Resource packto help generalpractitioners and otherprimary health careprofessionals in theirwork with refugeesand asylum seekersWritten by Dr A Carol Cheal and Dr Brian P FineUpdated by Dr Judith Eling

Revised June 2012First edition produced by The Refugee Health Team LSL September 2004

ContentsPage

Introduction 03

Common problems for GPs and primary health care professionals 04working with refugees and asylum seekers

Language and interpretation problems 05

Other problems in communication and establishing rapport 09

Cultural differences in approaches to health and disease 12

Lack of time 14

Common medical problems 16

The Sequence of Need 18

Medical problems - female genital mutilation 20

Complex or multiple symptoms 22

Bizarre behaviour, extreme distress and psychiatric problems 24

Discovering a history of rape, torture or other abuse 28

Children’s problems 33

Aggressive or demanding behaviour 39

People requesting certificates, letters and reports 41

Getting background information about patients 44

Entitlement to NHS services 45

Asylum seekers and refugees - effect on targets 48

Sources of help - useful contacts and resources 50

Clinical bibliography - sources of more clinical information 56

Glossary of terms and outline of the UK asylum system 58

References 68

Resource Pack

2

Introduction

Do you sometimes see patients whoare asylum seekers or refugees?

Do you sometimes have difficulties inworking with these patients?

This resource pack is designed to:

help you overcome the difficulties;

provide you with useful information;

make your work more satisfying, andmore helpful for your patients.

In the pack we* will detail thecommon areas of difficulty and suggestuseful approaches to each of them.

It is our intention that this pack will bea working tool. Individual pages will beregularly updated as patient needs andavailable services change.

* ‘We, the authors of this Resource Pack, Dr

Brian Fine (formerly a GP in Lambeth), Dr

Carol Cheal (formerly a GP in Lewisham),

have done research and development work

into the health needs of refugees, asylum

seekers and survivors of torture, particularly

in south-east London. We have trained and

worked at Freedom from Torture, formerly

the Medical Foundation for the Care of

Victims of Torture. We attempt to keep up to

date in this challenging and changing area of

medical work.

We would like to acknowledge the help and

encouragement of the following people in

the production and updating of this resource

pack: Dr Ann Lorek (consultant community

paediatrician), Professor Janice Rymer

(consultant in obstetrics and gynaecology), Dr

Peter Le Feuvre (GP), Dr Paul Williams (GP), The

Newham Language Shop, Carmen Rojas (service

manager of Three Boroughs Primary Health

Care Team) Marcia Martins da Rosa (former

Refugee Health Team leader) and the following

members and former members of the Refugee

Health Team LSL – Azhar Hammadi, Simin

Mousavi, Rookmin Singh and Cherrine Ricketts.

The resource pack was updated in 2012 by Dr

Judith Eling, GP with the Refugee Service,

Health Inclusion Team LSL. Dr Eling has been

providing weekly GP clinics for destitute

asylum seekers in Lambeth since 2006.

The Health Inclusion Team provides a GP

specialist service in partnership with the

Pavilion Medical Centre, Lambeth.

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Common problems forGPs and primary healthcare professionalsworking with refugeesand asylum seekers

Do you recognise any of the areasdescribed in the list below?

Language and interpretationproblems

Patients unwilling or unable to talk

Differences in understanding ofhealth, disease and treatment

Lack of time for complex problems

Lack of knowledge on medical,psychological or social problems

Multiple physical symptomswith no clear cause

Bizarre behaviour, extreme distressand psychiatric emergencies

Discovering a history of rape,torture or other abuse

Aggressive or demandingbehaviour at the reception desk

People requesting certificates,letters and reports

Lack of information aboutpatient or their background

Entitlement to NHS services(primary and secondary care)

Will asylum seekers and refugeesadversely affect targets?

Who can help me with thesecomplex problems?

How does the asylum system work?

What does the legal languagearound asylum mean?

NB This list can never be exhaustive, but

covers most of the issues identified in

research work done by a number of groups.

Case ScenarioA 28 year old man comes to the reception

desk of your surgery. He speaks little English

and is accompanied by another man who

speaks slightly more.

They say they have been told they need to

see a doctor, but it is not clear why. The

friend mentions a cough, and also that they

need a letter from the doctor.

The receptionists are very busy, the patient is

not registered with the practice and there

are no appointments left for the day.

What next?

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5

Language andinterpretation problems

Common problems include:

Patient does not speak English,or a language that you speak

It is unclear what language thepatient speaks

Patient is unable to communicatewith receptionists regardingappointments, etc

Patient and clinician havingdifficulties communicating

Patient is unable to understand thehealth ideas or concepts that arecommonly used by us

Patient has expectations of ourservice that are not appropriate

Patient does not understand how oursystems work - in the surgery or inthe NHS generally

Consultations take much longer ifthere is a language problem

Some suggestions for dealing withthese problems:

Use a professional interpreter

Use a family member or friendto interpret

Use a patient advocate

Use an interpreter from a refugeecommunity organisation (RCO), if available

Use written language materials -including a language recognitioncard.

Use a professional interpreter

This should be a trained interpreter.All primary care staff, including GPs and all the staff in a GP surgery, familyplanning clinic staff, health visitors anddistrict nurses, A&E Staff, can use theLambeth, Southwark and LewishamInterpreting Service. Their interpretersare trained in the language of healthissues.

Interpreters can be booked in advancefor face-to-face interpreting. In anemergency, when there is insufficienttime to book a face-to-face interpreter,the Interpreting Service can connectyou to a telephone interpreter.

The telephone interpreting service canbe used by passing the handset of yourphone between yourself and thepatient, or by putting the wholetelephone on ‘hands-free speaker-mode’ if possible. Some telephoneshave the option of an additionalhandset or earpiece to be plugged in.

For access to the LSL InterpretingService, see below. For GPs and GP staffyou will only need to give the addressof your practice. The service is availablefor telephone interpreting ‘out-of-hours’, including use by doctorsworking at SELDOC.

Use a family member or friend to interpret

In an emergency, this may be the onlyoption available to you, but there areobvious disadvantages.

The patient may not want to discloseinformation to a family member orfriend.

Children acting as interpreters may beat risk of hearing things which areinappropriate for their age.

Children may not be able to discloseinformation in front of another familymember.

The “interpreter” may not understandthe concepts or the language ofhealth matters.

The “interpreter”, being untrained,may give you their view rather thantranslating the patient’s own words.

For these reasons it is always better touse a professional, trained interpreter, if at all possible.

Use a patient advocate

Advocates are usually trainedinterpreters who also have a role inrepresenting the patient’s interests.As well as translating the patient’swords, the advocate may put forwardtheir own views and suggestions. In aconsultation this could be either helpfulor confusing.

It is important to clarify the role of theperson accompanying the patient at thestart of the consultation. Some PCTs arenow providing bilingual healthadvocates rather than interpreters.

Use an interpreter from a refugeecommunity organisation (RCO), ifavailable

Some RCOs can provide interpreters oradvocates. They may make a charge forthis service. The Health Inclusion TeamLSL might know which local RCOs offerthis service. Contact them on:020 3049 4700.

Use written language materials

Language recognition cards can helpreceptionists identify the patient’s firstlanguage and hence find a suitableinterpreter. The card can be accessed viathe Newham Language Shop website:http://www.languageshop.org.uk/languageidentification.htm

Downloadable appointmentcards - Newham Language Shop’swebsite has a function which allows a range of appointment cards to be translated into differentlanguages. This function can beaccessed onhttp://www.languageshop.org/translatedinformation.asp

Multilingual health resources - The Department of Health (DH) hasproduced a number of translatedleaflets, including a leaflet on the NHSfor newly arrived asylum seekers:http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_4123594

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An extensive list of resources is listedon the former Home Office RefugeeIntegration Portal Health website(now archived):http://webarchive.nationalarchives.gov.uk/20090805000644/http://www.nrif.org.uk/Health/Mental/contributingtothecommunity/index.asp?oi=02-02

Tips on working with interpreters:

Try to allow for the fact that aconsultation will take at least twiceas long with an interpreter present.

If the interpreter can arrive early andmeet the patient briefly before theconsultation, this can enable them toestablish rapport and possibly savetime in the consultation. However,issues such as confidentiality andthe appropriateness of this need to be considered.

It may be worthwhile clarifying therole of the interpreter before theconsultation - for example, do theysee themselves as having a patient-advocacy role or are they purely thereto translate what the patient says.

It is worth asking the interpreter totell you if there are any language orcultural problems in translating yourwords or the patient’s words.

Interpreting services for Lambeth,Southwark and Lewisham PCTs

1 Lower Marsh, Lambeth, SE1 7NTTel: 020 3049 3913For booking face-to-face interpretersoffice hours are from 09.00 – 17.00

When making a booking, please beprepared to give the patient’s name,health professional’s name, address forthe consultation, language name andappointment date and time.

Minimum notice period required tomake a booking depends on howcommon the language is.

For more common languages, mostbookings can be made with only a fewdays’ notice, however for rarer languages,at least one week’s notice is required.

Language Line

http://www.languageline.co.ukTo access a telephone interpreter 24/7 Tel: 0845 3109900

Please be ready to give yourorganisation’s name, their LanguageLine PIN code, language name, yourname and your occupation and to statewhether you require a call-out to thepatient’s telephone number (LanguageLine will arrange a three-way call sothat you can contact a patient byphone using an interpreter) or whetherthe patient is physically present.

Usually you will be connected in lessthan 60 seconds to an interpreter, butfor some languages there is a longerwait, so you might ask a receptionistto arrange the call for you and to putyou through when the interpreterbecomes available.

Resource Pack

Language Identification CardPoint to your language and an interpreter will be called

For further copies of this Language Identification Card,please contact the Newham Language Shop on 020 3373 4000.Reproduced with permission of Newham Language Shop.

Albanian

Amharic

Arabic

Bengali

Chinese

Farsi

French

Greek

Gujarati

Hindi

Lingala

Lithuanian

Luganda

Malayalam

Pashto

Polish

Portuguese

Punjabi

Russian

Serbo-Croat

Somali

Spanish

Swahili

Tamil

Tigrignia

Turkish

Urdu

Vietnamese

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Other problems incommunication andestablishing rapport

Many issues other than ‘not speakingthe same language’ can result inproblems with communication.

Common problems include:

Cultural issues

Gender issues

A history of post-traumatic stressdisorder in the patient

Fear or lack of trust in doctors andhealth professionals

Lack of knowledge or understandingof the role of the NHS

Misunderstandings ormisconcencptions aboutthe role of the GP.

Cultural issues

People from different cultures mayhave a different understanding ofareas relating to health and disease.These areas of difference may include:

The significance of particularsymptoms

The understanding of the humanbody and its systems

The approach to disease andtreatment

Taboos about discussing certain topics.

For this reason, some patients may bevery concerned about having bloodtests, for example. Blood may beregarded as having a very specificsignificance so a patient might bereluctant to have any taken.

It is important to try and understandwhat the patient thinks about theirsymptoms and to identify differencesbetween your perception and theirs.Only then can you begin to explainand gain the confidence of the patient.

Gender issues

It may be very important for a patientthat they are seen by or examined bya clinician of a particular gender.Failure to be sensitive to this issuemay offend very strongly heldreligious or cultural beliefs, and maydisrupt an individual’s socialfunctioning within their community.

The gender of an interpreter may alsobe important, and although it is notalways possible to accommodatespecific requests, it is worthmentioning this when booking a face-to-face interpreter.

The key issue is to be aware of thispossibility, and to be prepared todiscuss the problem with the patient,if unable to meet their request.Sometimes the presence of achaperone may be helpful for thepatient as well as for the clinician.

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Post-traumatic stress disorder

Patients who are refugees or asylumseekers may have suffered majortrauma prior to their arrival in the UK.Estimates of the prevalence of torturesuggest that as many as 30% ofrefugees may be survivors of torture1,2.Many of these patients will have post-traumatic stress disorder (PTSD)3.Amongst the features of this anxietydisorder is the development of extremeanxiety when faced with triggers orstimuli bringing back memories of theoriginal stress. Patients often go togreat lengths to avoid situations likelyto trigger these memories.

Please remember that triggers ofPTSD symptoms may include aspectsof a normal surgery situation, such aswaiting in a queue, or removingclothing for a clinical examination.These circumstances may bring backunbearably painful memoriesassociated with extreme anxiety.

Sometimes these problems can resultin angry outbursts, patients feelingunable to remain in the waiting room,or patients failing to turn up for theirappointments.

Fear or lack of trust of doctors andhealth professionals

Unfortunately, in some countriesdoctors have been involved in thetorture of prisoners. Also, people whoinflict torture sometimes claim to bedoctors, when they are not. In somecountries doctors and other healthprofessionals have a role in providinginformation to the state about patients.

In these circumstances it is notsurprising that patients are sometimesanxious about disclosing informationto doctors or other staff. We should beaware of this possibility, and reassurepatients of our impartiality and of ourprofessional duty of confidentiality.Patients need to know that we alwaystry to act in their best interests, ratherthan in the interests of somebody else.

Lack of knowledge or understandingof the NHS

Asylum seekers come from all parts ofthe globe, and from countries wherethe health care system may be radicallydifferent from the NHS. They maycome from a country that does nothave a system of primary care at all.Although most asylum seekers areprovided with induction packs explainingthe system, it is not surprising thatmany think we can help with problemsthat are not within our remit.

