat13%ofrefugeesandasylumseekerswhoattemptedtoregister

with a local general practitioner (GP) were incorrectly refused because of their immigration

status.17Thissituationislikelytoworseninlightofrecentchangestochargingpracticesinthe

UK.FromOctober2017,chargingforhealthcarehasbeenextendedtocommunitysettingsand

costsaretobepaidupfrontbeforenon-emergencytreatmentisgiven.18Thereisconcernthat

introducing such charges will not lead to cost savings in the long term, and may negatively

impact health outcomes in some of the most vulnerable, such as pregnant women seeking

asylum.19

2.5Previousliterature

Althoughonerecentstudyhasdocumentedtheperspectivesofasmallnumberofprimarycare

providers on the barriers to providing healthcare to migrant patients, including asylum

15http://www.rcgp.org.uk/policy/rcgp-policy-areas/asylum-seekers-and-vulnerable-migrants.aspx16AsylumMattersreport17http://www.independent.co.uk/news/uk/health-concerns-as-english-gp-surgeries-refuse-to-register-asylum-seekers-and-refugees-a7008081.html18https://www.gov.uk/government/publications/guidance-on-overseas-visitors-hospital-charging-regulations/summary-of-changes-made-to-the-way-the-nhs-charges-overseas-visitors-for-nhs-hospital-care19FarringtonR,SalehS,CampbellSetal.ImpactofproposaltoextendchargingforNHSinEngland.Lancet2016;388:459


12

seekers,20 to our knowledge, there have been no studies examining the perspectives of

healthcareprofessionals inotherspecialtiesonthe issuessurroundingprovidinghealthcare to

refugees and asylum seekers. Furthermore,we are unaware of any evidence that specifically

examines trainees’ experiences indealingwith thehealth issuesexperiencedby refugeesand

asylum seekers. In view of this gap in our knowledge, coupled with an appreciation that as

global displacement continues to rise, and the increasing pressures on UK healthcare

professionalstoactasgatekeeperstohealthcareforasylumseekersandrefugees,wesetoutto

examinehealthcareprofessionals’ currentunderstandingof refugeeandasylumseekerhealth

issues,identifyanytrainingneedsandexploreavenuesforfutureresearch.

3.AimsThissurveyaimedto:

1. examine NHS healthcare professionals’ current understanding of refugee and asylum

seekerhealthissues

2. identifyhealthcareprofessionals’trainingneedsonrefugeesandasylumseekerhealth

andexplorehowhealthcareprofessionalswouldlikethesetrainingneedstobemet;

3. identifyavenuesforfutureresearchonrefugeeandasylumhealthintheUK.

4.Methods4.1Pilotstudy

Tohelpusdevelopour survey,we conductedapilot surveyofHCPs. In this, individualswere

asked about their experiences of treating refugees and asylum seekers. Key themes that

emerged fromthis survey included: theeligibilityofdifferentgroups forNHScare, identifying

andtreatingvictimsoftorture,andtheneedfortrainingtoaddressknowledgegaps.

20LindenmeyerA,RedwoodS,GriffithLetal.Experiencesofprimarycareprofessionalsprovidinghealthcaretorecentlyarrivedmigrants:aqualitativestudy.BMJOpen2016;6:e012561


13

4.2Surveydevelopment

Followingthepilotsurvey,tenmultiplechoicesurveyquestionsweredevelopedaroundthese

key themes (Appendix A). The online software SurveyMonkeywas used to create the survey.

Thequestions focussedonHCPs’understandingof thedefinitionsof,andhealthcarerightsof,

asylum seekers and refugees, as well as exploring individuals’ professional experiences of

workingwiththevictimsoftorture.Thequestionnairewasdesignedtobeconciseandquickto

completeinordertomaximiseresponserate.Thequestionswerepeerreviewedpriortosurvey

distributionbyaGPwithspecialistexpertiseinmigranthealthandmedicaleducation.

4.3Samplingmethod

In order to reach as many participants as possible, we employed an opportunistic sampling

method. A hyperlink to the survey was distributed to over 1000 HCPs in the NorthWest of

England throughpre-existinghospitalemaildistribution lists, traineeemail lists, locumagency

emaillists,socialmediaandpersonalcontactswiththeauthors.

4.4Datacollection

Results were collected over 30 days in September 2016. SurveyMonkey software provided

overall responses to eachof the10questions. Responseswere further evaluatedby gradeof

trainingandspecialty.Responderswerebrokendownintothefollowingspecialtygroups:GPs;

hospitalmedicine;paediatrics;mentalhealthprofessionals,andotherhospital specialties.The

followinggradedistinctionsweremade:foundationyeartrainee;specialisttrainee;consultant;

qualified GPs and nurses and other health professionals (for brevity hereafter referred to as

alliedhealthcareprofessionalsorAHPs).Whileresponseswereanonymous,participantswere

askedtodisclosetheirspecialtyandgradetoallowstratificationoftheresultsformoretargeted

educationalinterventions.


14

5.Results

5.1Surveyresponses

Keyfindings

● 198peoplerespondedtothesurvey

● Theapproximateresponseratewas20%

● Participantsincludeddoctors,nursesandAHPsfromavarietyofspecialitiesandgrades

ofexperience.

