Sanctuary Seekers and Healthcare Conference Permjeet Dhoot Equality & Health Inequalities Team NHS England ( Sept. 2013)

Purpose – an overview Comments specifically on access to the NHS, outcomes and experiences and data collection. With a focus on mental health and maternal health inequalities. 2

Definitions & Duties Why commissioners, policy and planners of and service delivery should not view asylum seekers and refugees in the same way as ‘migrant’ communities or BME communities. There are similarities but also specific considerations and needs must be taken into account. Be mindful of the duties under: - Health & Social Care Act 2012, Sec. of State, NHS England and CCG’s – the need to have regard to reduce health inequalities in access and outcomes of services 2012 (Inclusion Health Board. and NHS England commitment to reduce health inequalities - Equality Act 2010 (amended 2012) - NHS Constitution Human Rights Act

Access to healthcare GP’s All asylum seekers and refugees are entitled to register with a GP and receive free NHS primary care GP practices retain the discretion to register refused asylum seekers to the same extent that they have this discretion in relation to registering any patient, regardless of his or her residency status. Asylum seekers and refused asylum seekers have the same rights to medical confidentiality as other patients. Immediately necessary medical treatment should never be denied to any person (DH led consultation – awaiting findings)4

Obstacles accessing GP care Registering with a GP is not dependent on immigration status.. Common barriers: Lack of awareness of entitlements (patient and staff) Lack of any papers, proof of address Language barriers Not knowing about primary care and role of GP’s Fear & vulnerabilities – association with ‘officialdom’. GP care can prevent ill health and provide access to other healthcare treatments available. 5

Examples of services not dependant on status Some NHS services are free to all patients, irrespective of their residency status accident and emergency services family planning services treatment of certain communicable diseases such as measles, tuberculosis and pandemic flu treatment for sexually transmitted diseases treatment required under mental health legislation or by order of a court 6

Access to hospital care GUIDANCE ON IMPLEMENTING THE OVERSEAS VISITORS HOSPITAL CHARGING REGULATIONS (current Department of Health, October 2012) Regulation 11(a) – Refugees 3.60 Anyone granted temporary protection, asylum or humanitarian protection under the immigration rules made under section 3(2) of the Immigration Act 1971 is recognised as a refugee and is exempt from charges. 7

Hospital Care Regulation 11(b) – Asylum seekers and others seeking refuge 3.61 Anyone who has made a formal application with the Home Office to be granted temporary protection, asylum or humanitarian protection which has not yet been determined is also exempt. Formal applications are those made under the 1951 UN Convention and its 1967 Protocol and also any other request for humanitarian protection, such as some claims made on protection from serious harm grounds under Article 3 of the European Convention on Human Rights. Relevant NHS bodies should seek their own legal advice if it is not clear under what circumstances a person is making such a claim. 8

Hospital Care Regulation 11(c) – Failed asylum seekers supported by the UKBA under section 4 or section A person who has had their asylum/humanitarian protection application and all appeals rejected becomes a ‘failed asylum seeker’. They will become liable for charges for their NHS hospital treatment at that point, even if they have been here for more than one year. HOWEVER there are a number of exceptions to this get advice and see regulations e.g. fresh application being submitted, continuation of treatment, supported by the UK Border agency, emergency care. 9

Maternal Health – a specific mention 10 Maternity treatment (current DH Regulations, October,2012) 4.7 Due to the severe health risks associated with conditions such as eclampsia and preeclampsia, and in order to protect the lives of both mother and unborn baby, all maternity services, including routine antenatal treatment, must be treated as being immediately necessary. No woman must ever be denied, or have delayed, maternity services due to charging issues. Although she should be informed if charges apply to her treatment, in doing so, she should not be discouraged from receiving the remainder of her maternity treatment. Overseas visitor managers and clinicians should be especially careful to inform pregnant patients that further maternity care will not be withheld, regardless of their ability to pay. GUIDANCE ON IMPLEMENTING THE OVERSEAS VISITORS HOSPITAL CHARGING REGULATIONS (Department of Health, October 2012)

Maternal Health evidence 11 However, health inequalities exist. The Confidential Enquiry into Maternal Deaths (2003–2005) found that Black African mothers, most of whom were recent migrants (including asylum seekers and those with unclear immigration status), were more than five times more likely to die than white mothers Late booking for, or no access to, antenatal care and a lack of access to translation services were some of the factors associated with mortality (Lewis, 2007). ( Race Equality Foundation, Health Briefing 2010 )

