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Asylum Seekers, Refugee & Migrant Health (2015)

Topic titleAsylum Seekers, Refugee & Migrant Health (2015)
Topic ownerLynne McNiven
Topic author(s)Robert Stephens
Topic quality reviewed2015
Topic endorsed byMigrant Health Forum 2015
Topic approved by
Current versionApril 2015
Replaces version2010
Linked JSNA topicsSexual Health, Viral Hepatitis, Smoking. Mental Health, Child Poverty, Diabetes, Maternity & Pregnancies, Safeguarding
Insight Document ID131972

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Executive summary

Introduction

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Introduction

Migrants are a diverse group consisting of those who migrate for work, education, family, socio-political reasons, persecution and war. The health needs of the migrant population are very heterogeneous, reflecting the great diversity of where people come from, the circumstances of their migration and the environment in which they live post migration.

What is an Asylum Seeker?

An asylum seeker is someone who has applied for protection through the legal process of claiming asylum and is waiting for a decision as to whether or not they are a refugee. In other words, in the UK an asylum seeker is someone who has asked the Government for refugee status and is waiting to hear the outcome of their application.

What is a Refugee?

A refugee is 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'

Source: Article 1, 1951 Convention Relating to the Status of Refugees

What is a Migrant?

The UN Convention on the Rights of Migrants defines a migrant worker as a "person who is to be engaged, is engaged or has been engaged in a remunerated activity in a State of which he or she is not a national." From this a broader definition of migrants follows:

"The term 'migrant' in article 1.1 (a) should be understood as covering all cases where the decision to migrate is taken freely by the individual concerned, for reasons of 'personal convenience' and without intervention of an external compelling factor."

This definition indicates that 'migrant' does not refer to refugees, displaced or others forced or compelled to leave their homes. Migrants are people who make choices about when to leave and where to go, even though these choices are sometimes extremely constrained. Indeed, some scholars make a distinction between voluntary and involuntary migration. While certain refugee movements face neither external obstacles to free movement nor is impelled by urgent needs and a lack of alternative means of satisfying them in the country of present residence, others may blend into the extreme of relocation entirely uncontrolled by the people on the move.

Source: UN Convention on the Rights of Migrants

Unmet needs and gaps

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  • Some groups of migrants experience difficulties accessing healthcare services due to a number of barriers, including poor understanding of the role of the NHS, language and healthcare entitlements.
  • Difficulties accessing appropriate mental health teams and navigating through the mental health system has been highlighted for asylum seekers, refugees and migrants within Nottingham.
  • There is a lack of interpreting services to cover out of hour’s services.
  • There is a lack of ethnicity recording amongst some services.
  • Nottingham has high rates of communicable diseases (HIV, TB, Hepatitis)
  • There are an increasing number of births to non UK born mothers.
  • The Impact of additional dispersal to Nottingham city on health & social care systems and initial support services is having a detrimental effect on the capacity of the 3rd sector in particular to meet needs/targets & the lack of long term funding.
  • Free or subsidised formula milk for the babies of HIV positive mothers is  available for asylum seekers on a case by case basis .(Needs to be requested)
  • There is a lack of a standardised approach/pathway or protocol to assessing individuals for social support who have No Recourse to Public Funds.
  • High smoking rates amongst some EU migrant groups.
  • Nationally, pregnant women with complex social factors are much less likely to access maternity services early in pregnancy and data suggests this is mirrored in Nottingham.  Early access amongst these groups during 2014/15 ranged from 10% to 83% (all below the 90% target).
  • Pregnant women who are recent migrants, asylum seekers or refugees, or those who have difficulty reading or speaking English are the least likely to access Maternity services within recommended timescales.
  • Almost one third of Nottingham’s births are to mothers born outside the UK. 280 (6%) mothers had difficulty reading or speaking English; these women and their babies are at increased risk of poor pregnancy outcomes.
  • There is an increasing need for translation services during pregnancy and challenges in gaining timely access to these services, particularly in emergency situations.
  • FGM, Forced Marriage & Honour Based Violence needs more specialist workers
  • Sexual exploitation including Child sexual exploitation and human trafficking
  • Concerns of young UASC migrants finding it difficult to access secondary school education at certain times in the years & at a specific age, also the numbers of exclusions from school of migrant children.  

Recommendations for consideration by commissioners

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  • Continue the implementation of work funded through the Migration Impacts Fund which includes:
  • Commissioning a health outreach team to work with asylum seeker and refugee communities
  • Notification for NHS Nottingham City of the arrival of new asylum seekers into Nottingham by target contract providers
  • Data collection and analysis of health needs of migrants
  • Translated welcome pack/information for migrants
  • Modification of the Asylum Seeker and Refugee Locally Enhanced Service
  • Health promotion work, including education about communicable diseases
  • Improving private housing conditions in the city & particularly Sneinton (where there is a large migrant population)
  • Assisting migrants to exercise their housing rights to secure appropriate housing that is not overcrowded
  • Consider targeted mental health work with the asylum seeker and refugee community to encourage access to mainstream mental health services. Also we need to have a particular focus on Unaccompanied Asylum seeking Children (UASC).  
  • Clarity of the mental healthcare structures and pathways to care for migrant communities.
  • Encourage ethnicity recording to ensure access to services is equitable for all groups.
  • Provide culturally appropriate education and screening for communicable diseases.
  • Promote antenatal & maternal services including access amongst migrant communities.(Obstetric & Screening)   
  • Clarify a mechanism through which HIV positive mothers can access funding for formula milk in order to reduce the risk of HIV transmission to their child through Public Health’s agreement for formula milk for HIV positive mothers on a case by case basis
  • Standardise the approach for assessing and providing social support for individuals with No Recourse to Public Funds.
  • Utilise 3rd sector organisations and community organisations in order to disperse health information and target at risk groups. For example, dispersal of smoking cessation information through Polish groups.
  • Provide training opportunities for key organisations in relation to the social and health needs of migrant communities.
  • Health protection through GP registration of Asylum seekers/Refugees to include health assessments and screening for TB, HIV & Hep B & C
  • Look at access to education for young migrants and exclusion from schools of young migrants
  • Provide figures on incidents of exclusion in city schools and investigate the option of ESOL classes for those UASC who arrive at 15-16 years old in the city.
  • More specialist workers/support services for migrants who have been trafficked, sexually exploited including FGM, Forced Marriage & Honour Based Violence as part of the serious crime bill 2015.
  • Training & raising awareness for professionals on their responsibilities in reporting FGM, HBV, sexual exploitation & FM.as part of the professional responsibility, and the Serious Crime Bill 2015.  

What do we know?

1. Who is at risk and why?

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This chapter will focus on the health needs of two groups of migrants: (1) asylum seekers and refugees and (2) EU migrant workers.

Asylum seekers: are recognised to have a high burden of need compared to other groups of migrants with evidence that their health deteriorates in the first 2-3 years following arrival in the UK. Asylum seekers tend to be young and so commonly have low rates of chronic conditions such as hypertension and diabetes, but experience higher burdens of communicable diseases, mental and sexual health problems. Many asylum seekers have experienced torture, persecution or rape and experience mental and physical sequelae as a result.

Asylum seeker women often access antenatal services late, black African women including asylum seekers and newly arrived refugees have a maternal mortality rate nearly six times higher than white women. Trends in the origin of asylum seekers largely reflects the current socio-political situations in the world with the main countries of origin for those seeking asylum in the UK Being Eritrea, Pakistan, Iran and Syria between September 2013 and September 2014.

Trends in the origin of Asylum seekers largely reflect current socio-political situations in the world with the main countries of origin for those seeking asylum in the UK being Eritrea, Pakistan, Iran and Syria: between Sept 2013 - Sept 2014.