It may help if we can work out whatthey are looking for, and then decidewho is the best person or organisationto help. This may not be within theNHS at all. We should not assume thatwe have a responsibility to find asolution for all problems, but we mightbe able to point patients in the rightdirection, and perhaps explain a bitmore about how things work in the UK.

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Misunderstandings or misconceptionsabout the role of the GP

This follows on from what is saidabove. If a person comes from acountry where there is no GP service,it is not surprising if they do not reallyknow the best way to use our service.

As we strive to make GP services moreaccessible, it may be that we are theone place where an asylum seeker canget access to a sympathetic ear, and aperson who is perceived to have thepower to help. Although it is a goodidea to try and help, it is also importantto ensure that the patient learns howsystems work in the UK, and where toget the most appropriate help.

In Lambeth, Southwark and Lewisham,it may be a good idea to refer thepatient for further assistance from theHealth Inclusion Team .

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Cultural differencesin approaches to healthand disease

Background

Issues for asylum seekers andrefugees

Counselling

Impact of rape and torture

Background

Most of us are aware of culturaldifferences between diverse populationgroups in South London. Sometimesthese cultural differences can bebarriers to the provision of health care.

For example, having epileptic fits mayhave a significance determined by theculture of the patient. This may resultin a reluctance to accept a diagnosis ofepilepsy and to take medication.Another example may be the patientwho is reluctant to remove clothing fora physical examination, because this isfelt to be offensive within their culture.

Issues for asylum seekers andrefugees

Among the diverse population ofrefugees and asylum seekers there arelikely to be many cultural differenceswhich we need to be aware of.Of course it is impossible for us toknow the culturally determinedhealth beliefs of all our patients.

It is helpful to be aware of these, avoidmaking assumptions, and enquiresensitively about patients’ ideas.

The educational level of the patientwill also effect their health beliefs and understanding.

Counselling

One concept which may be alien tosome asylum seekers from some areas,is counselling. In some countries in theHorn of Africa, for example, there is awidely held belief in ‘active forgetting’- in other words that healing takesplace best by not thinking aboutpainful and traumatic experiences4.This may work for some people, andthey may not like the idea of ‘talkingtherapies’ where they are encouragedto discuss their past traumas. Even so, a patient from these cultures mightbenefit from counselling if it ispresented in an appropriate andsensitive way.

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Impact of rape and torture

We have said that among asylumseekers up to 30% may be victims oftorture1,2. Many female asylum seekersmay have experienced rape whilst inprison, as an act of war, or during theirescape to Britain.

As well as suffering the obvious physicaland psychological consequences, insome cultures a woman who has beenraped is regarded by her family as anobject of shame and may be cast out6.This may complicate the presentationof rape - a woman feels not only theinevitable shame of having beenviolated, but fears that disclosure of herexperience may result in her completealienation from her remaining familyand community.

Issues of rape and torture mightemerge when offering a routineexamination such as a cervical smeartest. This may explain an unexpectedreluctance of a patient to undergo aphysical examination. The issuesaround rape and torture are discussed below.

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Lack of time

Lack of time is the most common difficulty raised by GPs and healthprofessionals in working withasylum seekers.

Many of us have had the experience ofspending a long time in a consultationwith an asylum seeker. We may feeloverwhelmed at the idea of seeing anasylum seeker, with a long list of complexproblems and a high level of anxiety,in a ten minute appointment. If aninterpreter is available, communicationis easier, but the consultation is likelyto take at least twice as long.

Some suggestions for coping withthis difficulty more effectively:

Prioritise the problems

Assume that a series of appointmentswill be needed

Deal with what is appropriate

Arrange double appointments,especially if an interpreter is required

Document your workload

Prioritise the problems

Prioritise - deal with the most urgentproblems first. Some problems canwait - don’t feel you have to dealwith everything at once. Many ofthe patient’s symptoms will be long-standing and cannot be sorted outvery quickly.

Many psychosomatic symptoms willimprove with time, and with a moresettled situation for the patient.

Assume that a series of appointmentswill be needed

If you deal with the urgent problemsfirst, other issues can be explored insubsequent consultations.

Most patients will appreciate theopportunity to return to see the sameclinician over a period of time.

Deal with what is appropriate

Patients may come to you with anexpectation that you can deal with allsorts of problems. Some may be outsideyour remit, and you need to make thisclear to the patient. The distress of thepatient may be relieved by talking tosomebody with appropriate expertise.

This may be:

A good solicitor

A caseworker from the RefugeeCouncil,

A worker from a refugee communityorganisation,

A social worker from the SocialServices Asylum Team,

A case worker from the HealthInclusion Team LSL (formerly theRefugee Health Team LSL),

A specialist from Freedom fromTorture (formerly the MedicalFoundation for the Care of Victimsof Torture)

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Complex medical problems may wellrequire investigations or referral tosecondary care, as for any otherpatient. Once again, these problemsare sometimes long-standing, and youmay need to assess the urgency ofany referral.

Arrange double appointments,especially if an interpreter is required

If it is possible to arrange a doubleappointment whenever an interpreteris booked, this wil help.

Also, it may be useful for the interpreterto spend a little time in the waitingroom talking to the patient first, anddiscovering what are the patient’spriorities, although the interpretermay not see this as their role.

Document your workload

It is important to document when you are seeing asylum seekers andrefugees with interpreters, and to be able to feed back to the PCT the effect on your workload.

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Common medicalproblems

Patients who are asylum seekersfrequently present with a varietyof symptoms. The causes of thesesymptoms may be physical,psychological or related to theirparticular social circumstances, as with any other patient.

However, symptoms in asylum seekersmay also be caused by:

conditions related to their countryof origin,

conditions related to theirexperiences in captivity, or

conditions related to their flightfrom persecution.

Conditions related to the country of origin

These will depend on the country orpart of the world that the asylumseeker comes from, and conditions thatare prevalent there. They may include:

Malaria

TB

HIV

Tropical diseases

Diseases of malnutrition

Poorly controlled chronic diseases,such as diabetes, hypertension

Female genital mutilation (female circumcision)

Conditions related to experiences incaptivity

These may include conditions resultingfrom war and civil strife, imprisonmentin poor conditions, and torture. Theyinclude:

Traumatic injuries, such as fractures,amputations, bullet wounds, dentaltrauma

Conditions secondary to torture, suchas shoulder or brachial plexusproblems caused by being suspendedby the arms

Unwanted pregnancy, sexuallytransmitted infections, or ano-genitaltrauma caused by rape

Eye and ear problems secondary tohead injuries

Post-traumatic epilepsy

Increased risk of peptic ulcer and H.pylori infection

Poorly controlled chronic diseases e.g.diabetes, hypertension

Diseases of malnutrition

Psychological problems - see sectionon ‘Bizarre behaviour, distress andpsychiatric problems’

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Conditions related to flight from persecution

These will be conditions acquiredduring the journey to asylum, oftenover a prolonged period of time and invery poor conditions. These conditionsinclude:

Skin infections and infestationse.g. scabies

Unwanted pregnancy, sexuallytransmitted infections, or ano-genitaltrauma caused by rape

Gastroenteritis

Psychological problems, includingacute stress reaction anddisorientation - see section on‘Bizarre behaviour, distress andpsychiatric problems’.

When considering these conditions,one helpful concept is that of ‘TheSequence of Need’, as described byDr P. Le Feuvre in 2000. This conceptencompasses the idea that the physicaland psychological problems of anasylum seeker are to some extentdetermined by how long they havebeen in the UK and how far they havegot towards being settled here.

The Sequence of Need describes fivestages in the process:

Arriving - this is the stage reached onarrival in the place of asylum, and ischaracterised by a state of euphoria

Settling - this is the next stage, whenthe person begins to feel very awareof what has been lost and that all isnot ideal here. It is characterised by astate of disappointment and afeeling of loss

Establishing - this follows when theperson is beginning to settle intotheir community in the UK, and ischaracterised as a stage of adjustment

Integrating - is when the personbegins to feel truly accepted, usuallysome time after the granting ofrefugee status. It is characterised as astate of acceptance

Departing - as when an asylum claimis refused and the possibility ofreturn or deportation may arise. It ischaracterised by a feeling of rejection

At each of these stages, particularmedical and psychological conditionswill be more likely to present.

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The Sequence of Need (P. Le Feuvre 2000)

Trauma, injuries, amputations, tortureInfections Sexually transmitted infections Infestations, e.g. lice, scabies Gastrointestinal Problems, including peptic ulcers Dental problems, including from trauma and torture Acute psychological problems

Psychological problems, including resulting from torture Psychosomatic pain, especially headaches, back andabdominal painSexually transmitted infections Pregnancy, including unwanted pregnancies from rapeDental problems Family tracing

Chronic health problems, e.g. diabetes, hypertensionAcute infections Sexually transmitted infections Continuing psychological problems, including PTSDSubstance abuse, especially. alcohol, khat, drugs Psychosomatic pain, especially headaches, back and abdominal painTrauma, including racist abuse and violence Preventive health issues, e.g. cervical smears,immunisations

Chronic health problems, e.g. diabetes, hypertensionLifestyle and culture issuesContinuing psychological problems, including PTSDPsychosomatic pain, especially headaches,back and abdominal pain

High stress levels AngerFearContinuing psychological problems

Arriving

Settling

Establishing

Integrating

Departing

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What can we do? Who can help us?

How can we respond to thesemedical problems? A number ofbasic principles apply:

Don’t panic

Assess the situation medically, as you would do with any other patient

Consider appropriate referrals to secondary care, as with anyother patient

Prioritise problems according to their clinical urgency

Assume that you will need extratime and follow-up appointments

If stuck get advice from

Hospital colleagues

Freedom from Torture:020 7697 7777www.freedomfromtorture.org

The Hospital for Tropical Diseases:contact the University CollegeLondon Hospital switchboard on0845 155 5000 and ask to be putthrough to the on-call tropicalmedicine registrarhttp://www.thehtd.org

The Three Boroughs Health Inclusion Team:020 3049 4700 www.threeboroughs.nhs.uk

Remember that some problemsresolve over time, and some requiresome investigation prior to referral

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Female genitalmutilation

This is a problem which may affectmany women from sub-Saharan Africaand the Middle East7. It is practised in awide variety of cultures and is notconfined to one religious group. Forexample, it is estimated that 98% ofwomen in Somalia have hadinfibulation (see below), 89% ofwomen in Sudan have had infibulation,and 90% of women from Ethiopia andEritrea have had some form of FGM8.

The age at which it is performed variesamong different groups, but is usuallybetween two and twelve. FGM is illegalin the UK and has been condemned bythe WHO.

What is female genital mutilation?

There are 3 main types of FGM:

Type 1Clitoridectomy - this involves excisionof the prepuce of the clitoris, with orwithout the clitoris itself.

Type 2Excision of the clitoris with partial ortotal excision of the labia minora.

Type 3Infibulation - excision of part or all ofthe external genitalia with stitching ornarrowing of the vaginal opening.

What are the effects of FGM?

Women may present to health servicesat various times with problems relatedto FGM:

Following menarche, girls may haveproblems because of insufficientopening left for the flow ofmenstrual blood - this can lead tohaematocolpos.

They may also suffer from urinaryoutflow problems leading torecurrent urinary infections.

Women may suffer from dyspareuniaor difficulty with penetration due toa pinhole introitus.

They may suffer from lack of sexual responsiveness.

Women may present requestingadvice about what help is availableto reverse the procedure.

The most common time for problemsto present is in labour - with prolongedor obstructed labour, requiring de-infibulation for delivery to occur.

There may be a problem followingdelivery, when relatives or even thewoman herself, may ask for her tobe re-infibulated (stitched back toher previous state), when repairingan episiotomy. This practice of re-infibulation is illegal in the UK.

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What can be done to help with FGM?

Surgical correction of infibulation(de-infibulation) can be carried outat any time. However, for a womanpresenting in pregnancy, de-infibulation should be performedelectively under anaesthesia at around20 weeks if possible. De-infibulationcan now be carried out under localanaesthetic at the Guy’s and StThomas’ NHS Foundation Trust AfricanWell Woman’s Clinic (see below).

It is important to know that it is illegalfor anyone to take a child out of theUK for the purposes of having FGMperformed elsewhere – anyone whosuspects this is planned should contactchild protection services immediately.There is comprehensive guidance onmanaging all aspects of FGM in the“Multi-Agency Practice Guidelines:Female Genital Mutilation”, publishedby the Foreign and CommonwealthOffice in 2011. This document can bedownloaded online atwww.fco.gov.uk/fgm

The London Safeguarding ChildrenBoard have produced detailedguidelines on what action should betaken to protect children who may beat risk of FGM and also provides otherFGM resources:http://www.londonscb.gov.uk/fgm/

There is an African Well Woman’s clinicat Guy’s and St Thomas’ NHSFoundation Trust which is run by FGMSpecialist Midwife Comfort Momoh,and she is also available for advice andfurther information about problemsrelating to FGM.

Comfort Momoh can be contacted atGuy's and St Thomas' on 020 7188 6872 or by email oncomfort.momoh@gstt.nhs.uk

There is a list of other hospitals andclinics in the UK offering specialist FGMservices athttp://www.forwarduk.org.uk/resources/support/well-woman-clinics

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Complex or multiplesymptoms

Asylum seekers often seem to presentwith several apparently unrelatedsymptoms. Consultations may also becompounded by requests for help withnon-medical problems.

