It is estimated that there are currently over 117,000 refugees in the UK. Many will have fled from war or imprisonment, and may have experienced physical or sexual abuse. The majority will have been separated from loved ones, either as a result of death or geography. For doctors, caring for this vulnerable group of people presents a number of unique challenges.
So, what are some of the problems refugees experience in terms of their physical and mental health? And what pracitcal steps can practices take to try break down some of the barriers refugees face when trying to access healthcare?
Refugees may speak little or no English and it may be difficult even to determine what language they are speaking. Keeping a language identification card at reception, such as that provided by the Refugee Council UK, can be helpful (see resources below).
A family member may be on hand to assist with translation, but there are several risks associated with this arrangement. For example, a patient may not feel comfortable discussing sensitive topics in front of a relative, or the relative may present their own version of events rather than directly translating what the patient says which could lead to confusion and result in a complaint later on. A child translator may be required to participate in an unsuitable conversation regarding, for example, violence or sexual abuse.
It is therefore best to access professional translators where possible, and local refugee organisations may be able to suggest appropriate individuals or services.
Double appointments are advisable if translation is required, as the consultation will inevitably be more time-consuming. Depending on the local population, it may be helpful to provide patient information leaflets and appointment booking forms in relevant languages.
Educating staff and patients
There may be anxiety about whether a refugee is entitled to register with a practice. It is important to ensure that reception staff have a basic understanding of the relevant legislation relating to migrants NHS entitlements (see below).
Broadly speaking, refugees are entitled to register with a general practice within the NHS and receive care free of charge. The RCGP has published a useful position statement outlining who is eligible to register with a GP.
The healthcare system in the patient’s country of origin may be very different to that in the UK. At the initial consultation, it is helpful to have a discussion about the role of the GP and how to access care. An awareness of local refugee groups and support services can aid in signposting patients to alternative sources of help.
Not all refugees’ needs will be medical and they may look to their GP, as a trusted member of society, for guidance.
Cultural awareness and other factors
Refugees form a culturally diverse group. People from different backgrounds react to stress in different ways, and there may be variation in the way in which particular conditions present. For example, multiple somatic symptoms may be a manifestation of depression.
Some patients may find certain investigations unacceptable; others may hold a belief that it is best to actively forget bad experiences rather than to seek treatment such as counselling.
Some may ask to see a clinician of a particular gender, due either to their culture or past events. If it is not possible to arrange for this, an explanation should be given, and it may be helpful to arrange to have a chaperone of the preferred gender present during the consultation.
Continuity of care can be particularly important for refugees. A trusting relationship with a GP can be key to enabling disclosure of torture or rape for example. Seeing the same individual over time can also mean that a distressing event does not need to be recounted at each appointment.
Refugees may present with a range of physical health problems. Many of these will be familiar to the GP; however, certain diseases may occur more commonly. For example, there may be a higher prevalence of infectious diseases such as TB and HIV in the patient’s country of origin. In the absence of a detailed past medical history it may be necessary to do some epidemiological fact-finding.
Conditions during travel to the UK may have been crowded and lacking in sanitation, leading to problems such as scabies and gastroenteritis.
Refugees may be living with the physical consequences of torture, such as post-traumatic head injury, brachial plexus injury as a result of suspension, malnutrition, and damage to eyes and ears.
In women of child-bearing age, it is important to consider sexual health and family planning, as well as the possibility of unwanted pregnancy. Depending on the country of origin, female genital mutilation may have occurred.
Refugees are in a uniquely vulnerable position. Having lived through traumatic experiences in their own country, they are then required to adapt to a new life in a different country, often without their usual support network.
Unusual behaviour may be due to an acute stress reaction, but mental illnesses such as depression or psychosis should also be considered, and indeed are more prevalent in this population.
GPs should be alert to the possibility of PTSD, which is commonly seen in victims of torture. Symptoms can include flashbacks, avoidance and emotional numbing; and referral of these patients to a specialist psychiatric service is likely to be necessary. NICE has published guidance on PTSD which may be useful in recognising the condition.
Other roles for GPs
Outside primary care, doctors can play a valuable role in organisations supporting refugees, signposting individuals to medical services, or providing treatment. If you are involved in such work, it is important to inform your medical defence organisation to ensure you are appropriately indemnified.
- Lucy Hannington is a medico-legal adviser at Medical Protection