Dudley Migrant Health Needs Assessment An initial qualitative health needs assessment of migrant communities in the borough of Dudley

Transcription

1 Dudley Migrant Health Needs Assessment An initial qualitative health needs assessment of migrant communities in the borough of Dudley January 2015 David Newall (Consultant in Migration and Migrant Health) Commissioned in January 2014 by the Office of Public Health, Dudley Council

2 Contents Page Foreword Introduction The Health of Migrants Types of Migration Methodology Migration Summary for Dudley Professional Perspectives Migrant Community Perspectives Discussion of Key Findings Recommendations Conclusion Glossary of Terms Appendices A. Sources of Migration Data B. Additional Services Identified for New Migrants C. I. Findings from the Pakistani Community Focus Groups II. Findings from Polish Community Focus Group III. Findings from the African Community Focus Group D. Recommendations and Proposed Action Plan References ACKNOWLEDGEMENTS We would like to thank those individuals from the public sector, health sector, voluntary sector and those from migrant communities in Dudley who were willing to share their time and experience in this project. We also want to acknowledge the invaluable support from the Office of Public Health of Dudley Council in commissioning this work and for their advice and support through the needs assessment process. For further information on this report and future actions please contact: Amarjot Birdi Programme Manager for Health Inclusion, The Office of Public Health amarjot.birdi@dudley.gov.uk Dudley Migrant Health Needs Assessment Page 1

3 FOREWORD Health inequalities exist in many groups of society with diverse needs and in the borough of Dudley, Public Health has a strong commitment to explore what this means at a local level and how this can inform service developments. Migration brings with it a wealth of diversity in terms of culture, language, food and skills, but it also brings different perceptions of health and health related services, often based on people s previous experience of different systems in other countries. We welcome this opportunity to explore the health experiences of migrant communities living in the borough to determine and support their needs in the future. Karen Jackson Interim Director of Public Health Office of Public Health Dudley Council Dudley Migrant Health Needs Assessment Page 2

4 1. INTRODUCTION The migrant health needs assessment was commissioned by the Office of Public Health in Dudley. The aim of the study was to improve the understanding of migration at a borough level and identify the key issues and gaps in existing health and social provision for recent migrants. The following report provides an overview of the key findings from the assessment which are intended to support commissioners and service providers in the borough to understand and respond to the needs of recent migrants The needs assessment sought to address the following: - Identify the range of services which are providing support for asylum seekers, refugees and other migrants in Dudley Borough. - To develop the existing Dudley migration summary 1. - Undertake interviews with service leads in the public and voluntary sector to identify issues, gaps and needs of new migrants from a service providers perspective. - Undertake qualitative research, through focus groups, to identify the new migrants experience, access, barriers, key health needs and expectations of health services in Dudley Borough. - Analyse the findings of professionals and migrant community data and produce a report with recommendations for the Office of Public Health. 1.2 Scope of the Study For the purpose of this study, a migrant refers to an individual who has moved from their usual place of residence to live in another country for reasons of work, education, family, socio-political persecution or war The study focuses on the experience and needs of migrants living in Dudley who have come to the UK since This is not intended to minimise the potential health and social care needs of other groups of migrants, but recognises that recent arrivals may face additional barriers linked to language and understanding of the system in the UK than those who have been in the UK over 10 years. Dudley Migrant Health Needs Assessment Page 3

5 2. THE HEALTH OF MIGRANTS Immigration status plays an increasing role in determining individuals entitlement and access to employment, education, welfare benefits, social care and some health services. The reasons for migration, the migrant journey, country of origin and the conditions which individual migrants face living in Dudley will affect individual migrants health outcomes and those of the borough 3,4. The connection between social factors and health outcomes has been understood for many years within Public Health. Whitehead and Dahlgren s model of the social determinants of health 5 (figure 1) identifies a range of factors, in particular domains that are seen to play a role in determining the overall health of an individual, migrants may hold different resources in some of the domains they identify when compared to the wider population in Dudley Migration itself is increasingly being seen as a social determinant of health, and policy makers and practitioners might consider how the different routes and reasons for migration might be expected to affect the balance of factors an individual migrant or group might be experiencing in Dudley Davis et al (2009) state, Social determinant of migrant health relate to factors that influence the migration process, reasons for migrating, modes of travel, length of stay, the migrants language skills, race and legal status Differing health needs, barriers to accessing health services, experiences of the NHS and variable health outcomes among people of the same nationality but whose reasons for migration and immigration status differs, illustrate the need to move beyond ethnicity alone as a prism to view the health needs of individuals in the local population 7. Commissioners and providers of health and social care need to understand the implications of these changes in the population Studies indicate that migrants, in general, make less use of the health service than the UK population and for several types of migration there is significantly lower use of NHS services 8. However, within this group there may be a small number of vulnerable individuals who may either have particular health needs or face additional barriers to accessing health services 9. Dudley Migrant Health Needs Assessment Page 4

