• We are sorry, but NCBI web applications do not support your browser and may not function properly. More information
Logo of bmjBMJ helping doctors make better decisionsSearch bmj.comLatest content
BMJ. Nov 21, 1998; 317(7170): 1444–1446.
PMCID: PMC1114300

Refugees and primary care: tackling the inequalities

David Jones, lecturera and Paramjit S Gill, senior lecturerb

As the 20th century draws to a close, outbreaks of hatred between human population groups show no sign of abating and conflicts continue to erupt. Families across the world find themselves forced to leave their homes and seek refuge where it can be found.

Globally, there are 18 million refugees with 230 000 living in the United Kingdom (see box 1).1 Almost half of these live in London, where 100 000 people are refugees or awaiting confirmation of refugee status.2 Asylum seekers come from several countries around the world (see box 2). Many refugees have health problems but experience difficulty having their needs met by the NHS.3 This article explores the challenges that refugees pose for primary care and suggests alternative strategies to address inequalities in the care of refugees.

Summary points

  • The refugee population in Britain is highly diverse and is likely to remain large as conflicts continue to occur throughout the world
  • Refugees, unlike other migrants, have had to flee to escape oppression
  • The refugee population is concentrated in the greater London area, but new legislation will result in dispersal throughout the United Kingdom
  • Refugees may be vulnerable to mental health problems yet have difficulty communicating their needs because of language barriers
  • All refugees are entitled to the full range of NHS services free of charge, including registration with a general practitioner
  • A strategic approach is needed to address the inequalities in primary care

What happens to refugees?

In Britain the geographical distribution of refugees has been influenced by many factors, including local authorities’ housing policies.4 The refugee population is not evenly spread but concentrated in areas where local authorities have given refugee housing a higher priority.5 Recent legislation will result in greater dispersal of refugees,6 which will make the provision of specialist services more difficult.

“Cultural bereavement”7 and coping with “deeply disruptive change”8 are widely shared experiences of migration. But refugees are distinguished from other migrants by their lack of choice. Refugees have had to leave their countries of origin to escape persecution, imprisonment, torture, or even death. Families may have been physically separated, causing much grief. Refugees are often preoccupied by worry about relatives left behind in their country of origin. Many refugees, including children, have no other relatives in the United Kingdom. Poverty and dissatisfaction with housing is widespread.4

Health problems

Some health problems, especially parasitic and nutritional diseases, are determined by the country of origin and vary between refugee groups.9 Mental health problems have been found to be influenced by various factors including language difficulties, family separation, hostility from the host population, and traumatic experiences before displacement.10 Some of these factors may be found in non-refugee migrants, but refugees are especially vulnerable. A recent UK study of Iraqi refugees found that all had been separated involuntarily from some close family members, 65% had a history of systematic torture during detention, and 29% were unable to speak any English. Over half of this group had significant psychological morbidity when tested.11 There is evidence that refugees who have not yet been granted the right to remain are under particular stress.12 Karmi has highlighted the importance of early recognition and treatment of psychological problems.13

Deficiencies of primary care

Although all refugees are entitled to the full range of NHS treatment free of charge, including the right to register with a general practitioner, there is evidence that some general practitioners are confused about this.3 A study in Islington found that 38% of refugees encountered problems registering with a general practitioner.14 Some patients are asked for passports when trying to register,15 which raises a number of questions. What happens to patients unable to produce a valid passport? Are they sent away? Who makes these decisions? General practices differ in their attitude. Some practices are, perhaps reluctantly, open for refugees whereas others are effectively closed, creating neighbouring practices with very different demographic profiles and unequal needs.

Information on general practitioners’ perceptions of refugees’ health needs is limited. Perhaps reflecting the low level priority that refugees receive on the national agenda, most studies are local and small scale, but they suggest that problems exist. Ramsey and Turner found that 50 general practitioners identified a diverse range of problems and five practitioners reported their own anxiety in dealing with patients “with special needs who seemed to take up a disproportionate amount of time.”16 Seventeen general practitioners in this study identified language difficulties as the reason for their associating refugee status with lengthy and time consuming consultations.

When refugees join a general practitioner’s list they are often registered on a temporary rather than a permanent basis. This prevents access to past records, if there are any, and removes financial incentives to undertake immunisation and cervical smear tests. Why do general practitioners avoid giving refugees permanent registration status? Some have justified this on the grounds that refugees move around and that this mobility makes it inappropriate to offer permanent registration. This reputation for high mobility may be exaggerated, as a 1995 Home Office study found that 70% of refugees had been living in their current home for more than a year.4

Refugee families are not likely to have enjoyed good quality primary care in their countries of origin. Immunisation rates may be low,17 and medical records are usually not available. Language barriers at the reception desk and in the consultation are common. Health authorities lack knowledge about the languages spoken in their districts and of the extent of the need for interpreter services. These are generally not available outside working hours18 and for acute consultations. Telephone interpreting using “hands free” technology may offer a solution to the practical problems in providing interpreting services for many different language groups dispersed between practices, but this remains underdeveloped.19

Effective communication improves health outcomes,20 and Meryn has argued that doctors have responsibilities to their patients that can be fully met only by effective communication.21 Lack of adequate professional interpreting services presents a barrier for all non-English speaking patients, but this barrier is larger for those with psychological and emotional difficulties that can only be explored verbally. If tragic mistakes are made as a result of communication failure does moral responsibility rest with the doctor or with a medical system which expects doctors to communicate well but fails to provide adequate resources?