Literature identifies the 4 key health needs of asylum seekers as being:

  • Mental health: Asylum seekers commonly experience anxiety, depression, and post-traumatic stress disorder and sleep problems. These symptoms result from the multiple losses and atrocities people have experienced, alongside displacement from their country of origin, social isolation, poverty and the uncertainty of the asylum process.
  • Maternal health: Women may have experienced rape or sexual violation leading to unwanted pregnancies or sexually transmitted infections. Delayed access to antenatal care and female genital mutilation lead to obstetric complications. The 7th Confidential Enquiry into Maternal and Child Health identified black African women including asylum seekers and newly arrived refugees as having a mortality rate nearly six times higher than white women. Following delivery, women may struggle as a single parent in poverty and isolation. There is low uptake of breast and cervical screening amongst asylum seeker and refugee women.
  • Communicable diseases: Depending upon the country of origin and circumstances of migration, some groups of asylum seekers and refugees can have high rates of TB, HIV and Hepatitis. Fear, stigma and mistrust of healthcare workers can lead to these conditions being under diagnosed.
  • Sexual health: Contraception may not be used due to cultural or religious reasons. Some may have experienced rape or sexual violation putting them at risk of sexually transmitted infections.

Migrant workers: are individuals who have arrived in the UK with the intention of finding employment. In May 2004, ten countries joined the EU: Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia and Slovenia. All but two (Cyprus and Malta) had certain restrictions placed upon them. These eight countries are known as the A8 countries. In 2007, Bulgaria and Romania also joined the EU and are known as the A2 countries. EU migrant workers tend to be young with good baseline health. Recognised health concerns include high smoking prevalence rates amongst some groups, increasing 02numbers of births to non UK born mothers and levels of alcohol use. The proportion of those aged 15 years and over who smoke in EU 27 countries ranges from 16% in Sweden to 38% in Greece. The smoking prevalence is 32% in Poland, higher than the UK average. The influence of migration to the UK upon smoking habits is largely unknown.   

Literature recognises that whilst there are specific health conditions that affect some groups of migrants, the main issue common to them all is one of accessing health services. A number of factors leading to low uptake of services by migrants include:

  •  Limited understanding of the UK health system, and in particular the role of the GP
  • Differing health seeking behaviours and expectations of healthcare services
  • Returning home for medical care amongst some groups of migrants
  • Language and cultural differences
  • Changing entitlements to healthcare services
  • Poverty acting as a barrier to access

Determinants of Migrant Health

The health of migrants is determined by three main aspects:

1) Individual characteristics:

  • Age: Most migrants, whether asylum seekers, refugees or EU migrants tend to be young with general health needs similar to those of the UK population of the same age. For young age groups, acute infectious illnesses, minor accidents and trauma, reproductive health issues and child health concerns tend to be the most commonly encountered health needs.
  • Gender: More women are now principle applicants and there are more single female asylum seekers, refugees & migrant workers. Females have a lower mortality than males, but use health services due to maternity, screening checks & are more inclined to use health services for general health inquiries.
  • Ethnicity: acts as a risk factor for certain conditions: Conditions such as sickle cell disease, thalassemia occurs amongst certain populations

2) Country of origin and the circumstances of migration:

  • Affluence of the country of origin: Individuals migrating from relatively affluent countries in order to work are likely to have good baseline health, whereas many asylum seekers come from low income countries affected by war where they may have experienced poor nutrition, unclean water and poor access to healthcare services. In countries with a lack of healthcare services, immunisation levels may be low alongside other preventative healthcare measures.
  • Prevalence of infectious diseases in country of origin: Many countries from which asylum seekers originate have high prevalence rates of infectious diseases. Some asylum seekers may be at risk of blood borne viruses (HIV, Hepatitis B&C) due to unprotected sex (including being due to rape), blood transfusions, contaminated medical equipment or mother to child transmission. Low rates of port of entry screening for tuberculosis on arrival in the UK, cramped living conditions and increasing rates of HIV co infection put individuals at risk of increased morbidity and mortality.
  • Cultural and behavioural practices in country of origin: Cultural practices such as female genital mutilation (FGM) has prevalence rates of more than 90% in countries such as Djibouti, Guinea, Somalia, Eritrea, Mali, Sierra Leone and Sudan. FGM involves all procedures which involve the partial or total removal of the external genitalia whether for cultural or non-therapeutic reasons. FGM causes a number of immediate and long term complications including difficulties urinating, recurrent urinary tract infections, fistulae, sexual dysfunction and obstetric complications. Women with FGM are more likely to have a caesarean section, episiotomy, post-partum haemorrhage or neonatal death.
  • Honour Based Violence, Domestic Violence & Forced Marriages; Victims with an insecure immigration status are particularly vulnerable as their rights to settlement or public funds, such as social security benefits and public housing, may be limited. They may be reluctant to come forward to seek help as they may fear deportation and/or destitution. Some stay in, or return to, abusive relationships, as they fear removal to their country of origin and the risk of further abuse, harassment and acts of violence. In some cultures, separated or divorce women are ostracised and harassed for bringing shame and dishonour on their families and communities.  
  • Smoking prevalence rates vary depending upon country of origin. The prevalence of smoking amongst some Eastern European countries is very high.
  • Circumstances of migration. For most migrants who voluntarily choose to enter the UK, the journey will be inconsequential. However, for some migrants including asylum seekers and those trafficked to the UK, the circumstances of their migration may have led to poor health. Some may have faced imprisonment, torture, sexual violation or unsanitary living conditions. Some estimate that up to 30% of asylum seekers may have experienced either physical or psychological torture depending upon the country of origin and definitions of torture.

3) Post migratory factors:

Once migrants enter the UK, their health will be affected by a number of physical, social, economic and cultural factors some of which are outlined below. Migrants are recognised to experience a number of barriers to accessing healthcare.

