MIGRANT HEALTH IN COVENTRY
Author: Dr Angelique Mavrodaris
Working Group:
Samantha Hewitt, Olivia Taylor,
Tanya Richardson & Khadidja
Bichbiche
CONTENTS
ABBREVIATIONS………………………………………………………………………………………………………………………………3
FOREWORD…………………………………………………………………………………………………………………………………….5
EXECUTIVE SUMMARY ……………………………………………………………………………………………………………………….6
1. BACKGROUND, SCOPE AND METHODOLOGY……………………………………………………………………………………….9
1.1 Background
1.2 Aims and Objectives
1.3 Methodology
2. EPIDEMIOLOGICAL DATA ………………………………………………………………………………………………………………21
2.1 Coventry population
2.2 Migration data sources
2.3 Migration in Coventry
3. HEALTH AND WELLBEING……………………………………………………………………………………………………………32
3.1 Primary care
3.2 Infectious diseases
3.3 Mental health
3.4 Secondary care
3.5 Non-communicable diseases
3.6 Public Health
3.7 Infant mortality and life expectancy
3.8 Health Issues identified during workshops
4. HEALTHCARE AND SERVICES………………………………………………………………………………………………………….43
4.1 Entitlements to NHS care
4.2 Current services in relation to need
4.3 Barriers to accessing healthcare
4.3 Community Participation and Assets
1
5. EVIDENCE OF EFFECTIVENESS………………………………………………………………………………………………………..55
5.1 Community engagement
5.2 Mental health
5.3 Information
5.4 Antenatal and postnatal services
6. RECOMMENDATIONS…………………………………………………………………………………………………………………56
6.1 Access and entitlement to health services
6.2 Language barriers, interpretation and translation issues
6.3 Health intelligence
6.4 Access to specific services
6.5 Protocols and guidance
6.6 Cultural barriers and cultural competence
6.7 Evaluation and audit
6.8 Sustainability and community assets
CONCLUSIONS………………………………………………………………………………………………………………………………..63
ACKNOWLEDGEMENTS…………………………………………………………………………………………………………………….64
APPENDICES………………………………………………………………………………………………………………………………….65
1.
2.
3.
4.
5.
6.
7.
8.
A8 Accession states
Coventry migrant health consultation questionnaire
Comparative assessment
Languages spoken by Coventry school children
Bilateral healthcare agreements
Entitlements to care
Coventry translation and interpretation services
Coventry Walk-in Centre services
REFERENCES………………………………………………………………………………………………………………………………….77
2
ABBREVIATIONS
BHN Black Health Network
CAB Citizens Advice Bureau
CALD Culturally and linguistically diverse
CCC Coventry Carers Centre
CEMAP Coventry Ethnic Minority Action Partnership
CLAS Culturally and linguistically appropriate health services
COE Council of Europe
CPU Community Partnership Unit
CRMC Coventry Refugee and Migrant Centre
CITU Coventry Interpretation and Translation Unit
EEA European Economic Area
EU European Union
FWT Foleshill Women’s Training
GCIM Global Commission on International Migration
GFMD Global Forum on Migration and Development
GMG Global Migration Group
GP General Practitioner
HIV Human Immune Deficiency virus
ICRMW International Steering Committee for the Campaign for Ratification of the Migrants Rights Convention
IDP Internally displaced person
IHR International Health Regulations
IOM International Organization for Migration
MAMTA Child and Maternal Health Project
MIDSA Migration Dialogue for Southern Africa
3
MiMi With Migrants, For Migrants
NCM New Communities Forum
NGO Non-governmental organization
NINO National Insurance Number Registration
ONS Office for National Statistics
RCP Regional Consultative Process
RECs Regional Economic Communities
SAWS Seasonal Agricultural Workers Scheme
TB Tuberculosis
UHCW University Hospital Coventry and Warwickshire
UK United Kingdom
UKBA United Kingdom Border Agency
UNHCR United Nations High Commissioner for Refugees
VAC Voluntary Action Coventry
WHA World Health Assembly
WHO World Health Organization
WMSMP West Midlands Strategic Migration Partnership
4
FOREWORD
Disparities, skill shortages, demographic imbalances, social networks, climate change as well as economic and
political crises and unrest are driving levels of migration worldwide. There are an estimated 214 million
international migrants, 740 million internal migrants and an unknown number of migrants moving through
informal channels all over the world.1 These numbers comprise a wide range of different migrating populations
including economic migrants, asylum seekers and refugees, students and undocumented migrants. It is clear
that their circumstances and vulnerability levels vary greatly, yet the collective health needs and impact of
migrating populations are extensive. The health of migrants and health issues directly associated with
migration are fundamental public health challenges faced by societies, both worldwide and in the United
Kingdom (UK).