There may be several reasons for thesecomplex and confusing consultations.

Lack of understanding of the roleof the GP within the NHS system

Psychosomatic symptoms

Multiple physical pathology

Previous abuse, such as tortureor rape

Lack of understanding of the role ofthe GP within the NHS system

Asylum seekers may come fromcountries with very different healthsystems from ours, and do not knowhow the NHS works, or what GPs orA&E departments are for. Thesedifficulties are explained in moredetail in the section on ‘Otherproblems in communication andestablishing rapport’.

Psychosomatic symptoms

Some or all the symptoms presentedmay be psychosomatic presentationsreflecting the wider problems of thisgroup of patients. These problemsinclude:

Coping with multiple losses, such asloss of family members, home, socialstatus, language and culture

Coping with the anxiety associatedwith going through the asylumprocess

Finding the time to go into theunderlying problems may well bethe key to tackling these symptoms.

Multiple physical pathology

Unlike many other young adultpatients that we see, asylum seekersmay have multiple physical pathologyproducing multiple symptoms. Thepathology is usually the consequenceof mistreatment, trauma anddeprivation. These traumas may haveoccurred in prison or captivity in thehome country, or during the journeyto escape from persecution.

Previous abuse, such as tortureor rape

Presentation with multiple symptomsmay be a reflection of previous seriousabuse, such as torture or rape (of bothwomen and men). It is worth notingthat amongst asylum seekers, theincidence of torture is variouslyestimated at between 5% and 30%1,2

depending on definitions used.

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Amongst people who have beentortured, it seems to be quitecommon to suffer from headaches,epigastric pain and back pain9. Allthree of these symptoms may bepsychosomatic in origin.

These symptoms may gradually resolvewith time and with resolution of thepatient’s unsettled situation. However,some patients who have experiencedrape or torture may require longerterm psychological help. They may notwish to discuss their experiences, but ifthey do, it can go some way towardsaddressing their problems. Otherpatients may benefit from a referralfor counselling, or to the specialistTraumatic Stress Service (currently viayour local Community Mental HealthTeam), or to Freedom from Torture.

Nevertheless, it is important to bear inmind the possibility of physical causesfor these symptoms. Headaches may berelated to previous head injuries. Ifthere are associated fits or funny turns,it might be wise to refer to aneurologist for investigation ofpossible post-traumatic epilepsy.Epigastric pain may follow changes ineating patterns and perhaps having avery inadequate diet in prison.Helicobacter pylori is more common inprisoners and it is worth checking forthis. Stress-related peptic ulceration isalso more common in this population.Back pain may be related to beatingsand suspension while in captivity.Torture survivors may have beensuspended for prolonged periods oftime from ropes or chains attached totheir wrists or ankles. They may alsohave been kept in uncomfortable orcramped conditions, being unable tolie down or stand up straight.

It is therefore worthwhile askingpatients who present with multiplesymptoms whether they havesuffered mistreatment in the past.

The presentation of these patientshas many parallels with that of survivorsof other forms of abuse, such as childsexual abuse. As we know, it may be along time before a patient feels able todisclose the underlying cause for aphysical symptom.

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Bizarre behaviour,extreme distress andpsychiatric problems

Aspects to be considered in this sectioninclude:

Acute stress reactions

Cultural variability in reaction todistress

Depression

Post-traumatic stress disorder (PTSD)

Substance abuse

Suicide risk

Psychotic illness

Vulnerability and resilience

Acute stress reactions

Patients who are asylum seekerssometimes present with behaviour orsymptoms suggestive of mental healthproblems. This behaviour can be quitebizarre or dramatic. However, beforemaking a diagnosis of a formal mentalillness, it is worth considering whetherthis could be a normal reaction to ahighly stressful situation. Rememberthat many asylum seekers will haveonly recently experienced imprisonment,torture, escape, danger and fear.

These people may now be in asituation where they do not speak thelanguage, they do not understand howsociety works in the UK, they lackfamily or other social support and theydo not know if they will be allowed toremain in the country. In these

circumstances it is not surprisingthat what may seem to be a relativelyminor frustration can trigger adisproportionate reaction. Thisdoes not mean that the patientis mentally ill.

Cultural variability in reactionto distress

Asylum seekers come to the UK fromall parts of the world. People reactvery differently to stressful situationsin different cultures10. It is important toconsider whether the patient’spresentation is a normal reaction inthe context of their own culture.

This can be quite hard to assess, butanother person from the samebackground as the patient may be ableto clarify things. Contacts with refugeecommunity organisations or discussionwith a member of the Health InclusionTeam LSL might be helpful.

Depression

Asylum seekers are particularlyvulnerable to depression11. They havesuffered many losses and are in a newand uncertain situation. Symptomssuggestive of depression should beassessed as with any other patient, andappropriate treatment and referralsconsidered. The risk of suicide shouldalways be assessed (see below).

Post-traumatic stress disorder (PTSD)

PTSD is an anxiety disorder triggered orcaused by one or more very severetraumatic experiences. The diagnosticcriteria12,13 state that it occurs within sixmonths of the trauma and that

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symptoms last for at least one month.

The symptoms include:

Re-experiencing the trauma asflashbacks, nightmares or otherintrusive memories

Avoidance behaviour - avoiding anysituation which may triggermemories of the trauma.

Emotional numbness and feelingdetached.

Hyperarousal - including irritability,angry outbursts, poor concentrationand insomnia.

PTSD is relatively common amongstasylum seekers3, particularly those whohave experienced torture, rape,violence or war. These experiences arevery common amongst asylum seekers -it is estimated that between 5% and30% of all asylum seekers have beentortured1,2.

The symptoms of PTSD can beextremely disabling, making it evenharder to cope with the difficultiesexperienced as an asylum seeker, suchas poor housing, lack of finances andlack of activity. It may result indifficulties in dealing with authorityfigures, who bring back memories ofthe original trauma, or in dealing withfrustration, and can be one of thereasons for problems occurring in GPsurgery waiting rooms.

PTSD sometimes settles by itself, overa period of time14, and is particularlyhelped by developing a new socialsupport network - if the patient candevelop links within the localcommunity or with a refugeecommunity organisation, for example.

In more severe or protracted cases,treatment with an SSRI antidepressantdrug can help, as can a range ofbehavioural treatments or counselling.There are NICE guidelines on themanagement of PTSD in primary andsecondary care(http://guidance.nice.org.uk/CG26).

Treatment of PTSD can be very difficultif the patient’s life is disturbed andunsettled, perhaps still waiting to hearif they will be given asylum, living inpoor quality, noisy accommodation,with uncertainty over the fate offamily and friends, and coping withlife in a new country. Sometimes theseproblems have to be resolved beforethe patient is able to address theproblems of PTSD. SSRI drugs can behelpful in alleviating some of thesymptoms in the meantime15.

In more severe cases it might beworthwhile getting help from theTraumatic Stress Service, based at theMaudsley Hospital. Analysis of theevidence for various approaches totreatment of PTSD suggests thattrauma-focused cognitive behaviouraltherapy, and eye movementdesensitisation and reprocessing(EMDR) are the best forms oftreatment. These forms of therapy areonly likely to be available from tertiarycentres such as the Traumatic StressService.

From 2004, referrals for treatment atthe Traumatic Stress Service are onlypossible from secondary care, so youwill need to refer the patient to yourlocal Community Mental Health Team(CMHT) first.

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Finally, it is always important toremember that PTSD is an independentrisk factor for suicide (see below). If thepatient is exhibiting suicidal thoughtsor plans, an urgent referral to yourlocal CMHT should be considered.

Substance abuse

Asylum seekers arriving in the UK sinceOctober 2002 have not been allowedto work, and there are severe restrictionsplaced on them even doing voluntarywork. This may mean that many ofthem have very little to do, apart fromworrying about their circumstances.They also are living on very smallamounts of money (the amountprovided by NASS is set at 70% ofincome support levels).

One result of this lack of activity andfrustration, sometimes combined withintolerable symptoms of PTSD (seeabove), can be the use of alcohol orother recreational drugs as a copingmechanism16. Some of these drugs maynot be illegal, such as the practice ofchewing Khat leaves, which is commonamong people from the Horn of Africa.khat contains chemicals that have aeuphoriant and stimulant effect,somewhat akin to amphetamines.

The excessive use of drugs such asalcohol and khat can lead to problemsof depression, lassitude, abdominalpain or overt psychiatric problems.There is concern in some communitiesabout the excessive use of khat amongstyoung Somali men, for example, andthe risk that reducing the intake ofkhat may lead to an increase in theconsumption of alcohol or other drugs.

Suicide risk

As a group, asylum seekers often havea number of known risk factors forsuicide. These risk factors includerelative young age, unemployment,lack of social support (e.g single,separated, loss of supportivecommunity). There will also besignificant numbers coping withcontinuing long-term painfulsymptoms as a result of torture.

In addition, as already stated above,many asylum seekers will also havepsychiatric illness that increases the riskof suicide, such as PTSD or depression,or sometimes both of these together.

In these circumstances it is alwaysimportant to make a clear assessmentof the risk of deliberate self harm orsuicide in asylum seekers withpsychiatric symptoms, exactly as onewould do for any other patient.

Patients with these background riskfactors for suicide may be atparticularly high risk of suicide atcertain times. These triggers mayinclude rejections such as Home Officerefusal letters (refusing the asylumclaim), or legal rulings rejecting theclaim for asylum. Significant numbersof asylum claims are incorrectlyrejected, being accepted at a laterstage of appeal. A patient withmultiple risk factors, having fled frompersecution and torture to claimasylum in the UK, may attempt suicidewhen the legal system appears toreject his or her story.

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Psychotic illness

Asylum seekers and refugees, likeanybody else, may present withsymptoms suggestive of psychoticillness. There is considerable debateas to whether severe and enduringmental illnesses such as schizophreniaare more common amongst refugees inthe UK. However, it is always importantto consider whether symptoms are aculturally appropriate response tostress, rather than a manifestation ofa psychotic illness (see page 24).

Nevertheless asylum seekers andrefugees may develop schizophreniaor other severe mental illnesses, andshould be treated as any other personwith these illnesses. It is worth tryingto establish whether the patient hada history of mental illness before theyleft their home country, and, if so, howthis was managed. If they do have asevere and enduring mental illness,it is possible that the stresses relatedto their persecution, and then theirflight from persecution, may triggeran acute episode of mental illness.

When a patient appears to have apsychotic illness, it is very importantto ensure that there is good clearcommunication with the patient,using an interpreter whenever possible.Getting advice on responses to stressin the background culture is alwayshelpful in attempting to understandwhat is going on.

Vulnerability and resilience

When thinking about the mentalhealth of refugees and asylum seekers,it is important to keep in mind thatthere are factors putting them atincreased risk of mental illness. Theseinclude multiple losses, low self-esteem,lack of support, worries and guiltabout family or others left behind.

Equally there may be factors thatconfer strength and resilience to them.In order to seek asylum, a person mayhave survived and then escaped froma very hostile and dangerous situation,and subsequently survived a long anddangerous flight to safety. Thissuggests that the asylum seeker maywell have significant strengths.

In fact many asylum seekers reachingthe UK are highly educated andqualified people, from a professionalbackground, or people who hadbusinesses in their home country, untilthe problems arose that led them toflee and seek asylum. The fact that theyhave managed to reach the UK suggeststhat they have personal qualities ofdrive, assertiveness and enterprise.

The process of seeking asylum in theUK can itself be dispiriting anddemoralising, resulting in loss of selfesteem and feelings of guilt anddespair. In these circumstances it canbe helpful to encourage the patientto focus on their strengths, skills andachievements, both in their life beforethey left their home country, and alsoin the ways in which they havemanaged to survive since they left.

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Discovering a history of rape, torture or other abuse

According to different studies, upto 30% of asylum seekers may besurvivors of torture1,2, so we needto have this possibility in mind whenseeing a patient who is an asylumseeker or refugee.

In considering these issues there arethree main areas of difficulty:

Establishing a diagnosis

How to help a patient once thehistory emerges

How the doctor, nurse or healthprofessional copes with these issuesemerging

Establishing a diagnosis

Possibly the biggest problem in helpingthese patients is the natural reluctanceto disclose what has happened, or totalk about it17. Torture and rape aresimilar in their effects to other abusivedisorders, such as child sexual abuse.Patients often feel an overwhelmingsense of shame and guilt, a loss of selfesteem, and often a major change inthe way in which they feel aboutthemselves. Non-sexual torture isprobably more common in maleasylum seekers and rape is morecommon in women, but both occur in men and women.

One clue may be patients presentingwith unexplained symptoms, such asheadaches, abdominal pain or backpain, or with multiple minor symptoms.In these circumstances, it is alwaysworthwhile considering the possibilityof torture or rape, and asking about it.The late disclosure of these experiencesis well documented18, and may notemerge for many years, exactly as withchild sexual abuse.

The important point is to be awareof the possibility of rape and tortureamongst this group of patients.

One issue for the clinician is how tohave the confidence to ask patientsabout these areas. We will deal withthis later. What is clear is that if thepatient does not spontaneouslydisclose their experience, it is notlikely to emerge if we do not ask.

How to help a patient once thehistory emerges

Once a history of torture and/or rapeemerges, a number of important areasrelating to management follow.

If a woman or child has been rapedrecently, the possibility of pregnancymust be considered.

