Refugees and asylum seekers

Refugees and Asylum seekers are amongst the most vulnerable groups in society. By definition an asylum seeker or refugee is fleeing persecution and seeking protection. Each will have individual experience; some may be fleeing war or torture and may have a wide range of physical and psychological health needs.

It is important to examine the differences between those who are considered ‘asylum seekers’ and those who have been granted refugee status as this may have a clear effect on their health needs and access to health care.

An asylum seeker is defined in the The facts about asylum  as:

"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 refugee is defined by the 1951 United Nations Convention as:

"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 nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it."

A refused or failed asylum seeker is a person whose asylum claim has been rejected and arrangements to leave the UK are being made. These individuals have limited entitlements and healthcare is included in this.

Studies have noted that the health needs of asylum seekers broadly mirror that of the general population. Due to circumstances such as war and poverty in their country of origin, and often a treacherous journey to the country in which they are seeking asylum, individuals may have very specific health needs that local services may not regularly encounter. It is approximated that 17% of refugees have a physical health problem affecting their daily life, with two thirds suffering from anxiety and depression ( Refugee health in London: key issues for public health ).

The current global security situation is volatile, with various conflicts in both the Middle East and North Africa increasing the number of those seeking asylum. The United Kingdom government has pledged to accept more refugees from Syria over the next 5 years and Calderdale Council has supported this.

The local picture

Published Home Office figures show that at the start of March 2016, 278 people were being supported in Calderdale while awaiting a decision on their claim. All of these were being accommodated. Those granted protection by the Home Office may then stay in the area as refugees ( Local migration profile for Calderdale ). In addition to this Calderdale Council has agreed to accommodate a further 50 Syrian refugees direct from refugee camps. These refugees will be vulnerable families, couples and unaccompanied minors.

Data is sensitive and difficult to obtain, however evidence suggests that Calderdale sees many of its asylum seekers coming from countries including Eritrea, Sudan, Iran, Afghanistan, Pakistan and increasingly from Syria (data collected in 2015 by St Augustine's Centre, Halifax). It is also noted that the majority of asylum seekers in Calderdale are single males as opposed to family groups.

It is unknown how many asylum seekers, whose claim has been rejected, currently reside in Calderdale.

Current legislation dictates that all refugees and asylum seekers awaiting a claim outcome should have access to both primary and secondary NHS care for free. During a high court battle it was discussed whether an asylum seeker who had their claim rejected would be entitled to free NHS care. After an appeal it was decided that care free to all, as outlined in the Department of Health’s guidelines, would be provided. Without insurance, other costs would be charged at 150% of the NHS costs ( NHS entitlements: migrant health guide ). This will have an obvious impact on the health of this population.

It is difficult to obtain information pertaining to clinical needs of the asylum seekers and refuges in Calderdale as this data is not collected in a quantitative format. Evidence suggests that the main physical health problems experienced by asylum seekers are communicable diseases, chronic diseases and dental disorders due to prolonged periods of poor nutrition. Studies have also shown poor antenatal and pregnancy outcomes amongst refugees and asylum seekers.

Mental health problems are also common amongst these individuals. In particular, post-traumatic stress is greatly underestimated and underdiagnosed.

Current provision

The current Syrian Refugee Relocation programme has involvement from many key stakeholders within the community, local authority and clinical commissioning group (CCG). Monthly meetings occur, and key discussions and plans are made prior to arrival of the refugee families. A health assessment is conducted and appropriately acted upon to ensure systems are in place to meet their health needs.

Once arriving in Calderdale, asylum seekers are often signposted to St Augustine’s community centre, for help, advice or support to those who require it. This is where many of Calderdale’s asylum seekers access the 'welcome programme', where is support is given for issues including General Practitioner (GP) registration, job applications and English lessons. Additionally, St Augustine's holds a number of mental health workshops and support groups.

Park Community Practice is currently identified as the GP practice that most asylum seekers attend. As part of the health needs assessment, discussions have been set up to see the best way that registration can be facilitated. This involves working closely with Group 4 Securicor (G4S), who facilitate the health assessment for asylum seekers, once a request for asylum has been made. In addition, Queen's Road medical practice is committed to improving the health of those in the area, and is in close proximity to where many asylum seekers are housed.

The Wharf Midwifery Team provides support throughout pregnancy to asylum seekers and refugees. This is of vital importance to those in the later stages of pregnancy, and those who have previously received minimal antenatal care.

The local schools and children’s centres also assist with asylum seekers and refugee children who have come to settle in Calderdale. The Jubilee Children's Centre has a dedicated key worker assigned to refugees and asylum seekers, who is involved in outreach work within the community.

User views

A health needs assessment was conducted with the support of St. Augustine’s charity, in order to identify areas of health needs for this particular population, see PDFHealth needs assessment: refugees and asylum seekers [PDF 642KB]. Obtaining quantitative data on specific health topics is difficult, as this kind of information is not collected in focus groups.

Physical health was identified as an important concern in asylum seekers and refugees. This included chronic conditions, diabetes, and previous heart problems, which many believed were exacerbated by their journey to the UK. In terms of maternal health, several women who had given birth in the UK experienced minimal problems. Children’s health was also discussed, and revealed that the main problems consisted of general childhood illnesses. Few women drew attention to some respiratory difficulties thought to be a consequence of damp housing and difficulties in access to healthcare.

