Written evidence submitted by Doctors of the World (DOTW) (COR0203)
1. Doctors of the World (DOTW) UK has seen that 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. Since the beginning of the COVID-19 pandemic, there has been an increased use of hotels (and Ministry of Defence sites) as asylum accommodation, which further exacerbated access to healthcare among people seeking asylum. We found that there is a lack of comprehensive screening of medical conditions by the Home Office before housing asylum seekers and lack of clear guidance and support for people who have pre-existing medical conditions or urgent and obvious healthcare needs. Regarding COVID-19 measures, we found that there is lack of a clear, tailored and translated messages about COVID-19 guidance for asylum seekers in accommodation, and there is confusion on how to manage an outbreak in these sites. There are problems in comprehensively assessing the accommodation sites with regards to their suitability to follow COVID-19 guidance for residents.
2. Use of institutional accommodation such as hotels, army barracks undermine residents’ ability to achieve their right to healthcare. We recommend that the Home Office take additional steps to review its accommodation policy and support provided through contracted agencies to ensure that accommodation arrangements do not inhibit meaningful access to health services. Please see detailed list of recommendations at the end of the document.
3. The Home Office provides accommodation and support for people seeking asylum who would otherwise be destitute. Since 2019, this support is provided through seven regional accommodation and transport contracts with three providers (Clearsprings Ready Homes, Mears Group and Serco) and a national contract for a helpline and support service (AIRE – Advice, Issue Reporting and Eligibility). In March 2020, the number of accommodated asylum seekers was nearly 48,000.
4. 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 often encounter barriers in accessing appropriate healthcare. People who have been forcibly displaced are reported to have multiple health needs. 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. 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.
5. 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.
6. We have seen that the healthcare provided for people in initial accommodation was insufficient even before the COVID-19 outbreak. 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. These health providers often don’t have mental health support or counselling services and they are unable to 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 to access 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 (see our review of healthcare in 3 IA sites in 2019 in Box 1).
7. As case box 1 showed, 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.
8. We have called for Home Office to support asylum seekers in initial and contingency accommodation to register with a GP in our previous evidence submissions. This is because 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.
9. The COVID-19 pandemic and the public measures introduced to stop the spread of the virus have also impacted healthcare access for asylum seekers. Data from people visiting DOTW clinics show that asylum seekers reporting ‘bad or very bad health’ made up 14.3% of all 330 service users accessing DOTW’s clinical services three months before the first lockdown. This has increased to 35.4% of all 259 service users accessing services three months after the first lockdown (See Figure 1). This increase is particularly concerning as people in the asylum process are in theory fully eligible for healthcare and are supported by the Home Office to access healthcare.
Figure 1 Health by immigration status from Doctors of the World Clinic data
10. Since the beginning of the COVID-19 pandemic, there has been an increased use of hotels as asylum accommodation, which further exacerbated access to healthcare among people seeking asylum.
11. 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.
12. DOTW runs a national advice line for people who cannot access mainstream healthcare. The main purpose of the advice line is to provide advice on how to get access to medical care and help patients to register with a GP. Evidence collected from DOTW’s helpline demonstrates that asylum seekers housed in Initial Accommodation Centres 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 42 patients who are housed at IA centres and hotels. None of these had a GP, and they had difficulty seeking healthcare, despite being in hotels for several weeks. Clinical concerns raised included mental health needs, regular medications that had run out including cases of interruption to antiretroviral treatment, and suspected cancers referrals.
13. In the Committee’s Fifth Special Report of Session 2019–21 (which is Government Response to the Committee’s Fourth Report - Home Office preparedness for COVID-19 (coronavirus): institutional accommodation), the Home Office acknowledges that “accommodation providers are required, where appropriate, to secure GP registrations for vulnerable service users, and provide ‘vulnerable’ or high-risk groups assistance in registering with a GP. However, our evidence from national advice line shows that vulnerable asylum seekers in IA hotels cannot 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, highlighting that hotel residents cannot register with a GP.
14. DOTW also runs outreach services on a mobile clinic to help vulnerable people get urgent medical advice and access to healthcare. See evidence from our 6-month outreach work for a hotel that is used to house asylum seekers in Box 2.
15. Accommodation providers play a significant role in ensuring access to healthcare for asylum seekers. 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”. Similarly, as part of the Home Office AIRE contract, service provider (Migrant Help) is required to handle requests for assistance related to “concerns over medical conditions or healthcare needs”. This assistance includes “contacting the appropriate emergency service, in the event that the Service User’s Request for Assistance represents an immediate risk to the health and wellbeing of a Service User and the Service User has not already done so” and to record the request and report it to the accommodation provider.