International migration involves a wider diversity of ethnic and cultural groups than ever before;2 significantly
more women are migrating today on their own or as heads of households; the number of people living and
working abroad with irregular status continues to rise; and there has been a significant growth in temporary
migration and circulation.3
Policy and practice, locally, nationally and internationally; to manage the health effects of migration currently,
does not adequately address the existing health inequalities, nor influencing factors of migrant health,
including barriers to access health services. There are clear examples of practices that fuel social exclusion of
vulnerable migrant groups, not responding to their health needs and widening the inequality gap. Many
migrants in an irregular situation lack access to health services, and many suffer unacceptable living and
working conditions.
Carefully managed migration can be a powerful force for economic growth and innovation in destination
countries, and poverty reduction and development in poorer origin countries, as well as provide important
human freedom and human development outcomes for migrants and their families.4 Growing numbers of
migrants, from increasingly diverse backgrounds, can increase diversity and cultural innovation but will also
make the development of effective integration policies more challenging. More effective systems will be
required to manage supply and demand issues, social change linked with migration and to protect the human
rights of migrants.5
There is much work ahead. Commitment and the involvement of all stakeholders will be fundamental to
address migrant health issues associated with rapidly changing and increasingly diverse societies.
5
EXECUTIVE SUMMARY
According to the 2011 Census, Coventry as a local authority has experienced the greatest migration since 2001
- second only to London. The increasing diversity of populations in Coventry is creating new challenges for
health and social care systems, which need to adapt in order to remain responsive and ensure delivery of
effective and culturally sensitive services while promoting equity, social cohesion and inclusiveness. To achieve
the City’s aim of reducing inequalities within the City, and in response to the City’s Marmot role, addressing
migrant health was a clear priority. This work was well-timed to take into account and respond to the effects
of welfare reform, European Economic Area and NHS structural changes.
The aim of this work was to understand the health needs of migrants across Coventry and to make
recommendations to ensure that services are responsive to these needs. The work also aimed to identify and
promote community assets in order to harness the positive impacts that migration brings to the City and
promote community cohesion and equality.
Information was extracted from a number of data sources (Census 2011, National Insurance Number
Registrations (NIN), Flag 4 GP registrations, Birth data, school census data, UK border agency data) and
triangulated to provide a picture of migration in Coventry. A number of health service data sources were used
to assess health needs. Literature and service reviews were conducted to supplement primary data.
Community engagement: Service providers, voluntary sector organisations and community champions across
the City were engaged to inform current health needs, available services and community assets.
Over 21% of the Coventry population are non-UK born and 12% arrived since 2001. Coventry’s migrants are
economic migrants, refugees and asylum seekers and students, mainly from Eastern Europe, Nigeria and a
growing Roma community. Over 100 languages are spoken in Coventry and 9% of households do not have any
person resident with English as their first language. In 2011, 27.7% of Coventry primary school children and
23.1% of secondary school children had a non-English first language. Births in Coventry increased by 30% since
2001 - all of the increase was attributable to births among non-UK born mothers (particularly African and
Eastern European).
The main issues in primary care included: Infectious diseases (including TB) and sexual health (including HIV
and Hepatitis); mental health including drugs and alcohol abuse; poor dental health (particularly among Roma
groups) and non-communicable diseases particularly in more established migrants (Diabetes in Asian groups
and hypertension in African groups). Poor health behaviours (smoking in Polish groups) were identified and
poor uptake of immunisation and screening were also reported among Roma, Eastern European and African
groups. A number of issues around access to healthcare were identified, particularly regarding language
barriers and GP registration. Poor uptake of antenatal services was reported.
Community representatives and voluntary sector organisations were engaged via workshops hosted by
Voluntary Action Coventry (VAC). A wide range of assets within migrant communities in Coventry are evident,
providing strong support networks and powerful platforms from which to impact on health.