Several mental health concerns were expressed by asylum seekers and refugees. Many experienced high levels of stress, resulting in a lack of sleep. Asylum seekers felt that feelings of uncertainty and fear led to great psychological distress, and in turn affected their physical and mental health. Several expressed concerns about whether their asylum claim would be affected due to the stigma of mental health. Particularly, some Arabic-speaking refugees and Farsi-speaking asylum seekers had concerns about the lack of psychological therapies offered as a result of difficulties in accessing language services. Many Tigrinya-speaking individuals felt that the health check upon arrival was insufficient, considering their experiences of abuse and exploitation.

Screening and Immunisations were discussed, with African women feeling that the level of care received by children was very good. Children born outside of the UK required ‘catch up’ immunisations, the schedule of which was explained thoroughly.

Many refugees and asylum seekers felt that certain processes were difficult, including GP registration and gaining access to other services. This was, in part, due to issues with language and confusion about the structure of services in the UK. Park Community Practice was felt to be the easiest place to register and ensure an appointment. However, several individuals felt that they were treated unfairly by some practices. Particular issues were also noted with the difficulties in registering with dentists in the area. Many individuals felt as though their dental health had been neglected, and had additional difficulties booking appointments due to the language barrier.

All individuals felt great appreciation for St Augustine’s centre, as this provided them with a safe space to discuss a range of issues. The opinion that this centre was a key factor in improving their physical and mental health was unanimous in all asylum seekers and refugees.

Overall, refugees reported better health than asylum seekers. This was due to a number of factors, including reduced psychological stress, opportunities to access healthcare, and an improved awareness of the services and entitlements they had.

Unmet need

Following conversations with different organisations around Calderdale, such as community teams, the local GP practices and St Augustine’s, several key themes came to light. These were similar to those discussed in research in other parts of the UK.

An important issue discussed was access to primary and secondary care, and the expectations of that care. Several individuals felt that they did not experience fair treatment when attempting to register and book an appointment at GP practices.

In terms of physical health needs, dental care was outlined as a key unmet need. Many individuals experienced difficulties in registering and seeing dentists in the area. Some reported being told that without bringing a relative to translate, they would not be able to register, and would not be able to see a dentist even in an emergency. This is of particular concern, as dental problems are often neglected in asylum seekers and refugees.

Mental health needs were also identified as being an unmet need. The needs of some individuals requiring treatment for mental health conditions were not found to be met. Despite being prescribed medication, no psychological therapies were offered, in part due to difficulties with language.

Several individuals felt that their housing concerns were not addressed. Some African- and Farsi-speaking individuals felt that damp housing and difficulties in access caused respiratory difficulties in their children.

Projected future need

The current global situation means that the UK can expect an increase in individuals seeking asylum from different places around the world, which may have implications on services and healthcare providers. Local services will play a key role in the experiences of asylum seekers and refugees.

It is vital that access to GP practices is improved, in addition to educating individuals about how the health system works in the UK. GP practices should be offered NHS registration guidance which outline key points, including the inability of some patients to provide identification and proof of address. In addition, it is necessary to liaise with other services to ensure they are aware of what is available, and what can be distributed if and when needed. Where possible, it would be advisable for GP practices to provide translated documents in advance. This would aid the GP practice in providing timely medical information, and would also allow the asylum seeker to prepare any questions beforehand.

Research from the Royal College of Midwives has shown the importance of care for pregnant asylum seekers and refugees ( Pregnant asylum-seekers: perceptions of maternity service provision - evidence based midwifery ). It has been advised that all women should be given a letter of referral to take with them on dispersal, in order to enhance the continuity of care.

As the number of those seeking asylum increases, the need for mental health services will also increase. Services must address the trauma of some refugees and asylum seekers through culturally sympathetic approaches.

Other areas include improving the quality of the living environment. Issues with dampness, overcrowding, and a lack of facilities have been shown to have a negative impact on the health of asylum seekers and refugees, and must be discussed further with G4S. Additionally, access to gym services is currently being discussed, as many felt that this could be a means of improving both the physical and mental health amongst asylum seekers and refugees.

Key considerations linked to the known evidence base (what works?)

Key recommendations from research conducted within the Health Needs Assessment will inform considerations for future planning. This includes what is considered to be good evidence-based practice in other areas similar to Calderdale related to the Health Needs Assessment results.

It is important to understand that the journey of an asylum seeker has an impact on both physical and mental health. The development of known and appropriate routes of access to healthcare should be made known, with interpreter services being made available. The language barrier is a key difficulty for asylum seekers and refugees that must be overcome. The psychological and emotional needs of asylum seekers and refugees are complex. Access to appropriate services and healthcare is imperative.

Importantly, asylum seekers and refugees are not a homogenous group and their needs will be individual just like the rest of the population.

Reference and further information

References

Further information

An insight into the health needs of asylum seekers and refugees can be found in the PDFHealth needs assessment: refugees and asylum seekers [PDF 642KB]

More information can be found in Further resources .

If further information is required please contact katie.comer@calderdale.gov.uk .

Always open first panel: 

Author

Katie Neill, Specialist Registrar, Public Health, Calderdale Council;
edited by Emily Powell, Public Health Intelligence Intern, Public Health, Calderdale Council.

25 January 2016, updated 25 November 2016.