COMMISSIONING HEALTH SERVICES FOR VULNERABLE MIGRANT WOMEN IN ENGLAND

Transcription

1 COMMISSIONING HEALTH SERVICES FOR VULNERABLE MIGRANT WOMEN IN ENGLAND EVIDENCE ON POLICIES AND PRACTICES DR HIRANTHI JAYAWEERA May 2016

2 Maternity Action Maternity Action is the UK s leading charity committed to ending inequality and improving the health and well-being of pregnant women, partners and young children from conception through to the child s early years. Maternity Action provides online information and telephone advice on maternity rights at work and in the benefits system. Maternity Action undertakes research and campaigns to improve the lives of all pregnant women, new mothers and their families. Reg. Charity Women s Health and Equality Consortium The Women s Health and Equality Consortium (WHEC) is a partnership of women s charity organisations who share common goals of health and equality for girls and women. WHEC aims ensure that health policy reflects the real needs of girls and women. It therefore pools the expertise of member organisations to better influence decision-makers and government. WHEC works to improve the sustainability of the women s and girls health and social care sector, and to strengthen women s and girls capacity to engage with the health and social care systems. May 2016 Acknowledgements I would like to thank Maternity Action and the Women s Health and Equality Consortium for funding the project on which this report is based. I am very grateful for the tremendous help, support and advice given by Ros Bragg and Rayah Feldman throughout the project. I would also like to thank Zoe Dexter for her invaluable help in designing and implementing the survey for CCGs and Public Health teams. I am very grateful to the survey respondents for their time and effort in participating in the survey, and especially to the commissioners and voluntary sector practitioners who agreed to be interviewed and gave up their time to provide the extremely useful and revealing in-depth evidence that forms the basis of the report.

3 Table of Contents Executive summary... 4 SECTION 1: SETTING THE SCENE Introduction Clinical commissioning and public health in the new NHS structure Access to NHS care for migrants SECTION 2: COMMISSIONING HEALTH SERVICES FOR VULNERABLE MIGRANT WOMEN POLICIES AND EVIDENCE Current policy framework Primary evidence Survey results Findings from phone interviews Good practice examples Box Box Box CONCLUSION AND RECOMMENDATIONS REFERENCES ANNEXE Roles and geographical areas of phone interviewees

4 Executive summary Overview It is important to commission and provide appropriate needs-based health services for migrant women whose characteristics and circumstances at any given time place them in a vulnerable situation that increases their susceptibility to poor health and difficulty in accessing healthcare. Specific vulnerable categories of migrant women may include asylum seekers, refugees, refused asylum seekers or other undocumented migrant women, women with no recourse to public funds that are supported by the local authority, trafficked women, Roma, women with limited fluency in English, and migrants from the European Union (EU) with no health insurance card. Service design and delivery also need to reflect all health conditions and life cycle stages, and take into account geographical diversity among new arrivals, and in settlement patterns. Arising from the 2012 Health and Social Care Act, within the last three years there have been significant changes in the way the NHS in England is organised that affect the design and delivery of healthcare to the population. At the same time changes to immigration rules, including within the 2014 Immigration Act, have led to increasing restrictions on eligibility and access to healthcare for migrants, and more restrictions regarding access to primary and community healthcare are expected. The aim of this report is to explore the ways clinical commissioning groups (CCGs) and local authority public health teams together with voluntary sector organisations are addressing health needs of vulnerable migrant women, factors that have shaped policies, and good and bad practices in local areas. The report makes recommendations for improvements in both policy and practice that may lead to better health outcomes for vulnerable migrant women. Primary research was conducted through an electronic survey aimed at representatives of CCGs and local authority public health teams in England and through in-depth interviews undertaken by telephone with 15 commissioners and voluntary sector healthcare providers in a range of geographical areas in England. Survey and interview topics were on awareness of information and health needs relating to vulnerable migrant women in local areas, the extent and nature of needs assessment, commissioning and service provision, perceived barriers to commissioning and providing services, and partnership working with other agencies. Key findings 1. The relationship between policies/guidance and practice There exist current policies and guidance on locally produced and owned strategic assessment and planning to improve health outcomes and reduce health inequalities, generally, and with 4