6 2.1.6 Reducing health inequalities remains a priority at a local and national level, however there are few examples where the needs of vulnerable migrants are routinely incorporated into commissioning plans. Increasingly the health needs and experience of migrants are being connected with health inclusion and health inequalities agendas at a national and West Midlands level 10. It is hoped that this needs assessment will assist organisations in Dudley to be able to consider the place of migrants within approaches to reducing health inequalities and delivery of broader NHS outcomes. Figure 1: Social Determinants of Health (Source: Whitehead and Dahlgren What can we do about inequalities in Health? Lancet, 1991, 338: ) In an age of super-diversity 1, approaches to reduce health inequalities in Dudley s population will need to understand and reflect the complexity of the migrant population and the specific social determinants that may affect their health. Age and gender are factors that influence the propensity to access health services and register with a GP and will influence the type of health services individuals may require. 1 Super-diversity: A concept developed by Steven Vertovec (2007) to describe the diversification of diversity. It recognises that local populations increasingly contain people from diverse countries of origin, with different migration patterns, different immigration status and their rights and entitlements to health, work, education and social welfare, different languages, cultures and religions, and age and gender profiles. Ethnicity is no longer a sufficient category to describe this diversity. Vertovec, S. (2007) Superdiversity and its implications, Ethnic and Racial Studies 30 (6):p Dudley Migrant Health Needs Assessment Page 5

7 2.2 The Challenges of Migration for the Health Service Current literature highlights the problems that migrants have experienced trying to access a range of health services. A number of reasons are cited for this including, the quality or lack of interpreting 11, lack of knowledge of NHS services 12,13, confusion about entitlement to NHS services 14, being denied GP registration 15, low levels of trust in GPs and poor experiences of care National and regional reports identify a number of common themes with regards to recent migrants access to health services and their health needs 17,18. It is suggested that local authorities and health organisations seek to understand and respond to the following issues at a local level: Access to primary care Communicable disease Maternity and child health services Lifestyle and healthy living Community engagement 2.3 Access The experience of primary care services is an area where some groups of migrants encounter persistent difficulties, with the potential knock on effect on A&E admission rates and the development and subsequent treatment of communicable diseases, such as TB 19. Evidence suggests that problems in registering with a GP are partly responsible for increased use of Urgent Care and A&E provision 20, The NHS constitution states that the NHS provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion or belief. Furthermore, it asks individuals to take responsibility to ensure they register with a GP 22. Confusion about the entitlement of different migrants to health services in England is resulting in individuals being refused registration with a GP. Working hours 23, information on local health services, language and cultural factors as well as peoples experience and expectations of the health service in the UK can also act as barriers to primary care. 2.4 Use of Accident and Emergency Services in Dudley Information on the use of A&E services is available at an ethnicity level for the Dudley Group Foundation Trust Hospitals. Whilst ethnicity categories do not isolate the non-uk born population and recent migrants specifically, such data can indicate higher than expected use of these services by certain ethnic groups, this in turn can inform a wider picture of health use and outstanding issues for these groups. Dudley Migrant Health Needs Assessment Page 6

8 2.4.2 Information has been provided for the period April 2013 Jan 2014 by the Commissioning Support Unit and is shown in the table below. It demonstrates the use of A&E services by individuals registered with a GP practice in Dudley and those residents who are not registered with a GP. The percentage use is contrasted with the proportion that each ethnicity made of Dudley s population in the 2011 census. The top five ethnic groups have been highlighted to illustrate the differences in A&E use and the non-gp registered population (Table 1). Rank GP Registered A&E attendees in Dudley Group Foundation Trust By ethnic group Percentage of all A&E Attendance for the period Percentage of Dudley population by ethnic group 2011 census Non GP registered A&E attendees in Dudley Group Foundation Trust by ethnic group Percentage of all nonregistered attendees for the period 1 White British 86.1% 88.5% Any other white 35.1% 2 Pakistani 4.2% 3.3% White British 31.8% 3 Indian 1.6% 1.8% Pakistani 6.1% 4 Any other White 1.1% 1.0% Any other Asian 5.4% background 5 Caribbean 1.0% 0.8% Indian 4.1% Table 1: Use of A & E at Dudley Group Foundation Trust April 2013 January The use of A&E by specific ethnic groups may have a range of causes and whilst acknowledging the limits of this data, it may indicate a slightly higher use of A&E by individuals who classified themselves as Pakistani or Caribbean The data shows a significant over representation of the Any other white category for non-gp registered attendees at A&E during this period. Whilst the number of non-registered attendees over this period is only 148 out of total attendance at A&E of 6,924, 35% of these are in an ethnic group who make up 1% of the population in the borough The 2011 census recorded 3035 individuals as Any other white ethnicity, yet this group had 701 attendances at A&E between April 2013 and January 2014, of which 48 were by individuals who were not registered with a GP Commissioners of primary care and A&E services need to understand the reasons for such apparent over representation by this group and the factors which cause the Pakistani and Any other Asian category to also figure highly in the nonregistered attendance. Further work is also required to clarify the extent to which A&E services are being used inappropriately due to convenience, lack of understanding of the NHS or problems with GP registration for some migrants. Dudley Migrant Health Needs Assessment Page 7

9 2.4.7 The Dudley Group of Hospitals (Dudley Group Foundation Trust) provided information on the recorded nationality of patients who attended A&E services in 2007/8 and 2013/14. There are significant gaps in recorded data for both years, with a non-recorded nationality for 42,690 (2007-8) and 24,377 (2013/14) attendances for those periods. The number of attendances identified as British for the years in questions were 52,034 (2007-8) which rose to 67,656 ( ). Information on the attendance for the top 15 non-british nationalities for these years is shown in table 2 below. Nationality Number or A&E attendances 2007/08 Rank 2007/08 Number of A&E attendances 20013/14 Rank 2013/14 Afghan Albanian American Bangladeshi 55 9 Chinese Indian Iranian Iraqi Irish Italian Jamaican Latvian Lithuanian Pakistani Polish Romanian South African Yemeni Zimbabwean Table 2: Attendance at Dudley A & E Service by Top 15 Non-UK Nationality Whilst acknowledging the margins of error in the data, and that it reflects number of attendances not necessarily a number of individuals from the given nationality that accessed A&E services, it raises some interesting questions Of the top 10 non-uk born nationalities in the borough from the 2011 census, Germany, Hong Kong, Kenya and the Philippines are not represented in the top 15. The top 15 includes countries where individuals may have arrived through the asylum process (e.g. Iran, Iraq and Zimbabwe), new migrant workers from the enlarged European Union (Latvia, Lithuania, Poland and Romania ) as well as individuals from the longer standing black and minority ethnic communities in the borough (Bangladesh and Yemen). Dudley Migrant Health Needs Assessment Page 8