198peoplerespondedtothesurvey(Tables1and2).Respondersweremostlydoctors,witha

smallernumberofnursesandAHPs.Gradeof trainingamongdoctorsvaried from foundation

doctors to consultants and among nurses from Band 5 to Band 8 (Table 1). Allied health

professionals who answered the survey included two psychologists, a safeguarding children

practitionerandanNHSmanager.Specialtybackgroundswhereencounterswithasylumseekers

maybemorecommon, suchas generalpractice,mentalhealth,paediatricsand sexualhealth

andgenitourinarymedicine,werewellrepresentedamongresponders.Inaddition,therewere

responders from a wide range of other specialty backgrounds including oncology, renal

medicine,strokemedicine,geriatrics,occupationalmedicine,orthopaedics,infectiousdiseases,

surgery, anaesthetics, radiology and emergency medicine. Only one responder declared a

specialist interest in working with refugees and asylum seekers. Three responders failed to

specifyagradeoraspecialty.

The approximate response rate to the survey was 20% (198 HCPs from approximately 1000

contacted).

Table1:Respondentsgroupedbygrade

Gradeoftraining Numberofrespondents.n(%)

GP 46(20)Consultant 39(20)Specialtytrainee 79(40)Foundation 9(5)Nurses/AHP 22(11)


15

Unknown 3(2)Total 198

Table2:Respondentsgroupedbyspecialty

Specialty NumberofrespondentsGP 48(24)Hospitalmedicine 50(25)Mentalhealth 40(20)Paediatrics 16(8)Otherhospital 41(21)Unknown 3(2)Total 198

5.2HCPs’understandingofthedefinitionsofimmigrationstatus

Keyfindings:

● Only21% (n=41)of respondents felt confident indefining the terms “asylum seeker”,

“failedasylumseeker”and“refugee”.

● GPswerethemostconfidentintheirknowledgeofthesedefinitions,whilstfoundation

doctorsweretheleastconfident.

● Havingpreviously treatedvictimsof torturedidnot increase individuals’confidence in

definingdifferentgroups.

Of 198 respondents, 21% (n=41) felt confident in defining the terms “asylum seeker, “failed

asylumseeker”,“economicmigrant”and“refugee”.63%(n=125)hadsomeideaofterminology

butwerenotconfident,and16%(n=32)werenotsureofthedifferences(figure1).


16

Figure1:Responsestothequestion"Howconfidentareyouaboutthedifferentdefinitionsof"refugee","asylumseeker"and"failedasylumseeker"

GPsweremost likely to describe themselves as confident in defining the difference between

refugees,asylumseekers,andfailedasylumseekers,with37%(n=17)ofGPssayingtheywere

confident.Foundationtraineesweretheleastconfidentwithdefinitions,with22%(n=2)being

unsureofthedifference.

HCPswhohadpreviouslybeeninvolvedintreatingvictimsoftorturewerenomoreconfidentin

theirabilitytodefinedifferentmigrantgroups.Approximatelyonethird(n=27)ofrespondents

whohadpreviouslytreatedtorturevictimsdescribedthemselvesasconfidentwhereasanother

third(n=24)wereunsuresureofthedifference.

5.3HCPs’understandingofmigrantgroups’eligibilityforNHScare

PrimaryCare

Keyfindings:

0 20 40 60 80 100 120 140

Confident- Iwouldbeabletoexplainthedifference

Someidea- Imayneedtorevisethedefinitionsbuthavesomeunderstanding

Notsureofthedifference

Definining"asylumseekers","refugees"and"failedasylumseekers"


17

● Atthetimeofsurveydistribution,NHSregulationsstatedthatrefugees,asylumseekers,

andfailedasylumseekerswerealleligibleforfreeprimarycare.

● Only26%ofrespondents(n=51)correctlyidentifiedrefugees,asylumseekers,andfailed

asylumseekersaseligibleforfreeprimarycare.

● 62% (n=123) of respondents believed that failed asylum seekerswere not eligible for

freeprimarycare.

● 28%(n=56)ofrespondentswereunsureabouteligibilityforfreeprimarycare

Only26%(n=51)ofrespondentscorrectlyidentifiedallthreegroupsaseligibleforfreeprimary

care(Tables3and4).GPsweremostlikelytoanswercorrectly,althoughonly43%ofGPs(n=20)

identifiedrefugees,asylumseekers,andfailedasylumseekersaseligibleforfreeprimarycare.

Only 13% (n=5) of consultants and 19% of foundation trainees (n=15) answered correctly.

Among specialty groups, paediatricians were the least likely to identify all three groups as

eligible for free primary care (13%, n=2, table 4).Only 18% (n=7) ofmental health specialists

identifiedallthreegroupsaseligible.

Table3:Numberofparticipantswhoansweredcorrectlybytraininggrade.

Traininggrade Numberidentifyingallthreegroupsaseligibleforprimarycarebygrade,n(%)

GP 20(43)Consultants 5(13)Specialtytrainee 15(19)Foundationtrainee 2(22)Nurses/AHPs 9(41)Total 51(26)


18

Table4:Numberofparticipantswhoansweredcorrectlybyspecialty.