6
Migrants and their families are entitled to accessible, high quality health care services (preventive, curative
and palliative), health promotion and health information. Some migrant communities may need targeted
services, such as translation services, and care should be delivered by a culturally competent health and social
care service to ensure they can achieve an equal level of health and wellbeing. Community assets should be
incorporated into an integrated Migrant Health Strategy.
A Migrant Health Network, based on the service providers and community groups that were engaged, was
established to facilitate knowledge transfer, service information and partnership working. This work will
inform a Coventry Migrant Health Strategy and action plan.
7
“In this country there is no war and there is no one coming to make
trouble for you;
And someone cannot rape you in your house
And compared to where I come from,
Here for me is better – much better.”
(Refugee now living in Coventry)
8
1. BACKGROUND, SCOPE AND METHODOLOGY
Key findings:
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Migrants are a diverse group and therefore their health needs will vary significantly
Migration is a dynamic process influenced by geopolitical and economic factors
No single data source can describe in any complete way the experience of health and
disease of migrants in Coventry or their use (or not) of health services
A Health Needs Assessment is a systematic method for reviewing the health needs of a
particular population, leading to agreed priorities and resource allocation that will lead to
improved health, improved access to healthcare and reduce health inequalities
Methodology included a literature review, interpreting sources of routinely collected data,
workshops and interviews with key service providers and community champions and
representatives
This project incorporated a community-based asset approach to understand better what
health and health service issues are important to migrants in Coventry, and to highlight
areas of best practice currently ongoing within migrant communities.
1.1 B ACKGROUND
1.1.1 INTRODUCTION AND CONTEXT
Migration has always been an important factor in the growth and development of the United Kingdom (UK). In
recent years, the UK has experienced very substantial increases in migration and, according to multiple data
sources, Coventry has attracted the highest number of migrants after London.6 The region’s industrial
strengths, its universities and colleges, its status as an asylum seeker dispersal site, its proximity to
Birmingham and London and its reputation as a welcoming city make it an attractive destination for a broad
range of both short- and longer term migrants.
Migration has the potential to be hugely beneficial to society. Migrants fill skills gaps in sectors ranging from
agriculture, hospitality to science so migration is seen to be a positive, essential and inevitable component of
the economic and social life of every country. Migrant workers actively contribute to economic prosperity,
they are often highly educated, and inward migration helps to balance the demographics.
Migration is a dynamic process, with numbers in different migrant groups fluctuating in response to political
and economic developments in the UK and internationally. Since the 1990s, numbers of migrants to the UK
increased initially among asylum seekers and refugees, but later among economic migrants and others,
especially after the European Union enlargement in 20047. Among those migrants monitored by the Office for
National Statistics, the relative changes over the past five years among constituent groups of migrants to the
UK are demonstrated in Figure 1.1.
9
Fig 1.1 Changes in migration patterns evident in the UK 2005-2009 (Office for National Statistics)
The term ‘migrant’ is a very loose term which includes at least four distinct groups: 8 Economic migrants,
international students, asylum seekers and refugees and irregular migrants, including undocumented people,
visa over-stayers and family joiners, among others. All these groups vary in terms of their size, age/sex
structure, economic power, and health and social care needs. It is not helpful to describe ‘migrant health
needs’ too generally, as the needs will vary by group and sub-group. Some groups may experience high
standards of health and have good access to healthcare services, whereas others will have much less
favourable health status and access to care.
The majority of migrants are young, fit, considered to be healthy, have no dependants and have come here to
work or study. Economic migrants are also often fit and well-educated and have relatively better health status
than their peers – the so-called ‘healthy migrant effect’. Some migrants though do have a greater susceptibility
to certain problems and disease than the rest of the population, i.e. some migrant workers can be quite poorly
paid and at a greater risk to high accident rates and injuries from lifting and handling. In the work environment
some migrant workers complain of physical attacks verbal and abuse and regular abuse can lead to mental
health problems. A minority of migrants may also be fleeing persecution and seeking asylum and may
experience worse levels of health, either because of this, or due to hazardous conditions during their search
for refuge in other countries.