  • Employment: EU migrant workers commonly undertake work that is low paid and described as “3-D jobs” (dirty, dangerous and degrading). In 2008, the three most common occupations of EU migrants were process operators, cleaners/domestic staff and warehouse operators. There is concern over exploitation of some migrant workers. Studies have demonstrated that EU migrants are employed in jobs that do not use their pre-existing qualifications or skills, have restrictive contracts and low pay. Employment can also be a protective factor against poor mental health as it provides purpose and social networks. Asylum seekers are not allowed to work leading many to struggle with enforced unemployment, social isolation and boredom.
  • Destitution and poverty. Many migrants can face challenges in accessing services due to being unable to afford public transport, medications or childcare. Limited finances and limited access to culturally familiar food may lead to poor nutrition post migration. HIV positive asylum seeker mothers are unable to access vouchers to assist them in buying formula milk for their babies leading some to continue breastfeeding their babies. Failed asylum seekers live in destitution, face homelessness, and have limited access to services. They may have unrecognised and untreated medical problems.
  • No recourse to public funds (NRPF). Some migrants (Failed asylum seekers not on section 4 support, A8/A2 migrants and some other migrants) who have no housing or income approach Nottingham City Council (NCC) for assistance. Where these individuals have no recourse to public funds (social care costs, benefits etc) Nottingham NCC is limited in the support it is able to offer such people. All those with NRPF who approach NCC are given an assessment to see whether or not they are eligible for support under the various pieces of relevant legislation. NCC is currently in the process of standardising its assessment process and will be seeking to also standardise, as far as is possible, the way in which support is provided.
  • Anecdotally, the economic downturn has led to an increased number of A8/A2 migrants facing homelessness and destitution. Where A8/A2 migrants have not been working for a full year whilst being appropriately registered and then become unemployed or, when they come to England without a job, they will have no recourse to public funds.
  • Housing conditions- Nationally it is recognised that some asylum seekers can be housed in substandard living conditions. There can be overcrowding, and scenarios of individuals being housed with members of the opposing tribal, social or political group.
  • 80% of migrant workers live in privately rented accommodation some of which may be in poor condition and/or be over occupied (including hot bedding etc) which is similar to sofa surfing. In addition to this there are some economic migrants that have tied tenancies which compromise their ability to exercise their housing rights.
  • Social isolation and hostility– Many migrants face considerable social isolation through loss of friends, family and social networks. They may encounter racism and hostility whilst living in the UK.
  • Legal claim: The process of migration is inherently stressful. It is recognised that the process of asylum and the uncertainly in which asylum seekers live cause additional mental health strains.
  • Language and literacy. Language is a vital tool for integration and accessing services. At least a third of asylum seekers arrive in the UK without English language skills. Some migrants may not be literate in their own language. This affects the ability of individuals to describe their symptoms and understand both verbal and written information given by the doctor. In some areas there is a shortage of interpreting services, particularly for out of hours work or acute situations; difficulties with interpreters cancelling appointments or failing to attend; a lack of continuity of interpreters; and concerns over confidentiality. Children can inappropriately be used as interpreters.
  • Understanding of services: Migrants are unfamiliar with the UK health services and may be seen to misuse services such as A&E due to their understanding of services that exist in their country of origin. Many young and healthy migrants, as with UK residents will not register with a GP unless they become unwell as they do not perceive it as a priority; Some EU migrants return home for their healthcare due to perceptions about longer waiting times in the UK compared to some EU countries.
  • Entitlements to healthcare services: Asylum seekers and refugees are entitled to free primary and secondary healthcare under the NHS. Legislation regarding the registration and treatment of failed asylum seekers has undergone numerous changes in recent years leading many healthcare practices to be confused and potentially deny treatment to some who are entitled.
  • Continuity of care: Asylum seekers can be “moved from place to place” by the Home Office or target contract providers with little warning, leading to difficulties with GP registration, healthcare programmes, fragmented treatment and a lack of medical records.      

2. Size of the issue locally

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Since 2004, there have been more than 1 million EU migrant workers from the EU accession countries entering the UK to work. These workers mainly have taken up low skilled jobs in elementary occupations or as process plant or machine operatives. Individuals from the A2 and A8 countries can enter other member states without a visa for a period of 6months and can reside in that country for a longer period if they are employed, self-employed, able to financially support themselves or are a student. There are more than 800 asylum seekers including dependents and unaccompanied minors living in Nottingham city who receive financial and/or housing support from United Kingdom Visa & Immigration (UKVI) formerly United Kingdom Borders Agency (UKBA) under section 4 & 95 support or social services (in the case of unaccompanied minors). Note: Section 95 of the Immigration and Asylum Act 1999 enables the provision of support to asylum seekers or dependents of asylum seekers who appear to the Secretary of State to be destitute or be likely to become destitute. Estimating numbers of refugees and failed asylum seekers is difficult as it is not possible to measure migration into and out of Nottingham. Using national estimates applied to Nottingham, it is estimated that there are about 7000 refugees and about 500 destitute asylum seekers living in Nottingham. Our current agreed limit for Asylum seekers is 1 Asylum seeker to 200 local residents, for Nottingham this equates to 1,529 because there are around 305,000 local residents in the city. There is no limit for refugees, as they are free to move to whichever part of the UK they choose.

Asylum Seekers

In October 2014 there were 779 asylum seekers residing in Nottingham city who have been assessed as destitute and are in receipt of housing or financial support from UK Visas and Immigration (UKVI) (Formerly UKBA). This figure excludes asylum seekers who are not assessed as destitute, refugees, failed asylum seekers and unaccompanied minors. This data provided by the Home Office provides a point prevalence of the number of asylum seekers receiving support at any one time, and does not show the number of asylum seekers arriving in an area, or the number ceasing to receive support due to either positive or negative asylum decisions. This number has remained increased steadily over the last year; in October 2013 there were 545 people receiving support from UKVI. Numbers are expected to continue to rise: the Home Office anticipates a 10-15% rise over the course of 2015 in the number of asylum seekers requiring support.

Nottingham City asylum seeker data from October 2014 shows that;

  • There were 799 asylum seekers being supported by UKVI in Nottingham City as of June 2015. 103 on (S4) support and 696 on (S 95) support source ::(EMSMP Home Office ASYS data).
  • An increasing number of asylum seekers are being placed in Nottingham as individuals, rather than as part of family groups. Historically, the majority of people placed in Nottingham have been part of family groups, but in recent months at least half of all those placed in Nottingham have been individuals. This is likely to continue to increase.
  • Asylum seekers are predominantly young, with 85% of principle applicants being between 18 and 39 years old.
  • 47% of principal asylum applicants are male; this is a considerable change compared with 2010 when 61% were male. Of those who are male, half are single. Comparatively, 87% of female principle applicant asylum seekers come to Nottingham as part of a family unit.
  • Asylum seekers placed in Nottingham City between March and September 2014 have come from a total of 48 different countries, with the main countries of origin being Iran, Pakistan, Nigeria, Afghanistan, Eritrea, Zimbabwe & China.
  • Data is no longer available about the languages spoken by asylum seekers. However, in September 2013, the most common languages spoken by asylum seekers were English, Urdu, Arabic and French. Of all asylum seekers supported by UKVI living in Nottingham City, 79% were non English speakers in September 2013.
  • Over a third of asylum seekers in Nottingham are currently housed in Arboretum and Berridge wards, a further third in Bridge, Mapperley and Dales wards, and the remaining third across all other wards apart from Clifton South.
  • Unaccompanied Asylum Seeker Children (UASC): A total of 12 unaccompanied asylum seeking children (UASC) are currently supported in Nottingham City by the Asylum Team, Nationally, 1,651 applications for asylum were received from unaccompanied minors in the year ending in September 2014. (Source: Nottingham Children’s Services 2014).

Refugees

  • The exact number of refugees living in Nottingham City is unknown, as upon being granted leave to remain, humanitarian protection or discretionary leave, individuals have the freedom to migrate within the UK. Based upon the report “Counting Up- A study to estimate the existing and future numbers of refugees in the East Midlands, Sep 2006” it is estimated that there are around 7000 refugees in Nottingham currently.
  • Failed asylum seekers: Individuals who receive a negative asylum decision should leave the UK once all appeals have been concluded. In reality, it is known that many continue to live in destitution rather than return to their country of origin. It is estimated that there are 500 destitute asylum seekers living in Nottingham based upon national estimation work.
  • Asylum seeker and refugee children living in Nottingham City: In May 2009, there were 319 asylum seeker children and 567 refugee children attending 87 of the Nottingham City primary and secondary schools. There were also an additional known 146 asylum seeker children below school age and 58 above school age. This totals to at least 1090 children within Nottingham City who are going through, or who have been through the asylum process.

EU Migrants

In May 2004, ten countries joined the EU: Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia and Slovenia. All but two (Cyprus and Malta) had certain restrictions placed upon them. These eight countries are known as the A8 countries. In 2007, Bulgaria and Romania also joined the EU and are known as the A2 countries. Individuals from the A2 and A8 countries can enter other member states without a visa for a period of 6months and can reside in that country for a longer period if they are employed, self-employed, able to financially support themselves or a student.

Nottingham has seen more than 8000 EU migrants enter the city to work since 2004, of which the majority have come from Poland. EU migrant workers are mainly young with general health needs similar to those of the UK population of the same age.  Prevalence rates of smoking are higher amongst many EU countries, such as Poland where the prevalence is about 32% (national UK rate 22%) The proportion of those aged 15 years and over who smoke in EU 27 countries ranges from 16% in Sweden to 38% in Greece.