Specialty Numberofparticipantsidentifyingallthreegroupsaseligibleforprimarycarebyspecialty,n(%)

GP 20(42)Hospitalmedicine 10(20)Mentalhealth 7(18)Otherhospital 12(29)Paediatrics 2(13)Total 51(26)

62% (n=123) respondents thought that asylum seekers whose claims for asylum had been

refusedbytheHomeOfficewerenoteligibleforfreeprimarycare,whilstrefugeesandasylum

seekerswithongoingclaimswereeligible.Onlyonehealthcareprofessional surveyed thought

thatnoneof thegroupswasentitledto freeGPservices.Almosta thirdof respondents (28%,

n=56)wereunsureabouttheeligibilityofthesegroupsforfreeprimarycare.

FreeEmergencyCare

Keyfindings:

● Atthetimeofsurveydistribution,NHSregulationsstatedthatrefugees,asylumseekers,

andfailedasylumseekerswerealleligibleforfreeemergencycare.

● 68%(n=128)ofrespondentsansweredcorrectly, identifyingallthreegroupsaseligible

forfreeemergencyhealthcare.

● Onethirdofrespondents(n=60)answeredincorrectlyanddidnotrecognisethatfailed

asylumseekersareentitledtofreeemergencycare.

Over two thirds (68%, n=128) of respondents identified all three groups of refugees, asylum

seekersandfailedasylumseekersaseligibleforemergencyhealthcarefreeofcharge(Tables5

and6).Onethirdofrespondents (n=60,32%)didnot identify failedasylumseekersaseligible

forfreeemergencyNHScare.


19

Table5:Numberofparticipantsstatingrefugees,asylumseekersandfailedasylumseekersentitledtofreeemergencycare,bygrade.

Numberidentifyingallthreegroupsaseligibleforemergencycarebygrade,n(%)

GP 36(78)Consultant 23(59)Specialtytrainee 49(62)Foundationtrainee 5(56)Nurses/AHPs 15(68)Total 128(68)

Table6:Numberofparticipantsstatingrefugees,asylumseekersandfailedasylumseekersentitledtofreeemergencycare,byspecialty.

Specialty Numberofparticipantsidentifyingallthreegroupsaseligibleforemergencycarebyspecialty,n(%)

Generalpractice 37(77)Hospitalmedicine 34(68)Mentalhealth 23(58)Otherhospital 26(63)Paediatrics 8(50)Total 128(68)

Grade of training did not appear to impact ability to identify those groups eligible for free

emergencycare;knowledgeappearedtobesimilarbetweenfoundationtrainees(56%,n=5)and

consultants (59%, n=23). WhilstmostGPs and hospital doctors surveyed knew that all three

groups were eligible for free emergency care, only 50% (n=8) of paediatricians answered

correctly(Table6).

Freenon-emergencycare

Keyfindings

● At the time of survey distribution, NHS regulations stated that refugees and asylum

seekers were eligible for non-emergency hospital care. In Scotland andWales, failed

asylumseekerswereentitled to freenon-emergency secondary care. InEngland,only

failed asylum seekers who received section 4(2) support from the Home Office or


20

section21support froma localauthoritywereentitled to freesecondaryhealthcare.

Failed asylum seekers were entitled to complete any course of treatment already

underwaybeforetheirapplicationwasrefused,freeofcharge.

● 32% of respondents (n=59) were unsure which migrant groups were entitled to free

non-emergencyNHScare.

● 4%(n=7)believednoneofthegroupswereentitledtofreenon-emergencyNHScare.

32% of respondents (n=60) said they were unsure which groups were entitled to free non-

emergency NHS care (Figure 2). Just over half of respondents answered correctly, with 56%

(n=107) identifying refugeesandasylumseekersaseligible for freenon-emergencyNHScare.

Seven(4%)saidnoneofthegroupswereentitledforfreenon-emergencycare(Figure2).

Figure2:Overallresponsestothequestion'whichgroupsareentitledtofreenon-emergencyNHScare'?

41%ofconsultants(n=16)and39%(n=31)ofspecialtydoctorswereunsurewhichgroupswere

eligible toaccessnon-emergencycare (Table7).Ratesofuncertaintyabouteligibility fornon-

emergency NHS care were high among HCPs, ranging from 25% (n=10) for mental health

professionalsto44%(n=7)forpaediatricians(Table8).

0 20 40 60 80 100 120 140

Asylumseekers

Refugees

Failedasylumseekers

Noneoftheabove

Notsure

Whichgroupsareentitledtofreenon-emergencyNHScare?


21

Table7:Numberofparticipantsunsurewhichgroupswereeligibleforfreenon-emergencycarebygrade

Traininggrade Numberofparticipantsunsurewhichgroupswereeligibleforfreenon-emergencycarebygrade,n(%)

GP 8(17)Consultants 16(41)Specialtytrainee 31(39)Foundationtrainee 2(15)Nurses/AHPs 3(14)Total 60(32)

Table8:Numberofparticipantsunsurewhichgroupswereeligibleforfreenon-emergencyNHScarebyspecialty

Specialty Numberofparticipantsunsurewhichgroupswereeligibleforfreenon-emergencycarebyspecialty,n(%)

Generalpractice 8(17)Hospitalmedicine 21(42)Mentalhealth 10(25)Other 14(37)Paediatrics 7(44)Total 60(32)

5.4Identifying,documentingandtreatingtorture

Keyfindings

● Overhalfthesurveyrespondents(55%,n=105)saidtheyhadtreatedapatientwith

psychologicalorphysicaleffectsoftorture.