This report, where possible, will describe the health needs of the various different types of migrants to
Coventry. However, data sources do not provide reliable, consistent or comparable information on the variety
of migrants. Furthermore, no single data source describes all types of migrants, or their experience of health
and disease. The lack of data on specific groups or their access to healthcare is a clear limitation, therefore this
report functions to provide a base and recommendations from which work on the health needs of migrants
can commence and identifies gaps for further investigation.
10
1.1.1 MIGRATION DEFINITIONS
Migrants are a very diverse group and can be classified in many different ways, for example by nationality,
country of origin (which could be country or birth or country of last residence), ethnicity, language or religion.
An important further classification is the legal status of the migrant as this can affect their right to access
health care in the United Kingdom (UK). National classifications of ‘migrants’ can include asylum seeker,
refugee, refused asylum seeker, migrants from Europe (especially the new EU accession states; the Accession
8), migrants from outside Europe, students and others due to marriage, family or short term visitors.6 Table
1.1 summarises current United National (UN) migrant definitions.
Table 1.1 UN Migrant Definitions9
Migrant
Students
Economic
Frontier worker
Asylum seekers
Irregular migrants
(or undocumented)
Displaced persons
Description
A large group which includes people of any age moving to another country for the
purpose of full time study.
People leaving their usual place of residence to improve their quality of life. This
may include long-term migrants or short-term seasonal workers.
Migrants who retain their usual country of residence but work in a neighbouring
state returning daily or weekly.
People with a fear of persecution for reasons of race, religion, nationality,
membership of a particular social group or political opinions, who enter a country
and claim asylum under the 1951 Geneva Convention. Once the fear has been
proven to be well founded, the claimant is granted refugee status.
Migrants without legal status owing to illegal entry or the expiry of their visa.
People fleeing an armed conflict or escaping natural or man-made disasters or their
effects. This term primarily covers persons displaced within the borders of their
country of origin (i.e. internally displaced persons) who would not come under
the1951 Geneva Convention.
1.1.2 MIGRATION IN COVENTRY
In 2006 net immigration to the UK was estimated to be 191,000 with 400,000 people leaving and 591,000
arriving in the UK for a year or more. This compares to a figure of 244,000 for net migration in 2004 (the
highest year recorded). More than a third of all migrants to the UK were students. Between May 2004 and
June 2006, around 427,000 workers successfully applied for work in the UK from the then eight European
Union accession states (Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Slovakia and Slovenia). This
represents a lot less than 1% of the UK population.
Coventry has a long tradition of welcoming people to the city from all over the world. These people have
bought new skills and expertise with them and have been proud to make Coventry their home. In 1685, for
instance, French refugees settled here following religious persecution in their country and introduced the
weaving trade to Coventry – a trade that helped make the city wealthy and successful. During the 19thand
20th centuries people came to Coventry from across England, Scotland and Wales, the Commonwealth and
Ireland to settle here, and in the 1970s the city made a new home for East African refugees fleeing from
Uganda and the regime of Idi Amin. More recently people have come to Coventry from Afghanistan, Iraq and
Africa and from the new accession states in the European Union, including Poland.
11
Today Coventry is a city of around 317,000 residents and has a younger population than average for the UK.
The population of Coventry is growing but this is largely due to natural population growth and not migration.
People move in and out of the city every year, including students from the UK and overseas who come to
Coventry to study in the city’s two universities. Coventry’s vibrant economy means that new people are also
arriving here to work, mostly from within the UK and the European Union. Others may come to Coventry as
asylum seekers because they fear for their safety in their home country.
Coventry’s migrants are predominantly economic migrants, refugees and asylum seekers and students. Most
economic migrants coming to Coventry come from within the European Union just as UK citizens can work
elsewhere in the EU. Some economic migrants, including people who are highly skilled, come from outside the
UK including South Asia and Africa. In Coventry the largest group of asylum seekers is Kurdish people from
Northern Iraq, others in the city come from Eritrea, Afghanistan, Somalia, Sri Lanka and around 60 other
countries.
1.1.3 LITERATURE REVIEW
Migration can be defined as “a process of moving, either across an international border, or within a State. It is
a population movement, encompassing any kind of movement of people, whatever its length, composition and
causes”.10 Migrants themselves encompass the overlapping categories of migrant workers (economic
migrants) and their families, long-term and short-term immigrants, internal migrants, international students,
internally displaced people, asylum seekers, refugees, returnees, irregular migrants and victims of human
trafficking.