If a pregnancy has resulted, complexissues around the continuance of thepregnancy or termination ofpregnancy must be explored.

In either male or female rape, thepossibility of a sexually transmittedinfection (including HIV) must beexplored and excluded.

In either male or female rape, thepossibility of ano-genital traumaticinjury should be considered.

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In the case of non-sexual torture,precise details of exactly what wasdone should be elicited. This will helpthe doctor to identify possiblephysical consequences. Amongst themore common consequences areshoulder or brachial plexus injuries asa result of the patient being hangedby their wrists, a process calledsuspension19. Other commonproblems are ear or eye damage, anddental trauma, but the consequencesof physical torture should be thoughtabout as in any case of trauma.

Probably the biggest areas ofdisability and disorder resultingfrom torture and rape are thepsychological consequences. Theseinclude depression, PTSD, otheranxiety disorders, psychosexualproblems, uncertainty about sexualorientation (particularly in men),loss of a sense of self worth and selfesteem. These problems need to bemanaged as with any other patient,using the resources available inprimary care as well as specialistservices, and possibly the help ofspecialist organisations such as theFreedom from Torture.

As well as the effects of torture or rape on the individual, cliniciansshould consider possible effects on other members of the family, the partner or children. They mayhave witnessed aspects of thetorture and rape, and certainly willbe living with the consequences.Sometimes a family approach tocare is appropriate.

How the doctor, nurse or healthprofessional copes with these issuesemerging

There are several issues for the clinicianin dealing with a patient with a historyof torture or rape. These include:

Anxiety about how the patientwill react when talking about theirexperiences

Anxiety about how the clinician willcope when hearing about thebrutality experienced by the patient

Anxiety about what to do next,once the history emerges

Linked to the above, anxiety aboutwhere to get help in dealing withthe patient

Concerns about how much time willbe involved in dealing with thepatient, once the history emerges

Anxiety about how the patientwill react when talking about theirexperiences

Many clinicians express anxiety that thepatient may become acutely distressed,or break down in some other way, oreven become suicidal, if a history ofprevious torture or rape is brought outinto the open.

In fact, it is likely that the patient willbe very distressed when talking aboutaspects of their mistreatment andabuse. The aspect that is mostdistressing will, of course, vary frompatient to patient. However, althoughtears may be shed and some angerexpressed, it is highly unlikely that thepatient will become more overtlyunwell than they are already.

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The patient will not talk about thesematters until they feel safe enough todo so, and this depends to a largeextent on the openness of the clinicianto hear their story. For many patientsit will be a matter of great relief thata professional they respect is preparedto hear the story and deal with theirconcerns about the consequences oftheir mistreatment.

Once a history of torture, rape or otherabuse or mistreatment emerges, it isimportant to organise follow up forthe patient. It is likely that they willhave very mixed feelings afterwards,and will find it hard to sleep orfunction for a few days followingdisclosure. Follow up with the clinicianwill therefore be vital, to reassure thepatient that they should expect to feelthe way they are feeling, and that theyare not going mad.

Anxiety about how the clinician willcope when hearing about thebrutality experienced by the patient

Many doctors will feel and sometimessay that they do not know how theywill cope if they hear stories of terriblebrutality committed against the patient.Discussing torture is not a commonplaceclinical experience, and usually onethat we are not prepared for in ourtraining. Nevertheless, there areparallels with hearing stories of childsexual abuse, for example, which mayalso remain undisclosed for many years.

In fact these concerns about our ownfeelings are very appropriate. As whenhearing other stories about patients’abuse or traumatic experiences, theclinician ends up “holding” a lot ofunpleasant feelings. Clinicians shouldensure that they have a source ofsupport in relation to these difficultconsultations. This could be acolleague, a professional supportgroup, another member of the team,or a partner or friend.

Problems will only arise if nobody isavailable to discuss the case, and theemotions engendered in the clinician.In these circumstances it is worthwhiletrying to contact a colleague who hasexperience in this area. Most of themwould be only too happy to discuss thecase, as they will have been in thesame situation themselves. Possiblelocal contacts are listed in the sectionon ‘Sources of help with these Complexproblems’ on page 50.

Anxiety about what to do next, oncethe history emerges

Once again, a common concern ofdoctors is that they will not know whatto do if the patient starts to talk aboutbeing tortured or raped. This will notbe a common experience for thedoctor and the doctor is unlikely tofeel prepared for this.

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In fact, it is likely that the patient willalso have these uncertainties. Thewhole point about the effect of tortureand other abuse is that it is kept secret,protected from view by a veil ofshame, guilt and fear. However, thefirst and most important aspect ofdisclosure is that it is extremely helpfulfor the patient simply to have a healthprofessional to hear the story, andnot to be rejected by that clinician.All that is required in the first instanceis the time and the willingness to hearthe story.

Once the details begin to emerge, andthis in itself may take some time orseveral appointments, then decisionscan start to be made about what thefurther management should be, andthis will, of course, depend on thedetails of what actually happened.

There may well be important aspects ofinvestigation or medical management,such as the need for screening forsexually transmitted infections, or forreferral for orthopaedic investigationor for physiotherapy. With disclosure,aspects of psychological managementcan be considered, depending on thesymptomatology and diagnosis. It maywell be appropriate to considerdiscussing the case with a colleaguewith more experience in the field.Possible contacts are listed in thesection on ‘Sources of help with thesecomplex problems’ on page 55.

Many of the concerns about ‘what todo next’, are really a concern abouthow the clinician will feel or copewith hearing the details of the story,and this should be considered asdescribed above.

Linked to the above, anxiety aboutwhere to get help in dealing with thepatient

This theme has been touched on inseveral places before. There are twoimportant aspects to this concern. Thefirst is that although dealing withtorture or rape can never be an easy orstraightforward business, it is notfundamentally different from manyother tricky consultations that GPs andother clinicians frequently deal with.

We see other patients with problemsand anxieties that have been kept secretfor a long time, such as sexual abuse,and we develop increasing confidencein dealing with these problems byrealising that there is no magic solution.The patient must be given the time theyrequire, and their symptoms, concernsand perceptions explored.

The second aspect is that there areclinicians and organisations that dealwith torture much more frequently whowould be available to give advice.Locally we have the Health InclusionTeam LSL and the Traumatic StressService. In North London there isFreedom from Torture, formerly theMedical Foundation for the Care ofVictims of Torture. Contacting theseorganisations, as well as generic servicesin secondary care may be very helpfulfor us when dealing with patients whohave experienced torture. The contactinformation for these organisations aregiven in the section on ‘Sources of helpwith these complex problems’.

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Concerns about how much time willbe involved in dealing with thepatient, once the history emerges

When a patient discloses a history oftorture or rape, it is not possible todeal with this quickly. It will be a majordecision for the patient to tell youabout what happened, and they needto be listened to. This will inevitablytake time, usually more than the timeallotted for the consultation.

This situation is, of course, no differentto that of any patient disclosing amajor problem in their life, such as thefact that they are deeply depressed,possibly suicidal, or the disclosure ofother significant traumas, such assexual abuse or rape.

Following on from this first disclosure,we should expect the patient to needquite a lot of time. This is perhapssomething that should be discussedfrom the outset, with plans made as towhen we can see them again, and theamount of time we can devote to theprocess of exploring the story.

There are options available to theclinician. It may be decided that thestory would be best explored in detailby another member of the practiceteam, such as the practice counsellor,or by another counselling agency.Equally, the clinician may feel that anearly referral for an assessment insecondary care is best. Discussing thecase with a specialist in the field, asdetailed in the section on ‘Sources ofhelp with these complex problems’may be helpful in deciding whetherthe clinician initially hearing the story isthe best person to allocate further timeto the patient.

It will be important to explain yourthoughts on further care with thepatient, to ensure that both they andyou are realistic about what can beoffered, and to prevent the patientfeeling rejected if you are referringthem to another professional.

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Children’s problems

Children who are asylum seekers orrefugees not infrequently present toprimary care providers. They may be amember of a family, or living with arelative. Sometimes they are alone, andare officially classified as‘unaccompanied minors’ (minors in thiscontext means aged under 18).

These children may have a number ofproblems related to being asylumseekers or refugees. There may also bechallenges or problems for practices inmanaging these patients. These issuesinclude:

Interpretation and advocacy

Immunisation problems and possibleeffects on meeting targets

Trauma and sexual violence

Disturbed behaviour

Medical problems

Issues for unaccompanied asylumseeking children

Child protection issues

Interpretation and advocacy

Children may be recruited to act asinterpreters for older members oftheir family, if their English is better.Although this may sometimes beunavoidable, it is generally consideredto be unacceptable. Children shouldnot be put in a position of hearingthings about older family membersthat are not appropriate for themto hear. Therefore it would be useful tohave interpreters present.

Equally, many child refugees may havehad experiences that they might notwish their family members to hear,and so should also be offered theopportunity to have an interpreter.It is important to remember thatmany child refugees will be sufferingfrom depression or post-traumaticstress disorder as a result of theirexperiences, and a significant numberof them, particularly the girls, mayhave been raped. In view of this, thegender of the interpreter should alsobe considered.

Further information on interpretingcan be found in the section onlanguage and interpretationproblems.

Unaccompanied children may needsome help in understanding andnegotiating new systems, such asappointment systems. This help mightbe provided by a social worker, asunaccompanied asylum seekingchildren are the responsibility ofsocial services.

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Immunisation problems and possibleeffects on targets

All children should be included in therelevant immunisation schedules, asfor the rest of the population. Problemsarise for a number of reasons.

The child and their parent/carermay not know or have the detailsof immunisations that the child hasalready received.

The country of origin of the childmay have a different immunisationprogramme to that currently in placein the UK.

Primary care clinicians may well notknow what immunisations to give,or how to implement a catch-upimmunisation programme.

Unimmunised children may prejudiceimmunisation targets, and adverselyaffect practice budgets.

Sources of advice and help are givenbelow, and the current schedule forundocumented or incompleteimmunisations is at the end of thissection on children’s problems. Ourexperience of refugee families is that theyare usually very keen for their children tobe protected by immunisation, and willreadily comply with plans, if these areexplained to them.

Trauma and sexual violence

Child refugees may be survivors ofwar trauma or accidents resulting fromthe process of escape from their homecountry. They may have been torturedthemselves or subjected to sexualassault or rape. These children mayrequire screening and follow up forsexually transmitted infections orpregnancy. A recent study ofunaccompanied children attendinga local community paediatric departmentrevealed that one in three of the girlshad been raped, as well as severalboys20. Some vulnerable children havebeen abused since arriving in the UK,and the risk of this should beremembered.

It is not uncommon for child refugeesto have witnessed extreme violencebefore their escape. They may haveseen members of their own family orothers abused, assaulted, raped,injured or killed.

Less commonly, older children mayhave been involved in acts of violenceagainst others. There are countries,such as Uganda, the DemocraticRepublic of Congo and Sierra Leone,in which children have been forciblyrecruited into regular or guerrillaarmies, and have taken part in orwitnessed acts of atrocity21.

Disturbed behaviour

The experiences of children escapingfrom their country, as well as thosemore disturbing experiences describedabove, can result in a range ofdisturbed behaviour. Sometimesdisturbance may result from the factthat children are supporting otherfamily members who are grieving or

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have mental health problems. Thepattern will of course depend on theage of the child, but may include:

Soiling and secondary enuresis

Aggressive behaviour

Behavioural problems in relation toother children, often noted at school

School refusal

Disturbed family relationships

Abnormally sexualised behaviourin young children

Inappropriate sexual activity orprostitution in older children

When approaching these presentations,clinicians need to be aware of thepossibility of undisclosed trauma, asdescribed above22. Sometimes theseproblems can be helped using theresources available within primary care,though specialist advice may be required. � See pages 36 & 37

Medical problems

Children may have any of the medicalproblems described in the section on‘Common medical problems’.

In addition child refugees may acquireinfections such as measles, due toabsent or inadequate immunisation.Children, particularly those not livingin a stable family unit, may be sufferingfrom malnutrition, and cases of ricketsand scurvy are now being identified.Refugee teenage mothers appear to beparticularly at risk of being malnourished.

Issues for unaccompanied minors

An unaccompanied minor is the termused by the Home Office to describea child under 18 outside their countryof origin who is not accompanied by aclose relative.

UASC (Unaccompanied Asylum SeekingChildren) are the responsibility of SocialServices. However, it is important to beaware that these children may beplaced in accommodation a long wayaway from their ‘home’ social servicesarea. This means that they may havevery little contact with a responsiblesocial worker. GPs and other primarycare clinicians should not assume thatsomebody is keeping a close eye onthese children and their needs.

Some children are age-disputed byUKBA, which means that the HomeOffice does not recognise their claim tobe under 18. The young person canthen dispute this Home Office decisionwith legal help. If they are unsuccessfuland are not recognised as being under18 they will be treated in the same wayas an adult asylum seeker, and will notreceive any support from social services.

UASC may have many problems, physicaland psychological. They are often verylonely and isolated, and may not knowwhat has happened to their familymembers. Sometimes a referral to theRed Cross International Tracing andMessage Service can be very valuable.

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These children may well be amongthe most vulnerable patients in thecommunity. They may have very littleexternal support, and being childrenmay have little relevant experience todraw upon. In addition, if they do notspeak English, they may be unable tocommunicate with others.

Child protection issues

As mentioned above, children who areasylum seekers or refugees can be inan extremely vulnerable position. Theymay have already been abused beforearriving in the UK, but can sometimesbe the victims of abuse in the UK.

