Asylum Seekers and Refugees

Introduction

Refugees and asylum seekers represent a complex and hon-homogeneous group of potential patients whose needs can be complex, challenging and, at times, urgent. They can present a challenge to Primary Care, both to our systems and to our skills. Health professionals may need to draw on a variety of resources to make sure that the care that is offered to this group is the best and most effective possible.

Globally, one in every 122 people is now either a refugee, internally displaced, or seeking asylum - around half of these are children under 18 years old.^[1] At the end of 2014 the UK housed just over 117,000 refugees, 36,383 pending asylum cases and 16 stateless persons. As of late 2015 the top three countries of origin were Eritrea (3,568), Pakistan (2,302) and Syria (2,204).^[2] Updated figures are always available from the Office for National Statistics.^[3]

This article gives a brief overview of the types of issues which refugees and asylum seekers raise for GPs, and offers routes to resources for further information. Resources may change over time but the principles are unchanging - we need to try to ensure that the care we offer to all our patients is effectively and expertly delivered and that it is focused to an appropriate level on those who need it the most.

Definitions^{[4, 5, 6]}

The media often use the terms refugee and asylum seeker broadly and interchangeably. However, an understanding of definitions can be helpful.

• A refugee is a person who, owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his/her nationality/habitual residence and is unable or, owing to such fear, unwilling to return to it.
  
  In the UK, a person is officially a refugee when they have their claim for asylum accepted by the government. Until then if they have applied for asylum they are an asylum seeker.
• An asylum seeker is a person who has left their country of origin and formally applied for asylum in another country but whose application has not yet been concluded.
• A refused asylum seeker is a person whose asylum application has been unsuccessful. Some refused asylum seekers voluntarily return home, others are forcibly returned and for some it is not safe or practical for them to return. Some may seek asylum elsewhere.
• An economic migrant is someone who has moved to another country to work.
• The terms illegal or bogus asylum seeker have no basis, since anyone has the right to apply for asylum in any country that has signed the United Nations' 1951 Refugee Convention and to remain there until the authorities have assessed their claim.
• International law does not say that refugees must claim asylum in the first country they reach.
• The United Nations' 1951 Refugee Convention recognises that people fleeing persecution may have to use irregular means in order to escape and claim asylum in another country - there is no legal way to travel to the UK for the specific purpose of seeking asylum.

Entitlement to GP services^[7]

Registration requirements

There is considerable misunderstanding and misinformation in this area.

There is no requirement for practices to see a patient's passport prior to registration.

• This is true irrespective of legal status but it remains common for practice receptionists to ask asylum seekers to show passports or evidence of identity. This can ONLY be asked if:
• You are registering the patient; AND
• This is a requirement for ALL PATIENTS registering with your practice.
• Asylum seekers do not have a passport. They may have a registration card but this can take some weeks after their arrival and application to come through.
• Asylum seekers should not be charged for GP services. They are not allowed to work and are given accommodation and a very small weekly subsistence allowance.

Refugees and asylum seekers
They are entitled to receive all NHS services.

Failed asylum seekers
These form two groups:

• Those who become section 4 supported:
• These are asylum seekers who continue to engage with the Home Office and who, for health or safety reasons, are unable to return to their country of origin immediately. These are placed on 'section 4 support' and are considered vulnerable patients. Section 4-supported failed asylum seekers are exempt from all charges. They are entitled to all NHS services.^[8]
• Those who become undocumented:
• Undocumented migrants may be failed asylum seekers who are no longer engaging with the Home Office, people who have entered the country irregularly or those who have overstayed a work/study/tourist visa.
• There are no Department of Health (DH) regulations concerning their entitlement to primary care. GPs have the discretion to register any patient, irrespective of residency status, unless the person resides outside the practice boundary.^[9]
• GPs also have a duty to provide immediate and necessary and emergency treatment free of charge
• The British Medical Association (BMA) and the Royal College of General Practitioners (RCGP) both support an overriding principle that GPs have a duty of care to all people seeking healthcare and that GPs should not be expected to police access to healthcare or turn people away when they are at their most vulnerable.^{[10, 11]}
• Undocumented asylum seekers are not generally eligible for hospital treatment unless to save life or to prevent a condition from becoming life-threatening. (It is not the role of the GP to police this entitlement.)
• Failed asylum seekers are eligible for:
• Treatment in A&E and walk-in centres.
• Family planning services.
• Sexual heath clinic treatment (excluding HIV treatment).
• HIV diagnostic services.
• Compulsory mental health treatment.
• Treatment of some communicable diseases.

The sequence of need^{[7, 12]}

The 'sequence of need' is a term devised in 2002 to describe five stages of need experienced by asylum seekers. Each is associated with different types of presenting complaints. Clearly not all asylum seekers and refugees will experience and prioritise their problems in the same way and the time taken to move through these stages may vary considerably. However, it can be helpful to consider the sequence if hoping to anticipate later problems.

• Arriving - the patient may be relieved and happy and only most acute issues tend to present.
• Settling - reality sets in with a sense of what has been lost. Subacute and psychological problems are likely to present.
• Establishing - the beginning of adjustment to new circumstances; patients start to prioritise their chronic health problems, and psychosomatic problems are most likely to surface, together with psychological problems relating to experiences of racism.
• Integrating - feeling accepted. Further chronic problems and psychosomatic problems are likely to present.
• Departing - if asylum if refused then deportation will ultimately follow - there are likely to be feelings of rejection, anger, despair, anxiety and uncertainty. Acute physical and mental health problems may resurface.

Issues affecting healthcare^{[7, 12]}

Language and communication issues

• Lack of interpreters and uncertainty over what language the patient speaks.
• Lack of a shared understanding of health issues and healthcare systems.
• Interpretation problems.
• Difference in understanding of health, disease and treatment.
• Different expectations.
• Patients unwilling to talk freely (eg, due to interpreter, due to fears of persecution).
• Lack of time for complex problems in the normal time frame of GP appointments.
• Extra time needed to consult with an interpreter.

Problems of presentation, challenge and complexity

These relate to complexity and multiplicity of the issues, to the patient's experiences and to the period of time for which they have been travelling. Patients are likely to have lost money, home, career, identity and expectations. They may have experienced bereavements, often multiple and often violent. The journey may have been uncertain, exhausting, traumatic and dangerous. A sense of safety based on the idea that bad things happen rarely may be lost and they may fail to speak freely.

• Patient factors:
• Communication difficulties.
• Multiple problems, multiple needs.
• Psychosomatic problems - headache and back pain are particularly common (but can also relate to head injuries and beatings and torture with suspension).
• Complex problems needing time and space to hear and understand.
• Differences in health understanding leading to apparent demanding or difficult behaviour.
• Lack of understanding of surgery appointment systems or of the role of a GP.
• Expectations which can't be met (which may lead to apparent over-reaction due to stress, confusion or feelings of rejection).
• Overwhelming or distressing stories - eg, torture, rape, child abuse, bereavement, violence.
• Stories which the patient cannot disclose or confront.
• Serious and/or urgent physical health issues.
• Serious and/or urgent mental health issues including depression and suicidal feelings, and severe stress with bizarre or dramatic behaviour.
• Needs which extend beyond the remit of the GP.
• Need for resources which are limited or absent.
• Doctor factors:
• Time pressure.
• Feeling of being overwhelmed, leading to negative responses.
• Lack of knowledge of access to resources.
• Symptoms that challenge our experience, abilities and confidence.
• Extreme symptoms - psychiatric emergencies, extreme stress, post-traumatic stress disorder (PTSD).
• Practice management issues:
• Uncertainty about how or whether to register a patient.
• Effect of asylum seeker patients on targets, practice funding, staff, other patients, sustainability of practice.
• Requests for letters, support, social care, advice, support, advocacy: professionals will want to help but may not know how to access the right resources.
• Possibility of expressions of racism within the surgery walls from other patients.

Some of these issues are generated by health professionals and the systems we have designed to deal with normal presentation patterns of our more predictable patient load. Some are particular to the patient, their experiences and their medical and other needs.

Management strategies^{[7, 12]}

Improving communication

• Lack of common language is a barrier to understanding, although many asylum seekers will have realised this and may bring a friend or advocate. However, if they don't you may not know what language(s) they are fluent in.
• Ideally a professional interpreter is booked in advance, arrives early and might, if the patient wishes, meet the patient briefly first. The length of time an interpreter needs to be booked ahead will depend in part on how common the language is and where, geographically, your surgery is placed.
• Language Line is a useful on the day resource. You need to give a number of details including your organisation's PIN and the language required. They can arrange a three-way call either to your telephone or to that of the patient (if the contact is a telephone consultation). There is usually a delay of about 60 seconds before connection but, again, if the language is rare it may be wise to book in advance. It is available 24/7 on 0845 3109900.
• Family members and friends may act as interpreters, which may be a practical solution and the preference of the patient. There are disadvantages with this approach, including confidentiality issues, embarrassment, potential conflicts and lack of good translating skills.
• You should avoid using children to interpret - this may embarrass the adults and give the child inappropriate responsibilities.
• If the patient is present, using hands-free speaker mode will enable a telephone-translated consultation to proceed more easily.
• Patient advocates, rather than interpreters, are provided by some Primary Care organisations and refugee organisations. They support the patient although they may add their own views and suggestions to the consultation.
• Written language materials can be helpful.
• The NHS Choices website 'language hub' provides links to sites offering health information in other languages.
• Google Translate may help you translate documents but the program does not cope well with colloquialisms.
• A language identification card allows patients who can read to point to their language, enabling you to call an interpreter.^[13]
• When working with an interpreter:
• Allow extra time.
• Discuss how you will work together before you start.
• Focus on and try to maintain eye contact with the patient, not the interpreter.
• Emphasise confidentiality and address the patient as 'you' not 'he/she'.
• Speak slowly and clearly 1-2 sentences at a time and watch for non-verbal cues.

Health understanding and expectations

• Be aware of the possible existence of culturally determined health beliefs - eg, around the significance of symptoms, or taboos around certain topics. Some patients may be reluctant to have blood taken because of views regarding its significance.
• Be aware that for some patients there may be strong taboos regarding the gender of the health professional, particularly where examination is concerned. This may also apply to interpreters.
• An ideal chaperone speaks the patient's language as well as yours; however, this is not essential.
• Try to understand the patient's ideas, concerns and expectations - avoid assumptions.
• Ask open questions; listen; understand.
• Explanations about the role of a GP in the NHS and what conditions are usually managed in Primary Care will often be needed, as some asylum seekers will come from countries where primary care is absent or very different.
• Referral to the local Health Inclusion Team may be helpful. Their role is to educate excluded groups in their use of health services, enabling them to improve their access to care.

Practice management issues

• Ensure information leaflets are available to download in other languages.
• Provide clear signposting of the appointments system.
• Put up clear signage stating that racism will not be tolerated.
• Support staff dealing with stressed or angry patients and encourage tolerance on the day. Provide training for dealing with difficult patients.
• All asylum seekers are entitled to NHS treatment and GP registration. Make sure that staff are aware of this and avoid placing unnecessary barriers. The BMA website provides advice on entitlement to care for asylum seekers.
• Do not charge asylum seekers for the provision of forms or letters. The weekly benefit paid to asylum seekers is minimal and they are not allowed to work.^[14]

Medical problems of asylum seekers

Physical health will depend in part on country of origin and the healthcare and living conditions they have been experiencing. Problems may relate to persecution in their country of origin or experiences on their journey, together with those resulting from lack of access to good sanitation, a regular healthy diet and regular healthcare for a prolonged period. They include:

• Infectious diseases, which include those not commonly encountered - eg, tuberculosis (TB), leprosy, malaria, tropical disease.
• The National Institute for Health and Care Excellence (NICE) advises tuberculin testing and CXR is advised for some groups, including new entrants to the UK who are from high-incidence countries.^[15] TB services vary by area but a referral is usually necessary.
• Chronic health issues which have been neglected - eg, diabetes, cardiovascular disease, malnutrition. There is an increased risk of peptic ulceration.
• Issues related to conditions on the journey - eg, infestation, saltwater immersion, gastroenteritis, acute stress.
• HIV must be considered. This group includes victims of sexual violence, those who have had paid sex and those who have used contaminated needles and blood products. HIV/AIDS is more common amongst refugees and asylum seekers but issues around stigma and confidentiality may prevent its being raised or disclosed.
• Female genital mutilation (FGM) is common in some ethnic and cultural groups, particularly in North Africa and the Middle East: for example, UNICEF found the rate of FGM in Eritrea to be 89% in 2013:^[16]
• Women may present with delay in menses, urinary and sexual problems and problems in labour and delivery. Surgical correction is best done before a planned pregnancy. A list of clinics offering advice is found through the Women's Health Research and Development Website, FORWARD (see under 'Resources', below).
• Immunisation:
• Lack of immunisation and screening: where there is no reliable history of previous immunisation, children should receive a full course as per the current UK recommendations.^[17]
• Adults should also be immunised as appropriate and women of childbearing age should be offered appropriate rubella protection.
• Hepatitis B and C serology should be offered to all new entrants.
• Mental health issues:
• Expressions of distress and coping strategies: these may vary culturally. Consider whether the presentation is a normal reaction in the context of the patient's culture. Feelings of loss, sadness and anxiety are normal.
• Psychosomatic symptoms: these can last for some time. Patients should be treated with a mixture of appropriate investigation and explanation and, where needed, counselling.
• Mood disturbance: anxiety, depression, guilt, shame and sleep disturbance are very common in this group. Avoid over-medicalising normal expressions of grief and distress.
• Psychosis: more florid psychiatric symptoms may be seen - most commonly in patients who have a previous history of psychiatric disturbance.
• Suicide risk: should be considered in those with depression or other psychiatric symptoms. For those fleeing terrible circumstances, having their story not believed can be the final straw.
• PTSD: this is a diagnosis which should be made cautiously, as it can medicalise common reactions but it is relatively common amongst asylum seekers. It is difficult to treat during conditions of continued uncertainty for the patient. Selective serotonin reuptake inhibitors (SSRIs) may be helpful but specialist referral is often necessary for trauma-focused cognitive behavioural therapy (CBT) and eye movement desensitisation and reprocessing (EMDR) therapy. PTSD can result in difficulties dealing with authority and 'systems', including the healthcare system itself. PTSD is a risk factor for suicide.
• Counselling: this may be an unfamiliar idea to groups who would usually discuss problems within the family (see below). In some cultures there is a strong belief in 'active forgetting', where thinking about previously traumatic experiences is actively avoided.
• Drug and alcohol use: there is little information about the prevalence of drug and alcohol use amongst refugee communities. However, the risk factors are prevalent in refugee communities. Particularly, asylum seekers are not generally permitted to work until granted refugee status.
• Injuries relating to conditions in the original country:
• Traumatic injuries - eg, shrapnel, bullets.
• Trauma secondary to torture (see below).
• Rape and unwanted pregnancy.
• Head injury sequelae: post-traumatic epilepsy, eye and ear problems.
• Torture:
• Many asylum seekers are victims of torture, physical or mental. This includes being forced to watch the torture of others.
• Difficulties include establishing the diagnosis and helping the patient tell their story as they are able. There is also likely to be an effect on the health professional hearing the story. Late disclosure is well documented, and you should consider the possibility of torture and ask about it directly.
• Long-term sequelae are common - eg, brachial plexus injuries.
• Torture and rape often occur together.
• Other family members including children may be witnesses. Remember to consider what support they may need.
• Survivors may be preoccupied with thoughts of permanent damage to their body.
• They may present with multiple minor physical symptoms.
• History of torture and rape can emerge during a routine physical examination. You should listen to what the patient wants to tell you, if they are wiling. Specialist referral is advisable. Freedom from Torture and the Helen Bamber Foundation offer support and advice (see 'Further help & information', below).
• PTSD symptoms relating to torture may be triggered by aspects of a medical consultation. Typically patients try very hard to avoid triggers which bring back memories of the original stress and such triggers may include the sight of medical instruments, queueing and removing their clothes.
• Rape:
• Many asylum seekers of either sex will have experienced rape or sexual violence.
• This may be complicated by feelings of shame which are upheld by other family members.
• Disclosure may come during routine examination.
• It is important to hear the story. Even if you have not been in this position before, remember that you are experienced in history taking - your skills will help the patient.
• Unwanted pregnancy and anogenital trauma and disease are common consequences. The latter should also be considered in men.
• The patient may not have had the chance to tell their story and may not yet wish to do so.
• Specialist rape counselling services are likely to be needed but testing for pregnancy, sexually transmitted infections (STIs) and HIV/AIDS is needed without delay.
• As for torture, the psychological sequelae are often prolonged and distressing. In men uncertainty about what this means for their sexuality can be an added cause for anxiety.
• It is important to arrange follow-up for torture or rape victims. Clinicians who have heard the stories will commonly need to debrief with a professional colleague themselves.
• Positive features:
• Asylum seekers are a group at high risk of physical and mental illness. They have experienced multiple losses, multiple traumas and, often, violence and prolonged fear. However, they are also people who have had the internal resources and resilience to survive these experiences. Many are highly educated and qualified; taking an interest in their skills and achievements may help them focus on what they have achieved.

Child asylum seekers^[7]

Children seeking asylum may experience any or all of the problems listed above. Their presence (and many are unaccompanied by immediate or even any family members) raises other issues including:

• Ensuring continued safety: for these vulnerable children the risk of abuse is present beyond their journey, including whilst in the care of social services.
• Witnessing crimes against parents and others.
• Involvement of the child in acts of violence of sexual violence.
• Lack of previous health information - even their age may be uncertain.
• Need to screen for STIs and find out about rape/sexual violence history in a child who may be unable to describe this.
• Acute anxiety regarding lost family members and survivor guilt. Behavioural disturbances are common, including low mood, aggression, enuresis, school refusal, encopresis.
• Children who have been subjected to or have witnessed sexual acts may develop early sexualised behaviour and prostitution.

Healthcare professional issues^[7]

Health workers may feel overwhelmed by the complex needs of refugees and asylum seekers and the lack of time, within current consultation structures, to offer them good care. Lack of time is the most common perceived difficulty.

Strategies to help manage the challenges
These include:

• Be calm and organised - you have learned to prioritise already; you can do this.
• Deal with urgent problems first but make it clear that you are prepared to own the problem and make follow-up, double appointments.
• Make appropriate referrals to secondary care and other agencies. You may be able to do this at the end of surgery.
• Psychosomatic problems often settle with time; use reassurance appropriately.
• Listen to patients.
• Consider your communication skills when using an interpreter (see 'Management strategies', above).
• Offer continuity of care and clear signposting.
• Arrange double appointments where interpreters are likely to be needed. It is generally advisable that practice staff are aware that interpreter appointments should be at least double in length.
• Identify the patient's needs early.
• Identify the most appropriate resources.
• Help patients understand the structure and function of the NHS.
• Don't try to solve every problem.
• Consider who else may be an appropriate advocate in other areas - eg, law. Consider recommending the patient contact refugee organisations, a social worker from the Social Services Asylum Team, a care worker from the local Health Inclusion Team.
• Consider creating a resource pack for your surgery.
• Consider running a training day for health professionals and frontline staff, to enable the surgery to manage asylum seekers in the best way possible.

Summary

Refugees and asylum seekers represent a challenging group which is likely to grow significantly in number over the coming years. The needs of asylum seekers are complex and need resources, time and effort. However, the need to tackle them well is imperative.

Preparing our teams, having the means to make space and time for patients who need it most and improving our understanding of the kind of problems we should anticipate helps us act in a more effective and compassionate manner.

Resources

Some resources offering information to health professionals and to refugees and asylum seekers are listed under 'Further reading & references', below. Organisations such as Praxis (based in London) and the Refugee Women's Resource Project offer support, information, advice and mentoring for vulnerable migrants and refugees. Many others are available in different parts of the country, sometimes provided by Primary Care organisations. A good practice resource pack should list what is available to you locally.

The refugee resource pack offered by Guys and St Thomas' NHS Foundation Trust offers useful further support and information and can be downloaded and printed if needed.^[7]