5 respect to specific population groups such as migrants, vulnerable populations (for example Roma, asylum seekers and refugees), those with mental health needs and women who have experienced FGM. However, there was little evidence both in the survey and interviews, of systematic assessment and planning relating to health across local areas even where there is some awareness of the size and diversity of local migrant populations. Thus there appears to be a mismatch between the policy framework on health inclusion, and inclusive practice for vulnerable migrant women within an environment where specialist services for example GP services for asylum seeking women are being eroded. But where there is a specific national policy/guidance/service pathway for example around FGM, looked after children, survivors of domestic violence or trafficking, pregnant asylum seekers, Syrian refugees there is more likelihood of needs assessment, research and intervention. 2. Where migrant women fit in relation to NHS commissioned services Interviews with commissioners and service providers reveal that NHS commissioned services especially by the voluntary sector for migrant women are often provided as part of support to a) both men and women migrants; or b) women generally, among which are migrant women; or c) vulnerable groups, among which are vulnerable migrants, mainly asylum seekers and Roma. As far as migrant women are concerned, the survey and interviews show that most NHS commissioned services that do exist are directed towards asylum seeking and refugee women, particularly around mental health and maternity. But most voluntary organisations providing NHS commissioned services do serve a wider range of vulnerable women with significant health needs including undocumented women. 3. Barriers to providing services for vulnerable migrant women Barriers highlighted by commissioners responding to the survey are mainly to do with staff capacity, funding and commissioning policy and lack of information on new migrants and health needs. Their overall lesser knowledge of commissioning gaps and relative remoteness from issues contrasted somewhat with the strength of knowledge, involvement and commitment of voluntary sector providers. From the point of view of voluntary sector providers the main barriers include: o Moving vulnerable women on to mainstream health services, such as mental health services or preventive health services for chronic illnesses, which are not designed to be inclusive in terms of taking into account the circumstances of some migrants. 5

6 o o Inequalities in wider determinants of health and in many cases severe deprivation affecting vulnerable migrants for example the impact of not having recourse to public funds or exploitative employment conditions leading to poor health outcomes. Commissioning gaps and inconsistent service provision across different geographical areas. 4. The extent of services for meeting health needs of vulnerable migrant women There is less evidence of good examples of service change to meet health needs of vulnerable migrant women, compared to numerous examples in most local areas of (relatively small) projects on needs assessment, and provision of training and information on signposting for health professionals, many of which did not necessarily have concrete positive results. Examples given include inadequacies in interpreting services, primary care practitioners not interested in referring migrants to specialist voluntary sector services, and lack of understanding of perceived needs of different local communities, including in relation to mental health services. There was also concern among voluntary sector interviewees about the extent to which the demarcation of responsibilities between CCGs and local authorities has led to more services, such as preventive health, being pushed back into the voluntary sector with limited support and funding provided, particularly for smaller voluntary organisations. 5. Statutory and voluntary sector service provision Overall there was widespread evidence in most areas reviewed, of joined up service provision between the statutory and voluntary sector. But perceptions of joined up working and partnerships varied. Statutory sector commissioners were more positive about the contribution of voluntary sector specialist provision towards easing staff burden in mainstream health services. While voluntary sector interviewees spoke of the significant enabling role they play in providing holistic outreach approaches and wrap-around support, there is considerable frustration about apathy or in some cases hostility of health professionals towards take up of the contribution made by voluntary sector providers, and more generally about procrastination among commissioners in responding to evidence on vulnerable migrants health needs. 6. Negative impact of increases in charging for services Given the proposal in the most recent Department of Health consultation to introduce charging for treatment in primary care for some categories of migrants, there was considerable concern and anxiety among voluntary sector service providers about the probable negative impact on 6

7 the continuation of services and programmes funded by the NHS that they currently run where women with precarious immigration status are users. Several voluntary sector interviewees spoke of the significant impact of the socio-economic circumstances and changes in these over time on health outcomes and access to care among vulnerable migrant women and the fact that commissioning does not always take account of broader determinants of health in these groups. 7. Good practice examples There were examples of good practice in voluntary sector provision, particularly regarding holistic approaches taken to dealing with barriers beyond direct access to healthcare, but which significantly impact on health outcomes and emotional health and wellbeing of service users. Recommendations Commissioners should attempt to follow and apply existing guidance and standards on inclusion health to vulnerable migrant women. This includes collecting good quality data about populations and social determinants of health, reviewing commissioning gaps more systematically with reference to providing a diverse and equitable service, and providing support for asset-based co-production approaches (that is, building action upon the skills, knowledge and capabilities of the communities themselves). Service pathways and interventions that exist for specific categories of vulnerable women for example around FGM, survivors of domestic violence or trafficking, pregnant asylum seekers should be utilised more effectively to gather information about the wider social determinants and needs of these groups. There should be more concerted attempts by commissioners and practitioners to act on the considerable available research findings and recommendations on health needs of vulnerable migrant women in local areas (for example, the need for appropriate interpreting support), even though it is mainly qualitative because of small numbers and composition. As one interviewee pointed out it would be good if conclusions from research were taken up somewhere, by somebody, at some point. Develop mechanisms to ensure that good practice in services like the examples highlighted in the report are shared across regions, counties, urban and rural areas. Provision of evidence-based services and early interventions can prevent negative consequences in health outcomes for vulnerable migrant women. 7