10 Commissioners of primary care and A&E services should seek to understand the extent to which a lack of knowledge of the NHS, barriers to GP registration and language issues have contributed to some of these nationalities, which are less numerous in the borough, having such a high representation in this data. It would be expected that these communities would include more recent migrants Finally, the significant rise in Polish attendances over this period should be explored with the community and providers of service to understand what lies behind this rise. 2.5 Dudley Walk-In Centre Data At present, information on attendees at the Dudley Walk-In centre is not available by country of origin or main language. However, the service has provided information on the use of Language Line {interpreting services} for the four quarters of the last financial year. Interpreting was provided in 22 different languages in each quarter and was used for between 139 (Jan March 2014) and 148 (April June 2013) appointments per quarter. Figure 2 illustrates the trends in use for the top five language requests by quarter during this period Hindi Polish Punjabi Slovak Urdu Other languages 5 0 Apr - June 2013 July - Sept 2013 Oct - Dec 2013 Jan - March 2014 Figure 2: Dudley Walk-In Centre Language Line Appointments by Language for 2013/ Organisations may wish to understand why there are marked differences in interpreting requirements between the DACHs service (Table 6, page 25) 24 and the Walk In Centre and to what extent this reflects the health needs and choices of where to access health services that are available for different ethnic or national groups. Does the absence of Chinese or Arabic interpreting requests at the walk-in Dudley Migrant Health Needs Assessment Page 9

11 centre infer anything about the health or health seeking behaviour of those communities? Are there other reasons why those groups who might be expected to figure in interpreting requests are absent? Is there a connection between them living in parts of Dudley where accessing this service is more difficult, due to geography, or do they have more family and friends to support their access to GP services in the places where they live? 2.6 Communicable Disease Data are recorded by ethnicity and also for UK Born and Non UK Born individuals for a number of communicable diseases. These data highlight how the burden of communicable disease falls more heavily on individuals born outside of the UK, but it should also be noted that we are dealing with very small numbers of cases when compared to the size of the UK born populations The Health Protection Agency report on communicable disease 25, highlights that in the UK 73% of new TB cases, 60% of new HIV cases and 77% of Malaria cases in 2010 were to individuals who were born outside of the UK There is extensive information on TB prevalence rates provided by the World Health Organisation and also on the Health Protection Agency s Migrant Health Guide 26. Current guidance indicates that individuals from countries where there are more than 40 cases per 100,000 head of population should be screened for TB. Where individuals face problems accessing a GP or new patient health checks do not allow sufficient time for appropriate screening for TB and other possible infectious diseases the impact on individual and public health could be significant Communicable Disease Data Data are collected on TB and HIV rates at a regional level with the number of new cases in Dudley being extremely low. Such information may be useful in ensuring awareness of speciifc health conditions and symptoms and access to screening and treatment is made available to the relevant migrant population in the borough The data for TB cases in the West Midlands in 2013 indicates that 65% of the cases in the region occurred in someone who was not born in the UK, for Dudley the rate for the same year was 52%, however specialists suggest that the figure has been unusually influenced by a higher than normal number of cases of White British ethnicity for this period % of those diagnosed with TB in Dudley during 2013 were from White, Indian and Pakistani ethnic groups. When comparing the borough with the West Dudley Migrant Health Needs Assessment Page 10

12 Midlands in terms of rates per 100,000 head of population, the rate of new cases in Dudley amongst Black Africans is significantly lower. This ethnic group has the highest rate in the West Midlands per 100,000 of any ethnic group in The extent to which this reflects a smaller Black African community in the borough or a need for more focused engagement with health professionals and communities to rasie awareness of TB is something which Public Health should review Figure 3 indicates the percentage of new TB cases by year for those born inside and outside the UK at a West Midlands and Dudley level. 70% 60% 50% 40% 30% 20% UK Born (WMids) Non-UK Born (WMids) UK Born Dudley Non-UK Born Dudley 10% 0% Figure 3 : New TB Cases by Year for UK and Non-UK born Population for West Midlands and Dudley At a global level, HIV rates are significantly higher, for new diagnosis and the numbers of individuals living with HIV, in Sub Saharan Africa 27. At a UK level around 52% of those receiving specialist HIV care are White and 34% are Black African 28. HIV rates are extremely low within the borough, with the number of new cases being diagnosed falling year on year since The highest proportion of newly diagnosed cases and individuals who have been diagnosed with HIV and are receiving HIV related support remains in individuals of white ethnicity who were born in the UK. 2.7 Maternity and Child Health Over 22% of the births in the West Midlands are to women who were born outside of the UK. Births to non-uk born women have risen significantly over the past 10 years. Research on infant and maternal mortality has continued to highlight the Dudley Migrant Health Needs Assessment Page 11