Increasing spending on refugee primary care

We consider increased spending on refugee health to be fully justified on clinical and ethical grounds but recognise that it requires considerable political courage to prioritise refugees at a time when other groups in the population, such as elderly people and the mentally ill, have been identified as in need of greater resources. It is important to remember that many refugees who settle in Britain have made valuable contributions to society.22

The General Medical Services Committee has successfully negotiated extra resources for those general practitioners whose work is thought to contain additional elements not presently properly rewarded.23 The care of refugees generates an additional workload for general practitioners, and there is evidence that current deprivation payments are not adequate.24 We believe that some of the £60m negotiated by the committee should be used to reward doctors caring for such patients. Financial audit would need to be robust.

What can be done to improve primary care for refugees?

A strategic approach is required, which should include providing refugees with intensive courses in spoken English. The Department of Health needs to commission an information pack that includes a certificate of entitlement to NHS treatment and to develop patient held medical records for refugees. The development of a national telephone interpreting service in a range of languages is a priority. A separate capitation payment for refugee patients, together with a new item of service payment linked to the duration of each professionally interpreted consultation, should be introduced.

Health authorities need to provide all practices with detailed guidelines for the process of registration and to introduce a mechanism to ensure ethical standards are being adhered to. Healthcare facilitators should be recruited from each specific refugee population and could help to provide patient held records with an accurate and detailed medical history and support health promotion and screening.

Primary care groups are being introduced25 and should be given the resources to address the distortions created by different practice policies towards the registration and care of refugees and other marginalised patients.

Conclusion

The refugee population is likely to remain large. High needs, especially psychological distress, combined with language barriers require a great deal of additional time in consultations. General practitioners in inner cities need adequate resources, especially interpreting services, and should be properly rewarded. We have outlined some ideas for dealing with this. A truly effective solution requires the political will to develop a comprehensive strategy at national level.

—Definition of refugees
—Top 12 countries of origin of refugees in Britain (1997)*

Acknowledgments

We thank all our colleagues and the anonymous referee for their helpful comments.

Footnotes

Funding: None.

Conflict of interest: None.

References

1. The state of the world’s refugees: the challenge of protection. London: Penguin; 1993.
2. Turnberg L. Health services in London: a strategic review. London: Department of Health; 1997.
3. Promoting the health of refugees. London: Refugee Health Consortium; 1998.
4. Carey Wood J, Duke K, Karn V, Marshall T. The settlement of refugees in Britain. Home office research study 141. London: HMSO; 1995.
5. Joly D. Haven or hell: asylum policies and refugees in Europe. London: Macmillan; 1996. pp. 120–138.
6. Home Department. Fairer, firmer, faster—a modern approach to immigration and asylum. London: Stationery Office; 1998. (Cm 4018.)
7. Eisenbruch M. From post-traumatic stress disorder to cultural bereavement: diagnosis of Southeast Asian refugees. Soc Sci Med. 1991;33:673–680. [PubMed]
8. Loizos P. The heart grown bitter: a chronicle of Cyprus war refugees. Cambridge: Cambridge University Press; 1981.
9. Dick B. Diseases of refugees—causes, effects, and control. Trans R Soc Trop Med Hyg. 1984;78:734–741. [PubMed]
10. Karmi G. Refugees in North West and North East Thames Regional Health Authorities. London: NETRHA, NWTRHA; 1992.
11. Gorst-Unsworth C, Goldenburg E. Psychological sequelae of torture and organised violence suffered by refugees from Iraq: trauma-related factors compared with social factors in exile. Br J Psychiatry. 1998;172:90–94. [PubMed]
12. Sinnerbrink T, Silove D, Field A, Steel Z, Manicavasagar V. Compounding of premigration trauma and postmigration stress in asylum seekers. J Psychol. 1997;131:463–470. [PubMed]
13. Karmi G. Refugee health requires a comprehensive strategy. BMJ. 1992;305:205–206. [PMC free article] [PubMed]
14. Islington Refugee Working Party. Report on questionnaire survey. London: Islington Voluntary Action Council; 1992.
15. Grant C, Deane J. London: Brixton Challenge, Lambeth, Southwark and Lewisham Health Authority; 1995. Stating the obvious—factors which influence the uptake and provision of primary care services to refugees.
16. Ramsey R, Turner S. Refugees’ health needs. Br J Gen Pract. 1993;43:480–481. [PMC free article] [PubMed]
17. Murphy A, Lynch M, Bury G. Caed Mile Failte: an assessment of the screening of 178 Bosnian refugees to Ireland. Ir Med J. 1994;87(6):174–175. [PubMed]
18. Hicks C, Hayes L. Linkworkers in antenatal care: facilitators of equal opportunity in health provision or salves for the management conscience? Health Serv Manage Res. 1991;4:89–93. [PubMed]
19. Jones D, Gill P. Breaking down language barriers. The NHS needs to provide accessible interpreting services for all. BMJ. 1998;316:1476. [PMC free article] [PubMed]
20. Stewart MA. Effective physician-patient communication and health outcomes: a review of the literature. Can Med Assoc J. 1995;152:1423–1433. [PMC free article] [PubMed]
21. Meryn S. Improving doctor-patient communication. Not an option, but a necessity. BMJ. 1998;316:1992. [PMC free article] [PubMed]
22. Credit to the nation. A study of refugees in the United Kingdom. London: Refugee Council; 1997.
23. Gough CB. Review body on doctors’ and dentists’ remuneration pay: 27th report. London: Stationery Office; 1998.
24. Majeed FA, Martin D, Crayford T. Deprivation payments to general practitioners: limitations of census data. BMJ. 1996;313:669–670. [PMC free article] [PubMed]
25. Secretary of State for Health. The new NHS—modern dependable. London: Stationery Office; 1997. (Cm 3807.)

Articles from BMJ : British Medical Journal are provided here courtesy of BMJ Group
PubReader format: click here to try

Formats:

Related citations in PubMed

See reviews...See all...

Cited by other articles in PMC

See all...

Links

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...