8 Among commissioning bodies there should be more support for and engagement with voluntary sector organisations, particularly smaller organisations that work with specific categories of vulnerable women, helping them overcome a variety of problems that impact on health and enabling them to engage productively with the NHS. There should be systematic assessment of the impact of charging policies for migrants on essential community health-related services provided by the voluntary sector for the wellbeing of vulnerable migrant women and prevention of destitution. Sharing of good needs assessment and commissioning practice (where it exists) among CCGs, public health teams, NHS England and Public Health England, would be helpful for counterparts in other areas who are seeking direction in this respect. A recommendation from a commissioner as well as a practitioner is for the creation of a system whereby medical records of more mobile new migrants can be held centrally rather than within individual CCGs and also shared between the UK and country of origin health systems where possible so as to ensure continuity of care. For example, this would be important for pregnant asylum seekers who may be dispersed across different areas. Funding should be provided to the Women s Health and Equality Consortium and Maternity Action to update the Guidance for commissioning health services for vulnerable migrant women that was produced in

9 SECTION 1: SETTING THE SCENE 1.1 Introduction Both women and men migrate internally within national borders and internationally across borders for a variety of reasons to do with factors at both origin and destination. The focus of this report is international women migrants in England. Recent statistics for the UK (Integration up North, 2015) show that women make up: Around three quarters of migrants entering the UK for family reasons (that is, to form, accompany or join families); A little over half of those coming to study; A little under half of those coming for employment; A third of those seeking asylum. The stock of female migrants rather than the flow as above, is generally measured by considering women who were born outside the UK, irrespective of length of residence. So this may include those who have been resident for a long time as well as those who arrived very recently. In 2014 women constituted 54% of the foreign-born population in the UK according to the Labour Force Survey (Rienzo & Vargas-Silva, 2015). Women also form a significant part of the estimated 618,000 undocumented migrants in the UK (Keith & Van Ginneken, 2015) although precise numbers are difficult to determine. The health status of different categories of migrants and their access to healthcare are determined by a variety of factors associated with both receiving and sending contexts and the entire migration process. These include demographic (e.g. sex, age) and socio-economic factors; where people live and with whom (family, neighbourhood, community); immigration and integration policies in the receiving country, as well as emigration policies in sending countries; impact of racism and discrimination; ethnic and cultural background (including language, religion and health-related practices); and migration histories, within which length of residence in the receiving country and transnational connections play an important part (Jayaweera, 2014 ). The focus in this report is on the health needs and factors affecting access to health services among migrant women who are in a vulnerable situation. Vulnerability is a state that is fluid, and can change with time and circumstances. In relation to health it has been defined as a mixture of characteristics and conditions which increases susceptibility to poorer health and difficulty accessing services (NHS Wakefield District, 2011, p. 12). It is linked to processes of exclusion rather than a group identity (Aspinal, 2014). Thus it may apply to any woman migrant at a particular point in time 9

10 but there are specific categories of women who may be in a vulnerable situation for a variety of reasons, all or most of the time. This report focuses particularly on the latter category while not excluding the former category where evidence on their health needs and barriers to healthcare emerge. The specific groups of vulnerable migrant women discussed in this report include asylum seekers, refugees, refused asylum seekers or other undocumented migrant women, women with no recourse to public funds who are supported by the local authority, trafficked women, Roma women, women with limited fluency in English, and migrants from the European Union (EU) with no health insurance card. This report also reflects many areas and aspects of health and healthcare of vulnerable migrant women. These include access to GPs and other primary care services; care during pregnancy, delivery and after the birth of a baby; care related to sexual and reproductive health, mental health, infectious diseases, and non-communicable diseases; health inequalities; uptake of screening and immunisations, care relating to older women, those experiencing domestic violence, and female Genital Mutilation (FGM); and preventive health and health promotion, including on health behaviour e.g. smoking, alcohol consumption, recreational drug use. Thus health-related issues at all life course stages of women are of concern. In terms of geography it is important to consider as many local regions and areas in England where migrants come to and/or settle in as possible. This means not just focusing on urban areas where there has been large scale migration historically and/or in the present, and which are now characterised by a concentration of one specific ethnic or country of origin group, or is superdiverse in that many different migrant demographies are represented (Vertovec, 2007). Effort was made in the survey and follow-up interviews to include areas characterised as new migrant gateways that in the past two decades have attracted specific categories of migrants including dispersed asylum seekers and migrants from EU Accession countries but where health and social services have had to adapt to provide services for a larger and more diverse local population (Waters & Jimenez, 2005). This report follows earlier work by Maternity Action and the Women s Health and Equality Consortium (WHEC) which reviewed policies and good practice for vulnerable migrant women and produced a Guidance for commissioning health Services for this category (Feldman, 2012). Since the publication of that report, there has been a significant restructuring of the administration of the NHS, creating Clinical Commissioning Groups (CCGs) as local commissioning agencies to replace Primary Care Trusts (PCTs), and creating responsibility for public health within local authorities. Further, the Immigration Act 2014 has led to several significant changes regarding eligibility and 10

