The UK has a long history of migration, which has given rise to a diverse population, comprising a range of nationalities, ethnicities and generations of migrants. In 2018, it was estimated that 14% of the UK population were born overseas (Office for National Statistics (ONS), 2018a). Predictions suggest that the scale of international migration, as well as displacement (migration driven by force, compulsion or coercion), will continue to rise (International Organization for Migration (IOM), 2017a). As the world becomes more interconnected, knowledge and understanding of how to care for migrant patients will become increasingly valuable and important for health professionals in the UK.
Why do migrants come to the UK and where do they come from?
Migrants come to the UK for a variety of reasons, but most commonly they come to work, study or accompany family members. According to the most recent estimates, the leading countries of origin of long-term international migrants to the UK were Poland, India, Pakistan, Romania and the Republic of Ireland (net UK migration was estimated to be 283 000 in the year ending September 2018) (ONS, 2018b). Asylum seekers and refugees make up a much smaller subset of the population.
In 2018, 15 891 people were offered protection in the form of grants of asylum – alternative forms of protection and resettlement (Home Office, 2018). UK asylum applicants in 2018 were most commonly from Iran, Iraq and Eritrea, while the majority of resettled refugees were of Syrian nationality and came to the UK through the Vulnerable Persons' Resettlement Scheme (Home Office, 2018).
What are the health needs and strengths of migrants to the UK?
Migrants are not a homogeneous group and their health outcomes and needs can be influenced by a range of factors, including their country of origin, length of time in the UK, living conditions, socioeconomic status, the circumstances of their migration, and other cultural, ethnic and genetic factors. Some migrants come from countries with a similar health profile to the UK, such as western European countries, the US, Australia and New Zealand, while others come from countries where disease epidemiology is very different, such as India and Pakistan (Wagner and Jones, 2011).
It is important to note that most migrants who come to the UK are young and healthy adults. However, there are certain populations that have specific health needs and they may be at greater risk of infectious diseases (such as tuberculosis (TB) or vaccine-preventable diseases, due to incomplete vaccination status); of mental health issues, or victims of modern slavery; human trafficking or sexual and gender-based violence.
The Government committed to resettle 23 000 of the most vulnerable people affected by the Syrian conflict by 2020, many of whom will have specific health needs because of experiences of trauma, torture, conflict and displacement before arriving in the UK. Health professionals must be cognisant of these less familiar health issues and contexts, while also recognising their patients' resilience and the role that they may play in developing and nurturing their resilience.
UK migrant populations provide a substantial contribution to society and can display considerable resilience when supported (IOM, 2017b). The UK also has a long history of using migrant labour to fill skill gaps in the health sector (Jayaweera, 2014) and migrant workers have made significant contributions and continue to play an important role in the healthcare workforce.
What services are migrants entitled to on the NHS?
All primary care services, whether general practice consultations, treatments provided by health professionals, or other equivalent services, are free of charge to everyone in England. Vaccinations in line with the National Immunisation Schedule (Public Health England (PHE), 2017a) are also free. However, there is still a knowledge gap among those working at the frontline of primary care. In a recent survey, almost one-quarter of health professionals interviewed (n=414, 23%) were not aware that general practice consultations were free to all migrants (Roche et al, 2018). This highlights the need for increased awareness around core health policies.
Access to free secondary healthcare is based on being ‘ordinarily resident’ in the UK (ie living lawfully in the UK on a properly settled basis for the time being) (Department of Health, 2016). This means that people not ordinarily resident in the UK may be charged for NHS secondary care services should they access them, including by referral. However, refugees, asylum seekers whose claim is active, and some refused asylum seekers are entitled to free healthcare at all levels of care. For a full description of NHS entitlements for migrants, see the Migrant Health Guide (PHE, 2014).
Although primary care is available to all, evidence shows that some migrant populations have lower engagement and wait longer to register with a GP
What stops some migrants from accessing healthcare in England?
