Brett Hatfield is an NHS Navigator for the DigitalHealth.London Accelerator and former refugee health nurse with the New South Wales Refugee Health Service in Sydney, Australia.
Mary’s story: Imagine you are Mary. Mary arrived in the UK in late 2019 after a two-year journey travelling from Tunisia through Libya, Italy, France and Belgium. She arrived in a shipping container with 35 other migrants, which she described as a harrowing experience. After applying for asylum with the Home Office, Mary initially stayed with her cousin and his family, but they live in a small 1-bedroom apartment in south London and she has been asked to leave within seven days. She suffers from poorly-managed hypertension, Type 2 Diabetes and severe post-traumatic stress disorder from being witness to a car bomb explosion in Libya. She is struggling to understand what services are available to people waiting for their asylum claim to be processed. Read on to learn more about Mary’s migration story.
Mary’s story has been a difficult one, but it is not unique for migrants to the UK. According to UNHCR statistics, at the end of 2020 there were 132,349 refugees, 77,245 pending asylum cases, and 4,662 stateless persons in the UK . We, as digital health leaders, have a duty to deliver fair and equitable services to all members of the community. Given recent events concerning refugees to the UK, we must now take this opportunity to reflect on how we deliver healthcare in the digital era to patients from refugee and asylum seeker backgrounds to ensure the needs of this particular community are adequately met.
The Migration Healthcare Experience
Migrants who arrive from countries lacking proper healthcare, who speak English as a second language, or who have particular health and social care needs can find navigating the NHS an insurmountable challenge.
Even before the pandemic, refugees such as Mary had been experiencing significant barriers when attempting to access and seek support for their health. Although primary care services are available at no charge to all migrants in the UK, refugee advocacy groups reported that migrants are often incorrectly refused GP registration or access to an interpreter for their appointment . People from refugee backgrounds can be sceptical of health services due to a mistrust in government based on negative experiences in their home country, or a fear that clinicians or admin staff will report them to the Home Office or expect them to pay for certain services. Compounding this issue, those going through the asylum process are particularly vulnerable as they often face complex psychosocial challenges and are sometimes destitute and homeless. If the UK Home Office finds them eligible for asylum support, they are provided with accommodation and around £5 per day to cover food, clothing and other essential items .
Digital Challenges for Migrants
The COVID-19 pandemic has further exacerbated these challenges, as many charities have been forced to close their offices and move to remote working, which further restricts access to advice and support for migrants . Adequate technology has become an essential criterion to accessing vital government services such as health and social care, resulting in digital exclusion which has become a real threat for migrants attempting to access the NHS. Some of these challenges include:
Access to mobile phones
The use of online and video consultation technology has skyrocketed since the onset of the pandemic. Access to smartphones is now essential to receiving care during periods of lockdown or ‘work from home’ orders. To complicate matters, many people seeking asylum in the UK have had their phones confiscated at the border, and smartphones are not routinely provided by the government and local charities. Those refugees that do have mobile phones are often on pay-as-you-go plans and struggle to access remote GP services that require text message responses to confirm appointments or monitor long term conditions . Newly arrived refugees may also have older smartphone models that do not support the latest apps, such as the NHS App, NHS Test & Trace, or apps used to submit online consultations at GP practices.
Navigating the NHS can be difficult for the average patient, but trying to navigate its many services with English as a second language can be more challenging still. Online consultations which require patients to complete lengthy health questionnaires are a particular struggle, and often caseworkers or volunteer advocates have to help complete these online forms in such cases. Difficulties in accessing interpreter services during GP or hospital appointments are also a barrier to expressing health needs and understanding clinicians’ advice.
Data and Wi-Fi plans with mobile phone networks are often expensive and unaffordable for people living on asylum support (internet is not always provided to asylum seekers in dispersal accommodation) . Where internet connectivity is provided, signal is often poor and downloading apps or opening web pages is a time-consuming task. Online and video consultations with health and social care professionals can be a very frustrating experience for both the patient and clinician due poor internet connectivity, in addition to language barriers.