11 access to healthcare for migrants. Both sets of changes will be discussed in more detail below. The two sets of legislation have implications for the care of vulnerable groups. It is not known how local commissioners have responded to the changes in entitlement to healthcare and there is also little available information on how Public Health bodies target migrant populations and how well they are working with CCGs. Also, there is evidence that some migrants and service providers may not have sufficient information about or understand a particular person s eligibility for NHS care, and fear of immigration sanctions arising from debt to the NHS may deter some migrants from seeking the healthcare they need (Doctors of the World UK, 2015). Aim The aim of the report is to explore the ways in which CCGs, Public Health departments, and Health and Wellbeing Boards (HWBs) together with voluntary sector organisations in selected areas address the health needs of vulnerable migrant women. It investigates any policies and practices that have been developed nationally and in local areas, factors that have shaped policies and practices, and how CCGs work with Public Health teams, and both bodies with other statutory and voluntary agencies in the area. It identifies good and poor practices, and barriers to service provision, and provides examples of and recommendations for best practice that can be replicated in other areas. Methods The methods used to generate evidence for this report were: Review of existing documents on policies, guidance and practices relevant to the provision of health services for vulnerable migrant women. An electronic survey of CCGs and Local Authority Public Health teams throughout England using Survey Monkey, to elicit what information exists on health needs of vulnerable migrant women in local areas, and the extent and nature of commissioning of health services (if any) that is available for these groups. Specific survey questions were on knowledge of local migrant populations and health needs, coverage of migrant health in Joint Strategic Needs Assessments (JSNAs) and Joint Health and Wellbeing Strategies (JHWSs) and commissioning responsibilities, categories of vulnerable migrant women in the local area, their health issues, commissioned services for them including advice services, barriers to providing services, and partnership working with other agencies. In-depth Interviews based on a topic guide and conducted by telephone with commissioners and statutory and voluntary sector health service providers in a range of geographical areas with diverse migrant populations. Potential interviewees were recommended by the survey 11

12 respondents, regional Strategic Migration Partnerships (SMPs), and through snowballing with interviewees. The aim of this part of the research, following the survey to commissioners, was to probe more broadly and deeply into what services are provided for vulnerable migrant women in the local area, what are the impacts of service provision on their access to and uptake of mainstream healthcare and health outcomes, what are the barriers and problems identified, the extent to which there is partnership working between different agencies, and examples of good and bad practice in service provision for vulnerable migrant women in local areas. Structure of the report The next part of Section 1 describes the NHS structure in England as a result of the 2012 Health and Social Care Act including the demarcation of responsibilities between CCGs and LAs and the roles of other agencies relevant to commissioning and providing healthcare for the population. This is followed by a consideration of the current structure of entitlements to NHS healthcare for different migrant categories and the impact of changes brought about by the 2014 Immigration Act. Section two begins with a brief review of the current policy and guidance framework on commissioning and providing health services that is relevant for vulnerable migrant women. Following this, primary evidence from: 1) the survey for CCGs and public health teams in LAs; and 2) in-depth interviews with commissioners and statutory and voluntary sector healthcare providers on existing services for vulnerable migrant women and challenges and barriers to provision, is presented and analysed. This section also includes examples of existing good practice in meeting health needs of vulnerable migrant women. The report ends with a summary of key findings and recommendations for commissioners and healthcare providers. 1.2 Clinical commissioning and public health in the new NHS structure Arising from the 2012 NHS and Social Care Act, since April 2013 the NHS has been operating within a new organisational structure. NHS England, the main clinical commissioning board responsible to the Secretary of State and the Department of Health but operationally independent, oversees the provision of NHS services and controls most of the budget. Given the specification in the 2012 Act that decisions about services should be made as locally as possible, the actual provision of services and management of the budget is performed at local level by over 200 Clinical Commissioning 12

