This week’s blog provides an overview of the unmet healthcare needs of immigrants, migrants, refugees and asylum seekers.
Immigrants, migrants, refugees and asylum-seekers in the UK encounter a number of difficulties in accessing care in the NHS including lack of awareness of available services and eligibility criteria, accessibility of health information, language barriers, a need for more cultural sensitivity and the need for better mental health care especially in immigrant removal centres.
In 2019, 677,000 people immigrated to the UK, with 270,000 people intending on staying more than 12 months (1). This figure has been broadly stable since 2016 (Figure 1). The UK also offered asylum to 20,339 people, which was a 17% increase on the previous year (1). Health status is important for successful integration into a new society, alongside employment/education and housing. Therefore, it is vital that an adequate system is in place in the UK to cater for healthcare needs of immigrants (those with permanent residency), migrants (temporary movement), asylum seekers (who have applied for asylum in the UK) and refugees (those granted asylum in the UK). These groups can be considered vulnerable populations, especially asylum seekers and refugees, with many experiencing emotional distress which can range from an ‘inability to eat to attempted suicide’ (2). It is well known that these populations have unmet healthcare needs due to a variety of complex barriers to care. In this blog we will explore some of these issues.
Figure 1- Long term immigration and net migration since 2010. Data taken from: ONS 2020 (1). *unadjusted estimate
Currently in the UK, primary healthcare services are free of charge for anyone (3). These include:
Secondary care services are residence based and only free to those who are ordinarily resident. This includes people who are citizens currently resident in the UK, or immigrants with indefinite leave to remain. Since the 31st December 2020, all foreign nationals coming to the UK for more than 6 months have to pay a health surcharge of £624 per year. Those in the UK for under 6 months need to pay for any secondary healthcare at the point of use. Asylum seekers and refugees are exempt from any charges. Those who are refused asylum can receive secondary care for free in Scotland and Wales, however in England this is only for those with support from the Home Office or local authority or under the Care Act 2014.
With a continually diversifying UK population, the recent COVID-19 pandemic and the effects of Brexit, we wanted to explore and shine a light on the unmet healthcare needs of immigrants, migrants, asylum seekers and refugees in the UK. We began by searching Embase and Medline using terms for unmet need (satisfaction, treatment gap etc..) and migrant, immigrant and asylum seeker. The search yielded 458 abstracts, with a final total of 9 publications included after screening for relevance. These were supplemented by white paper reports and content from webpages of official bodies relevant to migration.
From the evidence we found, asylum seekers who are undocumented, refused or those with outstanding applications or appeals seem to have the greatest unmet need. An audit was conducted by Doctors of the World who run a clinic in east London for those who are unable to access NHS treatment. Of a sample of 27 patients, 44.5% had a refused asylum claim and 37% had an outstanding human rights or asylum application or appeal. The average delay in treatment was 37.3 weeks with the longest being 4.1 years. Worryingly, 59.3% of service users required urgent or immediately necessary treatment, with an average delay of 36 weeks. Additionally, 2.5 years was the longest wait for a life threatening or serious health condition. According to the NHS guideline for treatment eligibility, any asylum seeker, irrespective of their status, is entitled to free primary healthcare, yet the Doctors of the World found 22.2% of cases who needed urgent or immediately necessary treatment were wrongly financially charged (4).
Additionally, a survey given to refugees and asylum seekers (including those with refused asylum) in Wales explored their awareness of unscheduled health services (Figure 2). Out of a sample of 57 people, 27% reported using an out of hours health service, with many reporting they used emergency services due to being unaware of how to access routine and out of hours care or if seeing a GP did not resolve their problem. Language was also expressed as a barrier. People with limited English reported difficulty explaining their healthcare needs through NHS 111 and 999 and this difficulty was heightened in an emergency (5). In contrast, in an observational interview-based study of unaccompanied child refugees they stated that their healthcare needs were ‘generally’ met (2).
Figure 2- The awareness of unscheduled health care services in asylum seekers in Wales. Data taken from: Khanom et al. 2019 (5)
A particularly vulnerable population are those in immigration removal centres. One of the studies identified investigated this population and included pending refugees, people with criminal deportation orders, failed refugees, foreign national prisoners, illegal entrants and overstayers. Using the Camberwell Assessment of Need (CANFOR) PRO tool to measure unmet need, psychological distress was reported to be the prevalent issue (Table 1), which is concerning as 74.3% of participants reported a mental health or neurodevelopmental disorder and people in these centres reported higher rates of depression, PTSD, autism and suicide than other incarcerated samples (6). A second study reported similar findings in foreign national prisoners, with disputed care pathways and high mental health problems (7).
|CANFOR tool unmet need||Frequency|
|Information about condition and treatment||21.8%|
Table 1 – Frequency of unmet need using the CANFOR tool. Data taken from Sen et al. 2018 (6).
Maternity care was a focus of three out of nine papers, three main barriers to maternity care in immigrant women (8):
Another study explored the experience of pregnant migrants, with migrant women reporting poorer experience of care than those who were born in the UK. Those who had been in the UK for more than 4 years reported less satisfaction with care during labour and birth (odds ratio = 0.52 vs. UK born women) than those who had been a resident for less than 3 years (odds ratio = 0.62 vs. UK born women) (9).
Another focus of research was vaccinations; two studies looked at the attitudes and unmet needs of Polish mothers and vaccination programmes. A highlighted issue was the difficulty in finding official UK government and NHS vaccination material and access to resources in Polish and information. Participants were also noted to lack confidence in the Scottish primary care model (10). However, it is worth noting in the second study, there were ‘strikingly similar’ considerations when deciding on vaccinations between native Scottish and Polish participants, and neither group felt official information addressed any concerns they had in enough detail. However, the Polish women were reported to have a more difficult time accessing information and advice form the NHS (11).
Emergent themes of this research include lack of awareness of available services and eligibility criteria, accessibility of health information, language barriers, a need for more cultural sensitivity and the need for better mental health care especially in immigrant removal centres.
The lack of evidence on this topic specific to the UK needs addressing. Most of the evidence was based on studies with small samples and limited information. For such a broad question, the inability to easily find data speaks for itself. Large scale primary data is desperately needed to identify specific areas for improvement. Additionally, the most prominent theme appeared to be the lack of accessible information on health and eligibility for services.
The unmet need of immigrants, migrants, refugees and asylum seekers is broad and complex. Each of these four groups has a unique eligibility to healthcare in the UK, as well as individual social and economic barriers, therefore larger scale research needs to be conducted into each of the four populations individually. With changes brought about by Brexit, this topic will only become more complex as new immigration policies are implemented, but it is certain that unmet need among these groups, particularly those more vulnerable, needs to be investigated and improved as a matter of urgency.