Tensions within families can be great,and children may receive physicalpunishments from their parents orcarers that can amount to child abuse.

Older children, particularly if they areunaccompanied, may become drawninto prostitution, or may have evenbeen brought into the UK by others,specifically for that purpose.Sometimes children are brought intothe UK to work in households as virtualslaves. Although these children maynot technically be asylum seekers orrefugees, they are at huge risk, andprimary care clinicians need to beaware of the possibility that they maybe seeing these children.

One specific child protection issue isthat of female genital mutilation(FGM). Some refugees come fromcommunities that have a tradition ofpractising FGM. This is illegal in theUK, and a highly risky procedure tothe girl, with possible consequencesdescribed in the section on ‘MedicalProblems - Female Genital Mutilation’.Instances have been reported ofrefugees attempting to take girls outof the UK to have FGM performedelsewhere. If this is suspected, cliniciansshould alert the authorities here, inline with local child protectionprocedures.

Sources of help for GPs and primarycare clinicians dealing with children

Medical advice

The Health Protection Agency produces a schedule of “Vaccination for individuals with incomplete oruncertain immunisation status”(see page 38) which should befollowed.

In Lambeth, Dr Ann Lorek at the Mary Sheridan Centre is a consultantcommunity paediatrician with aspecial interest in the health ofrefugee children.Tel: 020 3049 4005

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Social services

In Lambeth, the Asylum Seekers Teamprovides specialist social work supportto asylum seeking unaccompaniedminors.Tel: 020 7926 0785

Family Tracing:

The Red Cross’ London InternationalTracing and Message Services (ITMS)team can be contacted through localRed Cross offices. Their addresses canbe found on the Red Cross websitewww.redcross.org.uk Tel: 020 7704 5686.

Internet Resources

The Race and Equality Foundation's'Better Health website' collectsguidance, research reports andweblinks relevant to the health of asylum seekers and refugees. It can be found athttp://www.better-health.org.uk/

The former joint DH/Home OfficeRefugee Integration website which has now been archived athttp://webarchive.nationalarchives.gov.uk/20090805000644/http://www.nrif.org.uk/Health/index.aspprovides information, guidance andexamples of good practice to supportthe integration of refugees and isaimed at health professionals. It has asection providing resources on thehealth needs of refugee children.

The online resource ‘Meeting thehealth needs of refugees and asylumseekers’ covers the needs of children,adolescents and unaccompaniedminors and is hosted on the websitewww.migranthealthse.co.uk, followingthe link for DH/NHS Specialist Support.

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Aggressive or demanding behaviour at reception desk

Dealing with refugees and asylumseekers at reception will, of course,provide the same potential problems aswith other patients, but understandingsome of the possible complicatingissues might help.

Language problems

Patients with PTSD

Racism among other patients

Misconceptions about entitlementto health care

Language problems

Offering patients an interpretingservice into their own language givesa very positive message that you aretrying to be helpful. This in itself mayprevent other problems arising.

If it is not immediately clear whatlanguage is required, a languageidentification card at the front deskcan help to begin communication.If receptionists have a more privatearea of the reception counter wherethey can talk to someone, andperhaps speak via a phoneinterpreter, this may help to establishwhat is wanted, and the mostappropriate appointment to make.(See also the section on language andinterpretation problems and a samplelanguage identification card)

Patients with PTSD

As mentioned in the section onPTSD, patients with this conditionsuffer from flashbacks and avoidancebehaviour. They may becomeuncontrollably anxious or haveaggressive outbursts in certainsituations, such as feeling they are notbeing listened to, or having to wait ina queue. They may also find it difficultto keep appointments. This can be verydifficult to deal with in a situationwhere the surgery is trying to run aservice for all its patients and isextremely busy.

However, if staff have some under-standing of the factors underlying apatient’s behaviour, they are morelikely to be able to accommodatethe patient without causing majordisruption. Receptionists are wellaware that patients with otherpsychological or emotional problemsmay present in what seems at first tobe a challenging manner. Of course,the same rules and policies aboutaggressive behaviour in the surgeryand towards staff must apply to allpatients, and practice policies mayneed to be explained to patients intheir own language.

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Racism among other patients

In many areas resentment has arisenamong existing residents over servicesgiven to asylum seekers. This is a verydifficult issue and one that certainlyarises from policies and attitudesbeyond the remit of health services.However, it would seem to be sensiblethat services for asylum seekers shouldbe integrated as far as possible intothe existing health services.

It is an important principle that overtracism will not be tolerated on NHSpremises. Practices may wish to developapproaches to dealing with this, if itshould arise.

Misconceptions about entitlementto health care

Awkward situations can arise at thereception desk when staff are unsure ifa patient is entitled to register for NHSprimary care. This can lead to conflictand problems in reception.As a general rule, all asylum seekersand refugees are entitled to full NHScare, in general practice and in hospital.This question is fully addressed in thesection on ‘Entitlement to NHS services’.

Another issue that can lead to conflictat the reception desk is that someasylum seekers may have unrealisticexpectations of the service. This canarise if they do not understand howthe NHS and general practice in theUK works. See pages 10 and 11 for afuller discussion of this issue.

General principle

Avoiding problems at the receptiondesk is an important matter for thesmooth running of the service.Conflicts and aggressive behaviourcan arise from patients of any andall backgrounds. Many practicesensure that training in dealing withdemanding or ‘difficult’ patients isprovided for all staff.

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People requestingcertificates, letters and reports

Asylum seekers and refugees oftenpresent with non-health related issues.This may be because:

They are dealing with basic lifeissues, for example homelessness and housing, no money for food, or threats to personal safety

They do not understand the role of the GP

They do not know who else to turnto for help

Common requests from asylum seekersand refugees include:

Letters to help appeals againstdispersal to UKBA accommodationoutside London

Medical declaration to help inapplying for so called Section 4support from United KingdomBorder Agency (UKBA)

Letters in support of application forSection 21 support under theNational Assistance Act

Letters in support of housingapplications

Letters to help in appeals againstdispersal to UKBA accommodationoutside London

UKBA provides accommodation andsupport for destitute asylum seekerswho are still awaiting the outcome oftheir initial asylum application orappeal. This is essential because asylumseekers are not entitled to work or toclaim normal benefits, until theirasylum claim is decided. Theaccommodation is allocated on a no choice basis, and virtually allaccommodation allocated throughUKBA’s designated accommodationproviders is located outside Londonand the South East.

Patients sometimes request letters insupport of their appeal againstdispersal. Some asylum seekers mayhave contacts and communities inLondon and may particularly wish tostay here. Equally, there may beestablished refugee communities insome of the dispersal centres aroundthe UK, with well-established supportnetworks. It should therefore not beassumed that asylum seekers wouldbe in a worse situation if moved outof London.

Particular reasons for being exemptfrom dispersal include suffering from acondition which requires treatment atthe Freedom from Torture or the HelenBamber Foundation, or having adisability or medical condition that canonly be treated in London24,27.

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Medical declaration to help inapplying for Section 4 Support fromUKBA

Section 4 support comprisesaccommodation and financial support(currently £35.39 in the form of an“Azure” payment card that can be usedin certain shops) which is provided toasylum seekers who have beenunsuccessful in their asylum claim andmeet one of a number of possiblecriteria. One of the criteria is that theperson is “unable to leave the UnitedKingdom because of a physicalimpediment to travel or for some othermedical reason”. The patient would askyou to complete a medical declarationform issued by UKBA in which you areasked to state details of the medicalcondition that might render the patientunable to travel from the UK, as well asindicating when the patient might beable to leave the UK. If you feelunable to answer all or some of thesequestions you could indicate to UKBAthat you recommend they consultsomeone more expert such as a travelhealth professional or an aviationmedicine professional. It is veryimportant that the patientunderstands the implications ofsubmitting the form to UKBA, that isthey are agreeing to return to theircountry of origin once they becomemedically fit to do so. You might alsobe asked to provide a MatB1 certificatefor a pregnant asylum seeker who isdestitute, as this may enable her toapply for section 4 support; in this caseyou will not need to complete amedical declaration form.

Letters in support of application forSection 21 support under theNational Assistance Act

Destitute asylum seekers who haveexhausted their appeal rights and donot qualify for section 4 support maybe able to apply for section 21 supportunder the National Assistance Act. Thistype of support is provided by localauthorities, and usually the assessmentwould be made by their “no recourseto public funds” team. The asylumseeker will only qualify for this supportif they have a need for “care andattention”, which means they need“looking after” by another person. Thismeans the threshold for obtaining thiskind of support is quite high, andusually it is helpful if the patientapproaches a welfare solicitor to assistthem with the application. However ahealth professional can make thereferral to social services requesting anassessment (social services then have alegal obligation to carry out aneligibility test and an assessment ofneed). Further information on thisprocess can be found on IslingtonCouncil’s websitehttp://www.islington.gov.uk/advice/asylumimmigration/refugees_migrants/nrpf/Pages/default.aspx. The patientwill require some medical evidence tosupport their application, which can bea letter from the GP outlining theircondition, treatment, prognosis andexplaining why the patient has a needto be looked after.

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Letters in support of housingapplications

If and when an asylum seeker isgranted asylum, and so becomes arefugee, s/he loses entitlement to UKBAsupport after 28 days. Up to this pointthey have not been entitled to workand earn money, but they can now doso or claim Job Seekers Allowance.

It is often at this time that a refugeewill suddenly become homeless andhave no means of paying for rentedaccommodation. They will need toapply to the Homeless Persons Unit ofthe local authority, and a single manwith no dependants is unlikely to beoffered housing.

At this stage, a letter from a doctor or nurse can be helpful if the patient is vulnerable. This may be the case if they have a continuing medical orpsychological condition, such as fromthe effects of torture.

GP surgeries should not chargeasylum seekers for the provision ofletters, reports or statements as themaximum weekly cash or paymentcard allowance an asylum seeker whois a single person will be able to claimis currently £35.39 and others mayhave no financial support at all. If therequest for a report comes from asolicitor, it may be possible tonegotiate a fee for the provision ofthe letter or report, however giventhe constraints on legal aid, this maybe difficult.

In order to understand some of thepossible requests asylum seekersmay make, it can be helpful toknow about the asylum applicationsystem and asylum support services

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Getting backgroundinformation aboutpatients

Background information is sometimesvery important for health professionalsworking with asylum seekers andrefugees. This information usually fallsinto one of two categories:

Information about the patient andhis/her past medical history

Information about the patient’scountry of origin

Information about the patient andhis/her past medical history

Many asylum seekers, particularly thosesupported by UKBA, are given hand-held medical records when they arrivein the area. If an asylum seeker has hadthe opportunity to see a nurse fromthe Health Inclusion Team LSL, theirpast medical history may have beendocumented in the hand-held record.

It is important to ask such patientspresenting to the surgery to bringtheir hand-held record if they haveone, as it can save a lot of time inprimary care consultations.

Information about the patient’scountry of origin

Information about a patient’s countryof origin may be useful in understandingthe patient’s presentation. It can behelpful and interesting to know aboutthe situation in the country from whichhe or she has fled. It may also be usefulto find out the prevalence of certaindiseases, such as HIV, in his or hercountry of origin.

Sources of such information include:

1) The World Guide (2007) - bookpublished by New InternationalistPublications Ltd. Informationabout every country in the worldand is updated and published everytwo years. Can be seen on NewInternationalist website:http://www.newint.org/

2) Home Office Country of OriginInformation – detailed informationcovering geography, economy,history, state structures, humanrights, chronology and prominentpeople, for the most commoncountries of origin of asylumseekers to the UK.http://www.ukba.homeoffice.gov.uk/policyandlaw/guidance/coi/

3) The World Health Organisation’sGlobal Health Atlas -http://apps.who.int/globalatlas/has much information, includingthis Global HIV/AIDS on-linedatabase.

4) United Nations High Commissionerfor Refugees (UNHCR)’s Refworldwebsite has a vast collection ofreports relating to situations incountries of origin.http://www.unhcr.org/cgi-bin/texis/vtx/refworld/rwmain

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Entitlement to NHSservices – primary andsecondary care

This is one of the commonest areas of concern and confusion in relationto health care of asylum seekers and refugees.

The most recent legislative changes inthis area are the “Overseas VisitorsHospital Charging Regulations 2011”.Guidance on the implementation ofthis document can be found at:http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_127393. These came into force on 1 August2011 and cover entitlement to freehospital care for different groups ofoverseas visitors including asylumseekers and refugees. The mostimportant change to the previouslegislation is entitlement to secondarycare of some groups of refused asylumseekers, which has now been extendedand is explained in more detail below.

The BMA Ethics department issuedguidance in April 2012 on access tohealth care for asylum seekers andrefused asylum seekers which can be found at http://bma.org.uk/practical-support-at-work/ethics/ethics-a-to-z

The current legal situation in summaryis as follows:

All those with a positive decision ontheir asylum claim (refugee status,discretionary leave or humanitarianprotection) and asylum seekersawaiting a decision on a claim orappeal are entitled to all NHS carewithout payment. They can registerwith a GP and receive hospitaltreatment free of charge.

Unaccompanied Asylum SeekingChildren (UASC) with limited leaveare similarly entitled to free healthcare while their leave remains“current” until a decision is made onthe extension application and, ifrefused, an appeal is finallydetermined.

