Años posteriores: 1977- 1988

Migrants’ health needs reflect the diversity of the group but they are mainly affected by individual characteristics (such as age, sex and ethnicity), country of origin and circumstances of migration, and socioeconomic conditions in the host country

(Gilbert and Jones, 2006; Kelly et al, 2005). Young women, both those from Eastern Europe and those entering as family migrants, use health services during pregnancy (see section on gender).

Health risk can vary among groups. Trafficked migrants – including women who work in the sex industry – are particularly vulnerable to health risks, given their

dependence on the trafficker. Some groups of migrants, particularly undocumented migrants, may be especially at risk of infectious diseases but have very limited entitlement to health services (Gilbert and Jones, 2006). Undocumented migrant workers are often exploited and work in unregulated or sub-standard conditions which have their own health risks (Kelly et al, 2005). Some research also shows that the increased risk of infection in some non-UK born populations is in large part

related to the higher prevalence of specific infections in the countries from which they originate (Gilbert and Jones, 2006).

In relation to HIV/AIDS, Black Africans now represent the largest number of new diagnoses of all UK ethnic groups (Information Network on Good Practice in Health Care for Migrants and Minorities in Europe)²⁵. Almost 25,000 people born in sub-Saharan Africa were estimated to be living with HIV in the UK in 2006, a proportion 50 times higher than whites. Black Africans constitute 70 per cent of heterosexual diagnoses, but only 1.3 per cent of diagnoses among men who have sex with men (Parliamentary Office of Science and Technology, 2007; Health Protection Agency, 2007). Although there exists a range of HIV prevention services available to African communities across England, there are limitations in HIV health promotion services (Chinouya, 2001) due to limited funding and capacity building, evidence-based interventions, use of traditional modes of communication on intimate issues, and limited inter-agency and inter-regional collaboration. The recommendations in the report by Chinouya (2001) were to:

• Encourage inter-agency collaboration.

• Improve the dissemination of information about HIV prevention services.

• Increase sustainable funding and capacity-building.

25 See http://mighealth.net/uk/index.php/African_migrants_and_HIV

8.3 Access

Migrants themselves do not make great demands on the health system but this begins to change with family settlement (Institute of Local Community Cohesion (iCoCo)/Local Government Agency (LGA), 2007). Research shows that migrant workers themselves are less likely to need a doctor (Zaronaite and Tirzite, 2006).

However, registration to hospital services varies among groups. Australians, New Zealanders and EU citizens who come in on work and study visas are less likely to be registered with GPs than people coming from refugee-generating countries, who, despite obvious barriers to care such as language, are significantly more likely to be registered (Hargreaves et al, 2005). There are also problems in GP registration:

some migrants find the UK health system too complicated and have difficulty

registering with GPs; others prefer to use services in their home country rather than deal with the bureaucracy in the UK (IoCC, 2008). In a study of A8 migrants in the Grampians, most preferred to return home for the treatment of non-acute medical problems, as well as for dental care and visiting opticians, which were cheaper and perceived to be more easily accessible there (Communities Scotland, 2008).

The use of services by new migrants is influenced by a range of personal and organisational barriers. The very unstable lives of many migrants, especially those employed by agencies or gangmasters may disrupt the continuity of care and support (Taylor and Newall, 2008). Some groups have restricted access to particular forms of health care and this represents a stratification of rights to health care in the UK. For example, undocumented migrants and failed asylum seekers have to pay for all health services apart from those needed in an emergency or offered to facilitate infection control. They are also reluctant to use NHS services because they fear that the health services may report them to immigration authorities (Kelly et al, 2005).

Regulations regarding entitlements to health and social care may result in high-risk health situations and poor health outcomes (Taylor and Newall, 2008). However, strengthening community-based approaches and the delivery of more appropriate services to new migrants could alleviate pressures on hospital services and improve health outcomes (Hargreaves et al, 2005).