Access to information
For older migrants, digital and health literacy is often quite low, and engaging with health services can sometimes feel like more effort than it’s worth. Mistrust of government services is also a common experience for migrants from countries notorious for surveilling citizens, so smartphone apps such as the NHS Test and Trace service can lead to scepticism or re-traumatisation. A lack of reliable health sources in easy-to-read formats can also lead people to trust incorrect sources and conspiracy theories which can disseminate quickly.
Digital Opportunities for Migrants
While digital exclusion is a real threat for migrants such as Mary, technology can also present real opportunities to improve health delivery for people from refugee, asylum seeker or other migrant backgrounds. The following opportunities must be considered alongside the above challenges that can sometimes erode any benefits for new migrants.
People on asylum support are offered accommodation on a no-choice basis for where they are located across England. Depending on individual circumstances, some asylum seekers are forced to regularly move to different cities. Before the pandemic, this necessitated a change of GP every time they were offered accommodation in a different location, or some would even travel inter-city because they developed such a close relationship with a GP who understood their health needs. Mary was forced to change her GP three times after moving from London to Leeds and then Birmingham. The widespread introduction of virtual consultations makes it easier for asylum seekers to remain with their current GP, as most appointments can now be completed over the phone or through video consultation. Virtual consultations can also save money on transport costs, which can sometimes be unaffordable for migrants on asylum support.
Translation and Interpretation:
Before the pandemic, GP correspondence would often be via phone call or post. For migrants with English as a second language, receiving calls from unknown numbers, which may be their GP or hospital, can be anxiety-provoking. Letters from the NHS in English could also be difficult to read and understand. The move to digital communication has enabled patients with English as a second language to share text messages or digital letters with friends and family proficient in English to help them understand the context of the message. However, it should be noted that family and friends may also misinterpret the correspondence, so professional interpreting services should always be considered the gold standard.
Skills and networking:
A report by the Migrants Forum found that 58% of migrants and refugees they interviewed described loneliness and isolation as their biggest challenge in London, which stem from difficulties in creating meaningful networks upon arrival into a new country . New digital online tools for education and health enables people from migrant backgrounds to learn new skills, find better work, start businesses, explore new marketplaces, and build up a network of like-minded friends.
Tips for NHS, social care and innovators
The NHS is responsible for the health of 67 million people, 14% of which were born outside of the UK . While the NHS and innovators have come a long way in supporting vulnerable groups, we need to do more in ensuring that patients from migrant backgrounds receive fair and equitable health and social care in this new digital era. Here are a few tips on how to make your health technology more inclusive for migrants:
Understand what NHS services are available to migrants
Primary care services are available at no cost to all people visiting or living in the UK, regardless of their immigration status. Only some secondary care services are available to all migrants, such as accident and emergency services, COVID-19 diagnosis and treatment, and family planning services. More information can be found here.
Translation and/or interpreter services must be offered on your digital health platforms
Websites and online consultation forms with no option for language translation may deter patients with limited English proficiency from accessing essential health services. Patients should also be able to request an interpreter with the right language and dialect for any health-related matter.
Always have a back-up option for patients without the right technology
If patients require a smartphone or app to access your services, you need to consider what alternative pathways are available to those without access to a smartphone, strong internet connectivity, or the latest IOS or Android updates.
Equality and Health Inequality Impact Assessments (EHIA)
EHIAs should be a core component of all digital transformation work. It is essential that NHS project managers and innovators work alongside your organisation’s equality and diversity lead to ensure these assessments are thorough and actioned upon.
Deliver a trauma-informed service
A trauma-informed approach to healthcare aims to provide an environment where a person who has experienced trauma feels safe. This approach must be built into the technology and services we deliver to prevent the replication of traumatic experiences for our patients.
Video consultations over phone calls
Remember that video consultations are easier for patients with English as a second language because they can read your facial expressions and body language alongside the conversation, which can greatly aid comprehension.
Ask the community – they want to hear from you!
If you’re not sure, then ask. Migrant groups want services to meet their needs. Engagement with vulnerable groups should be a core focus of any digital transformation work and should begin as soon as possible to ensure your solution meets the needs of migrant patients and other groups.
If you would like to know more about Refugee health or share how your company is developing refugee-inclusive technology, please get in touch with DigitalHealth.London at email@example.com.
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