13 Groups (CCGs) which replaced Primary Care Trusts (PCTs) on 1 st April 2013, and to which all General Practitioner (GP) primary care practices in England belong. There are over 35,000 GPs in England, working in nearly 8,000 practices. CCGs commission most secondary care services including planned hospital care, rehabilitative care, urgent and emergency care, most community health services, maternity services and mental health and learning disability services. They can commission these services from any provider who meets NHS standards and costs, including from private sector providers, social enterprises and charities, as well as NHS organisations including hospitals. 1 From 2015/16, commissioning of local primary care (GP) services, which was previously undertaken by NHS England, is increasingly becoming the joint or full responsibility of CCGs. 2 The 2012 Act also changed the way Public Health services are commissioned. Since April 2013 Local Authorities (Councils) have direct input into the planning, provision and operation of health services at local level, and work with Public Health England (PHE), an operationally independent executive agency of the Department of Health, to improve public health locally. NHS England commissions about half the public health budget including national immunisation and screening programmes and public health services for children aged 0 5 such as health visiting. Local authorities are meant to promote more joined up working at local level across the NHS, public health, social care and other services, predominantly through local Health and Wellbeing boards (HWBs) in upper tier and unitary local authorities. 3 The mandate of HWBs is to work together to improve the health and wellbeing of their local population and reduce health inequalities. Members of HWBs include at least a local elected council member, representatives of the local Healthwatch organisation 4 and of each local CCG, director for adult social services, director for children's services and director of public health. HWBs can also expand their membership to include representatives from the charity and voluntary sectors. Importantly, HWBs are obliged undertake a Joint Strategic Needs Assessment (JSNA) for their area and develop strategies for how health needs of the local population can be addressed (Joint Health and Wellbeing Strategies JHWS) (Department of Health, 2013). JSNAs and JHWSs will be discussed in more detail specifically relating to the health needs of vulnerable migrant women later in this report. 1 NHS Choices: the NHS in England [accessed 11/02/2016] 2 NHS Commissioning: Primary Care Co-commissioning [accessed 11/02/2016] 3 See footnote 1. 4 As part of the 2012 Act a statutory organisation, Healthwatch, was set up in each local authority with a mandate to ensure that views and concerns of service users are taken into account in decision-making on local services [accessed 11/02/2016] 13

14 1.3 Access to NHS care for migrants Over the past two decades policy changes in England have brought increasing restrictions to entitlement and access to NHS health services for migrants. At present there is a distinction in regulations governing free access to NHS primary and community healthcare on the one hand, and those governing free access to NHS care in hospital and other secondary health settings on the other, with the latter dependent on the immigration status of the patient. While the NHS Act of 1964 specified that most health services are provided free at the point of need for people of England and Wales, the NHS Act 1977 first gave powers to the government to make charges for healthcare from people who are not ordinarily resident. 5 In the regulations, primary health care from a GP, including for people with no free access to routine secondary care, cannot be refused on grounds of race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition. An application to register can only be refused on reasonable grounds such as lack of space on the practice list or residence beyond the catchment area (NHS England, 2015). In 2015 a Guidance on patient registration in general practice was issued by NHS England Primary Care Commissioning to clarify rights of patients and responsibilities of providers in this respect. There was particular stress in the document on the need for the Guidance because of evidence that Practices are turning patients away on grounds of lack of documentation on identity and/or residence, and there is specific mention of particular groups such as homeless people and some migrants and asylum seekers who are denied registration. Reference is made in the Guidance to the statutory obligations for the NHS arising from the 2012 Act to reduce the risk of exacerbating health inequalities for specific sections of the community (NHS England, 2015, p. 5). Such guidance may have a positive effect on access to primary care for some categories of vulnerable migrants who have been confused about entitlement to primary care or found registration with a GP difficult. For instance, a recent Doctors of the World report showed that 83% of people attending their London clinic in 2014 had not registered with a GP (Doctors of the World UK, 2015). However, ironically at the end of the same year the Guidance was issued (2015), the Department of Health put forward a 5 Until re-defined in the 2014 Immigration Act ordinary residence was a common law definition referring to someone who is living lawfully in the United Kingdom voluntarily and for settled purposes as part of the regular order of their life for the time being, with an identifiable purpose for their residence here which has a sufficient degree of continuity to be properly described as settled (Powell, 2015). 14

15 Consultation on extending the already existing charging of some categories of migrants for access to secondary (hospital) care, to accessing treatment in primary care (Department of Health, 2015a). 6 This proposal constitutes the final phase of the Migrant and visitor NHS cost recovery programme launched by the Department of Health in 2014 (Doctors of the World, 2016). Charging regulations for secondary health care for people not ordinarily resident have existed since 2004 and are enshrined in the 2006 NHS Act. Categories affected include visa overstayers and refused asylum seekers. In accordance with a re-definition of ordinary residence as part of the 2014 Immigration Act to mean only those who have indefinite leave to remain (ILR) in the UK, all new temporary entrants from countries outside the European Economic Area (EEA) planning residence in the UK for six months or more, including workers on the points-based-system and their dependants, family members joining British citizens or permanent residents, and international students, are subject to an annual health surcharge currently ranging from 150 for international students to 200 for workers and family migrants, which allows them access to NHS hospital care free at the point of delivery (Department of Health, 2016). At present the following categories of healthcare are free to all, irrespective of immigration status or nationality: Treatment given in an accident and emergency department or similar walk-in centre 7, but excludes emergency treatment given elsewhere in the hospital. Services provided outside of an NHS hospital 8, unless the staff providing the services are employed by or working under the direction of an NHS hospital. Diagnosis and treatment of certain communicable diseases such as TB and pandemic flu. Diagnosis and treatment of sexually transmitted diseases including HIV. Compulsory psychiatric treatment. Family planning services (but not pregnancy termination). Treatment of a physical or mental condition caused by torture, FGM, domestic violence or sexual violence when the patient has not travelled to the UK for the purpose of seeking such treatment. In accordance with human rights obligations immediately necessary care including for maternity care, and urgent care in hospitals should be provided to all according to need, but are subject to 6 In the Consultation, it is not proposed to extend charging to GP and nurse consultations in primary care. 7 The possibility of charging for accident and emergency services, including ambulance services, is part of the Consultation. 8 These services, including healthcare provided by voluntary agencies, may also become liable for charging following the Consultation. 15

16 payment after treatment has been provided. Since October 2011 migrants with unpaid NHS debts of over 1,000 ( 500 since April 2016) may be refused re- entry or extension of stay (Department of Health, 2016). In summary, groups relevant to this report who, in accordance with current charging regulations, are exempt from NHS charges for secondary healthcare include: Non-EEA nationals subject to immigration controls who have paid the health surcharge. Short-term EEA nationals with an European Health Insurance Card (EHIC) and their family members EEA citizens exercising their treaty rights and their family members Vulnerable groups, which include: o refugees o those applying for asylum or humanitarian protection whose claims have not yet been determined o asylum seekers with Section 95 support from the Home Office under the 1999 Immigration and Asylum Act 9 o refused asylum seekers with support under Section 4 (2) of the 1999 Immigration and Asylum Act or those with support under section 21 of the National Assistance Act 1948 or Part 1 of the Care Act 2014 from a local authority to provide accommodation. 10,11 o children looked after by a local authority o victims of human trafficking, slavery, servitude or forced or compulsory labour o prisoners and immigration detainees o those covered by reciprocal healthcare agreements with countries outside the EEA. (Department of Health, 2016) Thus the main vulnerable groups not exempt from charging include visa overstayers, those entering the UK in contravention of immigration rules, refused asylum seekers with no Home Office or local 9 Asylum seekers are entitled to Section 95 support accommodation and/or subsistence - if they are destitute or likely to be destitute, and this support may continue if their claim for asylum is rejected but they have children under age 18 (Department of Health, 2016). 10 Section 4 support is given for those refused asylum seekers who are faced with barriers deemed genuine by the Home Office to return to countries of origin. Support under Section 21 of the NAA or now the Care Act 2014 is usually for people with disabilities. This support requirement is not needed in Scotland, Wales or Northern Ireland (Department of Health, 2016). 11 However, note that significant changes to support for refused asylum seekers under Section 4 and Section 95 in the 2015/2016 Immigration Bill (once it comes into effect) may also affect their exemption from charging for NHS services (Home Office, 2015). 16

17 authority support, EEA nationals with no EHIC or not exercising treaty rights, and visitors with less than 6 months leave to remain in the UK (Islington Council, 2015). 12 There is considerable concern among organisations that provide support to vulnerable migrants on the implications of current and proposed charging regulations on access to care and on health outcomes among these groups. These include voluntary sector organisations that provide frontline advice, help and support, and sometimes direct medical treatment, for those uncertain of their entitlement to healthcare and are fearful of attending hospital as they do not have the means to pay (Shortall, et al., 2015). It also includes health professionals in the NHS who fear that denying essential medical care to those in need is a violation of the medical ethics they operate within Chargeable non-eea patients will be charged 150% of NHS treatment costs (Department of Health, 2016). 13 See the website of Docs not Cops [accessed: 18/02/2016] 17