● Only12%(n=23)ofparticipantswereconfidentinquestioningapatientabouta

previousepisodeoftorture.

● Nearlyaquarterofparticipantssaidtheymayavoidquestioningaboutaprevious

episodeoftortureduetolackofconfidence.

● Overathirdofrespondentswerenotconfidentindocumentingoractioningtheclinical

signsofasuspectedepisodeoftorture.


22

Over half of respondents (n=105, 55%) said they had treated a patientwith psychological or

physicaleffectsoftorture(Figure3).

Figure 3: Responses to the question 'have you ever treated a patient with physical or psychological effects oftorture?'

More experienced doctors were most likely to have treated victims of torture, with 64% of

consultants and 65% of GPs saying that they had treated these patients (Table 9). However,

treating individualswithpsychologicalorphysicaleffectsof torturewasnot rareamongother

HCPs,with47%ofspecialtydoctors,55%ofnurses/AHPs,and11%offoundationtraineessaying

theyhadtreatedatorturevictimatsometime(Table9).

0 20 40 60 80 100 120

Yes

No

Notsure

Haveyouevertreatedapatientwithphysicalorpsychologicaleffectsoftorture?


23

Table9:Participantswhohadpreviouslytreatedavictimoftorturebytraininggrade

Traininggrade Numberofparticipantswhohadpreviouslytreatedavictimoftorture,n(%)

GP 30(65)Consultant 25(64)Specialtytrainee 37(47)Foundation 1(11)Nurse/AHP 12(55)Total 105(55)

Onlyaminorityofrespondentsfeltconfidentquestioningapatientaboutapreviousepisodeof

torture.Only23(12%)saidtheywereconfidentquestioningapatientwhohadpreviouslybeen

tortured,with56%able,but lessconfident thannormal (Figure4).Of the23respondents felt

confident questioning patients about previous torture, 91% (21 of 23) had previously been

involvedincaringforpatientsknowntobetorturevictims.

Figure4:Responsestothequestion‘howconfidentwouldyoube inquestioningapatientonpreviouseffectsoftorture?’

Over a fifthof all respondents (22%,n=43) said that theydidnot feel competentquestioning

patients about previous torture, and so may avoid this. Foundation trainees (78%, n=7) and

specialtytrainees(25%,n=20)weremostlikelytoavoidaskingabouttorture.

0 10 20 30 40 50 60 70 80

Confident

Lessconfidentthannormal,butstillable

Iwouldnotknowhowtodocumentandactionfindings

Notsure

Howconfidentwouldyoufeeldocumentingandactioningclinical

evidenceoftorture?


24

Confidenceratesindocumentingandactioningclinicalevidenceoftorturewerelow.Only19%

(n=37)of respondents said theywere confidentdoing this,with33% (n=66) saying theywere

lessconfidentbutstillable,and36%(n=72)sayingtheywouldnotknowhowtodocumentand

actionevidenceoftorture(Figure5).

Figure5:Responsestothequestion‘howconfidentwouldyoufeeldocumentingandauctioningclinicalevidenceoftorture?’

Similarly, levels of confidence in documenting and acting on clinical evidenceof torturewere

low across all training grades (range of ‘confident’ responses from 0-23%). In general, more

experienced doctorsweremost comfortable, however only 22% (n=10) of GPs, 23% (n=5) of

AHPsand21%(n=8)ofconsultantsdescribedthemselvesasconfident.

5.5HCPs’trainingneeds

Keyfindings

● 88%(n=164)ofparticipantsfelttheywouldbenefitfromfurthertrainingonissues

surroundingasylumseekerandrefugeehealth

● 79%(n=146)saidtheywouldprefertrainingledbyanexpertinthefield.

0 10 20 30 40 50 60 70 80

Confident

Lessconfidentthannormal,butstillable

Iwouldnotknowhowtodocumentandactionfindings

Notsure

Howconfidentwouldyoufeeldocumentingandactioningclinical

evidenceoftorture?


25

Themajorityofrespondents(n=164,88%)saidtheyfelttheywouldbenefitfromfurthertraining

onissuessurroundingasylumseekerandrefugeehealth(Figure6).

Figure6:Responses to thequestion ‘do you think youwouldbenefit from further trainingabout the rights andissuesofasylumseekerandrefugeehealth?’

Of theeightpeoplewhoresponded in the ‘other’ category, fourhadalready receivedspecific

traininginthisareaandthreesaidtheyrarelyorneversawrefugeesandasylumseekerssodid

not thinkmore trainingwasbeneficial.Mostpeople said theywouldprefer training ledbyan

expertinthefield(n=146,79%).

6.DiscussionThe aim of this survey was to explore healthcare professionals’ current understanding of

refugee and asylum seeker health issues, identify their training needs on the topic and

determinehowhealthcareprofessionalswouldlikethesetrainingneedstobemet.Bysurveying

198HCPsacrossarangeofspecialitiesandgrades,thisresearchhasidentifiedfourkeyfindings.

0 50 100 150 200

YesNo

NotsureIwouldnothavetime

Other

Doyouthinkyouwouldbenefitfromfurthertrainingabouttherightsandissuesofasylumseekerandrefugee

health?


26

6.1HCPshavelimitedunderstandingofasylumandrefugeeterminology

HCPshaveapoorunderstandingofthedefinitionsofthesegroups.Only21%ofrespondentsfelt

confidentdifferentiatingbetweenthegroups‘asylumseeker’,‘failedasylumseeker’,‘economic

migrant’, and ‘refugee’, with 61% having only some idea of terminology. Though GPs rated

themselvesmostabletodifferentiatedifferentgroups,only37%ofthisgroupfelt ‘confident’.

ThisresponsemayreflectHCPs’approachtopatientcare,which,inaccordancewiththeGMC’s

‘Good Medical Practice’ should: ‘treat patients and colleagues fairly and without

discrimination’.21

However, under recent government changes in NHS charging regulations, some groups of

asylumseekersandmigrantwillnowbesubjecttoup-frontchargingforarangeofcommunity

andhospitalhealthservicesinEngland.22Moreover,thelegalresponsibilityforidentifyingthese

patientsnowlieswiththehealthcareprovider;inshort,patientswillneedtoprovideHCPswith

documentationtoprovetheyareentitledforNHScarebeforetheycanbetreated.Asidefrom

thedeeplyproblematicmoralimplicationsofapolicythatextends,andshifts,theroleofHCPs

to that of immigration officers, this research identifies practical difficulties with these new

regulations.Putsimply,theHCPsinoursurveywereunclearaboutbasicterminologythatiskey

to identifying individuals subject to charging.Considerable resource is likely tobe required to

addressthistrainingneed,toensureadherencetotherulesof‘GoodMedicalPractice’outlined

above,andpreventprofilingofpatients.

6.2HCPsareunclearaboutwhoiseligibleforNHScare

Onlyaminorityofrespondentswereawareof theNHSregulations inplaceat thetimeof the

survey regarding access to NHS care Only 26% of respondents identified all three groups as

beingeligible for freeprimarycareandtherewerehigh levelsofuncertaintyregardingwho is

eligible for free non-emergency secondary health care, even amongst senior clinicians.

Worryingly, 32% of respondents were not aware that asylum seekers are eligible for free

emergencyNHScareirrespectiveoftheirimmigrationstatus.Ofsimilarconcern,only42%ofGP

respondents were aware that all forced migrants are eligible for free primary care. By21GMC:GoodMedicalPractice22https://www.gov.uk/guidance/nhs-entitlements-migrant-health-guide


27

highlightingasignificantknowledgegapamongstcliniciansintheirownfieldofexpertise,these

resultssupportandexpandonthefindingsoftheaforementionedDoctorsoftheWorldstudy,

suggestingthatlackofunderstandingofNHSeligibilityregulationsisafurtherbarriertotimely

access to healthcare among these vulnerable groups. Further academic enquiry into the

treatment of asylum seekers across a range of care settings, especially emergency care, is

needed,asbarriers tohealthcareamongthesegroupsmay leadtopreventablemorbidityand

mortality.ThisraisesimportantmoralandethicalquestionsforHCPsdelayingtreatmentonthe

basisofimmigrationstatus.Furtherinvestigationisrequiredexaminingwhetherlong-termcost

effectsofdelaysintreatmentwillneutraliseanyshort-termsavingsmadebyrestrictingaccess

toservices.

6.3NHSHCPsaretreatingpatientswhohavebeensubjecttotorture

Over half of the survey respondents (55%, n=105) said they had treated a patient with

psychologicalorphysicaleffectsoftorture.Tortureisthoughttobecommoninasylumseekers

andrefugees, thoughprevalencevariesacrossstudies,dependingonthedefinitionof torture,

samplingandreportingmethods.23TwoprevalencestudiesfromamentalhealthclinicinBoston

USAidentifiedtheprevalenceoftortureas84.3%and86.2%inaconveniencesampleofaround

200 asylum seekers.24 Torture prevalence is also dependent on the country of origin of the

asylum seeker or refugee; for example, in one study twice as many Afghan asylum seekers

reportedtortureincomparisontothosefromIraq(67.3%and30.6%respectively).25,26

23Kalt,A.,Hossain,M.,Kiss,L.,&Zimmerman,C.Asylumseekers,violenceandhealth:Asystematicreviewofresearchinhigh-incomehostcountries.AmericanJournalofPublicHealth2016;103(3):e30–42.24PiwowarczykL.AsylumseekersseekingmentalhealthservicesintheUnitedStates:clinicalandlegalimplications.JNervMentDis.2007Sep;195(9):715-2225Laban,C.J.,Gernaat,H.B.,Komproe,I.H.,vanderTweel,I.,&DeJong,J.T.PostmigrationlivingproblemsandcommonpsychiatricdisordersinIraqiasylumseekersintheNetherlands.JNervMentDis.2005;193(12):825-83226Ichikawa,M.,Nakahara,S.,&Wakai,S.Effectofpost-migrationdetentiononmentalhealthamongAfghanasylumseekersinJapan.AustralianandNewZealandJournalofPsychiatry.2006;40:341-346.