13 increased risks faced by vulnerable women who have recently arrived in the UK 29,30,31,32,33. The West Midlands has the highest rate of Infant Mortality of any English Region, and the extent to which migration may play a role in this is still unclear. Whilst the rates of infant and maternal mortality are lower in Dudley, maternity and child health services do need to understand the changing impact and complications which migration may bring for vulnerable migrant women who may require these services Improving early access to maternity services can be complicated by migration status and the barriers faced in GP registration. The diversity within some communities in terms of different migration statuses, different levels of English language and levels of access to wider social support networks are issues that need to be factored into the planning and delivery of maternity care and child health services Births to Non-UK Born Mothers Births have increased significantly in England over the past 10 years. The total number of live births in Dudley has increased from 3313 in 2001 to 3966 in Dudley has seen a smaller than regional rise on the proportion of births to non-uk born mothers during this period due to a continued rise in births to UK born mothers for the same period. The growth in number of births to non-uk born women in Dudley during this period is responsible for approximately 20% of the increase in total births The number of live births to non-uk born mothers has only increased from 10.35% in 2001 to 12.22% of all births for 2012; this remains below the regional average of 22.68% for The profile of non-uk born mothers has not changed significantly from 2001 to 2012, Figure 4 below illustrates the changes during this period. The proportion of births to mothers from the Middle East and Asia remains the largest in the area during this period, rising from 8% in 2001 to 8.3% of total births in Dudley in Births to mothers born in European Union countries have increased from 0.9% of all births in 2001 to 1.74% for For African born mothers the increase has been from 0.6% of births in 2001 to 1.4% in Dudley Migrant Health Needs Assessment Page 12

14 Figure 4: Mother s Country of Birth Live Births in Dudley Source ONS 2.8 Lifestyle and Healthy Living Limited data are available on the impact of lifestyle and healthy living issues for the migrant population at a local level. This makes it hard to identify the extent to which certain migrant groups or nationalities are represented or are absent from current programmes designed to deliver health improvement on these conditions. Some migrants in Dudley will come from countries which have higher rates of smoking and alcohol consumption than the general UK population. Similarly, the incidence of type 2 diabetes, Coronary Heart Disease and hypertension is high in some of these countries The effect of restrictions on employment, for example for those in the asylum system, may also increase an individuals sense of social isolation and have an adverse effect on mental wellbeing. For others the effect of poverty and low income which may result from their immigration status may affect their ability to maintain a healthy and balanced diet or maintain an active lifestyle, with a subsequent impact on their health outcomes The ability to target appropriate resources to improve the general health of the local population could be enhanced by a more detailed knowledge of the migrant population at a GP, public health and commissioning level. Dudley Migrant Health Needs Assessment Page 13

15 2.9 Community Engagement The new NHS structure places the patient and public at the heart of the health service and initiatives like Inclusion Health identify the need and new approaches to engagement with vulnerable groups, including vulnerable migrants. Some new migrants may lack appropriate information or understanding of the place of patient involvement in the NHS. For others the lack of formal community organisations may appear a barrier for engagement from the health sector. New bodies like local health watch and the CCG will require support in understanding the diversity of the local population and may require fresh approaches to community engagement to ensure the health needs and aspirations of new residents in a locality are reflected in the review and commissioning of services Research highlights mental health as a concern for those who may come to the UK via the asylum route 34,35 but also identifies the impact which social isolation, poverty, experiences of discrimination and lack of integration may have on the health and wellbeing of migrants 36. A number of reports also draw attention to the deterioration of migrants health over time in their new country 37. Dudley Migrant Health Needs Assessment Page 14

16 3. TYPES OF MIGRATION 3.1 Data on migration into the borough are available through a range of sources and will be considered in section 5. The most common reasons for migration into Dudley are for work, marriage or joining family and for asylum. In an era of superdiversity individuals from one nationality may have different immigration statuses, differing sources of support and different rights to work, study, welfare benefits and secondary health care. This section provides an overview of different immigration statuses which migrants in Dudley might have. Immigration can be a complex issue and questions about immigration status and its effect on a range of entitlements should be directed to a suitably qualified person or agency. 3.2 Asylum Seeker - A person who has applied for protection in the UK under the United Nations (UN) Convention relating to the status of refugees (1951) and is awaiting a decision on their claim from the Home Office, or who has an outstanding appeal against an initial refusal. Asylum Seekers can ask for support from the Home Office whilst their asylum claim is being decided. Dudley has been one of many dispersal areas for asylum seekers since Accommodation for asylum seekers in the borough is provided by G4S under the COMPASS contract with the Home Office. 3.3 Refugee - A person whose claim for asylum has been recognised by the UK Government and they have been granted leave to remain in the UK by the Home Office. Individuals may be granted refugee status and limited leave to remain in the UK, Humanitarian protection or Discretionary leave to remain in the UK. These decisions give individuals similar rights to work, housing, education and welfare support as UK nationals. 3.4 Refused Asylum Seeker - A person who has been through the asylum system and exhausted all of the rights they had to appeal against the decision to refuse asylum. There are limited support options available for those refused asylum seekers, a small number may be able to qualify for Section 4 support from the Home Office whilst they make plans to return to their country of origin. Dudley Migrant Health Needs Assessment Page 15