Maternal health evidence 12 Studies have shown poor antenatal care and pregnancy outcomes amongst refugees and asylum seekers. Asylum seeking, pregnant women are seven times more likely to develop complications during childbirth and three times more likely to die than the general population. (Best practice will be discussed during the day by lead facilitators and providers) Health Needs of Asylum Seekers Briefing Statement, Faculty of Public Health, 2008

Mental Health “I feel lonely and uncertain about the future. I am frightened of being arrested and beaten. I have flashbacks to what happened to me in my country. I feel hopeless and helpless. When I was at home I was a happy person.” ( 17-year-old girl from Ethiopia, Refugee Action, 2006:82) (Taken from P.Aspinal & C.Watters, Research Paper for E&HRC, University of Kent 2010) 13

Mental health ctd ‘ Mental health is one of the most frequently reported health problems among both dispersed asylum seekers and those in areas of traditional settlement, including anxiety, depression, phobias and post traumatic stress disorder. Rates are up to five times higher in some samples.. A study of over 800 Kosovan Albanian refugees settled in the UK yielded estimates of a diagnosis of PTSD in just under a half, and a major depressive disorder in around one fifth (Turner et al., 2003).’ (P.Aspinal & C.Watters, E&HRC, 2010) 14

Research conducted by Silove et al. (2000) on destitute asylum seekers in the South East of England found that more than half of asylum seekers in the sample were receiving medication for depression. (P.Aspinal & C.Watters, E&HRC, 2010) 15

Best practice – common features A humane, person-centred, rights-based and solution-focused approach to the needs of asylum seekers and refugees Specialist trained staff skilled in working with and understanding the needs of asylum seekers and refugees Respect for cultural experiences and migration Non-discrimination and promotion of equality Working with VCF groups - a community development approach - delivering care in community settings Access to qualified interpreters 16

Best practice decision-making that is timely and transparent and involves the patient, or their advocate/ carers, as fully as possible in the process promotion of social inclusion and independence local peer educators / peers support programmes / and health trainers a holistic, integrated social healthcare approach working with the wider health and social care sectors and local communities (Social Care Institute for Excellence 2010 with additions) 17

Wider determinants of health The health status of asylum seekers and refugees like our own are a result of where we come from, our past experiences, the current environment, our education and opportunities, socio economic conditions, family and friends, our sense of community participation & control over our own lives. The wellbeing of asylum seekers and refugees requires agencies working together to ensure early access to health care and support services: 18

Should services collect data on asylum seekers and refugees? What gets measured gets done? Effective planning and care planning There are gaps in national data collection. We don’t have a full picture of the status of people and therefore their take-up of health care and their health status. In particular for those who do not seek asylum straight away on entry and failed asylum seekers / destitute people The 2011 census now includes more detail on migration patterns which can be used to inform planning but immigration status is not collected. Some predictions can be made depending on ones previous country’s state of stability ( understandable reasons) 19

Data capture, data sharing and joint working at a local level is essential to ensure support & smooth transition across the public sectors. Establish centralised systems of data collection on the health outcomes and service use of people in local areas ( Jayaweera, 2010 Race Equality Foundation) Patient records – and dispersal and movement across the country. Slipping through the net The Commission on Integration and Cohesion (2007) recommend that data is collected locally Asylum seekers require reassurance of what data is used for – confidentiality and sensitivities. Once someone is a settled refugee should they have to declare their status? …complex 20

data Health / NHS practitioners, engaging with Public Health England nationally and Public Health locally in Local Authorities, asylum seeker and refugees themselves and VCF groups to gather data as a minimum service data Sharing of needs & outcome data for planning and setting of priorities to reduce health inequalities as part of local area Joint Strategic Needs Assessments 21

Moving forward – a joint approach To continue integrated multi-agency working – duties reflect this - to integrate Support joint work with Regional Strategic Migration Partnerships and Local authorities and role of Public Health and the VCF sectors are crucial Engaging with Clinical Commissioning Groups and Health & Wellbeing Boards, NHS England teams and local healthwatch Recognising asylum seekers and refugees experience a range of health inequalities. Commissioning and maintaining effective specialist services targeting asylum seekers and refugees. Employing health and social care staff with specific responsibilities to develop interventions and services to increase early access to and take-up of health care and entitlements and therefore reduce health inequalities 22

Further Information Royal College of Nursing London Health Observatory (Public Health England) Equality & Human Rights Commission Faculty of Public Health Refugee Council Inclusion Health Board groups/national-inclusion-health-boardwww.gov.uk/government/policy-advisory- groups/national-inclusion-health-board Refugee Action 23

Contact details Permjeet Dhoot Policy Directorate I Equality and health Inequalities Team NHS England I Quarry House I Leeds LS2 7UE mobile: