At the very end of last year health ministers announced that migrants and overseas visitors are to face new charges for some NHS services in England.
While GP and nurse consultations will remain free, other primary care services for which charges are being considered include minor surgery carried out by a GP and physiotherapy that has been referred by a GP. 1
The specific details of how these changes will be implemented are unclear but the plan outlining the charges is due to be released in March 2014.
Health Minister, Lord Howe, said: 'Having a universal health service free at the point of use rightly makes us the envy of the world, but we must make sure the system is fair to the hardworking British taxpayers who fund it.
'We know that we need to make changes across the NHS to better identify and charge visitors and migrants. Introducing charging at primary care[level] is the first step to achieving this.'
A number of services across the country based in community health projects and social enterprises do cater specifically to the complex needs that this patient group can present with and can help to divert them from using A&E and hospital facilities.
Nurse-led clinics
The Haven is a specialist primary care service which meets the initial needs of asylum seekers and refugees arriving in the Bristol and South Gloucestershire area. The service was established in 2003, a time when an increased number of asylum seekers were coming to Bristol. It was set up as a specialist service to meet the complex needs of this patient group and to facilitate access into general practice and other relevant services. More recently, the service has also provided for family members coming to join refugees in the UK.
The service is commissioned by Bristol CCG and is managed by Bristol Community Health, a community interest company.
The nurse-led clinics are held at Montpelier Health Centre, three mornings a week. Patients are offered: a comprehensive health assessment, investigation, treatment and follow-up of current and complex medical needs with referral as necessary, screening for communicable diseases, updating of immunisations, signposting of other services, information in their own language about the health service, help with registration with a local GP surgery, summaries of current health issues sent in writing to the newly allocated GP and access to help with healthcare costs.
The aim of the service is to reduce health inequalities by providing care that understands and responds to the particular needs of asylum seekers and refugees. It also relieves pressure on other services, and is able to identify the unmet needs of this population group and the service improvements that are required.
The patients that Anne Gachango, a specialist nurse for asylum and refugee health, based at The Haven, sees most often include those with mental health problems and the victims of rape and torture, and FGM. Patients commonly present with diseases such as TB, hepatitis B and HIV/AIDS, uncontrolled long-term conditions such as diabetes and hypertension, vitamin deficiencies and a lack of or incomplete immunisations. She is often required to administer specialist medicine for tropical diseases.
| Access to NHS care: refugees and asylum seekers | ||
|---|---|---|
| Like other UK residents, people with application for refugee status in the UK are entitled to use NHS services without charge. Asylum seekers are entitled to free healthcare from all NHS services while they are waiting for the outcome of their asylum application and appeals. They can receive without charge:
Source: www.refugeecouncil.org.uk |
| Vulnerable patients, rewarding practice |
|---|
| Mathew Sidebottom, advanced nurse practitioner at The Whitehouse Centre, recalls treating an asylum seeker with multiple health issues: 'A middle-aged Zimbabwean women came to the UK seeking asylum as she had been persecuted in her own country for her sexual orientation. Because she was a lesbian she had been beaten, verbally abused and even raped to be "cured" of her sexuality. She had suffered female genital mutilation (FGM) and had caught HIV from a man who had raped her in Zimbabwe. It was when she came to the UK, she found out she had HIV and also discovered she had inoperable breast cancer. This lady was still going through the legal process of seeking political asylum due to her persecution at this time. Her main concern was wanting to die with dignity in the UK. We were able to work with her legal team by providing medical evidence to support her need for special care for leave to remain in the UK. She was able to access primary care, palliative care and HIV treatment, and was able to fulfil her wish of dying with dignity.' |
The extra mile
However, working with such complex patient groups is not without its challenges. Mr Sidebottom, explains that patients often have different opinions and stigmas attached to various health problems. 'Their view of mental health, HIV and other problems is often different from the professional view in the UK and requires a large amount of input to understand their view and alleviate anxieties about health, infections, sexuality and psychological issues.'
Ms Gachango agrees that language barriers and culturally different viewpoints on health problems are one of the most difficult things about the job. 'The job requires an ability to communicate across language barriers and to work with interpreters. Consultations often take longer because of interpretation requirements and extra time is needed to explore and accommodate different cultural health beliefs and to build up trust.
'Practitioners also need to be aware of the rapidly changing asylum process and anticipate how the process may impact on a patient's care.'
Dr Totty also highlighted a lack of continuity as a challenge when working with vulnerable adults.
'As the patients have no fixed address, providing continuity of care can be difficult. An abnormal result or report can pose a challenge if the patient does not return and referrals that are not followed through can be frustrating.
'You are often dealing with patients with a limited background knowledge of their medical history and they may have moved from your books by the time their notes arrive,' he said.
External agencies
Partnerships with other agencies are vital to ensuring that these healthcare services provide a rounded service, Ms Gachango says. The Haven works in association with Refugee Action, Bristol Refugee Rights, British Red Cross, Refugee Women of Bristol, Trauma Foundation of South West, Womankind, BFriend, Unseen and the Brigstowe project. These services help the clients to access health services.
For services such as the Homeless Health Project to continue running in the future, partner agency working is essential, and in austere times these services become more necessary. 'In these financially restricted times, it looks certain that more and more people will potentially face the reality of what it is to become homeless at some point in their life,'said Dr Totty.
Rewards
Mr Sidebottom believes that the most rewarding part of working in a specialist GP practice is working with patients who have often come from troubled backgrounds with a complex mix of physical, psychological and social problems. 'By having the time to case manage these patients and prioritising their care needs, we see their health slowly improve in the majority of cases. In any other GP surgery, the GP and nursing team does not have the same liberty of time that we have at the Whitehouse Centre.'
He also highlights the importance of keeping these services running for the NHS. 'We effectively keep hospital admissions and A&E attendances down for our patient groups, bridge the gap between mental health, primary and secondary care services for our patients and ensure that these complex patients have access to specialist nursing and medical care.
'I fear that we will be seen simply as an "expensive GP surgery" and we are currently looking to produce evidence about what we do and the influence we have, including the benefits to the wider health economy.'
While the changes to the way migrants and overseas visitors access the NHS are being proposed to save money, services with staff trained specifically to deal with the vulnerable and displaced could be one way to ease some of the pressures on A&E and hospitals.
References
1. Department of Health. Sustaining services, ensuring fairness. 2013. http://bit.ly/1eUBUwo Accessed January 2014.