18 SECTION 2: COMMISSIONING HEALTH SERVICES FOR VULNERABLE MIGRANT WOMEN POLICIES AND EVIDENCE 2.1 Current policy framework The 2012 Health and Social Care Act introduced duties and powers for CCGs and local authorities as partners working through HWBs, to formulate and implement JSNAs and JHWSs as locally owned evidence-based processes of strategic assessment and planning to improve the public s health and reduce inequalities (Department of Health, 2013). JSNAs make assessments of the health needs of the local community, while JHWs are key strategic priorities for action based on needs identified in the JSNAs. Arising from recommendations of the 2010 Marmot Review (Marmot, et al., 2010) the DH Guidance states that: Their outputs, in the form of evidence and the analysis of needs, and agreed priorities, will be used to help to determine what actions local authorities, the local NHS and other partners need to take to meet health and social care needs, and to address the wider determinants that impact on health and wellbeing. (Department of Health, 2013, p. 4) The guidance stipulates that health coverage should include mental health as well as physical health, and health protection and prevention of ill-health. It should also cover the needs of the entire population including those vulnerable groups who experience inequalities and find it difficult to access services and those with complex and multiple needs. Local partnerships with other statutory sector organisations such as housing services, schools, police, and beyond these, with voluntary organisations, community organisations and local Healthwatch (see footnote 4) and directly with users, are considered imperative to gather information on unmet needs and co-produce community asset-based approaches to addressing needs including resources, social networks, skills and capacity of organisations and individuals (Department of Health, 2013). Specific national guidance and resource documents have been developed over the past few years to formally set out assessments and strategies to meet the needs of particular vulnerable population groups, and provide some good practice examples and recommendations. These centrally include reports in the Health Inclusion Programme of the National Health Inclusion Board, which consider the category of vulnerable migrants as well as Roma (within a separate category of Gypsies, Travellers, and Roma) among population groups who have the poorest health and for whom there is least information on health needs, including in JSNAs, and inadequate provision of healthcare 18

19 services (Inclusion Health, 2014) (Aspinal, 2014). 14 Standards for commissioners and service providers published by the Faculty of Homeless and Inclusion Health in 2013 refer to migrant health services that should apply to all vulnerable migrant categories including undocumented migrants, victims of trafficking and slavery, and those who are homeless and destitute. It sets out standards for full registration by GPs including for those without documentation, provision of culturally competent and language supported services, collection of country of birth information in primary care, access to the full range of primary care interventions including immunisations, referral to mental health services and secondary healthcare as appropriate, and liaison with voluntary sector organisations supporting vulnerable migrants (Faculty of Homeless and Inclusion Health, 2013). There is ongoing work by the Inclusion Health and Lived Experience sub-group of the NHS Equality and Diversity Council (EDC) to improve access to services, health outcomes and quality of care for those with lived experience of stark inequalities, including asylum seekers and refugees. Their work plan until 2017 includes ensuring people with lived experience have a voice and are able to influence the work of the EDC (for example in developing and disseminating an access to healthcare patient-facing leaflet on GP registration for asylum seekers and refugees) and strengthening primary care practitioners capability and responsibility in addressing equality and health inequalities impacts (NHS Equality and Diversity Council, 2015). Much of the current policy and guidance framework on addressing health needs of migrants draws on a slightly earlier guide (before NHS re-organisation) commissioned by the DH which focused specifically on including migrant populations in JSNAs and remains very relevant for current and future health services commissioning (Rose, et al., 2011). Several commissioners and voluntary sector providers interviewed for this report mentioned the relevance and importance of this guidance in providing a framework for the work they currently do to address health needs of migrants in their local areas. The guide sets out the importance of: 1) a basic understanding of the demography of a local area including change brought about through migration, as a first step to understanding local need; 2) gaining a thorough understanding of the social determinants of the health of migrants taking into account differences in migrant diversity in different areas; and 3) viewing migrant communities as assets rather than as drains on the system and utilising a coproduction approach involving all community members (service users, practitioners, voluntary and community organisations) in producing and disseminating knowledge and building longer-term capacity among networks of individuals and agencies (Rose, et al., 2011). 14 The other vulnerable groups covered by the Health Inclusion Board are: the homeless and rough sleepers; and sex workers. 19