The influence of migration to the UK upon smoking habits is largely unknown. Alcohol excess has also been highlighted as an issue amongst some groups. Nottingham has seen an increase in the number of births to non UK born women. In 2008 28% of births in Nottingham UA were to non UK born women, of which 5% were to women from EU accession states

Data from the Department of Work and Pensions indicates the number of people from outside the UK registering for a National Insurance Number (NINo). This data only includes those in work, looking for work or claiming benefits. It excludes dependants and students (unless in part time work) and does not indicate when individuals leave the UK. In the year to March 2014, 2,690 individuals from the EU accession countries (A8 and A2 countries) registered for a NINo in Nottingham. This was an increase of 570 people compared to 2012/13, and was mainly due to increases in numbers from Poland and Romania. Of those from EU accession countries registering for a NINo in Nottingham, 65% were from Poland, 12% from Romania and 7% from Hungary. It should, however, be noted that the restrictions on migration from Bulgaria and Romania were lifted in January 2014, so the year to March 2014 includes the first three months in which people from these countries were entitled to travel freely into the UK.   Workers from A8 countries are required to register to work in the UK under the Workers Registration Scheme (WRS). Between May 2004 and March 2009, 8,365 people have registered with the WRS in Nottingham. Of these people, 1,490 registered in the last year, a fall of over 700 since the previous year. Of the workers registered in 2008/2009, 53% were male and over 80% were aged between 18 and 34 years old. (Note this scheme is no longer in operation)

A study of EU Migrant Workers in Nottingham carried out in March 2009 estimated upper and lower limits of the number of EU migrants living in Nottingham as being between 2,410 and 5,623 depending upon the percentage of workers who returned home. This report looked at a number of issues including housing, education, language and access to services. Interviews were carried out with 235 migrant workers living in Nottingham, of which 86% were between 17 and 39 years old and 47% were single. Of those interviewed 81% were currently employed, with more than 50% working in elementary occupations or as process, plant or machine operatives. A high level of GP registration was found amongst this sample of EU migrants (83%) with 50% having been to see a dentist. Those not registered with a doctor reported that they would go home if unwell, or they were not registered with a doctor as they were currently healthy.

The Office for National Statistics published their 2014 Mid-Year Estimates of Population (MYE) this morning.  These give the City’s population as 314,300 as at 30th June 2014.

This figure is an increase of 3,400 (1.1%) on the 2013 MYE.  This is slightly higher than the percentage increase for England (0.8%), and an average increase when compared to the other Core Cities.  

The Components of Change released with the MYEs suggest that ‘natural change’ (the excess of births over deaths) accounts for just over 2,000 of the increase between 2013 and 2014.  Net migration accounts for a further 1,400, although there is a difference in net internal (within the UK) and international migration: the City lost 1,700 people due to internal migration, and gained 3,100 from international migration. 

The City also continues to see a large amount of population ‘churn’, with 25,600 people arriving from elsewhere within the UK and 27,300 leaving.  A table showing population by age and sex is available on Nottingham Insight at the following link: http://www.nottinghaminsight.org.uk/d/124594

Communicable diseases:

Nottingham City has high rates of TB, HIV and Hepatitis;

  • Tuberculosis: The number of cases of TB in Nottingham City has significantly risen over the last 10 years, giving a rate of TB more than double the national average in In 2008, 65% of cases of TB in Nottingham City were amongst the non-UK born, with the main countries of origin being Pakistan, India, Malawi, Zimbabwe, Sudan and South Africa. Nearly half of all cases were amongst those who had entered the UK within the previous 5 years. A notable change over the last 12 years is a large increase in the number of cases amongst those of African ethnicity. In 1996, 2% of cases of TB occurring in Nottingham were amongst those of African ethnicity compared to 34% in 2008.
  • HIV: The rate of HIV has climbed from 371 cases in 2005 to 428 cases in 2007. Of those diagnosed, 60% of cases were in African communities, and 67% were heterosexually acquired.
  • Hepatitis: Recent work calculating practice level prevalence estimates for Hepatitis B and C based upon demographic and drug user data has shown Nottingham City to have high rates above the national figures. There are an estimated 3683 cases of Hepatitis B (1.2% prevalence), and an estimated 3350 cases of Hepatitis C (1.0% prevalence) in Nottingham City. The UK is classified as a low prevalence country; most infections are acquired from adult risk taking behaviour associated with sexual practices & drug use. Estimates however suggest a small proportion of chronic infections are established as a result of infection acquired in the UK (around 200 per year) but an estimated 7,000 chronic persistent cases of Hep B in the UK are a result of immigration to the UK from high prevalence areas.

(Source: Viral hepatitis JSNA 2014)

Nottingham City

Screening for infectious diseases: Of the 832 asylum seekers living in Nottingham City in October 2009, 82% are from countries of high prevalence for tuberculosis (48% of which are countries of “very high” prevalence); 98% are from countries of high prevalence for hepatitis B and C; and 45% are from countries of high prevalence for HIV. According to current guidance, these individuals should be offered screening for these conditions.

Maternity data

In 2001 there were 3,279 live births to mothers within Nottingham unitary authority of which 14% were born to non UK born women. Since then, the proportion of births to non UK mothers has increased, so that in 2008 more than 1 in 4 live births in Nottingham UA were to mothers born outside the UK. One of the most notable changes is in births to mothers from the EU accession states who now represent 5% of all live births in Nottingham (see figure 1). Births to mothers born in African and Asian nations have also increased.

Figure 1: Live Births in Nottingham UA according to place of birth of mother in 2001 and 2008

Year

Total number of births in Nottingham UA for UK and non UK born mothers

Percentage of total number of births to non- UK born mothers (%)

Number of births to mothers born in EU accession countries

Number of births to mothers born in Africa

Number of births to mothers born in Asia

2001

3,279

14%

7 (0.2%)1

51 (2%)1

304 (9%)1

2008

4,181

28%

192 (5%)2

301 (7%)2

487 (12%)2

1 percentage of the total number of births to UK and non-UK born mothers for 2001

2 percentage of the total number of births to UK and non-UK born mothers for 2008

Maternity access

Women with complex social factors are far less likely to seek antenatal care early in pregnancy or to stay in contact with maternity services. Delays in accessing maternity care often results in worse outcomes for both mother and baby. One of the four key groups highlighted in the recent Confidential Enquiry into Maternal and Child Health[i] reports as having poorer pregnancy outcomes were: Women who are recent migrants, asylum seekers or refugees, or who have difficulty reading or speaking English. It is estimated nationally that 10.2% of total births are to this group.

According to NUH maternity data, during 2014/15, 319 (6.5%) of pregnancies were to recent migrants, asylum seekers or refugees, or those who have difficulty reading or speaking English. It appears that only 52% of recent migrants, asylum seekers or refugees, or those who have difficulty reading or speaking English accessed maternity (booking) within the recommended gestation. It is noteworthy that of the 10 births to asylum seekers or refugees, 9 (90%) accessed maternity services later than recommended and all of these accessed after 20 weeks gestation.

Female Genital Mutilation (FGM)

FGM comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons. Procedures are mostly carried out on young girls sometime between infancy and age 15, and occasionally on adult women. The practice is most common in the western, eastern, and north-eastern regions of Africa, in some countries in Asia and the Middle East, and among migrants from these areas.