Anyone who has come to the UKunder family reunion will not havemade an asylum application but willhave a passport stamp for leave toremain. They also have fullentitlement to health care.

Refused asylum seekers (thoseasylum seekers whose applicationfor asylum has been rejected andwho have exhausted all appealrights) are not eligible for freesecondary care treatment, exceptfor the following groups:

a) refused (“failed” in DHterminology) asylum seekers whoare being supported by theUKBA under section 4 or section95 are exempt from charges.

b) refused asylum seekers whomake a fresh application forasylum, temporary protection orhumanitarian protection willbecome asylum seekers againand will therefore be exemptfrom charges until that newapplication is considered.

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c) asylum seekers undergoing aparticular course of treatment whentheir asylum application is rejectedor when they stop receiving UKBAsupport. They will be entitled to freetreatment until that courseconcludes or they leave the country.

There are currently no DHregulations specifically concerningentitlement of refused asylumseekers to primary care. The DH 2011overseas visitors secondary carelegislation makes reference toprimary care in one paragraph. Itstates that GP practices have thediscretion to accept any person,including overseas visitors, to beeither fully registered as an NHSpatient, or as a temporary resident ifthey are to be in an area between 24hours and three months. GPs have aduty to provide, free of charge,treatment which they consider to beimmediately necessary or emergency.The DH document reiterates thatregistration with a GP practice isexclusively a matter for the GP.

In primary care, entitlement toregister does not depend on ordinaryresidence, immigration status ornationality. Practices can only refuseto register patients if their lists isclosed or if the patient does not livein their catchment area or they havesome other reasonable grounds. Suchgrounds must not be related to thepatient’s race, gender, social class,age, religion, sexual orientation,appearance, disability or medicalcondition. Therefore practices cannotrefuse to register a patient on thegrounds that they are a refusedasylum seeker.

Furthermore, there is no mechanismfor primary care providers to checkimmigration status of peopleregistering to join their lists (unlike insecondary care where suchmechanisms exist), nor is there anyobligation or expectation for primarycare providers to do so.

The following treatments are alwaysfree of charge, regardless of a person'simmigration status:

1) Emergency treatment which isprovided in a hospital emergencydepartment or walk-in centre. Thisdoes not extend to servicesprovided once the patient has beenadmitted as an in-patient.

2) Treatments of certaincommunicable diseases (i.e. thoselisted in schedule 1 of the NationalHealth Service (Charges to overseasvisitors) Regulations 1989).

3) Treatment received at a specialclinic for a sexually transmitteddisease. Free treatment for HIV hasbeen restricted, but as of October2012, anyone who has been in theUK for six months or more isentitled to free treatment for HIV.Until then only initial HIV testingand counselling were free for failedasylum seekers.

4) Compulsory psychiatric treatment.

5) Family planning services.

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6) Treatment which the treatingclinician considers to be'immediately necessary' must beprovided without delay regardlessof a person's immigration status. Itis not free of charge but must notbe delayed or withheld while theperson's chargeable status isdetermined, and must not bewithheld if the person is unable topay in advance. Maternity care,including antenatal, birth andpostnatal care, is always considered'immediately necessary'.

Documentation requested forregistration with GP surgeries

The only documents that canreasonably be requested from anasylum seeker when registering areevidence of address (to ensure they livein the practice area), and evidence ofidentity. This evidence can only berequested if it is asked of all patientsregistering with the practice.

It may be difficult for some asylumseekers to produce the same type ofdocumentation required of otherpatients. This applies to both proof ofaddress as well as evidence of identity.

For example, many asylum seekersstaying in the London area are lodgingwith friends or family. They willtherefore not be able to produce utilitybills or tenancy agreements as proof ofaddress. As they are not generallypermitted to work, they will also nothave bank statements or other incomerelated documentation. Those stayingin UKBA accommodation will generallyhave an offer of accommodation letter.

It is therefore important that practicesuse discretion in what kind ofdocumentation is required forregistration, for example they mightrequest a letter from a friend statingthey are staying with them, or a letterto their current contact address fromtheir solicitor, rather than a utility bill.

Asylum seekers will not be inpossession of a passport and willtherefore not be able to produce thisas evidence of identity. The onlyphotographic ID most asylum seekerswill be in possession of is the“Application Registration Card” (ARCcard) issued by UKBA asacknowledgement of an asylumapplication having been made. It is athe size of a credit card with a photo,and is currently issued at the asylumscreening interview. The interview canbe several weeks after arrival in theUK, so until then, an asylum seekermay not have any ID. Some asylumseekers are issued with a “StandardAcknowledgement Letter” rather thanan ARC card. For these reasons, it isagain important that practices areflexible in the type of IDdocumentation they request fromasylum seekers.

From a legal perspective, anyregistration policy, practice orcriterion which makes it harder forasylum seekers than those with UKnational origins to register is likely tobe unjustifiable, and so unlawful,indirect discrimination.

Help with prescription charges andother health costs for asylum seekers

Asylum seekers and refused asylumseekers may qualify for free NHSprescriptions, free NHS dentaltreatment, necessary travel costs to andfrom hospital for NHS treatment, freeNHS sight tests and the full value ofand NHS optical voucher towards thecosts of glasses or contact lenses.

In order to show exemption from thesecharges, a patient needs to be inpossession of a valid HC2 certificate.This is issued to any person who has a sufficiently low income. To obtain an HC2 certificate, an HC1form needs to be completed. This isavailable from many surgeries,hospitals, dentists and opticians.

It is helpful if primary care practitionerscan make newly registered asylumseeker patients aware of theirentitlement to apply for an HC2certificate; many would otherwise notbe able to cover prescription and otherhealth costs.

UKBA will automatically apply for HC2certificates for asylum seekers whenthey first apply for UKBA asylumsupport, however this does not includeall asylum seekers so it is important tocheck whether the patient has alreadybeen issued an HC2 certificate or not.

Will asylum seekers &refugees adversely affectNHS targets?

In the current ‘target-driven’ climate ofprimary care in the NHS, some GPs andpractice managers express concernsthat having large numbers of asylumseekers and refugees on their lists willadversely affect their ability to achievetheir targets.

This concern may apply to areas such aschildhood and pre-school immunisationtargets, cervical cytology targets,influenza immunisation targets, and allthe areas that fall within the Qualityand Outcomes Framework.

How realistic are these concerns?

What can be done to improveuptake?

What other general measures maybe helpful?

How realistic are these concernsabout targets?

There is little available data about theuptake of preventive health messagesand measures by asylum seekers orrefugees, so we can only comment onthis on the basis of anecdotal data.

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When asylum seekers first arrive in the UK, their main concern is likely to be that of achieving asylum andsafety. At this time, they are less likelyto be receptive to messages about theirlong-term health. Also, if an asylumseeker has been subjected to torture,particularly sexual torture, s/he is likelyto be somewhat anxious aboutintrusive or sensitive physicalexaminations.

It is worth bearing in mind thatrefugees in the UK come from manyparts of the world, where healthservices and public health informationmay be completely different from ours.

On the other hand, the main reasonthat asylum seekers come here is toachieve safety, and so in the long termthey are likely to be highly motivatedto accept offers of help with theirhealth and that of their family. Forexample, a number of GPs haveremarked that asylum seekers aremuch more likely to want theirchildren to be immunised againstinfectious diseases, such as measles,than the background population.

We should not assume that all patientsknow about preventive healthmeasures or the reasons for them.It is therefore important to establishwhat patients already know, and whattheir views are on these healthmatters. Then, an explanation, usingan interpreter if necessary, may be allthat is needed.

What can be done to improve theuptake of target-related preventivehealth measures?

A number of approaches are likely tobe of help. These include:

Patient education about how theNHS works

Health education targeted at groupswho may not have previouslyreceived these messages

Involving other appropriate membersof the team, such as health visitors

Sensitivity to the problems of asylumseekers, such as lack of trust andpreoccupation with other matters

Picking the right time to push thepreventive health message -sometimes this means waiting

Developing good and trustingrelationships with these patients

General measures that may beof help

If a practice or other primary careprovider has a problem with achievingtargets, and this is thought to berelated to the particular patient groupsin the practice population, it mightwell be worthwhile documenting theproblem, and taking this up with therelevant commissioning body. They willhave the same agenda of trying toachieve better uptake rates, and betterhealth for the whole population.

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If a practice or an area has a particularneed, such as a large number of asylumseekers, it might be possible to havethis problem recognised and additionalfunding found through the system of‘Enhanced Services’.

It is possible that particular work canbe done by refugee health teams ingetting the message across to relevantpatient groups about the benefit andimportance of public health measures.Equally these organisations might havevery useful suggestions about how toenhance uptake.

At all times it is important that GPpractices and other primary careproviders are aware of the entitlementof these groups of patients to NHS care(see the section “Entitlement to NHSservices”). All patients are entitled torefuse offers of preventive healthmeasures, and such a refusal shouldnever be used as a way of blocking apatient from entitlement to NHS care.

Sources of help withthese complex problems

Useful contacts and resources

Contacts and resources are classified into:

Local (south east London) resources

National resources

Useful information from these sourcescan often be obtained from writtenmaterial, by telephone, by email, orfrom web-based resources.

Local Resources - South East London

The Health Inclusion Team LSL

Refugee community organisations(RCOs)

Refugee Council London

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1) The refugee services of the HealthInclusion Team LSL

The Health Inclusion Team (HIT) is amulti-disciplinary team workingacross Lambeth, Southwark andLewisham which provides healthcare to specific hard-to-reachgroups of refugees and asylumseekers and aims to improve accessto other health services. It is part ofthe Three Boroughs Primary HealthCare Team (hosted by Guy's and StThomas' NHS Foundation Trust).The team is also able to organisegeneral or specific training forpractices, in areas related torefugee and asylum seeker health.

The Health Inclusion is an excellentsource of up-to-date informationfor clinicians and primary care staff.The best way to contact the team isby phone or email (see below).

Address:Health Inclusion TeamGracefield Gardens Health andSocial Care Centre,3rd floor, 2-8 Gracefield Gardens, Streatham, London SW16 2ST

Phone: 020 3049 4700

Fax: 020 3049 4701

Enquiry E-mail:rhtlsl.admin@lambethpct.nhs.uk

More information via the web-site:www.threeboroughs.nhs.uk

2) Refugee Community Organisations(RCOs)

There are a number of RCOs basedlocally in south-east London. TheHealth Inclusion Team LSL (see 1above for contact details) maintainsa services directory of suchorganisations, and might be able tosuggest helpful contacts for you.

3) Refugee Council

The Refugee Council at its variousLondon bases will help asylumseekers and refugees from allLondon boroughs, and is also thenational head office of theRefugee Council.

The Support and Advice Section willoffer support and advice to asylumseekers and refugees at all stages ofthe asylum seeking process. Advicecovers issues such as welfare (supportand entitlement), training, educationand employment, the asylum processand UKBA support system. Theservice is no longer on a drop-in basisand people seeking advice need tocontact the own-language telephoneadvice service (OLTAS) on 0808 8082255, where they can speak to anadvisor in a language of their choice.Clients may then be asked to attendone of their adult service units inNorth London, West London, orStratford, if necessary.

Therapeutic services for vulnerablerefugees and asylum seekers withhealth and mental health needs areavailable by appointment only fromthe Refugee Council offices inBethnal Green and Stratford.Appointments can be made by email attherapeutic@refugeecouncil.org.uk

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The Children’s Panel provideguidance to unaccompanied asylumseeking children.

Destitution services where destituteclients can receive practical adviceand support, a meal, and emergencyprovisions at the Refugee Council'sdrop-in destitution services aroundLondon on Mondays, Tuesdays,Thursdays and Fridays.

Mondays and Thursdays from 14.30-17.30Address: Central London Day CentreHinde Street Methodist Church19 Thayer StreetLondon W1U 2QJ

Tuesdays from 11.00-16.00Address: Deptford Day Centre999 ClubDeptford21 Deptford BroadwayLondon SE8 4PA

Website:www.refugeecouncil.org.uk

National Resources

1) Refugee Council

The Refugee Council providespractical services to refugees andasylum seekers and also has acentral role in lobbying andcampaigning on asylum seeker andrefugee policy. The organisationalso provides educational andinformation materials for a widerange of users (asylum seekers,schools, refugee communityorganisations, local authorities).

The website has useful informationon the asylum process and supportand welfare arrangements forasylum seekers, as well as policybriefings, research, and reportsprepared by the organisation. Thereare multilingual (20 languages)information leaflets for asylumseekers and refugees on topics suchas the asylum process, support,services and refugee integration.

http://www.refugeecouncil.org.uk/practice/services

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2) Freedom from Torture

Freedom from Torture, a registeredcharity established in 1985 andoriginally called the MedicalFoundation for the Care of Victimsof Torture, is the only organisationin the UK dedicated solely to thetreatment of torture survivors. Themain treatment centre is in London,with branches in Manchester,Newcastle, Birmingham andGlasgow. The organisation offersmedical consultation, examinationand forensic documentation ofinjuries, psychological treatmentand support, and practical help. It isalso aiming to educate the publicand decision makers about tortureand its consequences, and engagesin advocacy work to influencegovernment policy.

The website’s “Publications” sectioncontains an expansive clinicalbibliography around therapy fortorture survivors, clinicalexamination of torture survivors,medico legal report writing andother human rights topics. Thereare also country reports on torturebased on testimonies of FFT clients.