Although primary care in England is free and available to all, evidence shows that some migrant populations have lower engagement and wait longer to register with a GP compared to the general population (Thomas et al, 2010; Phillimore, 2016; Doctors of the World (DoTW), 2017). Studies have shown that migrants have been turned away from practices when trying to register owing to a lack of identification or proof of address, despite this information not being required by law (DotW, 2017; DoTW, 2015).
Research has also shown that migrants may be less likely to engage with health services and in particular primary care, due to fear of authorities, uncertain immigration status or fear of being charged for care (Aung et al, 2010; Jayaweera, 2014; DoTW, 2015; 2017; World Health Organization (WHO), 2016; Nellums et al, 2018b; 2018a).
The Safe Surgeries initiative by DoTW tries to address some of the barriers migrants face when accessing care. It highlights NHS principles and guidelines and encourages GP practices to declare themselves a safe practice for everyone. PHE (2014) produced the Migrant Health Guide and other resources to support health professionals in caring for migrant patients. The Migrant Health Guide is an open-access online resource that contains practical guidance on NHS entitlements, a range of health issues and country-specific information for more than 100 countries of origin.
Access to primary care
- Primary care in England is free of charge for everyone. Routine vaccinations in line with the National Immunisation Schedule, and testing and treatment for blood-borne viruses and sexually transmitted infections, are free in the UK
- A GP practice cannot refuse a patient because they do not have identification or proof of address
- A GP practice is not required to request proof of identity or of immigration status from patients wishing to register
- If a patient is refused registration, the GP must still provide, free of charge, any immediately necessary treatment requested by the patient for a period of up to 14 days
- Maternity care (including ante- and postnatal care in hospital or via community services) is classed as urgent and immediately necessary and should never be withheld.
‘Wherever possible, record ethnicity, country of birth and date of entry to the UK in notification forms and health information systems’
Assessing new migrant patients
The Migrant Health Guide (PHE, 2014) includes guidance on assessing new patients from overseas and highlights helpful information that a primary care practitioner might want to consider during an initial consultation. This information is also available as a checklist (migrant.health, 2016). Some of the key topics that a health professional may want to consider when assessing a new migrant patient will be discussed.
Immunisation
It is important to ensure that all migrants are up-to-date with their immunisations, as newly-arrived migrants to Europe are less likely to be immunised than the existing population (Mipatrini et al, 2017). PHE recommends immunisation status should be checked in general practice at the time of registration, and that new migrants should be brought up-to-date with the UK schedule (PHE, 2017a). Additionally, WHO stated that migrants should be vaccinated without unnecessary delay according to the schedule of the country in which they intend to stay for more than a week, with priority given to measles, mumps and rubella and polio vaccines (WHO et al, 2015).
Studies have shown that well-informed migrants routinely accept vaccination, sometimes at a rate higher than the host population (Guttmann et al, 2008). However, difficulties may arise due to lack of awareness of the need to check immunisation status (by both the individual themselves and the health professional), incomplete vaccination documentation, and problems with interpreting vaccination records from overseas. There are also the many barriers to migrants successfully registering with a GP, which have previously been mentioned. The PHE (2013) guidance on vaccination of individuals with uncertain or incomplete immunisation status provides a one-page summary for health professionals who administer vaccinations. This is in addition to PHE's collection of guidance on immunisation, such as the Green Book, patient leaflets, and information for health professionals on specific immunisation programmes (Box 1).
