Written evidence submitted by Doctors of the World
1.1 Doctors of the World (DOTW) UK runs clinics which provide medical care, information and practical support to people unable to access NHS services. Our patients include refugees, people seeking asylum, people who have been trafficked, people experiencing homelessness, sex workers, migrants with insecure immigration status and Roma communities. Asa medical organisations that helps people to access to healthcare, DOTW submits this evidence to improve health provision in asylum accommodation.
1.2 Although all asylum seekers (and those refused asylum seekers that are supported by Home Office i.e. section 4 and section 95 support) are entitled to access all NHS services free of charge, evidence shows that people who are forcibly displaced can have diverse health needs, but they often encounter barriers in accessing appropriate healthcare. Due to the outbreak of the COVID-19 pandemic, systemic barriers to health services have increased, and facilitating access to healthcare for people staying in asylum accommodation has become an increasing challenge for the Home Office, accommodation providers, local healthcare services and NGOs. Whilst length of stay in Initial Accommodation (IA) frequently exceeds the Home Office target of 19 days, deferral of routing during the pandemic has led to thousands of residents staying in IA and Contingency Accommodation for a number of months with limited to no healthcare provision. The Home Office has also procured dozens of new hotels to house asylum applicants without establishing local healthcare infrastructure to support residents, some of which are located remotely and at a significant distance from health facilities.
2.1 People who have been forcibly displaced are reported to have multiple health needs, yet research suggests that such individuals often find it particularly challenging to access appropriate healthcare in the UK despite being fully entitled to access all NHS services. Poor understanding of the NHS and how to access it is a significant barrier and asylum seekers are also often prevented from registering with a GP because they don’t have proof of address, ID or proof of regularised immigration status,.
2.2 GP registration is the main point of entry to the NHS; as well as managing conditions in the community and protecting public health, GPs are also the gateway to secondary (hospital) care. Patients who are not registered with a GP have significantly reduced access to NHS services frequently accessing care via A&E or walk in services. Support to register with a GP is only available to a limited group of people living in asylum accommodation and consequently many people in initial and dispersal accommodation are not registered with a GP and do not have access to adequate healthcare.
2.3 On arrival to asylum accommodation (both initial and dispersal), accommodation providers are required to provide direct support when a person is in “obvious and urgent” need of immediate medical care. Obvious and urgent care is defined as “a medical condition which is causing distress or a risk to the Service Users health and wellbeing”. Under the Asylum Accommodation and Support (Schedule 2) Statement of Requirements, accommodation providers are required to provide direct support when a person is in “obvious and urgent” need of immediate medical care. Obvious and urgent care is defined as “a medical condition which is causing distress or a risk to the Service Users health and wellbeing”. Immediate emergency assistance would be required, but not limited to, when the following type of event occurs: loss of consciousness, fits or fainting during the journey; heavy blood loss, suspected broken bones; severe chest pain; difficulty breathing or shortness of breath; numbness or weakness of the face, arm or leg, especially on one side of the body; sudden confusion, trouble speaking or understanding; trouble seeing or blurred vision, or trouble walking, dizziness or loss of balance; overdose, ingestion or poisoning; pregnancy complications, including, but not limited to, labour pains; an inflamed eye or a foreign body in the eye; attempted suicide; acute toothache and/or facial swelling; excessive vomiting.
2.4 In these situations, accommodation providers are required to do the following:
1) If, during transportation or on arrival at the accommodation, anyone is in obvious and urgent need of medical care:
a) take them to the nearest GP surgery for registration, treatment and referral; or
b) take them to the nearest hospital accident and emergency department for treatment, or call the emergency services if immediate assistance is required; or
c) take all necessary action, required in the reasonable opinion of the Provider, to ensure the timely and sufficient care for the Service User; and
2) If notified by the Home Office that a someone has need of urgent medical care:
a) take them to the nearest GP surgery for registration, treatment and referral; or
b) take them to the nearest hospital accident and emergency department for treatment
3) As a follow up in cases of immediate emergency assistance, accommodation provider is required to arrange for the Service User to be registered with a GP as a matter of urgency when they subsequently take up Accommodation.
2.5 DOTW suggests extension of the requirement to go beyond ‘transport and arrival’, and recommends that, where residents present with obvious and urgent medical needs, the accommodation provider ensures that residents are supported to access immediate medical assistance (A&E where appropriate) and are supported to register with a local GP.
3.1 Many residents in IA centres will be newly arrived in the UK. They may have recently experienced trauma and are struggling to adjust to their new life, yet they have particularly poor access to NHS services and little knowledge of their right to healthcare. In most IA centres healthcare is provided by a designated healthcare provider. These healthcare providers are responsible for arranging initial non-mandatory health screening and providing basic, interim primary care. Accommodation providers are required to provide direct support when a person is in an “obvious and urgent” need of medical on arrival.
3.2 In practice, very few asylum seekers in IA are registered with a GP or receive support to do so. This arrangement with a designated health screening and provision is not sufficient to address the needs of some residents. Health providers often don’t have mental health support or counselling services and they don’t refer people to secondary care services. Because asylum applicants are not registered with mainstream health services, they are not provided an NHS number, and this can be a barrier for many applicants who need specialist healthcare from NHS hospitals. In some locations, a single health service is located at one accommodation site but covers a number of accommodation sites meaning some residents are several miles away with little access to transport services. People in IA, including those with serious health conditions, often do not know of their right to register with a GP if they are not satisfied with the care provided by this designated healthcare team.
3.3 Case Study 1: DOTW conducted a local needs assessment exploring healthcare access across 3 IA centres in England during 2019. The needs assessment found that:
As part of the assessment, the DOTW clinic provided consultations to 9 residents living in IA and found unmet healthcare needs and evidence that people had poor access to the NHS. Every patient had unmet healthcare needs and 22% needed an urgent GP appointment based on their clinical condition. None of the patients were registered with a GP or demonstrated correct understanding of their entitlement to NHS services.
3.4 During normal circumstances healthcare arrangements in IA are insufficient to meet people’s needs and some struggle with poor physical and mental health for months. During the pandemic, the 19-day maximum stay target is frequently exceeded in IA, and asylum seekers can go without comprehensive healthcare for long periods of time. The pandemic has also increased the need for people to have good and easy access to medical advice and NHS services.
3.5 Evidence collected from DOTW’s helpline demonstrates that residents do not have good access to mainstream health services, and they needed further help from our caseworkers. Since April 2020, DOTW helpline have received calls for help from 32 patients who are housed at IA centres and hotels. While 5 of them identified themselves as having mental health needs, 2 needed access to medication and 1 needed cancer screening. Considering the existing support mechanisms within the IAs, this evidence indicates that residents in IA hotels still need extra support to access healthcare, and that their conditions and medication needs are not picked up through initial health screening. Similar evidence is published recently by the National Audit Office and Home Affairs Committee, highlighting a ‘deeply concerning” lack of access to mainstream health services (GPs) for those in IA during COVID-19 outbreak.
3.6 Case study 2: Since August 2020 DOTW has run 10 clinic sessions at a hotel in London used as temporary IA, carrying out initial health screening and supporting residents to register with the local practice. To date, the team have supported 38 of the 170 residents. Data collected during sessions indicates that
50% of residents we spoke to identified as having a mental health need, over 60% took medication and of these, over 70% did not know how to access a repeat prescription. 84% of residents did not have a HC2 certificate to enable them to access free prescriptions. Our caseworker notes show following issues:
3.7 As there is little prospect of meeting the 19-day stay in initial accommodation target during the pandemic, DOTW recommends that accommodation providers ensure that, within one day of arrival, all residents are signposted to their nearest GP, and that all people seeking asylum are provided with information in language they understand on:
3.8 Accommodations providers should be required to provide direct support to register with a GP to those in initial accommodation and hotels with pre-existing medical conditions. In line with Home Affairs Select Committee’s recommendation, the Home Office should ensure that this change is made, if necessary, by a variation to the Asylum Accommodation and Support Statement of Requirements document.
3.9 The Home Office should ensure the local health commissioning groups are informed in advance before opening new accommodation (including hotels) in their area.
4.1 Accommodation providers are required to establish how GP and dental services for asylum seekers are organised in the areas they operate, and to provide appropriate support to help people to register. In practice, individuals must often register with health services unsupported if they have been unable to effectively communicate their needs to their housing officer, or the officer has not delivered a comprehensive induction.
4.2 Under normal circumstances, support for registering with health services is limited to ensuring that people have all the necessary information, in a language that they understand, to register with their local GP practice and dentist, within one day of arrival at dispersal accommodation.
4.3 In some specific circumstances, accommodation providers must take direct action. If notified by the Home Office that a Service User has a pre-existing medical condition requiring that the Service User should be registered with a local GP, the provider, is required to take the Service User to a GP surgery within five Working Days of arrival at the dispersal accommodation, and shall provide assistance in helping the Service User to complete the registration process, if such assistance is required. If the person is without a supply of prescribed medication, this assistance has to be given on the day of arrival at dispersal accommodation, if a person is in urgent need of a new supply of prescription medication, within two working days of arrival.
4.4 The Asylum Accommodation and Support (Schedule 2) Statement of Requirements includes a list of pre-existing medical conditions that require a Provider to assist a Service User in registering a GP:
4.5 In the event that the Home Office notifies the accommodation provider that a Service User is disabled or incapacitated to the extent that they cannot make the journey alone to receive treatment, the Provider shall make arrangements for them to be accompanied.
4.6 Under normal circumstances, within two working days of a “dispersal event” the accommodation providers are required to notify the GP Practice (covering the area into which a Service User is dispersed) with the names and addresses of any Service User moving out of or into the area of the relevant GP Practice.
4.7 Accommodation providers should also ensure the following arrangements in some specific circumstances:
● If 10 or more service users are placed in an area covered by the same GP practice in the same week, the provider should notify the GP practice and the GP practice asylum health care worker should “meet all the individuals together so that they can, if they wish, be registered with GPs at the same time”, within 2 days.
● If it is obvious on arrival at the accommodation that previous unreported health needs exist, the Provider must inform the relevant GP Practice or take emergency action to assure the safety and wellbeing of the Service User.