Address: 111 Isledon Road, Islington, London N7 7JW

Phone:020 7697 7777

www.freedomfromtorture.org

3) MEDACT - Medical Action forGlobal Security

Medact is a global health charitywhich undertakes education,research and advocacy on thehealth implications of conflict,development and environmentalchange. Refugee and asylum healthis one of the areas on which theorganisation campaigns, inparticular on the issue ofentitlement to NHS care for refusedasylum seekers. The website has alot of useful reports, briefings andlinks on this issue.

Address: Medact, The Grayston Centre, 28 Charles Square, London N1 6HT

Phone:020 7324 4734

www.medact.org

4) The Red Cross

The Red Cross refugee services help vulnerable asylum seekers andrefugees access essential services.The organisation providesemergency provisions for thosefacing severe hardship and alsogives orientation support andadvice. The organisation has alsofocused resources on helpingdestitute asylum seekers andsupporting young people andrefugee women.

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The main Refugee Support Unit forLondon (providing orientation, casework, emergency provisions, aclothing project and a women incrisis service) is at:

Address:Aztec Row, 5 Berners Road, London N1 0PW

Phone: 020 7704 5670

There are also second-handclothing projects at:

Address:Bethnal Green Clothing Project, 1 Pott Street,London E2 0EF (Mondays 10am-4pm)

And

Address:Croydon Clothing Project, 47 Coombe Road, London CR0 1BQ (Thursdays 10am-4pm)

Website:http://www.redcross.org.uk/What-we-do/Refugee-services

5) “Better Health” websiteThis is hosted by the Race EqualityFoundation and has a wealth ofrelevant resources.

Website:http://www.better-health.org.uk/

6) Department of Health – archived information

The former DH Asylum Seeker Co-ordination Team produced and commissioned information on refugee health. The documentsare archived at

Website:http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Healthcare/International/AsylumseekersAndrefugees/index.htm

7) Home Office Country of OriginInformation Service (COI service)

This provides sourced informationon asylum seekers’ countries oforigin, focusing mainly on humanrights issues. The information isaimed at UKBA officials involvedin the asylum determinationprocess. It is compiled frominformation sources such as the USstate department, the UNHCR,human rights organisations andnews media.

Website:http://www.ukba.homeoffice.gov.uk/policyandlaw/guidance/coi/

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8) South East Migrant Health websiteThis hosts various relevant resourcesincluding “Meeting the healthneeds of asylum seekers andrefugees”, by Angela Burnett andYohannes Fassil, which wasoriginally produced in 2002. Itincludes practical information,details of useful contacts andexamples of good practice and can be found at http://www.migranthealthse.co.uk/

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Clinical Bibliography

Sources of more clinical information

Refugees and Asylum Seekers

1) Burnett A, Fassil Y. Meeting theHealth Needs of Refugees andAsylum Seekers in the UK, 2002.Comprehensive information withpractical advice, details of usefulcontacts and resources andexamples of good practice. Theupdated version is available as anonline resource.http://www.migranthealthse.co.uk/dhnhs-specialist-support

2) Department of Health. Caring forDispersed Asylum Seekers – AResource Pack, June 2003. Apublication from the Departmentof Health (jointly with the RefugeeCouncil), covering entitlement tohealthcare, support arrangements,health guidelines, social carelegislation and mental healthsections. Download fromhttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4010379

3) Burnett A. Guidelines for HealthWorkers Providing Care for AsylumSeekers and Refugees, The MedicalFoundation, 2002. Available onlineon http://www.better-health.org.uk/resources/toolkits/guide-health-workers-providing-care-asylum-seekers-and-refugees

4) Burnett A, Peel M. What bringsasylum seekers to the UnitedKingdom? BMJ 2001; 322: 485-488.

Torture and Human Rights

6) Bunett A, Peel M. The health ofsurvivors of torture and organisedviolence. BMJ 2001; 302: 606-609.

7) Medical Foundation. Guidelines forthe examination of survivors oftorture. Medical Foundation, 2010.

8) Peel M, Lacopino V. The MedicalDocumentation of Torture.Greenwich Medical Media Ltd,2002. A comprehensive textbook onthe work of doctors in providingexpert medical evidence for courtsof law.

9) Basoglu M (ed.). Torture and itsconsequences. Current TreatmentApproaches. Cambridge UniversityPress, 1992. A definitive textbookon medical and psychologicalaspects of torture, and treatmentof torture survivors.

10) TUN Office of the HighCommissioner for Human Rights.The Istanbul Protocol. UN Office ofthe High Commissioner for HumanRights, 2004. The first set ofinternational guidelines fordocumentation of torture and itsconsequences, widely used inpreparation of medico-legal reportsto document consequences oftorture. The document can bedownloaded from the UNHCR’sRefworld website http://www.unhcr.org/refworld/docid/4638aca62.html

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11) British Medical Association. Themedical profession and humanrights. Handbook for a changingagenda. BMA, 2001.

12) British Medical Association.Medicine betrayed. Theparticipation of doctors in humanrights abuses. Zed Books, 1992.Available from the BMA. Anexcellent historical and ethicalperspective on doctors and humanrights abuses, including torture.

13) World Medical Association.Declaration of Tokyo. Guidelines forphysicians concerning torture andother cruel, inhuman or degradingtreatment or punishment inrelation to detention andimprisonment. WMA, 1975.

14) Rape as a Method of Torture –Edited by Michael Peel. MedicalFoundation for the Care of Victimsof Torture 2004.

General Background Reading

15) Storr A (ed.). Humandestructiveness. The roots ofgenocide and human cruelty.Routledge, 1991. An interestingsmall book, exploring thepsychological backgound of humancruelty and torture.

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Glossary of termsand an outline of theUK asylum system

Article 3 (of ECHR)Article 3 of the European Conventionon Human Rights (ECHR) states that ‘noone shall be subjected to torture orinhuman or degrading treatment orpunishment’. A person can make a claimfor protection based directly on Article 3of ECHR as states are prohibited fromreturning a person to a country whereshe/he may suffer a violation of his/herrights under Article 3.

Asylum seeker An asylum seeker is someone who ispresent in the UK and has requestedinternational protection under theterms of the 1951 United NationsConvention relating to the Status ofRefugees. An asylum seeker is definedas someone who has made a claim forasylum and has either: i) yet to receivean initial decision on their claim or ii)been refused asylum by the UKauthorities but still has a legal avenueto appeal against the UK's decision torefuse asylum. An asylum seeker islegitimately in the UK until such timeas they have been refused asylum andhave exhausted all legal rights ofappeal - there is no such thing as anillegal asylum seeker.

An asylum seeker is usually not allowedto take up paid employment and is notentitled to benefits.

Asylum supportAsylum seekers who are destitute maybe able to receive accommodationand/or subsistence support from theUK Border Agency (UKBA). This formof support is also referred to as'UKBA support’, see below. If theyhave additional care needs, due tochronic illness or disability they mayalso be eligible to support from theirlocal authority.

Case ownerThe UKBA uses ‘case owner’ to refer toan official within its New AsylumModel who is responsible for an asylumseeker’s case throughout the process,from application to the granting ofstatus or removal. Their roles includedeciding whether status should begranted, dealing with asylum support,integration or removal. The UKBA alsouses the term to refer to an official atSenior Executive Officer level withinthe Case Resolution Directorate (seebelow) who is responsible for severalteams of case workers.

Discretionary Leave is a form of immigration status grantedto a person who the UKBA has decideddoes not qualify for refugee status orhumanitarian protection but wherethere are other strong reasons why theperson needs to stay in the UKtemporarily.

DispersalDispersal is the process by which theUKBA moves an asylum seeker toaccommodation outside London andthe South East. They are first moved toinitial accommodation while theirapplication for asylum support isprocessed. Once the application hasbeen processed and approved they aremoved to dispersal accommodationelsewhere in the UK.

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ELR – Exceptional leave to remainThis was a form of immigration statusin use before April 2003. It wasgranted to asylum seekers who theHome Office decided did not meet thedefinition of a refugee as defined inthe Refugee Convention but it decidedshould be allowed to remain in the UKfor other reasons.

Family reunionFamily reunion is the policy enablingpeople to bring their spouse anddependent children to join them in theUK. Those granted refugee status canapply for family reunion immediately.

Further submissionsFurther submissions can be made byunsuccessful asylum seekers if theirpersonal circumstances or thecircumstances in their home countryhave changed. Further submissions canonly be made in person at LiverpoolFurther Submissions Unit. Some asylumseekers can make further submissionsat a regular reporting event and thosewho meet the exceptional criteria maybe able to send further submissions bypost rather than in person.

The Geneva Convention This is theUnited Nations convention adopted in1951 which defines a refugee as: aperson who:

a) has a well-founded fear ofpersecution for reasons of race,religion, nationality, membership ofa particular social group, orpolitical opinion;

b) is outside the country they belongto or normally live in; and

c) is unable or unwilling to returnhome for fear of persecution.

In 1967 a supplementary UN ProtocolRelating to the Status of Refugees wasadopted, applying the criteria of the1951 convention to any person,anywhere in the world, at any time.The UK and 130 other countries aresignatories to the Geneva Conventionand/or the supplementary protocol.

ILR – Indefinite leave to remain is aform of immigration status given bythe UKBA. It is also called “permanentresidence” or “settled status” as itgives permission to stay in the UK on apermanent basis. People with thisstatus are allowed to work legally inthe UK and are entitled to benefits.

Immigration removal centreImmigration removal centres aredetention centres. They are used todetain people under Immigration Actpowers, including those at any stage ofthe asylum process, not as the titlemight imply, just prior to removal.

Judicial reviewIn the context of asylum claims, judicialreview enables the applicant tochallenge the way in which an asylumdecision was made, usually on thegrounds that the decision was illegal,procedurally improper, irrational ordisproportionate. Judicial reviewscannot be used to challenge theasylum decision itself, this is the role ofthe Immigration and Asylum Chamber.(First Tier Tribunal or Upper Tribunal)

Legacy case denotes a person whoseasylum case was not within the NewAsylum Model (NAM) by the 5th March2007. There is a backlog of legacy casesthat the UKBA is currently processing.

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Limited leave to remain is theimmigration status conferred to thosepeople granted refugee status since 30August 2005. It is valid for 5 years. Theperson needs to apply for indefiniteleave to remain prior to the 5-yearperiod running out, otherwise they willlose all rights to benefits and theirneed for protection will be re-examined. A person with limited leaveto remain is allowed to work in the UKand is entitled to benefits.

National Assistance Act 1948 (NAA)The National Assistance Act 1948 giveslocal authorities the responsibility toprovide accommodation and servicesto people with a disability or othercare need. It also puts an obligation onlocal authorities to conduct anassessment of anyone who mightrequire residential care. In practice, theUKBA is responsible for asylum seekerswhose need for care and attentionarises solely because they are destituteor from the effects of destitution,while local authorities are responsiblefor asylum seekers whose needs areadditional to being destitute.

New Asylum Model (NAM)The New Asylum Model was introducedby the UKBA for all new asylum claimsin April 2007. NAM entails a ‘caseowner’ from the UKBA who isresponsible for processing theapplication from beginning to end,including making the initial decisionwhether or not to grant refugee status.

Refugee A refugee, as defined by theUnited Nations Geneva Convention1951, is a person who:

a) has a well-founded fear ofpersecution for reasons of race,religion, nationality, membership of a particular social group, orpolitical opinion; and

b) is outside the country they belongto or normally live in; and

c) is unable or unwilling to returnhome for fear of persecution.

As of 30th August 2005, thosegranted refugee status in the UKhave been given 5 years’ limitedleave to remain rather thanindefinite leave.

Refugee Status This means that theperson has been recognised by theUKBA as a refugee under the terms ofthe Geneva Convention.

Refused asylum seeker A personwhose asylum application has beenunsuccessful and who has no otherclaim for protection awaiting adecision. Some refused asylum seekersvoluntarily return home, others areforcibly returned and for some it is notsafe or practical for them to returnuntil conditions in their countrychange.

Section 4 supportSection 4 of the Immigration andAsylum Act 1999 gives the UKBApower to grant support to somedestitute asylum seekers whose asylumapplication and appeals have beenrejected. Support granted underSection 4 is also known as ‘hard case’support.

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Regular Reporting EventThe visits an asylum seeker is requiredto make to a reporting centre, as setout in the IS 96 letter. These are oftenweekly, but may be reduced tofortnightly or monthly in certaincircumstances such as poor health.

Subsistence supportSubsistence support is the cash elementof UKBA support. Asylum seekers whohave accommodation, for examplewith friends or relatives, can apply forsubsistence support only. This form ofsupport is also known as cash support.

UK Border Agency (UKBA)The UK Border Agency (UKBA) is anexecutive agency of the Home Office.The agency manages and enforcesimmigration control in the UK,including applications for permission tostay, citizenship and asylum. It isresponsible for policy development inthese areas of law.

Unaccompanied asylum seeking children Unaccompanied asylum seekingchildren are children (under 18 years ofage) who have applied for asylum intheir own right, who are outside theircountry of origin and separated fromboth parents, or previous/legalcustomary care giver. Upper Tribunal(UT) appeals can be made to the UTagainst dismissal of an appeal by theFierst Tier Tribunal (FTT). If the UT findsthat there are errors of law in the FTTdetermination, they may hear the casethemselves and make a new decision.