20 None of the current inclusion health policy approaches explicitly address the health needs of vulnerable migrant women. The most comprehensive approach in this so far is the WHEC and Maternity Action guidance produced before NHS re-structuring and immigration policy changes (Feldman, 2012). Some specific recommendations in this for commissioners, in summary, are: Including data on migrants in JSNAs that is disaggregated by gender as well as ethnicity/nationality, and data on women by migration situation. Women should be fully represented in multi-agency forums on reviewing needs and developing services for migrant communities. Language support and interpreting and translation services should be gender sensitive and have equality impact assessment according to gender as well as race and other issues. There should be awareness of the most appropriate form of delivery of primary care services for vulnerable migrant women and any alternative models of care. Mental health services should be flexibly designed and delivered so as to provide gender and culturally sensitive support. There should be performance indicators and training for recognition of and response to gender-based violence at initial health checks, and referral pathways to appropriate physical and mental health services for migrant women. A policy and pathway on maternity care for vulnerable migrants should be implemented, including partnerships with voluntary sector support organisations and needs-awareness training of maternity staff, to achieve the same standards of care as recommended by NICE for all pregnant women. There should be support for community based methods of enhancing preventive health, screening and chronic disease management among vulnerable migrant women and it is important to ensure that interventions do not take place without their informed choice. Two pieces of very recent guidance have implications for health services for vulnerable migrant women. One, the DH guidelines on commissioning services for women and girls with or at risk of FGM, set out pathways of referral, care and support generally, alongside surveillance and safeguarding measures applicable especially for girl children and pregnant women. These pathways include clinical interventions, including as part of maternity services in the case of pregnant women, mental health support through NHS psychology services, and referral to voluntary or community organisations with specialist experience of supporting women who have FGM. A patient-centred healthcare response is emphasised (Department of Health, 2015b). Two, the 2015 guidance on 20

21 commissioning mental health services for vulnerable adult migrants (defined as those adversely affected by the circumstances leading to or resulting from migration) sets out standards and recommendations for commissioners that stress the importance of recognising gender-specific needs of women and reinforces the importance of integrated commissioning and service development and delivery in partnership with migrants, health advocates and community organisations, with clear equality impact assessment of all care pathways (Fassil & Burnett, 2015). All of the above commissioning policies and guidance have in common an emphasis on better information gathering on the needs of the population groups in question whether they are vulnerable migrants in general or women in these groups specifically. They also emphasise reducing inequalities in access to healthcare and the importance of co-production strategies with users in designing, developing and delivering services aimed at these groups. The following section considers primary evidence on the realisation in practice of this policy and guidance framework and examines current barriers, as well as good practices, that impact on effective service commissioning in the specific case of vulnerable migrant women Primary evidence The main evidence base of this project is a survey of CCGs and local authority public health teams in England, followed by telephone interviews with a range of commissioners and statutory and voluntary sector service providers (see Section 1, Methods). The aim of both types of primary research was to elicit information and views on current commissioning and provision of services for vulnerable migrant women in local areas. The survey took place in January 2016, and the interviews in February and March Survey results There were survey responses from 13 CCGs and 6 Public Health (PH) teams covering a range of regions in England: North, North West, North East, West and East Midlands, London, South East, South, but mainly urban areas within these. The relatively poor response rate for the electronic survey probably reflects the lack of information about migrant health needs in general among commissioners as revealed in the results, as well as possibly the greater priority given to public health concerns at a broader population level. It is also important to note that the survey responses 21

22 are not representative of all CCGS and local authorities in the country, those in areas where there was more commitment to meeting migrant health needs were possibly more likely to respond. Ten (10) out of the 13 CCGs and three of the six PH teams that responded said that there was data on the size and composition of the migrant population in the local areas they covered. But the overwhelming majority 11 out of 13 CCGs and five out of six PH teams - were not aware of any information on migrant health needs in their areas. An organisational role with specific responsibility for migrant health only existed among a third of CCGs and PH teams surveyed, and migrant health was not a standing item for any of the HWBs. The survey responses revealed that the inclusion of migrant health in JSNAs is patchy across the different areas. Six CCGs and three PH teams said migrant health was covered in the JSNA. Three CCGs and two PH teams stated that there was specific coverage of vulnerable migrant women in JSNAs. Specific strategies regarding health issues for vulnerable migrant women, as embodied in JHWS, is even rarer, mentioned by one CCG and one PH team. While the sample size of this survey was very small relative to the number of CCGs and PH teams in England, the patterns revealed here about limited and variable representation of migrant health issues in general, and knowledge and strategies relating to vulnerable migrant women in particular, are not inconsistent with evidence from the in-depth interviews as shown below. Asylum seekers and refugees appear to be the categories among vulnerable migrant women for whom there is most likely to be local targeted health policies, programmes and practices, as mentioned by all CCG respondents and half of PH respondents who answered this question. Women with limited fluency in English also figured prominently in CCG responses, while meeting health needs of women with NRPF supported by the LA was highlighted in the PH team responses. For CCGs health issues of most concern regarding vulnerable migrant women were mental health, pregnancy and post-birth care, and FGM (over four fifths) followed by access to GPs and uptake of screening/immunisations. For PH teams, the most important issues were sexual and reproductive health, followed by health inequalities (social determinants of health), health relating to domestic violence, FGM, and pregnancy and post-birth care. The differences in health issues reflect the differences in commissioning and funding streams between CCGs and PH teams. Other health areas such as health behaviour, and preventive health/health promotion were also mentioned by both types of respondents, but there was little mention of the health of older women or noncommunicable diseases among either. 22