The issue of entitlement is crucial. Other than in the case of certain exemptions, specific regulations require NHS trusts to charge for health care that is provided to anyone who is ‘not ordinarily resident in the UK’²⁶. This means ‘someone who is lawfully in the United Kingdom voluntarily and for settled purposes as part of the regular order of their life for the time being, with an identifiable purpose for their

residence here which has a sufficient degree of continuity to be properly described as settled’ (Kelly et al, 2005). However, in 2003, abuse of access to NHS care became a

26 See The National Health Service (Charges to Overseas Visitors) Regulations 1989.

www.hmso.gov.uk/si/si1989/Uksi_19890306_en_1.htm.

major issue for the Government. Though without any firm numbers or availability of a rigorous study, the Government introduced new regulations in April 2004 in order to combat ‘health tourism’, where migrants are said to come to the UK to access health care (BBC, 30 December 2003).

The regulations targeted: failed asylum seekers and others with no legal right to be in the country; overseas visitors; heavily pregnant women who live overseas coming to the UK just to give birth (even if their partner lives here) and business travellers to the UK and their dependants. These groups were to pay for treatment in NHS hospitals.

As from 1 April 2004 failed asylum seekers and others with no legal right to be in the country were no longer to be treated; dependants of permanent residents in the UK were only entitled to free treatment if they were themselves permanently resident in this country; and business travellers and their dependants who fell ill while in the UK were not entitled to free treatment (Kelly et al, 2005). Access to secondary care was limited except for Accident and Emergency (A&E), infectious diseases such as TB, sexually transmitted diseases except HIV/AIDS, compulsory psychiatric treatment for those detained under the Mental Health Act and treatment deemed ‘immediately necessary in the opinion of the clinician’. However, although patients are charged, they must be given treatment (Médecins du Monde, 2008). The Médecins du Monde study of 883 users of a health care project for migrants in London questioned the extent of health tourism (also see National Aids Trust 2008 for HIV/AIDS) and found that most of those they treated had been living in the UK for an average of three years and that, for many, the major problem was accessing GPs.

The recent case of R (A) v West Middlesex University Hospital Health Trust 2008]

EWHC 855 (Admin) was in relation to a rejected asylum seeker, but it has a wider application for lawfully present and ordinarily resident migrants. It established that current Department of Health guidance allowing hospitals to refuse all but

‘immediately necessary treatment’ to some migrants unless payment was forthcoming was unlawful.

8.4 Gender

The main issue raised in relation to gender and health care is access to antenatal care and maternity services. Despite the restrictions, all women are entitled to antenatal care, which falls under the category of ‘immediately necessary’. In the Médecins du Monde project, the largest single number of visits (118 in 2006–7, or 22 per cent) was for reasons of pregnancy, childbirth and family planning (Médecins du Monde, 2008). Many women had turned to the clinic to get help to access such care as well as terminations. Although the project was able to register their patients with GPs, many were refused access to free terminations. Thus exceptions to the 2004 regulations are not always applied in practice.

There is evidence of pressures on maternity services, where women arrive late in the pregnancy, making planning service provision difficult (IoCC/LGA, 2008). In some areas the increase in birth rates among migrants is said to have contributed to the closure of some units, so that midwives could be moved to areas of more urgent need²⁷. The London Strategic Health Authority argued that the increase in the number of births to migrant women, and the fact that ‘births within migrant groups can often be more difficult, more dangerous and more expensive – with much higher rates of type 2 diabetes, tuberculosis and HIV among mothers who often turn up very late in their pregnancy’, partly explained why maternity services in London performed poorly. In central London, senior consultants and health managers put the blame for unacceptably poor standards on a lack of resources to deal with the pressures of migration²⁸.

In their study of the impact of migration on maternal and infant health in the West Midlands, Taylor and Newall (2008) concluded that infant mortality was a significant problem among large migrant communities with high levels of deprivation. Although the data is poor, there is evidence that children of migrants have a higher stillbirth rate than those born to British mothers in Birmingham. Among the various migrant groups, women seeking asylum and the growing number of women with ‘No

Recourse to Public Funds’ are particularly vulnerable. The authors recommend that

‘infant mortality strategy must take account of the needs of migrants, including developing methods to systematically monitor the impact of migration and

immigration policy upon outcomes, and ensuring that services meet needs and that a multi-sector approach is required in order to address infant mortality within this group, as so many of the issues relate to the “wider determinants of health”’.