Migration poses challenges to the organisation and delivery of effective and culturally sensitive health and
social services. Migrants’ fundamental health needs are not always appropriately met, thus raising concerns
with regard to equity, social cohesion and inclusiveness. A large proportion of migrants move through legal
channels yet may experience difficulty in accessing health care.
Recent migrants often have to deal with poverty, discrimination and limited access to social benefits and
health services, especially during the early stages of insertion into a new environment. For their part, lowskilled and seasonal migrant workers are often concentrated in occupations with high levels of occupational
health risks. Family members, including children, may also be involved in this work and thus exposed to these
risks.
Population movements generally render migrants more vulnerable to health risks and expose them to
potential hazards and greater stress arising from displacement, insertion into new environments and
reinsertion into former environments. The migration process itself, may have negative health implications for
migrants, in particular among subgroups such as vulnerable migrants, trafficked persons, refugees and
smuggled migrants, involving clear health risks. There is also a strong association between population
movements and the spread of disease.
Victims of human trafficking, especially women and children, are particularly vulnerable to health problems
and are more likely than other groups to suffer from communicable and non-communicable diseases, as well
as from mental health problems.
Migration, when triggered by disaster or conflict, food insecurity, disease, or climate change and other
environmental hazards, is closely linked both to the destruction of livelihoods and, often, to disruptions to the
health system.
12
Health inequalities arise largely as a result of discrimination, inequalities in income, and unequal access to
education, employment and social support networks, to all of which disadvantages vulnerable immigrant or
refugee populations and trafficked persons are disproportionately prone. While equal access to health care is
important, so too are health promotion and disease prevention measures, which are often overlooked when
discussing the health of migrants.11
Perceptions regarding migrants often overlap with concepts of ethnicity and ethnic minority groups where
these concepts are distinct. A population health approach is necessary in order to align strategies, policy
options and interventions for improving health outcomes among migrants. The City’s goal is to avoid
disparities in health and access to health services between migrants and the host population. A second
important principle is to ensure migrants’ health rights which include limiting discrimination and ensuring
access to preventive and curative interventions. Regarding migrations resulting from disaster or conflict, is vital
to put in place lifesaving interventions so as to reduce excess mortality and morbidity. In addition, it is
important to minimise the negative impact of the migration process on migrants’ health outcomes. These four
principles were developed as the basis for a policy framework for defining public health strategies for migrants
at the 2008 World Health Assembly. A range of policy options that need to be addressed are illustrated in
Figure 1.2.
Reduce occupational health
hazards; better information,
inspection, implementation
of safety regulations.
Combat social exclusion and
discrimination; improve rights of
non-citizens, improved policies on
education, employment, social
protection, housing and asylum.
Reduce barriers
to employment
and match work
to qualifications.
Ensure safe water
supply and
hygienic living
conditions.
Inclusive
educational
policies, attention
to language and
cultural barriers
and segregation.
Appropriate and
accessible health
services,
improved
monitoring of
health status and
service use and
better research.
Increased
availability of
healthy food,
target health
eating
campaigns.
Empowering migrant and ethnic
minority communities, mobilizing
health assets and strengthening social
networks; combating isolation,
loneliness and vulnerability.
Measures to improve knowledge of health risks and ability to
implement it. Strengthen healthy cultural traditions.
Encourage avoidance of known risk factors and unhealthy
lifestyles through positive and culturally sensitive education
and health promotion work.
Fig 1.2 Policy measures tackling the determinants of health for migrants.
(Adapted from Rechel et al 2012)
Better housing,
reduce
overcrowding and
environmental
hazards, improved
transport and
access to essential
amenities.