17 3.5 European Economic Area Nationals (EEA) This group can include individuals who are seeking to exercise their EU Treaty rights to seek work, study or join family members in another part of the European Union. This includes individuals from the A8 and A2 European Union countries: A8 Countries Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia and Slovenia. A2 Countries Bulgaria & Romania. The following non-eu countries are also part of the EEA Iceland, Norway & Liechtenstein 3.6 Croatian Nationals - Croatia joined the EU on the 1st July Individuals from Croatia are allowed free movement within the EU but the UK has placed restrictions on Croatian nationals access to the UK labour market. Individuals may come to the UK to study or to work as self-employed. Anyone wishing to take up formal employment requires an accession workers registration card and permission from the Home Office. Individuals who have been working continuously for a year in the UK can apply to the Home Office for a registration certificate, the restrictions on their ability to take up employment will then cease. 3.7 Economic Migrants (From outside the European Economic Area) Access to the UK for work or study is regulated by UK Government via the points based system 38. There are five tiers in this system, which are described below. The Government receives advice from the Migration Advisory Committee on shortage occupations and Tier 2 has been subject to an annual quota for some time. Employers & Education establishments need to hold a valid certificate of sponsorship from the Home Office in order to take individuals from outside the UK into employment or onto courses. Tier 1 Highly skilled migrants (can include self- employed individuals) Tier 2 Skilled migrants (individuals who come to the UK with a firm job offer) Tier 3 Low skilled migrants (this tier is not currently open) Tier 4 Students Tier 5 Temporary workers and individuals here under the youth mobility scheme 3.8 Students (Non EEA Nationals) Now covered under Tier 4 of the points based system. Individuals will be required to prove they have the means to pay for course fees and living costs whilst they are studying in the UK. Dudley Migrant Health Needs Assessment Page 16

18 3.9 Spousal/Family Migrants: A person who has obtained permission to enter the UK as a spouse of a UK citizen or to join existing family member(s). New income thresholds for the UK partner, and English language tests for spouses, have been introduced for people wishing to come to the UK via this route. The spouse will have No Recourse to Public Funds as a condition of their entry into the UK for the period of their spousal visa although they will be able to work No Recourse to Public Funds - Individuals with a number of different immigration statuses can have No Recourse to Public Funds. This may be due to them being in the country illegally; overstaying their original visa; or may be a condition applied to their entry to the UK e.g. Spousal migrants. In practice it means that an individual or family has no entitlement to a range of public funds or services e.g. welfare benefits, social housing, or some social care services as a result of their immigration status Overstayers - A person who previously had leave to enter or remain in the UK but did not or has not made an application to extend their leave prior to its expiry. This group of individuals will also have No Recourse to Public Funds Victims of Trafficking The UN Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children (2000) defines trafficking as: Trafficking in persons shall mean the recruitment, transportation, transfer, harbouring, or receipt of persons, by means of threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the person of exploitation. Exploitation shall include, at the minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude or removal of organs. 39 Victims of trafficking may be either children or adults Visitors - An individual who is here for a short period of time for the purpose of holiday, work or visiting family. For secondary health care purposes the definition of a visitor is much broader and includes individuals who are in the UK unlawfully. Dudley Migrant Health Needs Assessment Page 17

19 4. METHODOLOGY The aim of the study is to improve the understanding of migration at a borough level and identify the key issues and gaps in existing health and wider social provision for new migrants in Dudley Borough. Quantitative data will be gathered on the impact of migration at a Local Authority area level and build on the existing Dudley Migration summary 40. These data were used to inform the qualitative element of the health needs assessment and ensure that the most relevant migrant populations in Dudley were selected for the focus groups The needs assessment builds on a brief review of current literature with relation to migration and migrant health. This information has been used in the study to inform the selection and discussion of key topics and to highlight the consistency of the findings in Dudley with previous studies The study compares and contrasts the understanding and experience of service providers within the public and voluntary sector with the experience and perspectives of recent migrants to the borough. There is a particular emphasis on health needs, access and use of health and social care services by recent migrants The assessment took the form of a qualitative study, through the use of semistructured interviews and focus groups to explore these issues. The work undertaken with representatives from migrant communities has a strong participatory element, which places an emphasis on new migrants themselves framing the issues being considered and proposing specific recommendations for the health sector based on their experience and expectations. 4.2 Interviews with Professionals Professionals working in the health, social care, housing and voluntary sector were identified and asked to participate in a semi-structured interview. We planned to undertake between 10 and 15 interviews with professionals from a range of organisations The interviews enabled participants to clarify their experience and understanding of migration within the borough, its impact on services and the range of issues, needs and gaps in service provision they consider new migrants face in Dudley. A semi-structured approach allows participants to highlight issues which are significant to them, within the area of study, and provide opportunity for the researcher and participant to clarify and reinforce the meaning attached to specific issues. Dudley Migrant Health Needs Assessment Page 18

20 4.3 Focus Groups with New Migrants and Migrant Communities Focus groups were prescribed by the Office of Public Health in Dudley, as the most practical way of identifying the range of issues related to access and expectations of the health services from the new migrant communities We intended to hold three focus groups, with each group reflecting a particular new migrant community who are living within Dudley. Four groups were eventually run to allow for single gender sessions in one community. The Office of Public Health provided some suggested points of contact to deliver the focus groups. The final decision on selection of groups was informed by the data collected from professional interviews and also a review of current migration data for Dudley A focus group approach allows for a variety of methods to be utilised depending on the dynamics of the specific group. It provides a useful method of gaining background knowledge of an issue and may be less threatening for individuals to participate in. It allows for the development of knowledge within a group context where participant engagement can enable meanings to be reflected on and developed and lead to agreement of priorities and potential actions The membership of each focus group was influenced by the community organisations who were asked to coordinate the session. Whilst recognising that community organisations may not have contact with a representative sample of the new migrant population, the advantages of this approach lay in helping to facilitate participation, provision of a familiar venue and most importantly helping to address issues of trust which might influence individuals willingness to participate in this process. Attempts were made to ensure a balance of gender, age, single and family status and migration status within the groups. This was achieved in all but the Pakistani community, where a fewer number of males attended the focus group Data on age, gender and nationality of participants was recorded for the purpose of understanding the representativeness of the group members. The facilitator of the group provided an explanation of the purpose of the focus group, ensured participants understood that confidentiality and anonymity of their involvement would be maintained and that they understood and were prepared to consent to participation in the focus group The focus groups were asked to consider their knowledge of the NHS, their experience of trying to access health services and barriers they may face, the main health needs within the community and their expectations of the health service in Dudley. Dudley Migrant Health Needs Assessment Page 19

