In need of surgery

All asylum seekers – even those awaiting deportation – are fully
entitled to primary health care. But a growing body of evidence
suggests that many people are facing a long series of hurdles to
get the care they are entitled to.

It starts with bureaucracy. An asylum seeker’s passport to primary
health and dental care is an HC2 form. But to get an HC2 form, they
have to fill in form HC1, which is a complex 16-page document only
available in English. Asylum seekers are advised to obtain help
from English-speaking hostel staff or health workers to complete
the form, but this can be a lengthy and sensitive process. The HC2
form is only valid for six months, after which they must fill out
another HC1 form.

Having negotiated the first hurdle, for some the problems are only
just beginning. As the gatekeepers to the rest of the NHS, GPs are
entitled to refuse to take people onto their lists. As a result,
people working with asylum seekers say it is by no means uncommon
for someone to trudge miles between various surgeries trying to
register with a GP, being turned down at each one.

GPs may well have good reasons to be reluctant to take new
patients. There is a severe national shortage of GPs and many now
have closed lists to enable them to meet the needs of the existing
population adequately. In addition, asylum seekers often have
complex health needs, and very poor or non-existent English, which
can make them difficult to deal with. Interpreters and translation
services are in short supply and are expensive, and using partners,
friends or children to translate can be inappropriate and
inaccurate. As a result, consultations with asylum seekers need to
be carefully planned and can be very time-consuming for
hard-pressed health workers.

Yet despite these difficulties, the Department of Health says there
is no extra money for treatment of asylum seekers or for
interpreting services. Some health authorities are paying GP
practices more for taking on asylum seekers – for example, £40
per head or more in Wakefield – but few have gone down this
route.

Also, asylum seekers can bring a number of complex medical issues
with them that make real demands on health professionals. Specific
health needs of asylum seekers can range from common ailments that
the host population has – such as colds, flu and stomach bugs to
far more specific illnesses and problems associated with their
country of origin. These include gynaecological difficulties
connected to female genital mutilation, HIV, tuberculosis and
hepatitis B, as well as mental health problems and psychological
distress. They may also include the physical and mental aftermath
of torture, rape or imprisonment.

The issue of TB hit the headlines recently when outbreaks of the
disease prompted accusations against asylum-seekers and refugees.
Research for the British Thoracic Society suggests that asylum
seekers are up to 22 times more likely to have TB than people born
in the UK, although few arrive in the country with an active form
of the disease.

Instead, health staff working with asylum seekers say they tend to
develop the symptoms of TB within the first two or three years of
living in the UK – often as a result of overcrowded living
conditions and poverty. Asylum seekers are routinely screened at
their point of entry, but screening tends to be basic – identifying
those who are coughing, for instance, or checking for a TB
immunisation scar. People who develop the disease after entering
the country may also be misdiagnosed by medical staff who are not
familiar with the symptoms.

HIV is also a major issue for asylum seekers, particularly those
from sub-Saharan Africa. While specialist services do exist in some
areas, there are strong cultural factors at play such as shame and
fear or reprisals or rejection by family members that may prevent
people from seeking help. In addition, many asylum seekers fear
that a diagnosis of HIV would result in their claim for asylum
being rejected.

Sarah Montgomery is a GP working exclusively with asylum seekers in
Folkestone, which receives large numbers of arrivals each month and
has upwards of 45 different languages spoken on its streets. She
says that for the majority of newly-arrived people, health is not
their first priority – they are more likely to be worried about
family or loved ones back home.

She stresses the importance of building trust over time.
“Sometimes, people come to see you a number of times for what
appear to be very trivial reasons, and it can be tempting to get
irritable with them. But you have to remember that they don’t have
any reason to trust you at first – you have to earn their trust. It
might be the fourth, fifth or sixth visit to the surgery when they
finally tell you what they wanted to talk about. It’s important
that you give them the time and support to feel able to discuss
things with you.”

Montgomery acknowledges that mainstream practices find asylum
seekers challenging. “They tend to have problems with our
appointment system – they are leading very chaotic lives, they
don’t know about our transport arrangements – and so they turn up
two hours late, which throws your appointment system out. Illness
is often seen as a family matter, so the whole family turns up and
you have 10 people in the waiting room. You have to enter into the
chaos with them and be flexible.”

So what can social care staff do to help asylum seekers gain access
to our health care system? Tony Pascoe is team manager for
Southampton City’s asylum team, which has what he describes as a
“fairly watertight” system for people who arrive after dispersal by
the National Asylum Support Service. “Everyone has an initial
health screening with a nurse, who then arranges for a GP to follow
up on any health problems.” Rather than having a specialist GP
practice for asylum seekers (as in Folkestone) Southampton’s health
authority allocates a GP to asylum seekers on arrival and writes to
them to let them know how to sign up.

Once people have had their urgent health needs addressed, Pascoe’s
team acts as a broker so that anyone with mental health needs,
child and family problems or disabilities can get help from the
mainstream social services department.

A key part of the task, according to Pascoe, is giving people
information about how things work and what they can expect. He
argues that even basic information about how the NHS is structured,
what a GP does, and how to get help for health problems is valuable
to people who are struggling to make sense of an entirely different
set of systems. In Southampton, new arrivals receive a welcome pack
in their own language telling them about how to access health care,
leisure facilities and education services – something that many
other local authorities are also doing.

“Alongside that,” Pascoe adds, “it’s important that social care
staff know themselves about what is available so that they can give
advice and help people access it.” He also feels that making sure
the host community is well informed and involved in the process is
vital.

Another strength that social care staff may have is the time and
ability to listen. While counselling is available to asylum
seekers, and is free, GPs often feel that what people really need
is someone to listen, rather than offer medical assistance or
formal therapy. Informal or formal advocacy can make a big
difference to the service asylum seekers receive from the NHS, too,
Montgomery argues, as can a little persistence and enthusiasm from
professionals. “I think it’s important to be positive about asylum
seekers,” she says. “An awful lot of what I do is positive – it’s a
privilege to meet and work with these people. We don’t talk about
the rewards enough.” 

– For further information see Dr Angela Burnett, Guide to
Health Workers Providing Care for Asylum Seekers and Refugees,
Medical Foundation for the Care of the Victims of Torture, 2002.