Vulnerable migrants: different journeys Seeking asylum Fleeing domestic violence in the UK . Managed migration programmes

asylum: Definitions Asylum seeker Refugee Sought on the basis of a well-founded fear of persecution because of race religion political opinion nationality membership of a particular social group Is outside their country of nationality or residence (if no nationality) Is unable, or owing to such fear, unwilling to return to that country Geneva Convention 1951 Refugee Has been granted right to remain in the country in which they have sought asylum Or granted right to remain under a managed migration scheme. November 2015 Asylum Seeker Health

Gateway protection programme UNHCR settles 80,000 each year worldwide 750 per year in UK. Stateless and intractable refugee situations. Partnership approach for 1 year intensive support and orientation.

Vulnerable persons relocation scheme Special scheme for Syrian resettlement 2015: New political climate, 20,000 announced over 5 years. 5 years humanitarian protection status. Right to work, public funds, family re-union.

Common health problems Skin infections (fungal infections, scabies) HIV, STIs and sexual health problems Neglected chronic diseases Tuberculosis Post head injury and other chronic pain syndromes Complex post traumatic stress disorder Physical manifestations of psychological distress

Challenges and opportunities: what we have found New patient checks: A powerful opportunity for screening (HIV, Hep B and C, STIs, FGM, cervical cytology) but a matter of delicate timing. Partnership working and signposting. Get to know therapists, refugee advice and advocacy organisations, faith groups, emergency housing Taking every opportunity to keep in contact with patients (up to date details and support workers) Focusing on what you can do, not what you cant. Innovative ways to engage patients in getting feedback on services. Challenging but worthwhile. Imaginative approaches to multidisciplinary teams: Building relevant, supportive MDTs

Working with vulnerable migrants; what are your hot topics? Making sense of the asylum system? Challenges of interpreted consultations? Changes to migrants’ entitlement to health care? New rules on reporting and referral of FGM? Managing unrealistic expectations of healthcare? Health impacts of current government policy; how should we respond? Refugees and immigration in the media; influencing the narrative? Models: Specialist “safety net” practices? Challenging consultations with vulnerable groups? How to improve attendance rates (especially in secondary care)? Dealing with the emotional impact on ourselves?

Asylum process Initial application and screening interview Dispersal. Support (case worker, benefits, accommodation) Asylum interview Positive decision 5Y leave to remain 5Y humanitarian protection Discretionary leave Negative decision Appeal Section 4 support: Trying to leave Unfit to travel Judicial review Human rights act Loss of all benefits, housing and can detained or deported Detention (fast track)

Current Healthcare Entitlements of Refugees and People Seeking Asylum Asylum seekers Refused Asylum seekers Primary healthcare Free Secondary healthcare Charged Emergency healthcare Maternity care

Proposed Healthcare Entitlements of Refugees and People Seeking Asylum Asylum seekers Refused Asylum seekers Primary healthcare Free Charged (partially) Secondary healthcare Charged Emergency healthcare Maternity care

Immigration Act 2014 Measures Tougher criteria for access to free care Introduction of an up-front ‘Migrant Health Levy’ (visa surcharge for non-EEA visitors and students). More proactive identification of chargeable patients, more aggressive cost recovery by hospitals Extending charges to primary care and A&E care! Widely held concerns New barriers to care for the most vulnerable. Will lead to delayed presentation with problems deteriorating into health crises Worrying public health implications from under treated infectious diseases A heavy burden of new bureaucracy for GPs and A&E. Restrictions on access will be wider than intended due to patient fears, health professionals’ confusion and lack of documentation amongst the most vulnerable.