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A summary of the UKasylum system (Correct at August 2012)

In March 2007 the Home Officeintroduced the New Asylum Model(NAM). Under this system each newlyapplying asylum seeker is allocated acase owner who is responsible for allaspects of their case, from beginningto end. The UKBA’s stated aim is for aconclusion to be reached on newapplications within six months. Thecase owner is the single point ofcontact on the progress of theapplication, both for the applicant andfor their legal representative. The caseowner is responsible for interviewingthe applicant, for making the initialdecision on their application, formanaging the support they areentitled to receive, and for assistingeither integration in the UK in the caseof a positive decision or for arrangingreturn to the country of origin, eithervoluntarily or by enforced removal.

1) Applying for asylumUKBA expects persons wishing toclaim asylum to make their asylumapplications as soon as “reasonablypracticable”. This would normallybe at the port of entry to the UK.There is a risk that an asylumseeker will not be entitled to UKBAsupport (financial andaccommodation) if they have madetheir application at a later stage(this rule comes under the powersof section 55 of the Nationality,Immigration and Asylum Act 2002). A person already in the UK whowants to claim asylum needs tomake their application at theAsylum Screening Units (ASU) inWellesley Road, Croydon (either bymaking an appointment or

attending the walk-in service there)or in Liverpool.

2) ScreeningThe person making the applicationwill be interviewed briefly (seebelow) and fingerprinted andphotographed. Applicants areasked to bring passports (which willbe retained by UKBA), policeregistration certificates, other IDand passport photos, as well asdocumentation of their financialand accommodation arrangementsand documents supporting the basisof their asylum application. Theapplication and screening process issimilar whether the asylumapplication is made at the port ofentry or at the Asylum ScreeningUnits in Croydon and Liverpool.

The screening interview consists ofquestions on bio-data, travelhistory, health, a summary of thebasis of the claim, securityscreening and family background.

Depending on the individualcircumstances of the applicant, forexample whether they are deemedto have committed an immigrationoffence (e.g. entering the UKwithout proper documentation orby verbal deception) they are theneither detained or given temporaryadmission. If they are not detainedthen an Application RegistrationCard (ARC) will usually be issuedalong with the IS96 (a letter statingreporting requirements), and arouting letter. Some applicants areissued with a StandardAcknowledgement Letter ratherthan an ARC card at this point.

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If the applicant has requestedaccommodation it will be initiallyprovided in Initial Accommodation(hostel-type accommodation, currentlyin London this is in Croydon and asmall number of places in Southwark).

3) First meeting with case ownerThis should take place within a fewdays of an asylum applicationbeing made. If the applicant hasapplied for accommodationthrough UKBA, the case owner willusually be in the region where theperson is dispersed to. The caseowner will explain the asylumprocess, invite the applicant to theasylum interview, offer help infinding legal representation andconfirm reporting arrangements.

4) The asylum interviewThe asylum interview should takeplace about a week after the firstmeeting with the case owner.Attendance at the interview iscompulsory; otherwise the claimwill be automatically refused. Thisinterview is the only chance for theindividual to explain to UKBA whythey fear return to their country.They need to satisfy the caseowner about who they are andwhich country they are from, andare also expected to provideevidence of what they say in theform of documentation. Theapplicant is able to bring a legalrepresentative to the interview ifthey wish (this is unlikely to bepossible if the legal representativeis funded through legal aid).Alternatively they can ask for theinterview to be tape-recorded.

5) Waiting for a decisionWhile waiting for a decision fromUKBA the applicant will beexpected to report regularly to anofficial centre, as specified on theirIS96 document. Usually reporting isrequested weekly. If an applicantfails to present at the specifiedtime each week, the support theyare receiving may be stopped andthey may be detained.

The case owner will decidewhether the applicant is entitled toreceive support. The current levelof cash support for a single adult is£36.62 and for a single parent it is£43.94). There are higher rates forchildren and additional funds forpregnant women. Housing isallocated on a no-choice basis.Most UKBA accommodation isoutside London and the South East(Midlands, North East, North West,Wales, and Scotland). Asylumseekers waiting for a decision arenot normally allowed to work.

6) The asylum decisionThe UKBA states that the asylumdecision should be given withinabout 30 days from the date onwhich the application was made;however practical experience showsthat it usually takes significantlylonger. The case owner makes thedecision and communicates it tothe applicant. The case owner maygrant refugee status orhumanitarian protection status, orrefuse to grant asylum. However, incertain circumstances, if asylum isrefused, discretionary leave toremain may be granted.

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a) If the applicant is granted refugee status:

The applicant is recognised as arefugee and they will be given arefugee status document and aresidence permit that allows themto enter and stay in the UK for aninitial period of five years. Limitedleave for five years was introducedin August 2005. Holders of thisstatus whose limited leave is aboutto expire, need to apply to UKBAfor an extension of their leave. Thisis called applying for permission tosettle in the UK and if successfulresults in granting of indefiniteleave to remain. This applicationneeds to be made in the monthbefore the limited leave expires,otherwise the individual loses theirpermission to stay and their rightto benefits and an in-depth reviewof the case is carried out.

People who hold refugee status oranother form of positive decision(humanitarian protection ordiscretionary leave) are entitled tothe same benefits as other UKresidents and are allowed to work.

UKBA support includingaccommodation will be withdrawn28 days from the date of grantingrefugee status, so it is importantthat the person is advised to applyfor benefits as soon as possible,otherwise they might findthemselves destitute.

b) If the applicant is not recognised as a refugee under the RefugeeConvention:

The case owner may decide theyshould be able to stay forhumanitarian or other reasons andgrant a form of status calledhumanitarian protection status,usually for five years. They areissued an immigration statusdocument along with a residencepermit. Once humanitarianprotection status expires, theperson can apply for extendedleave and/or settlement (after fiveyears of leave to remain).

If the case owner decides there areno reasons for the applicant to stay,they will be expected to leave theUK. They will be informed aboutoptions for returning to theircountry of origin, includingthrough the Voluntary AssistedReturn and ReintegrationProgramme. If the person does notleave the UK, UKBA state that theywill enforce removal, and that theyare likely to detain the person untilthey are removed from the UK.

If an asylum application has beenrejected and appeal rightsexhausted, the person will losetheir entitlement to any UKBAsupport including accommodation.However it is possible for someonein this position to apply for Section4 support from UKBA(accommodation and financialsupport to the value of £35.39 perweek payable through an “Azure”payment card), if they meet one ofa set of requirements.

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These are:

i) Taking all reasonable steps to leavethe UK

ii) Being unable to leave the UKbecause of a physical impedimentto travel or for some other medicalreason (e.g. advanced pregnancy).

iii) Being unable to leave the UKbecause there is currently no viableroute of return available

iv) Having applied for a judicial reviewof the asylum decision and havingbeen given permission to proceedwith it

v) If there is otherwise a breach of theperson’s rights, within the meaningof the Human Rights Act 1998. Thiscan include someone havingsubmitted further representationswhich seek a fresh claim for asylum.

7. AppealAsylum applicants who havereceived a written notice of arefusal decision from UKBA canappeal against the refusal. Ideallythey should have the help of alegal adviser when appealing theirasylum refusal. They need to lodgetheir appeal by completing a formwithin 10 working days of the dateof the refusal decision letter. Theappeal will be initially decided byan independent tribunal called theFirst Tier Tribunal (FTT) of theImmigration and Asylum Chamber.This is heard by one or moreimmigration judges, sometimesaccompanied by non-legalmembers of the Tribunal.

An asylum seeker should continueto receive support from UKBA forthe duration of their appeal.

8. Fresh claims/further submissions

A “fresh claim” can be made if:

a) there is sustantive new evidenceemerging after the person hasexhausted all appeal rights,

b) if there has been a significantchange in the political situationin the country of origin

c) if the applicant has developed a life-threatening medicalcondition

d) if there has been substantialchange to the life orcircumstances of the applicantoccuring in the passage of timefrom the initial decision.

If UKBA decide that this submission of evidence significantly differs frommaterial previously considered, it willbe accepted as a fresh claim to beheard in the Upper Tribunal. If not, the applicant can apply directly to theUpper Tribunal.

Further appeals to the AdministrativeCourt (also called the High Court) for ajudicial review, or to the Court ofAppeal or the Supreme Court are alsopossible but generally require expertlegal help.

If UKBA accepts the newly submittedmaterials as a fresh claim, and thenrefuses the new claim for asylum, the person may have access to ajudicial review.

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9. DetentionA person who has been asked toleave the UK may be detainedwithout warning while theirremoval from the UK is beingarranged. UKBA currently has 11immigration removal centresaround the UK where peopleawaiting removal are detained (theclosest to London are Brook Houseand Tinsley House near Gatwickand Colnbrook and Harmondsworthnear Heathrow). Asylum applicantswho are detained have the right toa bail hearing, but they have toinstigate the process. Asylumapplicants are likely to havepractical difficulties in securing bail.

Legal advisers can makerepresentations for the release of their clients.

Further details on the asylumprocess can be found on the UKBAwebsite:http://www.ukba.homeoffice.gov.uk/asylum

and on the Refugee Councilwebsite:http://www.refugeecouncil.org.uk/practice/basics/process.htm

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References

1) Burnett A, Peel M. The health ofsurvivors of torture and organisedviolence. BMJ 2001; 322: 606 - 609.

2) Peel M, Iacopino V. The medicaldocumentation of torture.Greenwich Medical media Ltd.,2002.

3) Van Ommeren M, De Jong JTVM,Sharma B, Komproe I, Thapa SB,Cardena E. Psychiatric disordersamong tortured Bhutaneserefugees in Nepal. Arch GenPsychiatry 2001; 58: 475 - 482.

4) British Medical Association. Asylum seekers: meeting theirhealthcare needs. BMA, 2002.

5) Adams KM, Gardiner LD, Assefi N.Healthcare challenges from thedeveloping world: post-immigration refugee medicine. BMJ 2004; 328: 1548 - 1552.

6) Burnett A, Fassil Y. Meeting thehealth needs of refugees andasylum seekers in the UK.Department of Health, 2002.Updated version available onlineat:http://www.migranthealthse.co.uk/dhnhs-specialist-support

7) Black JA, Debelle GD. Femalegenital mutilation in Britain. BMJ 1995; 310: 1590 - 1592.

8) Momoh C (ed.). Female GenitalMutilation. Radcliffe Publishing Ltd, 2005.

9) Weinstein HM, Dansky L, IacopinoV. Torture and war trauma survivorsin primary care practice. Western Jof Med 1996; 165-3: 112 - 117.

10) Dein S. ABC of mental health:Mental health in a multi-ethnicsociety. BMJ 1997; 315: 473 - 476.

11) Jones D, Gill PS. Refugees andprimary care: tackling theinequalities. BMJ 1998; 317:1444 - 1446.

12) World Health Organisation.Chapter F43.1. Post-traumatic stressdisorder. In: World HealthOrganisation. ICD-10 Classificationon Mental and BehaviouralDisorders. WHO, 1992.

13) American Psychiatric Association.Chapter 309.81. DSM-IV criteria forpost-traumatic stress disorder. In:American Psychiatric Association.Diagnostic and Statistical Manualof Mental Disorders. 5th ed. APA,1994.

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14) Rothbaum BO, Foa EB, Riggs DS,Murdock TB, Walsh W. Aprospective examination of post-traumatic stress disorder in rapevictims. Journal of Traumatic Stress1992; 5: 455 - 475.

15) Friedman MJ. Current and futuredrug treatment for post-traumaticstress disorder. Psychiatric Annals1998; 28: 461 - 468.

16) United Nations High Commissionerfor Refugees, World HealthOrganisation. Alcohol and otherdrug problems. In: Mental healthof refugees. UNHCR/WHO, 1996.

17) Hinshelwood G. Shame, the silentemotion. Psychosexual MedicineJournal 1999; 22: 9 - 12

18) Ball O. Late disclosure. MedicalFoundation for the Care of Victimsof Torture, 2002.

19) Skylv G. The Physical Sequelaeof Torture. In: Basoglu M (Ed).Torture and its Consequences -Current Treatment Approaches.Cambridge University Press.1992.

20) Lorek A, ConsultantPaediatrician Lambeth Primary CareTrust. Personal communication.

21) Somasundaram D. Child soldiers:understanding the context. BMJ2002; 324: 1268 - 1271.

22) Physicians for Human Rights.Children and Torture. In: Physiciansfor Human Rights. ExaminingAsylum Seekers. A healthprofessional's guide to medical andpsychological evaluations oftorture. Physicians for HumanRights, 2005.

23) HM Government. The Nationality,Immigration and Asylum Act 2002.Available on-line from HMSO on:http://www.legislation.gov.uk/ukpga/2002/41/contents

25) Peel M (ed). Rape as a method of torture. Medical Foundation for the Care of Victims of Torture;2004.

26) Refugee Council InformationServices, 2008.

27) UK Border Agency. HealthcareNeeds and Pregnancy DispersalGuidance. UKBA, 2012.

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Notes

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Resource Packto help generalpractitioners and otherprimary health careprofessionals in theirwork with refugeesand asylum seekers

Produced by the Health Inclusion Team (HIT) LSL1st edition September 20042nd edition March 2005This edition June 2012

Address:HIT, 3rd floor, Gracefield Gardens,Health and Social Care Centre, 2-8 Gracefield Gardens, London SW16 2ST

Phone:020 3049 4700

Email:gst-tr.referralsBBVHT@nhs.net

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