28

Despitethehighprevalenceoftortureamongstasylumseekersandrefugees,andthehighrates

of clinical encounters with the victims of torture reported in this survey, the majority of

respondentsdidnotdescribe themselves as confident in enquiring about torture.Worryingly,

23%ofrespondentsstatedthat,asaconsequenceofthis lackofconfidence,theymightavoid

askingquestionsaboutexperiencesoftorture.Similarly,confidencetodocumentandactupon

evidenceoftorturewaslowacrossallspecialtiesandallgrades;only20%ofrespondersstated

they were ‘confident’. This lack of confidence in identifying victims of torture is particularly

concerningsince thechanges in legislationmade inAugust2017 thatmandate thatvictimsof

torture,femalegenitalmutilation,anddomesticorsexualviolencearenotrequiredtopayfor

treatmentofanyconditioncausedbythatviolence.27Thepsychologicalandphysicalsequelae

of torture can be profound, and include treatable conditions such as major depression and

PTSD.28Appropriatelydocumentingverbalaccountsandphysicalevidenceof torturecanhave

life-alteringimplications,especiallyforasylumseekerswhoselegalrighttoremainintheUKis

uncertain. The lack of knowledge and confidence highlighted in this survey has serious

implications;byavoidingquestionsabouttortureinhigh-riskpatients,HCPsmaydenyvictimsof

torturetheirhealthcareentitlements.Furthermore,theymayhinderanindividuals’immigration

applicationifthetorturegoesunrecognised.

6.4HCPswantmoretrainingonasylumandrefugeehealth

The vast majority of respondents stated they would benefit from further training on issues

surrounding asylum seeker and refugee health,withmost (80%) preferring training led by an

expert in the field. These findings extend across a broad range of specialties and experience.

Despite a relative increase in confidenceamongmore seniorhealthprofessionals, there is an

acceptanceoftheneedforeducationacrosstheboard.Thisisevenmorepressinginlightofthe

27https://www.gov.uk/government/publications/guidance-on-overseas-visitors-hospital-charging-regulations/summary-of-changes-made-to-the-way-the-nhs-charges-overseas-visitors-for-nhs-hospital-care28SteelZ,CheyT,SiloveD,MarnaneC,BryantRA,vanOmmerenM.Associationoftortureandotherpotentiallytraumaticeventswithmentalhealthoutcomesamongpopulationsexposedtomassconflictsanddisplacement:asystematicreviewandmeta-analysis.JAMA.2009;302:537–49.


29

recentchangestochargingwhichplaceevenmoreresponsibilityonfront-lineNHSstafftocheck

individuals’immigrationstatusesbeforeprovidingtreatment.Thesechargeswerenotinplaceat

thetimethissurveywasconducted,but,toourknowledge,theUKGovernmenthasprovidedno

specifictrainingforHCPsinlightofthechangeinlegislation.

Appropriate training and education for staff determining who is, or is not, eligible for NHS

treatment isvital.Weneedtobeabletoensurethatpatientsaretreatedfairly,promptlyand

without discrimination in accordance with their human rights and the codes of practice that

governhealthcarepracticeinthiscountry.It isalsoimperativethattherearenoinappropriate

treatmentdelaysandorincorrectchargingduetoHCPs’lackofunderstandingandknowledge.

Weneedtoensuretheprocessofeligibilityassessmentisdoneinatimelyfashion,minimising

theadditionalworkloadforalreadyoverburdenedNHSstaff,aswellassafeguardingagainstthe

profiling of individuals based on race, country of origin, religion or language, rather than in

accordancewiththelaw

7.LimitationsThesurveyhasanumberoflimitationsthatshouldbeconsideredwheninterpretingtheresults.

7.1.Samplingmethod

The samplingmethodwas opportunistic, designed to capture asmany responses as possible

within a limited timeframe and with limited resources. With this method we achieved a

responserateofaround20%(198fromapproximately1000HCPscontacted),anditispossible

thatthoserespondingtothequestionnaireactedasaself-selectinggroupwithsomedegreeof

pre-existinginterestinthetopic.

The numbers of respondents in grade and specialty sub-groups varied significantly.

Consequently, the cross-group comparisons are to be interpretedwith caution. Some groups,

suchasfoundationdoctors,wereunderrepresented(5%,n=9),whilstspecialisttraineedoctors

(40%, n=79) and consultant and GP grades (43%, n=85) represented the majority of survey


30

respondents. Furthermore, although nurses and AHPswere included in the survey, they only

madeup11%(n=22)ofresponders.

However,theprimaryaimofthisprojectwasnottoproducehighlypoweredstatisticaldata,but

rathertoprovideanoverviewofHCPs’understandingoftheissuesaroundrefugeeandasylum

health,identifygapsintheirknowledgebaseandexploreavenuesforfurtherresearch.Thus,if

thesampledidhaveapre-existinginterestinthetopic,theprevalenceofsuchuncertaintywhen

dealingwiththesepopulationgroupsinahealthcaresettingisanimportantfinding.

Apotentialavenue for furtherworkon this topicwouldbe thedevelopmentofa surveywith

specificsamplingmethodsdesignedtoreduceanyself-selectionbiasandallowformorerobust

cross-specialty comparisons. These measures would help us to design specialty and grade-

specificinterventionsandtrainingtoincreaseHCPs’understandingandconfidenceinthisarea.