4.8 DOTW recommends that the Home Office and accommodation providers should ensure the local health commissioning groups are informed in advance before opening new accommodation (including hotels) in their area.
4.9 Accommodation providers should conduct comprehensive induction for all asylum seekers and that they ensure all asylum seekers are registered with a GP as soon as possible, prioritising the specific circumstances listed in the Statement of Requirements.
4.10 Accommodation providers should follow Home Office’s Healthcare Needs and Pregnancy Dispersal Policy.
5.1 Doctors of the World UK’s COVID-19 Rapid Needs Assessment reported some significant accommodation-related barriers to access health advice and services. Residents in asylum accommodation faced barriers in accessing essential health information and following advice about COVID-19, due to circumstances people find themselves living in, for example:
● Shared accommodation with people who are not friends or family
● Accommodation with communal facilities such as bathrooms and kitchens
● Overcrowded accommodation, including limited space for storing items
● Places with no access to water and sanitation facilities (e.g. laundry)
● Lack of control over behaviour of others that they live with, which presents risk to them
● limited or no facial resources to purchase phone credit and data to access COVID-19 information and/or NHS services or to purchase soap and hygiene products.
5.2 During the early stages of the pandemic some IA providers reportedly delivered advice that conflicted with the government advice e.g. advising people to spend more time outside during lock down if they felt unable to physically distance indoors. Some asylum seekers reported feeling unsafe. Staff in IA carried out risk assessments to identify people who would be classified as vulnerable or extremely vulnerable, however, healthcare staff reported that some asylum seekers living in IA had communicated that they felt this happened too slowly.
5.3 Some people reported that other people in their accommodation did not believe that COVID-19 was real. Belief in COVID-19 myths spread rapidly, particularly within groups who have low levels of trust in authority. One participant stated the following: “One of my flat mates, she is the kind of person that believes there is no coronavirus and the other one extremely believes the coronavirus is caused by the devil. The one that believes there is no coronavirus, she invites some of her friends over and you can’t stop her. When people come in I just have to make sure my daughter is in the room and make sure she washes her hands every time. I take a long time to explain to this flatmate, I tell her it is real and people are dying. And the one that believes the coronavirus is even in the air, is saying that even if you open the door she is screaming that coronavirus is in the air [sic]. It is different to what I believe, it is difficult.” Newly recognised refugee
5.4 DOTW’s clinic sessions at a London Hotel used as a temporary IA also showed that most residents do not have access to COVID-19 guidance in their own language, even though the average time that they spent in the country is only a few months and that they are very likely to need translated information to understand health information and advice. Caseworkers also noted that there is no clear pathway to manage residents who develop symptoms of COVID-19. 2 residents with fever were left untested for COVID-19, and staff were not able to effectively communicate with residents and isolation was not implemented. Even though a local find and treat team who were testing residents of the homeless hotels said testing can be provided through them, there still needs to be a clear protocol in place for staff at the hotel to prevent an outbreak.
5.5 Accommodation conditions also put extra barriers for residents to follow healthcare advice on shielding and self-isolation. Communal living and eating areas, and shared bathroom facilities make physical distancing and self-isolation difficult. Overcrowding in IA, caused by the suspension of dispersal, was raised as a key issue. Cleanliness is reported to be poor in these shared accommodations, and people who are clinically vulnerable or extremely vulnerable, including pregnant women and people with medical conditions feel particularly unable to follow the recommended guidance. One participant said: “How is it possible to self-isolate in a shared house with three mums and 6 children where you share a toilet and bathroom? And if we have to self-isolate there is no way of us getting food.”
5.6 Government’s advice on staying at home and avoiding public gathering deemed technology and smart phones only resource of information and access to services, which created barriers like not having access to broadband internet for asylum seekers living in IA: “They pay us weekly, it’s not like a bulk money. The money we have is hardly enough to eat for the whole week. And there is no way we can take help from any other person. I haven’t had credit on my phone for 4 to 5 days. No calls are possible if you run out of credit. You have to wait for people to call you.” Newly recognised refugee
5.7 DOTW recommends the Home Office, Department of Health and Social Care and Public Health England work with community groups and voluntary sector organisations to produce translated, tailored and accessible COVID-19 guidance for asylum seekers in initial accommodation, hotels and dispersal accommodation. This is in line with the recommendations in the Academy of Medical Sciences report ‘Preparing for a challenging winter 2020/21’ and Public Health England’s report ‘Beyond the Data: Understanding the Impact of COVID-19 on BAME Communities’.
5.8 The Home Office and accommodation providers should integrate translated COVID-19 guidance into existing service provision to ensure all residents in asylum accommodation, including hotels, have the latest COVID-19 health information and advice
5.9 Accommodation providers should work with local authority and the regional Director of Public Health and local commissioning groups to ensure residents in asylum accommodation can access testing services, including providing transport when necessary
5.10 DOTW recommends the Home Office and Accommodation providers ensure all people in asylum accommodation have their own bedroom and free access to Wi-Fi, and to provide support for those who need to self-isolate.
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