21 4.4 Ethical Considerations The professionals who agree to participate in the semi-structures interview were asked to provide their informed consent prior to any interview. Their responses are not attributed to them neither is their organisation identified within the final project report. Comments that included identifiable references within the interview have been amended to maintain anonymity The semi-structured interviews do not ask for any personal or sensitive data, but seek to identify the understanding and impact of migration and perceived migrant health and social care needs from a service provider perspective. The participants understood that the findings from the interviews and focus groups will be presented to the Office of Public Health in Dudley and will be used to help shape responses to the health and social support needs of new migrant communities in the borough Participation in the focus groups was on the basis of informed consent. Given that these sessions were being coordinated with the help of a community sector group, issues of anonymity and confidentiality were harder to maintain, as the participants in the focus group and the organisation who had assisted in running the session knew who participated. However, participation outside of this context would not be identifiable It is understood that some migrants concerns about being identified to public bodies can create significant fear and anxiety, due to either their previous experiences or as a result of their current immigration status. A briefing on the purpose of the focus groups and the health needs assessment was provided to participants that reinforced the issue of confidential participation and that their personal information would not be shared with anyone except the facilitator. The focus group sessions started with the facilitator addressing the issue of confidentiality, voluntary participation and non-attributability within the session. Individuals were informed that the focus of the session was not their individual health condition or immigration status and these should not be shared within the session Individuals required a level of English language in order to participate. The risk of working with interpreters in the context of focus groups is both that confidentiality can be breached and that interpreters can filter participants responses. We recognise that levels of English are in themselves one of the factors which may significantly effect individuals ability to access and make use of health and social care systems and reinforce a sense of isolation. However, as the purpose of the focus group is to identify general issues within new migrant communities, we anticipated that these issues would be highlighted by community representatives. Dudley Migrant Health Needs Assessment Page 20

22 4.4.6 There are risks in participatory approaches of raising people s expectations of change in service design and delivery. Many vulnerable groups in society are often over consulted and yet receive limited feedback from those who have requested their input. The Office of Public Health was asked to consider how migrants from the new communities might receive feedback on the health needs assessment and how they can be kept informed and involved as this agenda is taken forward The report and recommendations have been shared with those organisations who helped facilitate the migrant focus group session. The Office of Public Health will, in developing its response to the report, provide an opportunity for migrants and those organisations who work with them in Dudley to have an overview of the research and to propose ways in which they would like to be engaged with Dudley Council and other stakeholders in developing responses to the health needs of their communities. 4.5 Analysis of Results The findings from professionals and migrant communities was analysed to draw out common themes and distinctive issues for the delivery of health and social care within the borough. These findings were compared with the evidence and recommendations from previous studies in the UK on migrant health. The report makes a series of recommendations for action at a local level and for future research which we hope will support the Office of Public Health, the health and voluntary sector in developing appropriate responses to the evidence which has been obtained in this process. The findings and recommendations will also be shared with those who participated in the interviews and those migrant community representatives involved in the focus groups. Dudley Migrant Health Needs Assessment Page 21

23 5. MIGRATION SUMMARY FOR DUDLEY 5.1 Introduction This section provides a summary of the available data on population and health that can illustrate the development and impact of migration in Dudley. Whilst recognising that there are limits, particularly in the recording of ethnicity and migration status in some data sets, we hope that what follows will be of use in developing an understanding of migration in the borough for policy makers, commissioners and providers of health and other services in Dudley Information on migrant populations can be obtained from a range of data sources, however no one source is able to provide a detailed picture of all new migrants to the UK that have settled in the Borough. The West Midlands Public Health Observatory (2011) How many migrants are there in the West Midlands and who are they? report provides an overview of the different data sets, what they can tell us and their relative strengths and weaknesses. Information on the various data sets which have been used in this section is provided in Appendix A Census Data According to the 2011 Census, the population of Dudley was 312,925, a rise of 7,825 (2.6%) residents in the past 10 years. 88.5% of the Dudley population in the 2011 census indicated their ethnicity as White British. Since 2001 the area has seen a gradual change in the proportion of its residents who were born outside of the UK. This change has been driven by a number of factors, such as the dispersal of asylum seekers by the Home Office from 2000, refugee resettlement, the enlargement of the European Union in 2004 and 2007 and migration for marriage or to join existing family in the borough Non UK-Born Population The 2011 census highlights a moderate increase in non-uk born residents in Dudley since 2001, but the increase is below the average for the West Midlands. 2% (6,344) of Dudley s residents were born outside of the UK and arrived in the UK since The proportion of non-uk born individuals arriving in the past 10 years is the lowest in the West Midlands, comparable to the percentage increases in Shropshire and Staffordshire, but significantly lower than the West Midlands average of 5.2% for this period. The proportion of the non-uk born population in Dudley who had arrived prior to 2001 was 3.3%, compared to 6 % for the West Midlands Region. 0.9% of Dudley s population arrived from outside the UK in the past 5 years. This is significantly lower than the regional average for this period, which was 2.9%. Dudley Migrant Health Needs Assessment Page 22