Box 1.Useful resources
- Public Health England – Migrant Health Guide: https://www.gov.uk/topic/health-protection/migrant-health-guide
- Doctors of the World – “Safe Surgeries” toolkit: https://www.doctorsoftheworld.org.uk/what-we-standfor/supporting-medics/safe-surgeries-initiative/safe-surgeries-toolkit/
- NHS England – Guidance on patient registration for GP practices: https://www.england.nhs.uk/publication/primary-medical-care-policy-and-guidance-manual-pgm/
- Doctors of the World – migrant.health portal: https://migrant.health/
- The Truth About TB – Tuberculosis specialist nurse pack: https://www.thetruthabouttb.org/wp-content/uploads/2016/08/Nurse-Resource-Pack-on-TB-Management-Control-Prevention.zip/
- Equality and Human Rights Commission – Guidance on helping people seeking asylum access health care: https://www.equalityhumanrights.com/en/refugees-asylum-and-immigration
- Public Health England – UK TB strategy: https://www.gov.uk/government/publications/collaborative-tuberculosis-strategy-for-england
- Public Health England – UK measles and rubella strategy: https://www.gov.uk/government/publications/measles-and-rubella-elimination-uk-strategy
- World Health Organization – HIV and hepatitis strategies: https://www.who.int/reproductivehealth/ghs-strategies/en/
- Public Health England – The Green Book: https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book
- Public Health England – Immunisation collection: https://www.gov.uk/government/collections/immunisation
- National Institute for Health and Care Excellence – Hepatitis B and C testing: people at risk of infection: https://www.nice.org.uk/guidance/ph43/chapter/recommendations#whose-health-will-benefit
- Health Education England – Identifying and supporting victims of modern slavery: https://www.e-lfh.org.uk/programmes/modern-slavery/
Offering immunisation to migrants is important, as outbreaks of vaccine-preventable diseases (including measles and hepatitis A) have been reported in migrant populations in the European region (Mipatrini et al, 2017). The number of measles cases in Europe trebled in 2017, with large outbreaks still ongoing in several countries. Several measles outbreaks in the UK in 2017 and 2018 have been linked to migrations from Europe, particularly Romania, with initial spread concentrated in the Romanian and other under-vaccinated communities. Many of the people affected were not registered with a GP and did not speak English, so community outreach and engagement, including domiciliary vaccination and community clinics, was a key component of the outbreak response (PHE, 2019b).
The European Centre for Disease Prevention and Control (ECDC) (2018) has published guidance on screening and vaccination for infectious diseases in newly arrived migrants in the European Union and the European Economic Area, and states that information regarding immunisation should be available in multiple languages, particularly those most commonly spoken by arriving migrants. PHE has developed a new leaflet aimed at encouraging vaccination uptake among new migrants to the UK. The leaflet will be available in a range of different languages and has a secondary aim of informing migrants of how to access healthcare in England. It has been developed with input from migrants living in England and stakeholders involved in care provision.
Risk of infectious diseases
Infectious disease surveillance
Migrants tend to bear a disproportionate burden of some infectious diseases when compared to the UK-born population. They are therefore an important group to monitor infectious diseases and target for interventions to prevent and control the spread of infection, particularly TB, measles, rubella, HIV, and hepatitis B and C, where the UK or WHO is working towards an elimination goal. However, data on the health of migrants in the UK is limited, as much of the healthcare administrative data is recorded and reported on ethnicity, rather than migration history or country of birth (Care Quality Commission, 2010). Wherever possible, record ethnicity, country of birth and date of entry to the UK in notification forms and health information systems.
Active and latent tuberculosis infection
TB in England disproportionately affects the non-UK born population. In 2017, nearly three-quarters (71%, n=5,010) of TB notifications in England, where place of birth was known, were among people born outside of the UK, largely in the Indian subcontinent and Africa. TB rates were also 13 times higher in the non-UK versus UK-born populations (PHE, 2018).
It is important to consider the risk of TB in patients who have recently arrived in the UK from high-incidence countries, and to refer them early to TB services. Late diagnoses are associated with worse outcomes for the individual and, in the case of pulmonary TB, with a transmission risk in the community. It is likely that most TB cases in England are the result of ‘reactivation’ of latent TB infection (LTBI), an asymptomatic phase of TB that can last for years (PHE, 2016). The national latent tuberculosis infection (LTBI) testing and treatment programme for new entrants from high incidence areas is an effective and cost-effective public health intervention, recommended by the National Institute for Clinical Excellence (NICE).