Women who have undergone FGM are much more likely to suffer obstetric complications at childbirth than women who have not been subject to the procedure.  These women have complex needs and often initial access to health care services may be via maternity services. Since the 1st September 2014, it has been mandatory for NHS acute hospital providers to collect data on FGM. For the period of September 2014 to February 2015, there were:

a)            3110 newly identified cases of FGM reported nationally.

b)            46 newly identified cases of FGM reported nationally were under the age of 18

The Serious Crime Act 2015 strengthens the law around FGM by extending the extra-territorial jurisdiction of the offence; provides anonymity for victims; creating a new civil protection order; and a new offence of failing to protect a girl from FGM and placing a new duty on professionals to notify the police of such offences. This will require awareness raising and training of all professionals in contact with these communities..

Data on the number of Nottingham residents who have undergone FGM is not available. However, during the six month period between September 2014 and February 2015, there were 104 active cases of FGM and an additional 29 newly identified cases reported by Nottingham University Hospital Trust. This will include women who are resident outside of Nottingham City, yet gives a good indication of the prevalence within the local population.

Local Government Associations (LGA) – Female Genital Mutilation: A councillor’s Guide (FGM) 2015. Local Government Association Local Government House Smith Square London SW1P 3HZ, Telephone 020 7664 3000Fax 020 7664 3030Email info@local.gov.ukwww.local.gov.uk © Local Government Association, January 2015

For a copy in Braille, larger print or audio, please contact us on 020 7664 3000.We consider requests on an individual basis. L15-40

People smuggling

The appeal of a better life in the UK, combined with political instability, economic pressures and environmental issues at home are crucial factors in many migrants' decision to come to and remain in the UK.

The majority of illegal migrants are thought to rely on organised crime groups when coming to the UK, or during their time here.

Criminals involved in immigration crime operate in various ways; some may act alone or be part of a small group, whilst others form extensive global networks with members based in a number of countries to facilitate illegal migration.

The producers and suppliers of false travel and supporting documents are also key specialists in this criminal market. Counterfeit and forged documents are used in illegal immigration by air. They are also used by criminals for fraudulent visa applications, applications for leave to enter and for leave to remain. Fake documentation is also used to make applications for legitimate travel documents, which the applicant would otherwise not be eligible for.

Organised crime groups assist illegal immigrants to attempt entry to the UK clandestinely or overtly by the abuse of legitimate means of entry and use a variety of methods and routes to do this. There are key gathering points on these routes where the facilitators and smugglers congregate. Turkey is a key point for illegal migrants, Greece is the principal gateway into the EU from Turkey and France is the main point for clandestine entry into the UK. Attempts to enter the UK by illegal methods remain focused on South East ports.

Criminals also assist migrants to enter and regularise their stay in the UK illegally by establishing bogus colleges, organising sham marriages and exploiting a range of other migration categories. Document forgers, money launderers and corrupt professionals such as solicitors, are involved in this activity.

Human Trafficking

Human trafficking is the movement of a person from one place to another into conditions of exploitation, using deception, coercion, the abuse of power or the abuse of someone’s vulnerability. It is possible to be a victim of trafficking even if your consent has been given to being moved.

Although human trafficking often involves an international cross-border element, it is also possible to be a victim of human trafficking within your own country.

There are three main elements of human trafficking:

  • The movement – recruitment, transportation, transfer, harbouring or receipt of people
  • The control – threat, use of force, coercion, abduction, fraud, deception, abuse of power or vulnerability, or the giving of payments or benefits to a person in control of the victim
  • The purpose – exploitation of a person, which includes prostitution and other sexual exploitation, forced labour, slavery or similar practices, and the removal of organs

Children cannot give consent to being moved; therefore the coercion or deception elements do not have to be present.

Countries throughout Europe translate and interpret the Palermo Protocol in different ways so the definition of what constitutes human trafficking can differ between nations.

The UK Human trafficking centre (UKHTC) plays a central role in the NCA's fight against serious and organised crime. Find out more about the UK Human Trafficking Centre.

Types of human trafficking

There are several broad categories of exploitation linked to human trafficking, including:

  • Sexual exploitation
  • Forced labour
  • Forced labour involves victims being compelled to work very long hours, often
  • Domestic servitude
  • Organ harvesting
  • Child trafficking

Find out more about the different types of human trafficking.

Report human trafficking

In the first instance the point of contact for all human trafficking crimes should be the local police force. If you have information about human trafficking or hold urgent information that requires an immediate response dial 999. If you hold information that could lead to the identification, discovery and recovery of victims in the UK, you can also contact the charity Crime stoppers anonymously on 0800 555 111. (Source: National Crime Agency (NCA))

No recourse to public funds (NRPF)

It is difficult to ascertain the number of people with NRPF being supported by Nottingham City Council (NCC). NCC is currently in the process of putting in place sufficient monitoring arrangements to enable this to be properly assessed.

Issues of Inequality

Migrants tend to live in disadvantaged areas and so face the inequalities associated with this. Failed asylum seekers have limited entitlements to secondary care. Combined with poverty they can struggle to have their health needs met.

Notable changes since JSNA April 09

The Serious Crime Act 2015, placing a new duty on professionals to notify the police of such offences (FGM)

Metropolitan Housing Trust as secured funding from the Clinical Commissioning Group Nottingham City to deliver a BME mental health service from April 2015 – 2018.

Migrant Help service introduced a new telephone advice service and weekly outreach service and is now the lead service for asylum support.

Refugee Action service lost the contract for asylum support and is no longer operating in the city of Nottingham, but does work with voluntary returns in east midlands..

NNRF is the lead organisation in New Communities Alliance (NCA) a consortium that was established in April 2014 as part of Nottingham city council “Community of identity” funding. Working alongside 17 partner organisations delivering activities & services to this user group, they also administer a small grant to small grass roots groups who are outside the consortium. (For more info see NNRF Report 2014)

Newly arrived asylum seekers not being eligible to access ESOL for 6 months which is an additional barrier to language learning/integration.

3. Targets and performance

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Public Health Outcomes Framework:

Domain 3: Health Protection – Objective: The population’s health is protected from major incidents and other threats, whilst reducing health inequalities.

·         People presenting with HIV at late stage of infections:

In 2011, the proportions of HIV diagnosed late among black African and black Caribbean heterosexual men was 66%, compared to 47% in white heterosexual men. Among women, the proportion diagnosed late was highest among black African (61%) and black Caribbean (47%), compared to 44% in white women (PHE, 2013a). In Nottingham City, in 2012, 64% of persons living with HIV were of Black African or Black Caribbean ethnicity. 

In 2012, Nottingham City’s HIV prevalence was 2.78 per 1000 of the population (Public Health England, 2013), exceeding the national threshold recommended for universal screening in GP practices and acute hospital admissions, which is set at 2.0 per 1000 of the population. In Nottingham City, between 2010 and 2012, 66% of new diagnoses were made late (CD4 <350) and 42% made very late (CD4 <200). This is an increase when compared to the period 2006-10, when 62% of new diagnoses were made late and 35% very late. This is considerably poorer than other high prevalence areas in England. (Source: Public Health England (SOPHID data 2012))

Mortality from communicable diseases (Source 2011-2013 PHOF):

Directly standardised rate - per 100,000

  • Mortality from communicable diseases (Male) - 72.1 (ENG), 88.6 (NOT) - significantly worse than England
  • Mortality from communicable diseases (Female) - 56.2 (ENG), 50.5 (NOT) - no significant difference to England
  • Mortality from communicable diseases (Persons) - 62.2 (ENG), 65.9 (NOT) - no significant difference to England

4. Current activity, service provision and assets

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SPECIALIST SERVICES:

Nottinghamshire & Nottingham Refugee Forum (NNRF)

NNRF is an independent voluntary organisation that works with refugees and asylum seekers providing advocacy, practical advice, support, and friendship. This year at the forum from October 2013 – October 2014 7,173 users have visited the service an average of 593 users per month. NNRF runs a One Stop Shop & Into the Mainstream Project, both are currently funded by Nottingham City Council Public health & Nottingham City Council “communities of identity” grant, from the Migration Impact Fund, both services provides appointments for advice about housing, benefits, education and health case work, The other is working solely with new arrivals dispersed to the city, the most common queries are regarding GP registration; booking or attending a GP or hospital appointment; mental health concerns; and help completing HC2 certificates.