24 5.2.3 Countries of Origin The top ten countries (non-uk) of origin in the borough from the 2011 census are provided in the table below. Country Number of residents (2011 census) Pakistan 4,081 India 2,250 Jamaica 862 Poland 783 Germany 585 Zimbabwe 484 Hong Kong 301 Kenya 267 China 242 Philippines 217 Table 3 Top 10 Non- UK countries of origin for residents in Dudley 2011 census Individuals who come to the UK, and who have settled in Dudley over time are concentrated in different parts of the Borough. The census information can be used to identify wards with higher populations of certain communities. Data in the 2011 census highlights that the wards of St James, St Thomas, Netherton, Woodside and St Andrews are home to the largest number of individuals who were born outside of the UK. These areas were also identified in the interviews with professionals as part of the migrant health needs assessment The location of nationals from each of these top 10 countries within Dudley is not uniform across the borough, although there is evidence of concentrated residence in some wards. The following tables indicate where the highest numbers of individuals from each of the top 10 countries of origin live in Dudley. The data highlights individuals born in India and Pakistan live in significant numbers in Halesowen, Cradley and Wollescote and Lye and Stourbridge, as well as in those wards listed in with the highest numbers of non-uk born national residents Whilst not all new migrants are identified in the census data, this information might be of use to commissioners and providers who wish to deliver some targeted health programmes for certain communities or to ensure that the language and cultural needs that may be present within some groups are factored in to the delivery of services. Dudley Migrant Health Needs Assessment Page 23

25 CHINA No. Brierley Hill 32 St James 23 GERMANY Amblecote 27 Belle Vale 31 Brierley Hill 39 Halesowen North 25 Halesowen South 24 Netherton, Woodside and St Andrews 24 Norton 44 Pedmore and Stourbridge 25 Quarry Bank and Dudley Wood 30 Wollaston and Stourbridge 43 Wordsley 26 HONG KONG Brockmoor and Pensnett 22 Pedmore and Stourbridge 21 St James 19 Wollaston and Stourbridge Town 52 INDIA Castle & Priory 173 Halesowen North 247 Halesowen South 136 Netherton, Woodside and St Andrews 189 St James 403 St Thomas 282 IRAN Brierley Hill 24 Brockmoor and Pensnett 13 Netherton, Woodside and St Andrews 12 St James 22 St Thomas 12 JAMAICA No. Belle Vale 25 Brierley Hill 23 Castle and Priory 80 Halesowen North 27 Netherton, Woodside and St Andrews 113 St James 213 St Thomas 190 PAKISTAN Brierley Hill 245 Cradley and Wollescote 506 Halesowen North 203 Lye & Stourbridge North 636 Netherton, Woodside and St Andrews 343 St James 216 St Thomas 1,134 PHILIPPINES Brockmoor and Pensnett 29 Netherton, Woodside and St Andrews 30 POLAND Brockmoor and Pensnett 56 Brierley Hill 51 Castle and Priory 68 Cradley and Wollescote 53 Netherton, Woodside and St Andrews 33 St James 148 St Thomas 149 ZIMBABWE Belle Vale 26 Brierley Hill 43 Brockmoor and Pensnett 29 Castle and Priory 32 Coseley East 28 Netherton, Woodside and St Andrews 31 St James 61 St Thomas 43 Table 4: Electoral Wards with the Highest Numbers of Residents Born in One of the Top 10 Non-UK Countries of Origin for Dudley from 2011 Census. Dudley Migrant Health Needs Assessment Page 24

26 5.3 Main Languages for Dudley Residents The census indicates that 96.8% of the population have English as their main language. The table and chart below illustrate the top 15 non-english languages spoken in the borough. Rank Language Number of individuals with this as a main language 1 Urdu 2,423 2 Punjabi 1,648 3 Polish Arabic Gujarati Pakistani Pahari (With Mirpuiri and Patwari) French Cantonese Farsi Bengali(With Sylheti and Chatgaya) Kurdish Pashto Shona Tagalog/ Filipino Spanish 100 Table 5: Main Non-English Languages (Aged 3yrs and Above Census) Figure 5: Top 15 non-english spoken languages Source ONS Dudley Migrant Health Needs Assessment Page 25

27 Interpreting Data Dudley Council s Directorate of Adult Community Housing Services (DACHS) provides interpreting and translation services for council departments, the Department of Work and Pensions and some other non-council organisations. The service is delivered through a mix of salaried staff and sessional workers. We are grateful to DACHS for the provision of their interpreting data for 2009/10 and 2012/13. The information relates to a number of appointments that an interpreter was provided not the number of individuals who required language support. (NB: this service ended in April 2014) These figures are provided as an illustration for comparison with the information from the census on non-english languages and show the range of language requests which were responded to. Language 2009/10 (Appointments) 2012/13 (Appointments) Arabic Bengali British Sign Language 0 0 Chinese Gujarati 38 0 Punjabi Urdu Total for period Table 6: Salaried DACHS Interpreting Provision for Selected Years There were a total of 363 appointments with sessional interpreters in addition to the above statistics for the period April 2012 to March Twenty three different languages were used with the top 10 requests as follows below: Language Number of appointments British Sign Language 175 Polish 82 Russian 22 Albanian 13 Farsi 12 Vietnamese 10 Lithuanian 9 Deaf Adv 6 Gujarati 6 Total for the top 10 languages for Sessional provision 335 ( 92% of all sessional appointments) Table 7: Top 10 Sessional Interpreting Language Requests 2012/13 Dudley Migrant Health Needs Assessment Page 26