Migrants are also more likely to present with extra-pulmonary TB (EPTB) compared to UK-born people, therefore it serves to be vigilant of the signs and symptoms of EPTB among those who might be at risk. TB can be a stigmatising diagnosis due to the associated risk factors. A caring and respectful attitude towards patients is essential and can help ensure treatment compliance and the success of public health measures, such as contact tracing.
Hepatitis B and C testing and treatment
Migrants born in intermediate or high-prevalence areas for blood borne viruses (BBVs), including hepatitis B, hepatitis C and HIV, are at increased risk of these infections. NICE (2013) guidance recommended that general practices test individuals at higher risk of BBV, including migrants from higher prevalence countries (2% risk or greater), to increase diagnoses and offer referral for treatment, which is potentially curative for hepatitis C. A study of policy and practices of general practice staff in England showed that the vast majority of screening for BBVs in migrants was opportunistic, with less than 40% (n=258) of responding practices offering universal opt-out screening for BBVs in new migrants registered with their practices (Roche et al, 2018). There is now compelling evidence from a multi-site study in general practices in the UK, called HepFREE, that interventions at general practice level – including algorithms on primary care information systems to flag migrant patients and automated invitations for testing – could increase the uptake of testing and access to care of migrants and be highly cost-effective (Flanagan et al, 2019).
The Migrant Health Guide contains country-specific information for over 100 countries of origin to help practitioners make informed decisions about testing their patients based on risk factors (PHE, 2014). Remember to routinely record BBV testing and diagnosis data in health information systems.
Visiting friends and relatives overseas
Almost two-thirds (65%; n=525) of malaria cases in England in 2017 were among people born in Africa who had acquired their infection while visiting friends and relatives (VFR) in their home country (PHE, 2017b). The majority of annual hepatitis A cases occur in migrants who travel overseas when VFR, where information is available (PHE, 2019a). VFR travellers tend to travel for longer and stay as part of the local community while overseas. They may not seek travel health advice or vaccination, and they may not consider themselves at risk because the destination is familiar to them.
Health professionals may want to consider asking migrant patients opportunistically about their travel plans when they attend for other reasons, and encourage them to attend for further travel health advice and vaccination if appropriate. It is also important to be vigilant to the signs and symptoms of travel-associated infections in unwell patients, and to always take a detailed travel history.
Human trafficking and modern slavery
There were an estimated 10 000–13 000 potential victims of modern slavery in the UK in 2013 (Home Office, 2014; HM Government, 2017); however, accurate prevalence measures are difficult to obtain. Human trafficking, a form of modern slavery, is a hidden crime and it is rarely obvious that an individual has been trafficked. However, evidence has shown that trafficked individuals often make contact with the healthcare system while being exploited (Macias-Konstantopoulos, 2016). In a study conducted in the US, 88% (n=98) of female survivors reported being medically evaluated at least once while trafficked, but none were identified as being victims (Lederer and Wetzel, 2014).
Gaps in training may play a part. In a cross-sectional survey with NHS professionals, 1 in 8 participants reported previous contact with a patient whom they knew or suspected had been trafficked; however, very few (<5%) were aware of the true scale of human trafficking in the UK. The majority (86.8%) reported that they lacked knowledge of what questions to ask to identify potential victims, and 78.3% reported that they had insufficient training to assist trafficked people (Ross et al, 2015).
The Migrant Health Guide (PHE, 2014) has information about detecting, responding to and caring for people who may have been trafficked, and signposts to other resources that may be useful for the healthcare provider. It also highlights potential red flags for identifying victims, safeguarding principles, such as consulting with the patient before contacting other support services (such as police) to assure patient and provider safety, and ways to help prevent disempowering or re-traumatising trafficked individuals.
