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EDITORIALS: Sally A Hull and Kambiz Boomla Primary care for refugees and asylum seekers BMJ 2006; 332: 62-63 [Full text]

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Underfunding of primary care in deprived areas affects everyone

james n hardy   (16 January 2006)

Health in need is the health indeed - medical services to refugee population

ANIL JOSHI, Shivakumar Shankaranarayan, and Pawankumar BC Raju   (19 January 2006)

The public health perspective

Ike Anya   (25 January 2006)

Underfunding of primary care in deprived areas affects everyone 16 January 2006
james n hardy, GP principal Bethnal Green Health Centre, 60 Florida Street, London E2 6LL Send response to journal: Re: Underfunding of primary care in deprived areas affects everyone	Editor The paper by McColl (1) and the commentary by Hull and Boomla (2), raises important questions about the provision of primary care in areas with high levels of deprivation. It is misleading to focus on refugees and asylum seekers as it suggests that the only problem is one of discrimination against this group – although there may be some truth in this assertion, the reality is far more complex. There is a problem with accessing primary care for all Tower Hamlets residents and by extrapolation, for those in other areas with similar populations. This is nothing new - such communities have always been relatively under-resourced. But what has changed is the clamour for increased quality of service provision and increased levels of access at the same time as there has been a shift of work from secondary to primary care. Primary Care Trusts, in contrast, find themselves in the unenviable position of having to cajole general practitioners into quantifiable action whilst being squeezed by the Department of Health to deliver increasingly unrealistic targets. Meanwhile primary health care teams grapple with recruitment and retention and at full capacity, struggle to balance service delivery from their inadequate premises when there is little hope of improvement. In this climate it is small wonder that registration with primary care is problematic. If Project-London effectively highlights this issue and greater funding comes our way, fine, but the reality is that greater pressure will be exerted on the same workforce and that there will be no extra public service investment. Dr James Hardy (1) McColl K, Pickworth S, Raymond L. Project: London - supporting vulnerable populations. BMJ 2006; 332: 115-7 (2) Hull S & Boomla K. Primary care for refugees and asylum seekers BMJ 2006; 332: 62-63 Competing interests: I am a general practitioner in Tower Hamlets
Health in need is the health indeed - medical services to refugee population 19 January 2006
ANIL JOSHI, Senior House Officer Addenbrooke's Hospital, Cambridge, CB1 8EF, Shivakumar Shankaranarayan, and Pawankumar BC Raju Send response to journal: Re: Health in need is the health indeed - medical services to refugee population	Health is wealth. A healthy tissue leads to a healthy individual and this in turn leads to a healthy community and consequently a healthy country. The arrival of Médecins du Monde1 to help marginalised people in UK is no doubt a strong step taken towards creating a healthy community. However, there are some issues as to why this has become important and their future implications on the society. There are many asylum seekers, migrants and refugees who are staying in various pockets in the country. The questions that health service providers have to answer should always be medical and never political. The latter can be tackled by the government bigwigs. The NHS should be able to provide health services to any person irrespective of his social status or political origin. There are many people who have been refused registration at the GP offices simply because they are not eligible or the practices are completely full. Although the efforts of Médecins du Monde are commendable, in the long run there will be questions raised on the efficiency, adequacy and appropriateness of their services. Other aspects that this organisation needs to answer are the plans they have taken in dealing with investigations and higher referrals2? Individuals from the vulnerable groups come from varied backgrounds. Asylum seekers and refugees are not a homogenous group of people3. Accidents, communicable diseases and mental illnesses to name a few are quite common among them. If these individuals are denied treatment, it can not only have physical and psychological impact on these people but can also seriously affect the local population. Sexually transmitted diseases are very rampant and ever increasing. There will always be contact with local crowd. Some individuals, due to their isolation, unemployment and poverty will be suffering from anxiety and depression. Without treatment, all these lead to further deterioration of their condition. The implications of denied health service can be far reaching. The individuals will be pushed further down the social ladder. Sexually transmitted diseases will be travelling on an upward curve and consequently the health of the local people will be on a downward spiral. Desperation and depression lead to suicide or even harming others. An increase in crime rate will follow suit. National Health Service should hence dig deep into the matter and look out for optimal solutions. Also, there has been widespread confusion about the rules and therefore the asylum seekers and refugees have wrongly been denied access to primary and secondary health care4. Not that all individuals of these groups be treated for all conditions. There has been serious misuse of health services in the past. Individuals have queued up for treatment of conditions which are not at all life threatening and there have been numerous instances of surgeries being performed when they could have got it done elsewhere with time not necessarily being a factor. This grossly affected the waiting list for procedures. Some of the ways to tackle these issues would be to provide a temporary registration with the local GP till their stay, adequate information and education, free treatment on the first couple of visits and also for emergency and life threatening conditions. There should also be a decision taken on a case-to -case basis so that relevant and important conditions are not missed and are adequately treated. Although it may strain the resources in treating more people than desired, if all the above consequences are taken into account, it may prove beneficial and economical in the long run. References: 1. Médecins du Monde. www.medecinsdumonde.org.uk 2. Sally A Hull and Kambiz Boomla. Primary care for refugees and asylum seekers. 2006;332;62-63 BMJ 3. Burnett A, Peel M. Health needs of asylum seekers and refugees. BMJ 2001;322:544-7. 4. Karen McColl, Sarah Pickworth and Isabelle Raymond. Project: London. supporting vulnerable populations. BMJ 2006;332;115-117 Competing interests: None declared
The public health perspective 25 January 2006
Ike Anya, Specialist Registrar in Public Health Bristol Joint Directorate of Public Health, Bristol PCTs, BS2 8EE Send response to journal: Re: The public health perspective	Hull and Boomla rightly point out that inequalities in access to healthcare for marginalized groups speak profoundly about the kind of society we live in. But beyond the moral, the public health perspective speaks in favour of ensuring adequate health coverage of the entire population for the benefit of all. First, many of these marginalized groups also face the challenges of poor or inadequate housing, malnutrition and socioeconomic deprivation; and so not surprisingly are vulnerable to infectious diseases, with consequences not just for those groups but for all of society. Secondly, from a resource perspective, providing only primary care and emergency care may mean that medical conditions are allowed to deteriorate until the individual qualifies for emergency care with subsequent escalation in costs to the health service. Government policy on entitlement to treatment must take into account ethical considerations; but must also be based on good evidence and a holistic review of resource implications. Competing interests: None declared