Rapid Responses to:

EDUCATION AND DEBATE: David Jones and Paramjit S Gill Refugees and primary care: tackling the inequalities BMJ 1998; 317: 1444-1446 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Increasing health inequalities for refugees

Helen Hogan   (27 November 1998)

refugees and primary care: consider service use

Caroline Free   (3 March 1999)

Increasing health inequalities for refugees 27 November 1998
Helen Hogan, General Practitioner University Health Centre, Reading, RG2 7HE Send response to journal: Re: Increasing health inequalities for refugees	Increasing health inequalities for refugees. Editor- Jones and Gill’s article raises the profile of poor health amongst refugees. Their paper outlines the barriers currently affecting the ability of primary care to decrease the burden of ill-health carried by this group. Primary care alone will not be able to address the complex health needs of refugees. Indeed, the authors themselves call for the institution of a “comprehensive strategy at national level”.(1) The Government’s recent White Paper- “Fairer, Firmer, Faster- A Modern Approach To Immigration and Asylum ”,(2) lays out a strategic approach to the processing of asylum claims and the settlement of refugees in this country. Unfortunately no reference is made to improving their health status. In fact, this White Paper in many ways contradicts the Government’s commitment to reducing health inequalities as set out in “Our Healthier Nation”. (3) If the White Paper’s suggestions are implemented refugees entering the UK are likely to be dispersed widely around the country and will have no access to cash-based benefits. Their increased isolation and poverty will lead to worsening health status. Many services available in areas with a high density of refugees may not be available to more dispersed groups including local health authority out-reach services, comprehensive language support, and specialist mental health services targeted at victims of torture.General practitioner’s too, may experience difficulty dealing with the wide- ranging social, psychological, and physical needs of these individuals if unsupported by such services. Particularly in London, refugee community groups provide vital support and advice to newly arrived refugees. Many are working with local health authorities to promote health within their own communities and some have been able to actively lobby for increased recognition of their unique health problems. Dispersed refugees are unlikely to have access to refugee community groups or to attain the level of organisation required to form them. Under the new proposals refugees will face greater difficulties accessing the NHS, substantial barriers to appropriate specialist health services and as a consequence poorer health. For a Government whose stated aim is to reduce levels of ill health particularly amongst vulnerable and socially excluded groups the White Paper is a disappointment and represents a lost opportunity to create a coherent national strategy which looks holistically at the health and social needs of refugees. 1 Jones D, Gill P. Refugees and Primary Care: tackling the inequalities. BMJ1998;317:1444-6 2 Our Healthier Nation. London:HMSO,1998. 3 Fairer, Firmer, Faster- a modern approach toimmigration and asylum. London:HMSO,1998;CM4018. Helen Hogan General Practitioner The University Health Centre, Reading RG2 7HE
refugees and primary care: consider service use 3 March 1999
Caroline Free, GP/research associate Guys, Kings and St Thomas'School of Medicine Send response to journal: Re: refugees and primary care: consider service use	In the article 'refugees and primary care: tackling the inequalities' the challenges that refugees pose to the GP day time service are clearly outlined(ref 1). The services which refugees use to meet their primary care needs and how they use them should also be considered if inequalities are to be addressed by appropriate strategy and allocation of resources. In a pilot survey in the ethnically mixed London borough of Lambeth, Southwark and Lewisham in 1997 less than 1%(95%CI-0.1-2.1) of callers to the GP out of hours co-operative (SELDOC) did not speak English well(ref 2). In this survey all those who telephoned the GP out of hours co- operative over one weekend in April were included in the study. GP completed questionnaires asking the patients first language and assessing their English language skills according to a scale ranging from 'good' to 'not at all'. There was a 95% response rate with 308 questionnaires completed. A survey of the English language skills of attenders at one of the three A and E departments in the same area found 9.1% (95%CI 6.8-11.4) did not speak English well(ref 3). 2.7% of these were tourists. 606 questionnaires were completed in this survey. Vietnamese refugees with limited English language skills have stated that they are unable to use services which require the use of English language on the telephone - rendering GP out of hours service unavailable to them. They voiced difficulties in making appointments (ref4). Further studies are required to identify the extent to which the difference in the results obtained in the two surveys we carried out reflect differences in the use of services for primary care needs. The impact of this on health outcomes should be identified. It seems that there may be important impacts of culture and language on which health services are used. A number of groups, such as the homeless are more likely to use Accident and emergency for their primary care needs, even though only immediate care can be provided and not the full range of primary care services. Provision of primary care by GP's in A+E has been developed in some centres. This in combination with interpreting services could form one strategy addressing the primary care needs of refugees presenting to Accident and Emergency. Direct access to interpreters(ref 5), perhaps through the New NHS direct, could enable non-English speakers as well as English speakers to be directed to the most appropriate service to their need. Increasing our understanding of the way in refugees use services for primary care needs and why will usefully inform policy. A comprehensive strategy addressing the primary care needs of refugees in the range of health service settings to which they present is likely to be more effective than addressing, in isolation, those needs which present to the GP. References. 1. Jones D, Gill P. Refugees and primary care: tackling the inequalities. BMJ 1998:317;1444-1446. 2. Free C. (unpublished data, full details of the survey available on application to author) 3. Leman P. Interpreter use in an inner city accident and emergency department. J Accid Emerg Med1997;14:98-100. 4. Free C, White P, Shipman C, Dale J. Access to and use of out of hours services by members of Vietnamese community groups in South London. Family Practice 1999 in print 5. Free C, McKee M . Meeting the needs of black and minority groups. BMJ 1998:316:380. Caroline Free Research Associate and GP. Dept of General Practice and Primary Care, KCSMD. Weston Education Centre, Cutcombe Road, London SE59PJ. Peter Leman Honorary lecturer, Accident and Emergency Department, Guys Hospital, London SE1