Mental health
Most migrants are healthy and resilient, but certain communities may be at increased risk of developing mental health conditions as a result of their experiences before, during and after migration (Rousseau and Frounfelker, 2018). Stress-related disorders, such as anxiety and depression, are generally more prevalent among refugee populations compared to the general population. Adjustment issues are also common among anyone who has been separated from family and friends or is integrating into a new society.
Exposure to extreme and uncontrollable events such as conflicts and natural disasters can result in severe and long-term post-traumatic disorders (IOM, 2011), that may require referral to specialist services. Unaccompanied children and survivors of torture, sexual and gender-based violence may be particularly vulnerable. The psychological impact of torture is long-lasting and referral to appropriate services, such as those offered by the Freedom from Torture organisation, should be considered for torture survivors.
It is also important to be aware of different cultural and religious perceptions and attitudes towards mental health. In many cultures, mental illness is a source of shame, stigma and taboo. It may be regarded as a personal weakness, a punishment for past sins or a form of possession by supernatural agents or spirits. Be aware that your patient may have their own sociocultural constructs of mental health and may manifest symptoms in a non-specific way. It is common to see psychological distresses expressed in a physical manner (‘somatisation’), for example, in the form of headaches, backaches and stomach aches, in non-western cultures where psychological problems are stigmatising (Mehraby, 2009).
Sociocultural considerations
A patient's expectations of the healthcare system may differ depending on what country they come from. They may not be familiar with the role of a practice nurse nor may they expect to be seen by a nurse for diagnosing illnesses and ailments or receiving routine immunisations. They may also expect to see a specialist doctor on initial consultation, rather than a general practitioner.
It can be helpful to spend time with a patient at the start of a consultation to explain how the NHS works, including the roles of primary care staff and how to access different types of care, in order to manage expectations. Patients may also have different perceptions of health and illness as shaped by their culture. Some considerations when working with migrant patients are:
- Language: does my patient need an interpreter? What considerations do I need to make when requesting and using an interpreter (eg language/dialect, gender, appointment length, how to address the patient)?
- Gender: what is acceptable to my patient in terms of a consultation or diagnostic examination? Do they know they can request a chaperone? Do they wish to be seen by someone of the same gender?
- Cultural beliefs and practices: does my patient have any religious or cultural beliefs that need to be considered? Is my patient at risk of any cultural practices that are not lawful in the UK, such as female genital mutilation (FGM)?
- Sensitivity: how can I build trust and rapport with my patient? What issues might be sensitive to them? How can I address sensitive topics without alienating or stigmatising them?
- The NHS: what does my patient know about the NHS? How does this compare to the health system where they have come from? Do they know which service is appropriate for different types of care? Do they know their entitlements?
- VFR: does my patient have any plans to visit friends and relatives overseas? What is my patient's recent travel history? Have I included travel history when requesting laboratory investigations?
KEY POINTS
- In 2018 an estimated 14% of the UK population were born overseas
- Understanding how to care for migrant patients is becoming increasingly important for health professionals in the UK
- Most UK migrants are young and healthy adults who come to work; however some migrant populations bear a disproportionate burden of disease compared to the general population
- All primary care and equivalent services, and vaccinations in line with the National Immunisation Schedule, are free of charge to everyone in England
- Public Health England's Migrant Health Guide is an open-access online resource that contains practical guidance on NHS entitlements, a range of health issues and country-specific information for more than 100 countries of origin
CPD reflective practice
- What have I learned from this article? Is there any new information or guidance that I was not aware of previously?
- Think of a time when you interacted with a migrant patient. What did you do well? What were the challenges? Is there anything you would do differently now, based on what you have learned?
- Reflecting on your practice, what could you and your team do to ensure the care you provide is more socially and culturally inclusive, drawing on the suggestions in this article?
- What are the main steps for detecting, responding to and caring for victims of human trafficking in England?