This article relates to the CQC key questions: Is your practice responsive to people's needs? and Is your practice well-led?
The Refugee Council define refugees and asylum seekers as:
- Refugee: a person who ‘owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country…’ (Definition quoted from the 1951 Refugee Convention)
- Asylum Seeker: someone who has lodged an application for protection on the basis of the Refugee Convention or Article 3 of the ECHR
Asylum seekers and refugees face many of the same health problems as the UK population; however, they are likely to have poor awareness of the NHS and fear barriers to treatment that delay them accessing care.
It is also important to consider the country of origin in which healthcare provision may have been poor, as well as the health impacts (both mental and physical) of leaving their country, being detained in the UK and the reasons for them fleeing. They may well have experienced war, conflict or torture. Separation from family, poor housing and social isolation can also have profound impacts on their health.
There is much confusion and misinformation regarding the registration and treatment of this group. The Immigration Act 2014 began the process to change the definition of ‘ordinary resident’ for accessing NHS services which will impact what services asylum seekers and refugees are entitled to free of charge. However the process for this is still underway and guidance from the Department of Health is currently in development.
What the CQC expects
Until this issue is resolved, CQC expects practices to abide by the key tenets of providing care in the NHS:
- Practices have a contractual duty to provide emergency and immediately necessary treatment free of charge for everyone
- Practices cannot refuse registration for reasons relating to any ‘protected characteristic under the Equality Act 2010, including race, gender, class, age, religion or belief, disability, sexual orientation, gender identity or pregnancy status and to comply with the NHS constitution should also not refuse to register people on other grounds such as social class, appearance or medical condition.
- No documentation should be required in order to register with a GP. Overseas visitors have no legal obligation to provide proof of identity or immigration status; however, asylum seekers may be able to provide an ‘application registration card’ (ARC) provided by Immigration Services
- If not in permanent housing, asylum seekers and refugees can be registered as a temporary patient for a period of up to three months
In addition to registering refugees and asylum seekers as patients, CQC expects practices to fulfil the following fundamental standards that relate to equality for patients. These are most obviously relevant to refugees and asylum seekers in terms of race (which includes nationality) being a ‘protected characteristic’ under the Equality Act 2010. Refugees and asylum seekers are a diverse population so other protected characteristics such as age, gender, disability and sexual orientation will be relevant for individual refugees and asylum seekers also:
- Regulation 10 (1) Service users must be treated with dignity and respect…. the things which a registered person is required to do to comply with paragraph (1) include in particular…. having due regard to any relevant protected characteristics (as defined in section 149(7) of the Equality Act 2010) of the service user.
- Regulation 13 (1) Service users must be protected from abuse and improper treatment in accordance with this regulation…. Care or treatment for service users must not be provided in a way that includes discrimination against a service user on grounds of any protected characteristic (as defined in section 4 of the Equality Act 2010) of the service user,
The BMA has developed guidance on the treatment of asylum seekers:
The British Refugee Council has produced a leaflet for asylum seekers and refugees outlining their entitlements:
Two examples of good practice:
York Street Health Practice
York Street Health Practice runs a specialist service for those seeking asylum in Leeds. To engage with this population, the practice adopts a proactive outreach approach:
- The team are notified by the Home Office of asylum seekers housed in the local area. The practice sends out a letter to them inviting them to register and with information about services provided.
- The practice provides drop in clinics for PAFRAS (Positive Action for Refugees and Asylum Seekers). Once a week a nurse and case worker from the practice give advice on registration, health problems and referrals to secondary services.
- A solicitor and benefits advisor hold clinics at the practice that are widely advertised, encouraging asylum seekers and refugees to attend for holistic care.
- A drop-in service is being developed to respond to the chaotic lifestyles of the vulnerable populations they care for. This will ensure that those seeking care can access an appointment with a doctor or nurse on the same day, helping build positive relationships with service users.
- The practice employs people who have personal experience of the asylum system and are multi-lingual to assist with queries.
Feedback from the practice’s Patient Participation Group includes:
- 'Reception staff are always welcoming'
- 'It’s like a family to me'
- 'I am happy with the care I receive; all consultations are centred on me'
- 'I get an appointment to see the GP on the day'
- 'Staff members have a very positive attitude'
Mulberry Practice/Central Health Clinic
Mulberry Practice was set up in Sheffield in 2002 when it became a dispersal city (key area of accommodation) for asylum seekers. They recognised the very different health needs and demands on general practice this population presents, and that services needed to be adapted to be made more suitable. The practice has developed over time and now provides a comprehensive holistic service that meets the needs of their population:
- Weekly New Arrival Clinics: the local housing provider funds a mini bus that takes new arrivals to the practice, inviting them to register on that specific day. The registration process includes same day screening including TB, HIV and hepatitis B, sexual health services, and general health checks. Asylum seekers are only asked to provide their Application Registration Card (provided to all asylum seekers on dispersal in to the community) or letter from UK Visa and Immigration as proof of identity at registration.
- Nurse practitioner led appointment system: every patient is seen by a nurse practitioner who can deal with most health problems. If a GP appointment is required, they are given one either on the same day or a pre booked appointment for later in the week. As well as appointments, there are daily morning drop in clinics available.
- A range of staff: nurse practitioners, GPs, specialist counsellors, specialist health visitors and practice nurses,. They also maintain a collaborative relationship with secondary care services to provide an onsite infectious disease clinic and links with specialist midwives.
- Interpreting services: interpreters are provided by Sheffield Community Access and Interpreting Service (SCAIS). This local service supports the huge number of languages in the city, and provides access to employment for asylum seekers with language skills once given leave to remain. The practice has a strong belief in the importance of face to face interpreting as opposed to telephone interpreting, and uses this wherever possible.
Feedback from patients:
- 'It’s made me feel like I am somebody in society'
- 'I was not in a good mentally and physically situation but you helped me with my mental illness to cope with my problems and make myself stronger'
- 'Everyone that works here is so nice and helpful'
- 'It’s the first time in my life I came across such good medical care it is true, true, true'
- 'You have been my inspiration, motivation, support, and friend. You have changed my life for good and I thank you for that'
Dr Emily Phipps is clinical fellow and Mandy Hooper is senior equality, diversity and human rights officer at the CQC
More CQC resources
- View the full CQC Essentials series on Medeconomics
- CQC's recommended reading to help practices meet regulations and prepare for an inspection