7.2Datacollection

Wedesignedasurveywithconcisequestionsandmultiplechoiceanswers.Thesurveyhasnot

been independently validated. It can be argued that asking clinicians to choose between

‘confident’ and ‘some idea’ in reference to an aspect of their clinical knowledge is not a fair

representationofrespondents’real-worldknowledgeandclinicalpractice,asthequestiononly

measures the confidence they have in their ability to cite definitions. A more accurate

knowledgeassessmentmayhavebeenachievedbyaskingparticipantstoselectthedefinitions

fromalistofoptionsortypethemfree-text.However,thechosensurveydesignofferstwokey

advantages.Firstly,itkeptthesurveysimpleandshort,akeyfactorinmaximisingresponserate.

Secondly,itmeetstheaimsofthestudy:exploringtheperspectivesofHCPs.Whilstthelackof

confidenceamongstHCPsidentifiedbythisresearchmaynotalwaystranslatetoreal-worldsub-

optimal practice, it does imply that there is a large knowledge gap among HCPs about a

populationtheyarecaringfor,theirlegalresponsibilities,andentitlementtoNHScareforthese

groupsofpatients.


31

8.RecommendationsThisreporthashighlightedasignificantgapinHCPs’knowledgeofthehealthneedsofrefugees

and asylum seekers and their eligibility for NHS care. This appears to translate to a lack of

confidenceinidentifyingandtreatingsuchpatients.Inlightofthesefindings,andoftherecent

changes to charging for NHS care,MedactManchester recommends the following actions to

increaseawarenessoftheissuesandencouragebettertrainingformedicalprofessionals.

8.1 ThereisanurgentneedfortrainingforfrontlineNHSstaffonthehealthneedsofrefugee

andasylumseekersandtheireligibilityforNHScare.

Thistrainingshouldcoverfivekeyareas:

a. understanding the complexhealthneedsof refugeesandasylumseekers, and

howtheymaydifferfromtheordinarilyresidentpopulation;

b. understanding terminology used to describe refugees and asylum seekers,

including how this may change over time. This would require a basic

understandingoftheasylumprocess;

c. exploring the moral, ethical, and legal, responsibility healthcare professionals

haveinassessingindividuals’rightstohealthcareintheUK.Thismustbedone

inkeepingwithprofessionalcodesofpracticesuchas‘GoodMedicalPractice’;

d. identifying and appropriately documenting evidence of torture. This should

include information on signposting to groups experienced in dealing with

refugeesandasylumseekerhealth;

e. we suggest this training beprovidedby individualswith experience in dealing

withthecomplexitiesofrefugeesandasylumseekerhealth.Thisshouldinclude

allstakeholders,andcouldincludeNHSprofessionals,thirdsectororganisations,

andmembersoftherefugeeandasylumseekercommunity.

8.2 Refugeeandasylumhealthshouldbeintroducedasacoretopicinmedicaleducation

fromundergraduateleveltoseniorlevelcontinuingprofessionaldevelopment.


32

8.3 ThereisaneedforfurtherresearchonHCPsandrefugeeandasylumhealthintheUK

Avenuesforfurtherresearchinclude:

b. ExpandingtolookatHCPsinotherregionsoftheUK

c. GreaterinclusionofHCPsotherthandoctorse.g.nursing,midwifery,dentistryand

otherAHPs

d. ExploringtheimpactofthenewlegislationonHCPs’understandingofrefugeeand

asylumhealth

8.4Refugeesandasylumseekersmustcontinuetoreceivehealthcareinlinewiththeirhuman

rightsandthecodesofpracticethatgoverntheprovisionofhealthcareintheUK.


33

AppendixA:SurveyQuestions

MedactRefugeeandAsylumSeekerHealthSurvey

1. Pleaseenteryourgradeandspecialty2. WhichgroupsareentitledtofreeGPservices?(Selectallthatapply)

a. Asylumseekersb. Refugeesc. ‘Failed’asylumseekersd. Noneoftheabovee. Notsure

3. Howconfidentareyouaboutthedifferentdefinitionsofasylumseeker,refugee,‘failed’asylumseeker,andeconomicmigrant?

a. Confident–Iwouldbeabletoexplainthedifferenceb. Someidea–Imayneedtorevisethedefinitionsbuthavesomeunderstandingc. Notsureofthedifferenced. Other(pleasespecify)

4. Whichgroupsareentitledtofreeemergencycare?(Selectallthatapply)a. Asylumseekersb. Refugeesc. ‘Failed’asylumseekersd. Noneoftheabovee. Notsure

5. Whichgroupsareentitledtofreenon-emergencyNHScare?(Selectallthatapply)a. Asylumseekersb. Refugeesc. ‘Failed’asylumseekersd. Noneoftheabovee. Notsure

6. Haveyouevertreatedapatientwithphysicalorpsychologicaleffectsoftorture?a. Yesb. Noc. Notsure

7. Howconfidentwouldyoufeelquestioningapatientaboutprevioustorture?a. Confident–nodifferenttonormalclinicalenquiryb. Lessconfidentthannormalbutstillablec. Notcompetent–Imayavoidquestionsaboutprevioustortured. Notsuree. Other(pleasespecify)

8. Howconfidentwouldyoufeeldocumentingandactioningclinicalevidenceoftorture?a. Confident


34

b. Lessconfidentthannormal–butstillablec. Iwouldnotknowhowtodocumentandactionfindingsd. Notsuree. Other(pleasespecify)