New Arrivals Coordinator Service

The New Arrival Coordinator is based within Nottingham City Council’s Community Cohesion Team which is part of Community Protection  The Coordinator responds to the needs of  newly arrived asylum seeker and refugee families by assisting them to access main stream and specialist services, benefits and entitlements that will help families to integrate. The Coordinator receives referrals from UKVI and G4S for all families dispersed to Nottingham. Once families arrive an appointment is arranged immediately, assisting with the completion of school registration or early years documents and providing help and information about other services including healthcare.

NHS Nottingham city CCG Local Enhanced Services (LES)

Clinical Commissioning Group Nottingham City – Locally enhanced service (LES): CCG Nottingham City commissions a LES for refugees and asylum seekers. GP practices are required to have a minimum of 10 asylum seekers or refugees to be eligible to take part with a payment given for every 10 consultations with asylum seekers or refugees. Failed asylum seekers, including those receiving section 4 supports whilst awaiting departure from the UK are not eligible for payment under the LES. To date, the LES has never been evaluated to assess the effectiveness and standard of care asylum seekers and refugees are receiving. Between 1st April 2008 and 31st March 2009, there were more than 6000 consultations claimed for under the LES by 28 GP practices. The numbers of consultations ranged from 10 to 950 over a year. There were three practices that claimed for more than 500 consultations which were practices in Sneinton, St Ann’s and the Meadows.

FGM Specialist Midwife

A Female Genital Mutilation Clinic runs twice a month, across the two sites of Queens Medical Centre and City Hospital. Women with suspected or known FGM are referred from the community for examination and appropriate planning for antenatal and labour care.

Interpreting services

The Interpreting Services are a district wide service covering both Nottingham City and Nottinghamshire County. The service provides interpreters to GPs, hospitals and other practitioners working in the healthcare trust. The service currently has 107 interpreters covering 52 languages. Interpreters are available from Monday to Friday from 8am to 6pm. Outside of these hours, in an emergency or where an interpreter is unavailable, language line, a phone interpreting service can be used. An action plan to increase out of hours cover and meet training needs is being implemented following an Equality Impact Assessment highlighting some gaps in service provision. During 2008, Nottingham Interpretation Services had 8000 interpreter bookings for a total of 56 languages, with Polish, Arabic and Urdu being the most common.

ESOL provision

The ability to speak English is a crucial skill to be able to access services. BEGIN (Basic Educational Guidance in Nottinghamshire) is an organisation that acts as the central portal for ESOL classes in Nottingham. They manage all the college waiting lists in Nottingham, matching individuals to courses that suit their requirements. BEGIN collects data on all their applicants storing this in a central database.

STEPS

Metropolitan BME Mental Health service (New service commissioned March 2015) A BME Outreach Support Service to foster positive mental wellbeing and promote awareness of available support and access to NHS or community services. The service provides community engagement to develop a better understanding of positive mental wellbeing within Nottingham’s communities. 

Sign Post to polish success

The Polish Community Group “The Signpost to Polish Success” (SPS) provides services and activities for Polish new arrivals in Nottingham. It offers signposting /information session Mon - Thur (Mon.12.30pm-5.30pm, Tue.11.30am-5.30pm, Wed. 12.00am,-5.00pm, and Thur.9.30am-2.30 pm) and English language lessons on Monday and Tuesday evenings. You can contact SPS by writing to them or arriving at their address within the opening hours.

Refugee Futures

The aim of the service is to provide a high quality resettlement/floating support service to refugees and their families from within Nottingham City.

Nottingham Arimathea Trust: Nottingham Arimathea Trust provides housing and support for destitute asylum seekers and refugees. Sometimes asylum seekers find themselves stuck in a limbo when they are denied the right to live and work in the UK but at the same time it is impossible for them to return to their country of origin. This service provides support to these people by providing a roof over their heads and helping them to submit a fresh claim for asylum.

GENERIC  PROVISION:

Emmanuel House Support Centre

Emmanuel House exists to support homeless, vulnerable or isolated adults in and around Nottingham. We provide diverse and accessible services that meet basic need and empower individuals to make positive changes in their lives.

The Friary

Drop-in centre for homeless and unemployed people, Advice on issues around housing, debt and benefits. Food parcels, bedding, clothing, Showers, laundry and barber. They have a homeless health team, including GP and nurse, Dentistry, optometry and chiropody. Support around substance misuse issues including Hepatitis A and B vaccinations, HIV and hepatitis C tests and Social activities, IT suite.

Street Outreach Team

Frame work’s Street outreach Team has two main functions, the first is engage with rough sleepers and help them access accommodation and support. The second is to work in partnership with other agencies such as local authorities to quantify the extent of street homelessness. Staff members visit known rough sleeping hotspots in the early hours of the morning in order for them to identify and engage with those in the greatest need of support. Working with housing, health, the police and voluntary sector agencies the service works to identify the most appropriate accommodation and support options. This can also include referral to drug and alcohol treatment services or assistance in returning to their town or country of origin.

Homeless Health Team

Nurse Specialist; Health care and advice provided by nurses for homeless people at hostels and day centres and street outreach.  There is a Midwife and health visitor for homeless families at refuges and other temporary accommodation. Outreach health care and help with accessing mainstream services, Joint clinics with local GPs and other voluntary sector agencies.

Migrant Health Forum (MHF)

The migrant health forum meets quarterly and works with services specifically around health concerns like, prevention and protection of this group and local communities GP registration  

Multi-agency Forum (MAF)

The Multi –Agency Forum is a group of services that meet quarterly to look at all different aspect of Asylum seekers /Refugees & Migrant issues from housing, social care, education and immigration etc.

East Midlands Strategic Migration Partnership Board

The aim of the East Midlands Strategic Migration Partnership (EMSMP) is to provide a regional advisory, development and consultation function for member organisations from the statutory, voluntary, community and private sectors - for the co-ordination and provision of advice, support and services for migrants. EMSMP covers the counties of Derbyshire, Leicestershire, Lincolnshire, Northamptonshire, Nottinghamshire and Rutland. There are three unitary authorities in the East Midlands: Derby, Leicester and Nottingham. The Partnership was established in 2000 to co-ordinate activities regarding asylum seekers in the Region/Area. Since then the role has progressively expanded to include strategic coordination in respect of all forms of international migration. The lead organisation is East Midlands Councils. Membership is open to all local authorities, other statutory authorities, voluntary sector organisations and private sector organisations that are involved or have an interest in these activities.

AWAAZ BME mental health  

AWAAZ is a registered charity that provides a mental health service to individuals from the BME and new emerging communities with a mental health problem. The organisation also provides self-directed support for individuals from the BME communities.

Community midwifery services

Midwifery care is delivered at GP surgeries and children’s centres across the city. Community midwives provide antenatal support and post-natal care for 28 days following delivery. Mothers are assessed as to their need for extra support in the postnatal period which is provided by Maternity Support Workers who provide help on issues such as breast feeding and accessing benefits. Antenatal clinics are held in the community for Polish, Punjabi and Urdu speakers. There are specialist midwives with a focus on homelessness, drugs and alcohol, domestic violence and mental health issues.