16. In assessing what to advise and what actions to take in urgent medical situations, both AIRE service provider and Accommodation providers rely on the perception of Service Users. It is not clear when to take service users to the nearest GP or to a nearest hospital, or when to call NHS111 or 999, resulting in some cases where service users were not signposted to A&E when they should have been. Moreover, there seems to be a lack of comprehensive screening of vulnerability and medical conditions by the Home Office before housing asylum seekers (See Case study 1).
17. Our 2020 review of healthcare provision in IA and the specific case study from one of these IAs clearly show that, apart from not being able to register with a GP, asylum seekers with medical conditions are not flagged up before they are housed and their urgent and obvious medical needs are not addressed appropriately and sufficiently.
18. We understand that through regional initiatives (e.g. the Greater London Authority’s convening role on London Asylum Task and Finish group) there have been some operational changes in the way healthcare is provided (e.g. ensuring all people in initial accommodation to register with a GP). As our evidence from advice line demonstrates, even with such regional initiatives there are people with no registration with a GP and with unmet health needs, and many other regions where there is not a system of default GP registration and a meaningful and easy access to a GP for people in IA. With the Covid-19 vaccines being attached to NHS numbers, there is now more than ever necessity to register all residents with a GP for them to be factored in local vaccination plans.
19. 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)
● 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.
20. 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.
21. 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 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
22. 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.
“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.” Testimony from the report
23. 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
24. 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. There were posters in the hotel informing residents to approach to hotel staff if they showed COVID-19 symptoms, but these were only in 3 languages, even though most residents arrived at the UK during the summer. Hotel staff was not using professional interpreters in their communication, they were asking for help from some residents who can speak English to communicate with residents. The figure 2 shows that majority of people did not have access to translated information in their own language about the COVID19 guidance.
25. Caseworkers also noted that there was confusion about the pathway to manage possible COVID-19 outbreak or to get tests for residents who develop symptoms of COVID-19. Even though local Public Health teams have become more proactive recently, there still needs to be a clear protocol and communication with local public health teams in place to avoid an outbreak in hotels used as initial accommodation centres. See Box 3 for further information on our review of a COVID-19 outbreak in a hotel we did outreach work at.
As there is little prospect of meeting the 19-day stay in initial accommodation target during the pandemic,
a) Providers must ensure that all residents housed or anticipated to be housed in Initial and Contingency accommodation for 19 days or longer are registered with a GP* and are provided with information in a language they understand on:
b) All residents with pre-existing medical conditions that require a Provider to assist a Service User to register with a GP (as specified in the Asylum Accommodation and Support (Schedule 2) Statement of Requirements Appendix D.1.6 pertaining to dispersal accommodation) should also be provided with direct support to register with a GP within 1 day of their arrival in Initial/Contingency accommodation
The Home Office should ensure that this change is made, if necessary, by a variation to the Asylum Accommodation and Support Statement of Requirements (in line with the recommendation of Home Affairs Select Committee) and via the dissemination of clear guidance to all contracted providers.
All accommodation sites
AIRE and Accommodation providers should adopt and use a clear triaging tools designed for non-clinical staff while dealing with urgent medical conditions.
AIRE and Accommodation Providers (Home Office to ensure training and guidance.)
DOTW recommends the Home Office to work with other public organisations and 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’.
translated COVID-19 guidance should be integrated into existing service provision to ensure all residents in asylum accommodation, including hotels, have the latest COVID-19 health information and advice. Hotel staff should be provided a language phoneline service to communicate symptoms and guidance of COVID-19.
The Home Office and accommodation providers and AIRE
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.
Any new accommodation centres are risk-assessed for possible COVID-19 outbreak and 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.
Home Officer and Accommodation providers
 National Audit Office report on Asylum Accommodation and support, July 2020 Available at: https://www.nao.org.uk/wp-content/uploads/2020/07/Asylum-accommodation-and-support.pdf
 ‘Access to primary health care for asylum seekers and refugees: a qualitative study of service user experiences in the UK’ British Journal of General Practice, Kang, Tomkow and Farrington, 2019 (Available at:https://bjgp.org/content/69/685/e537#ref-6)
 ‘The lived experiences of access to healthcare for people seeking and refused asylum’, The Equality and Human Rights Commission, Nellums and others, November 2018.
 Registration Refused Briefing, Doctors of the World, August 2019 Available at: https://www.doctorsoftheworld.org.uk/wp-content/uploads/2019/08/Reg-refused-research-briefing.pdf
 National Audit Office report on Asylum Accommodation and support, July 2020 Available at: https://www.nao.org.uk/wp-content/uploads/2020/07/Asylum-accommodation-and-support.pdf
 ‘A Rapid Needs Assessment of Excluded People in England During the 2020 COVID-19 Pandemic’, Doctors of the World, May 2020, available at: https://www.doctorsoftheworld.org.uk/wp-content/uploads/2020/06/covid-full-rna-report.pdf