9. Doyoufeelthatyouwouldbenefitfromfurthertrainingabouttherightsandissuesofasylumseekerandrefugeehealth?

a. Yesb. Noc. Notsured. Iwouldnothavetimee. Other(pleasespecify)

10. Whatformatofeducationalsupportwouldbemostusefultoyou?a. Trainingsessionledbyexpertinthefieldb. Onlineeducationalmaterialc. Posterorflyerd. Helpline/help-emaile. Noneoftheabove

AppendixB:ResponderFeedback

Thankyousomuchfortakingthetimetocompletethesurvey.Thiswillhelpustoseewhat

medicalprofessionalsalreadyknow,aswellaswhatkindoftrainingmightbeusefulinthe

future.Wethoughtitmightbehelpfulforustoprovidetheanswerstosomeofthequestionsaskedin

thesurvey.Sohereyougo.

(N.B.Ifyouwouldlikeustoemailyoua1pagehandoutwiththeinformationbelowand/or

wouldliketojointheMedactManchesteremaillist,thenpleaseemail

[email protected]).

Definitions

Accordingtothedictionary,arefugeeissimplyapersonwhoisfleeingtheirhomeforrefugeor

safety.FollowingthemassexodusofpeoplesfromtheirhomesafterWW2,theUNheldseveral

conventionsinordertoclarifythelegalstatusofsuchpeople.The1948UniversalDeclarationof

HumanRightsrecognisedtherightofpersonstoseekasylumfrompersecutioninother

countries.The1951RefugeeConventiondefinedarefugeeas:


35

Apersonwhoowingtoawell-foundedfearofbeingpersecutedforreasonsofrace,religion,

nationality,membershipofaparticularsocialgrouporpoliticalopinion,isoutsidethecountryof

hisnationalityandisunableor,owingtosuchfear,isunwillingtoavailhimselfoftheprotection

ofthatcountry;orwho,nothavinganationalityandbeingoutsidethecountryofhisformer

habitualresidenceasaresultofsuchevents,isunableor,owingtosuchfear,isunwillingto

returntoit.

However,apersonwhoarrivesinanewcountryandclaimstomeettheabovedefinitionhas

notlegallygained‘refugeestatus’untilithasbeenbestoweduponhim/herbythehostcountry.

IntheUK,thisisdonebytheUKBorderAgency(UKBA).Peoplewhoarriveinthiscountryhave

toapplytotheUKBAforasylum.Whentheydoso,theyaredefinedasasylumseekers(i.e.

peoplewhoareseekingasylum/refugeestatus).IftheUKBArejectsaperson’sclaim,then

he/sheisafailedasylumseeker.

Aneconomicmigrantisapersonwhohasmovedtoanewregiontoseekanimprovementin

livingstandards,mostoftenbecausethelivingconditionsinhis/herownregionarenotstable.1

EntitlementtoNHSCare

AsylumseekersareentitledtofreehealthcarefromallNHSserviceswhiletheyarewaitingfor

theoutcomeoftheirasylumapplicationandappeals.Thosewhoseasylumapplicationhasbeen

successful(i.e.thosewhohavegainedrefugeestatus)cancontinueaccessingallhealthcare

servicesindefinitely.

Thosewhoseasylumapplicationhasbeenrefused(“failedasylumseekers”)areentitledtofree

primaryhealthcare,emergencytreatmentinA&E,testsandtreatmentforinfectiousdiseases,

familyplanning,anytreatmentforaphysicalormentalconditionresultingfromtorture,FGM,

domesticviolenceorsexualviolence,NHSdentalandeyecare,andprescriptions.Furthermore,

anyhospitaltreatmentstartingpriortoapersonbecominga“failedasylumseeker”shouldbe

continuedfreeofchargeuntilthatpersonleavestheUK.


36

Thismeansthatfailedasylumseekersareliabletopayachargeforanynewaccesstohospital

servicesthatisnotoutlinedabove.However,trustsmustnotdelayanytreatmentdeemed

necessarypriortothepersonbeingsenthome,andcanstillprovidehealthservicesattheir

discretiontothesepatientswhenthereisnoprospectofthatpersonpayingforit.

Workingwhetherapersonfitsintooneoftheabovedefinitions,orrememberingwhetheror

notapersonisentitledtocareisNOTtheresponsibilityoftheclinician.Treatingcliniciansare

notobligatedtodeterminewhetherindividualpatientsareeligibleforfreenon-emergency

treatment,orwhethertheyareabletopayforit,beforetheyadministertreatment.Incontrast,

cliniciansmustfollowclearguidancesetoutbytheGeneralMedicalCouncilandensurethey

makethecareofthepatienttheirfirstconcern.Forthisreason,treatmentshouldbegivento

patientsbasedontheirneed,nottheirimmigrationstatus.

1Agrowingliteratureisfindingthatowingtotheongoingturmoil,particularlyinNorthAfricaandthe

MiddleEast,thedifferencebetweenaneconomicmigrantandarefugeeisbecomingincreasinglyblurred.

Thishasledtotheuseofanewterm:forcedmigrant.

Documents

Healthcare professionals’ views and experiences of … professionals’ views and experiences of dealing ... issues in the first two groups in this ... providers such as SERCO and