Nottingham Tuberculosis Specialist Services

The service has a team consisting of Respiratory Consultants and Three specialist TB Nurses. It provides outpatient and inpatient support for the diagnosis and management of those with suspected and confirmed TB. It receives referrals for TB screening from port of entry. These individuals are followed up and invited for screening. All those requiring further investigation with a Mantoux test are referred to the TB services.

Nottingham City Genito-Urinary Medicine (GUM) Clinic

Nottingham City GUM clinic is located at Nottingham City Hospital and is the central point for sexual health screening and treatment for patients across Nottinghamshire. Patients can be referred by their GP or can attend drop in sessions. Services include testing for sexually transmitted infections, HIV testing and psychosexual counselling. Interpreters are available when booked in advance. The clinic has specialist HIV nurses who are involved in the counselling and follow up of those with HIV. The team work with the HIV Positive Care team.

New Leaf, smoking cessation service

The New Leaf service is the main local provider for smoking cessation. New Leaf helps approximately 2000 people to stop smoking per year. New Leaf has literature translated into a number of languages including Polish, Arabic and Kurdish. The service has carried out a Peer Educator Project where individuals from ethnic minority groups were recruited to target those from their community with information about smoking cessation and New Leaf services, but there is no evidence of the outcome to date, It is hoped to carry out a similar programme with the Polish community, again there is no evidence and we are waiting for results from contacts in New Leaf & other related services. Interpreters are used by the new leaf where required, with good ethnicity recording within the service. All New Leaf Advisors receive cultural awareness training including about different smoking habits and the tobacco products used by different people groups.

Adult/Children’s Social Care

The various social services teams within Adult Support and Health (ASH) and Children’s Services (CS) provide support as appropriate to those with no recourse to public funds. This includes accommodation, subsistence payments as well as social care services. Those that may be eligible can be assessed by the relevant social work team.

Mental Health: CCG commissioned Psychological Therapies

There are 3 providers for people experiencing mental health/wellbeing issues, 1) Let’s talk wellbeing - Wellbeing, providing a range of talking therapies for people experiencing common difficulties such as feeling low, anxious or stressed. Wellbeing is provided by Nottinghamshire Healthcare in partnership with Rethink and the Nottingham Counselling Service and provides services in Nottinghamshire County and Nottingham City. 2) Insight Healthcare - Insight Healthcare works throughout Nottingham City to provide NHS funded talking therapies. The NHS in Nottingham understands that one in four of us will experience a common mental health problem in our lifetime. Insight Healthcare in Nottingham City provides a range of therapies to help you cope better with what is troubling you. 3) Trent PTS - Trent PTS is an approved NHS provider of psychological therapies. They are commissioned by the NHS to provide free, flexible, responsive and accessible high quality psychological therapy service. They provide treatment for depression, anxiety, loss, grief, trauma relationship problems and many other conditions. As part of the Improving Access to Psychological Therapies (IAPT), they provide therapy in Derbyshire, Nottingham City and North Wirral.  

5. Evidence of what works (what we should be doing)

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National

  • Caring for Dispersed Asylum Seekers. A Resource Pack. Department of Health. (2003)
  • Meeting the Health Needs of Refugees and Asylum Seekers in the UK. An information and Resource Pack for Health Workers, NHS. Burnett, A. and Fassil, Y. (2002).
  • Migrant Health a Baseline report 2006 – The Health Protection Agency
  • The Health Needs of Asylum Seekers, Briefing Statement. Faculty of Public Health. (2008)
  • The Social Care Needs of refugees and Asylum Seekers – Social Care Institute of Excellence 2006
  • Confidential Enquiry into Maternal and Child Health. Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer, 2003-2005. Dec 2007. The 7th Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom.
  • Crossing borders: Responding to the local challenges of migrant workers. Jan 2007. Audit Commission
  • Floodgates or turnstiles? Post-EU enlargement migration flows to (and from) the UK by Naomi Pollard, Maria Latorre and Dhananjayan Sriskandarajah (April 2008) – Institute for Public Policy Research
  • World Health Organisation WHO | Female genital mutilation
  • Social work immigration & Asylum – Debate, Dilemmas & Ethical issues for social work & social care practice. Debra Hays & Beth Humphries (2004)

Local

  • Asylum Seeker and Refugee Health Needs Assessment, NHS Nottingham City. Dr Ruth Bunting, August 2009.
  • Migrant Workers in Nottingham. University of Salford. Salford Housing & Urban studies unit. Lisa Scullion, Gareth Morris and Andy Steele. March 2009.
  • NNRF – Annual Report 2014 

6. What is on the horizon?

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·         New Immigration Act 2014

·         Possibly a ( New Immigration Bill 2015)

·         New NHS surcharge to migrants

·         Increase in Maternity services use for non UK born mothers in particularly (Polish)   

·         Increase in dispersal numbers & asylum claims in Nottingham city

·         Changes to claiming benefits for migrant workers

·         6 months to access ESOL for newly arrived asylum seekers

·         The Serious Crime Act 2015

·         Landlords may need to check immigration status

·         Lack of Educational places & particularly concerns for year 9 pupils who cannot sit exams due to joining late & issues with language 

7. Local views

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THE FOLLOWING VIEWS WERE GATHERED FROM USERS (Source: NNRF report 2014)

“We are meeting each other and are friendly together……we come from different countries – we come together as one here…..no one is discriminated”

“I have enjoyed everything really, especially making more friends and we got to meet people from the NHS which was something helpful”

“This is the only group I am involved in at the moment; we did a university trip, fire service workshop and learnt about relationships”

“We don’t always show our appreciation but thank you guys! You actually give your time to ensure the day to day running of the Forum goes smoothly, that in itself says a lot about the kind of people you are!”

“It’s too easy to take you for granted and forget that you’re here because you want to make a difference in the world, but whatever you do, you are appreciated.”

“It showed me the way I get help here with school etc.”

“It’s really important, it’s fun and I find something to do. I don’t get bored.”

“All of the volunteers have made me feel completely welcome and have been so supportive since I have started at the Forum. It has been a pleasure to work with them all.”

What does this tell us?

8. Unmet needs and service gaps

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  • Accessing primary care and healthcare services. Migrants face a number of potential barriers to accessing healthcare services. Through funding from the Migration Impacts Fund, it is aimed to introduce a health outreach team in order to facilitate GP registration, educate migrants about NHS services, and collate data regarding need. Educating about the need to access midwifery services prior to 12 weeks is also important.
  • Access to mental health services for migrants. Asylum seekers and refugees have a high burden of mental health problems. Accessing appropriate mental health teams and navigating through the mental health system has been highlighted as difficult within Nottingham.
  • Lack of therapeutic services for children and young people with specific specialist workers (familiar with trauma faced on journey/forced to flee/.being separated)  Lack of specialist mental health services for UASC and refugee young people and difficulty accessing CAMHS.  An example of a service to aim for is the new recently funded project being run by refugee council: in London for separated asylum seeking children:http://www.refugeecouncil.org.uk/what_we_do/childrens_services/my_time
  • Language support. There is a lack of interpreting services to cover out of hour’s services. Healthcare services need to be made aware of the provision of Language Line which can be used in these circumstances. English language lessons and the barriers to accessing these classes need to continue to be worked upon.
  • Difficulties of data collection on the health of migrants and a lack of ethnicity recording amongst some services.
  • Culturally appropriate education and screening for communicable diseases. Current screening of new entrants is haphazard and inconsistent. Through screening, potentially treatable disease can be identified to allow reduction in morbidity and mortality, alongside potentially reducing transmission between individuals.
  • Formula milk for HIV positive mothers regardless of immigration status. Through educating mothers not to breastfeed and providing an appropriate alternative (formula milk) a child can potentially be prevented from acquiring HIV. Currently, there is not funding for formula milk for these mothers. The long term cost savings, moral and ethical implications of preventing HIV transmission are enormous.
  •  Nationally, pregnant women with complex social factors are much less likely to access maternity services early in pregnancy and data suggests this is mirrored in Nottingham.  Early access amongst these groups during 2014/15 ranged from 10% to 83% (all below the 90% target).
  • Pregnant women who are recent migrants, asylum seekers or refugees, or those who have difficulty reading or speaking English are the least likely to access Maternity services within recommended timescales.
  • Almost one third of Nottingham’s births are to mothers born outside the UK. 280 (6%) mothers had difficulty reading or speaking English; these women and their babies are at increased risk of poor pregnancy outcomes.
  • There is an increasing need for translation services during pregnancy and challenges in gaining timely access to these services, particularly in emergency situations.
  • The Serious Crime Act 2015, places a new duty on professionals to notify the police of FGM. This will require awareness raising and training of all professionals in contact with pregnant women.
  • No Recourse to Public Funds. Lack of a standardised approach to assessing individuals for social support who have No Recourse to Public Funds.