28 5.3.5 If the mainstream and sessional interpreting bookings for 2012/13 are combined the top 5 languages required for interpreter are: Punjabi (210); British Sign Language (175) Urdu (167) Chinese (161) Arabic (137) Polish is the third largest non-english spoken language in the borough yet is only 6 th in terms of language request. This may indicate that for some communities the reasons for migration, for example to work or study, could influence the level of English individuals arrive with, or that in for some migrant groups that language need remains unaddressed Other organisations in Dudley make use of interpreting and translation in the promotion and delivery of their services. An analysis of their data might provide a more comprehensive understanding the language needs within the local community. Some data were provided by the Dudley Walk-In Centre and are included in the migrant health section. (See Fig. 2 page 8) 5.4 Long Term Migration Long term migration estimates indicate that for the year 2011/12, 600 international migrants arrived in Dudley whilst 300 left. International migration for Dudley would appear to have been at a similar level in Short Term International Migration The ONS estimated there were 70 short term migrants into this area in Further information on the number of Non-UK short term residents in Dudley from the 2011 Census is available on the NOMIS website individuals were identified as short term residents at the time of the census, with the largest group coming from the Middle East and Asia (79). 5.6 Children and Young People In 2011, 11.8% of the primary school aged children and 7.7% of secondary school pupils in the area have a non-english 1st Language. This compares with a regional average of 18.9% for primary pupils and 13.8% for secondary school pupils In 2011, 19.1% of primary school pupils and 17.7% of secondary school pupils are from a non-white British ethnic origin. This compares with the 30.6% for primary pupils and 25.9% for secondary pupils in the West Midlands as a whole. Dudley Migrant Health Needs Assessment Page 27

29 5.7 National Insurance Number Data National insurance numbers issued to overseas nationals can provide an idea of the number of new migrants coming into the borough to work. In 2013 there were 554 NINOs issued to overseas nationals in Dudley. This is a fall of two on the previous year. The number of national insurance numbers issued to overseas nationals in Dudley is at a lower level than 2004, having reached a peak of 916 in 2007, it has fallen significantly since The number of national insurance numbers issued to individuals from the A8 European Union countries in 2012 was 216, representing 39% of all national insurance numbers issued to foreign nationals in the borough for this period. When combined with those issued to individuals from other European Union states the proportion rises to 46% for The graph below highlights the diversity of individuals being issued national insurance numbers in Dudley. It highlights how Pakistan and Poland remain significant sources of new migration into the area. Figure 6: National Insurance Numbers for Overseas Nationals in Dudley for selected years: Top 10 Countries of Origin (Source: DWP NINO s to overseas nationals Stat-Xplore) Dudley Migrant Health Needs Assessment Page 28

30 5.7.4 The following chart highlights proportion of national insurance numbers issued to EU nationals from the A8 & A2 accession states and compares the number of applications nationals from these countries made under the Workers Registration scheme, for the period when this was a requirement for those wishing to enter the UK labour market. The workers registration scheme ended on 30 th April Asylum Seekers Figure 7: Comparison of NINOs for Overseas Visitors, A8 & A2 Nationals and Workers Registration Data for Dudley (Source: DWP NINO to overseas nationals Stat-Xplore and ONS Local Area Migration Indicators) Asylum seekers have been given accommodation by the Home Office in Dudley since Numbers of individuals claiming asylum and requiring support whilst their asylum application is processed have fallen significantly over the past 8 years, as illustrated in Figure 8 below At the end of the 1st quarter of 2013 there were 149 individuals in receipt of Section 95 support (accommodation and/or subsistence only payments) in Dudley. A small number of individuals may also have been receiving Section 4 support from the Agency, but these figures are not currently included in the ONS Migration Statistics Quarterly reports. UK Visas and Immigration may be able to provide the Local Authority or Clinical Commissioning Group with this information or they may be able to request this from the COMPASS Accommodation Provider G4S Care & Justice Services UK Ltd. Dudley Migrant Health Needs Assessment Page 29

31 5.9 Migrant Health Data Figure 8: Asylum seekers supported by the Home Office in Dudley (Source ONS - Quarterly Immigration statistics) Migrants Registering for GP services Migrant patients who have never previously registered with the NHS are given a marker for their first patient registration, known as Flag 4. Flag 4 registrations in the authority in 2012 were equivalent to 2.2 per every 1,000 of the resident population This represents 680 new migrant patient registrations in , a reduction of 157 on the previous year. The Clinical Commissioning Group or Public Health department may be able to break this information down further into nationality, gender and age profiles by analysing GP patient registration data. Dudley had a lower level of new migrant GP registration per 1,000 residents than the West Midlands Region, which was 8.3 per 1,000 resident population in In undertaking the migrant health needs assessment it has become apparent that Flag 4 data no longer appears to be available to colleagues in the Clinical Commissioning Group or the Office of Public Health. The ability to analyse new patient registration data at a local level and identify the nationalities of those who are able to register with a GP could be of real benefit in both addressing potential shortfalls in GP registration and also to enable the targeting of specific health messages and treatment. Dudley Migrant Health Needs Assessment Page 30

32 New Migrant GP Patient Registrations for Dudley mid year Flag 4 new patient registrations by year /4 2004/5 2005/6 2006/7 2007/8 2008/9 2009/ / /12 Figure 9: New Migrant HP Patient Registrations for Dudley mid year (Source ONS Local Area migration indicators) State of Individual Health by Proficiency in English Language The 2011 census asked people to indicate whether they considered their health was good or bad. These responses have also been correlated to individuals level of English proficiency for those aged 3 years and over in the borough and is shown in the figure below. Figure 10: State of Self-Reported Health by English Language Proficiency Dudley Migrant Health Needs Assessment Page 31