 

9. Knowledge gaps

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There is a lack of data in respect of total numbers of Asylum seekers, Refugees & Migrant workers in the city after entering UK or after positive & negative status confirmation.

There is a shortage of experienced services & professional mental health workers in the city that work with users who have witnessed, and been exposed to massive traumas like war, torture & death.

What should we do next?

10. Recommendations for consideration by commissioners

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  • Continue the implementation of work funded through the Migration Impacts Fund which includes commissioning a health outreach team to work with asylum seeker and refugee communities
  • Notification for NCC Public Health of the arrival of new asylum seekers into Nottingham by target contract providers (G4S) etc
  • Data collection and analysis of health needs of migrants 
  • Modification of the Asylum Seeker and Refugee Locally Enhanced Service
  • Health promotion work, including education about communicable diseases
  • Improving private housing conditions in Sneinton (where there is a large migrant population)
  • Assisting migrants to exercise their housing rights to secure appropriate housing that is not overcrowded
  • Consider targeted mental health work with asylum seeker and refugee communities to encourage access to mainstream mental health services & clarify progress on mental healthcare structures and pathways to care for migrant communities.
  • Specialist mental health project/support for UASC/YP
  • Encourage ethnicity recording to ensure access to services is equitable for all groups.
  • Promote antenatal services amongst migrant communities & clarify a mechanism through which HIV positive mothers can access funding for formula milk in order to reduce the risk of HIV transmission to their child.
  • To have a Public Health agreement for formula milk for HIV positive mothers on a case by case basis
  • Conduct a Health Equity Audit of early access to maternity services and develop strategies for increasing early access among groups of women identified as least likely to access early, including recent migrants, refugees, asylum seekers and those who have difficulty speaking or reading English.
  • Ensure adequate provision of translation services during pregnancy and birth. Multilingual leaflets and materials should be standard practice.
  • Face to face interpreting services should be encouraged and telephone interpreting as a minimum used at each appointment when required. Family members, legal guardians or partners should not be used as an interpreter in the antenatal or postnatal period unless in an emergency
  • Develop a local FGM board to write overarching strategy & pathway for city & county based on the Department of Health FGM pathway to ensure identification/assessment and appropriate referral. This will then be taken on by both safeguarding boards.
  • Prioritise mandatory training on FGM in service specifications to ensure awareness and effective referral processes.
  • Standardise the approach for assessing and providing social support for individuals with No Recourse to Public Funds.
  • Utilising 3rd sector organisations and community organisations in order to disperse health information and target at risk groups. For example, dispersal of smoking cessation information through Polish groups.
  • Provide training opportunities for key organisations in relation to the social and health needs of migrant communities. Ensure an understanding of culture is fostered.( training for front line staff in GP practices etc)
  • Greater consideration and understanding of commissioned housing providers (should they be housing specialist) 

Key contacts

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Lynne McNiven, Consultant in Public Health, Public Health Nottingham City Council lynne.mcniven@nottinghamcity.gov.uk

Robert Stephens, Insight Public Health Manager, Public Health Nottingham City Council Robert.stephens@nottinghmacity.gov.uk

References

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Audit Commission (2007). Crossing borders: Responding to the local challenges of migrant workers. Available at http://www.audit-commission.gov.uk/reports/NATIONAL-REPORT.asp?CategoryID=&ProdID=05CA5CAD-C551-4b66-825E-ABFA8C8E4717  [Accessed 27 January 2010]

Bunting, R. (2009) Asylum Seeker and Refugee Health Needs Assessment, NHS Nottingham City.

Burnett, A. and Fassil, Y. (2002). Meeting the Health Needs of Refugees and Asylum Seekers in the UK: An information and Resource Pack for Health Workers. Department of Health. Available at http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_073382.pdf  [Accessed 27 January 2010]

Centre for Maternal and Child Enquiries (CEMACH) (2007) Confidential Enquiry into Maternal and Child Health. Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer, 2003-2005. The 7th Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. Available at http://www.cmace.org.uk/publications/CEMACH-publications/Maternal-and-Perinatal-Health.aspx [Accessed 27 January 2010]

Department of Health (2003) Caring for Dispersed Asylum Seekers: A Resource Pack. Available at http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4050915.pdf  [Accessed 27 January 2010]

Faculty of Public Health. (2008) - The Health Needs of Asylum Seekers, Briefing Statement. Available at http://www.fph.org.uk/uploads/bs_aslym_seeker_health.pdf   [Accessed 25 September 2015]

Health Protection Agency (2006). Migrant Health: A baseline report. Available at http://www.nric.org.uk/IntegratedCRD.nsf/f0dd6212a5876e448025755c003f5d33/b0388e87754bca518025796c004399f9   [Accessed 25 September 2015]

Local Government Associations (LGA) (2015) Female Genital Mutilation: A councillor’s Guide

Nottingham Nottinghamshire Refugee Forum (2015) Annual Report 2015

Noon, L. (2009)-Origins Evaluation Report: January 2009. NHS Nottingham City.

Oxendale, G. (2009).Immigration from the EU Accession states to Nottingham- National Insurance Registrations and Workers Registration Scheme. Nottingham City Council.

Pollard, N., Latorre, M. and Sriskandarajah, D. (2008). Institute for Public Policy Research Floodgates or turnstiles? Post-EU enlargement migration flows to (and from) the UK

Rose N, Stirling S, Ricketts A, & Chappel D (2011) Including migrant populations in Joint Strategic Needs Assessment - A Guide

Scullion, L., Morris, G. and Steele, A. (2009). A study of A8 and A2 migrants in Nottingham. University of Salford. Salford Housing & Urban studies unit. Available at http://usir.salford.ac.uk/9262/1/Main_Report_-_Nottingham_Migrant_Worker_April_2009.pdf  [Accessed 25 September2015]

Social Care Institute of Excellence (2006) The Social Care Needs of refugees and Asylum Seekers Available at http://www.scie.org.uk/publications/raceequalitydiscussionpapers/redp02.pdf  [Accessed 27 January 2010]

UK Visas & Immigration (2014) Immigration Statistics July to September 2014. Available at https://www.gov.uk/government/statistics/immigration-statistics-july-to-september-2014 [Accessed 4 December 2014]

World Health Organisation (2008). Female Genital Mutilation Factsheet. Available at http://www.who.int/mediacentre/factsheets/fs241/en/index.html  [Accessed 27 January 2010]

Glossary