13
1.1.4 CULTURAL BACKGROUNDS
The greatest numbers of migrants to Coventry originate from Eastern Europe (Poland in particular), Asia
(particularly India and China), West and Central Africa (Nigeria in particular) as well as increasing migration of
Roma communities. Coventry is also a national dispersal site for asylum seekers and refugees – although
numbers are small, this group has acute and significant health needs due to the persecution and violence they
have been exposed to in their countries of origin. From a health perspective, migrants bring with them diverse
epidemiological profiles based on different environments and endemicities of disease in their countries of
origin. For some groups, such as refugees and asylum seekers, their illness picture is a direct result of the
experience of migration. Migrants also have widely divergent past experiences and interpretations of Western
medicine. Most of all though, migrants bring with them their cultural beliefs and practices, including those
involving health and illness, which often contrasts with host country norms. Apart from the epidemiology of
health among migrants, it is important to understand and develop and awareness in the diversity of cultural
backgrounds among migrant groups; because while illness and disease many be universal, the definition of
health, the interpretation of symptoms, and remedies and treatments to promote and restore health are very
much culturally defined. Awareness of these cultural differences is fundamental to health effective and
appropriate provision of responsive health services for migrant populations. To illustrate the impact of cultural
background in health, health perceptions of the Roma group (estimated to be around 7000 people) in
Coventry are presented below.
R OMA ( PLURAL NOUN ), R OM ( SINGULAR NOUN ), R OMANI ( ADJECTIVE )
Culture and immigration The Roma originated in India and migrated across to Europe, becoming established in
the Balkans by the 14th century and in Western Europe by the 15th century. Several waves of migration of
Roma from Eastern to Western Europe occurred in the mid-19th century (when Roma slavery was abolished in
Romania), from Yugoslavia in the 1960’s and 70’s, in the 1990’s with further economic and political changes in
Eastern Europe and post 2008 with changes in the European Union (EU). It is estimated that over 8 million
Roma live in Europe and that many still reside in large ghettos on the outskirts of urban areas, particularly in
Eastern Europe.
There are differences among Roma groups (Four major Roma nations, of which families make up clans) but a
number of common factors include:
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Strong social/cultural bonds preserving Romani culture
Social isolation from non-Roma society (Gadje)
Practice of a range of cultural rituals
Loyalty to family and clan.
Health beliefs and practices A range of broad beliefs and practices related are listed below and have been
included to support decision-making and service provision when planning services for Romani communities.
These beliefs are based on specific Romani groups thus application to all communities should be made with
caution, awareness and sensitivity.



Illness classified into either rromane nasvalimata (natural to Roma) or gadzikane nasvalimata
(results of contact with non-Roma)
For rromane nasvalimata a female traditional healer is often consulted; for non-Roma illness
mainstream healthcare may be sought
Diet and health are linked (perceived value, not nutritional)
14
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Ill health equated to ill fortune
Mainstream healthcare perceived as causing more harm than good - used only for acute conditions
Preference for older physicians, requests for specific treatments or colours of medication
Often share medication
Illness concerns whole clan, when member is in hospital clan members are expected to stay with the
person throughout the day and night to protect and perform caring rituals
Fearful of anaesthesia and important for family to gather when person coming out of anaesthesia
Women are considered to be ‘polluted’ (marimé) during menses, pregnancy and 6 weeks after birth
of child and childbirth should not occur at home (may bring impurity)
Tendency for high birth rates and early first pregnancies - Mother should be allowed to practice
ritualistic cleansing after delivery
Children are a major focus and believed to bring good fortune. Viewed as the responsibility of the
whole clan and teenagers are expected to look after younger children. Children expected to learn a
trade and begin adult socialisation after the age of 10 years
Extensive ritualistic processes around end-of-life.
General health issues Poverty, isolation, stigma and lack of support all contribute to a low life expectancy of
just below 65 years in Roma communities in Western Europe. Certain Roma practices and culture may also
lead to particular health issues:

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
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By avoiding non-Roma communities and life; childhood and adult immunisation programs, health
screening and other health promotion activities are also often avoided
Social isolation behaviour leads to refusal to register births and deaths and higher incidences of
consanguineous marriages
Beliefs regarding pollution (marimé) makes cervical and colon screening difficult to promote
High fat and salt diets and high prevalence of smoking – Implications for non-communicable diseases
Crowded living conditions – Increased incidence of communicable diseases.
1.1.5 POLICY AND LEGISLATION
The United Kingdom Border Agency (UKBA) provides information for persons seeking to enter or remain in the
UK for employment purposes. It also provides regular updates on the national shortage occupational list for
work permits and is the agency with the responsibility to prevent illegal immigration.
In accordance with European Union (EU) regulations, European Economic Area (EEA) nationals are free to live
in any EEA country, and are able to enter the UK to visit and seek employment without work permits. The
Workers Registration Scheme introduced in 2004 picks up residents from the Accession 8 states (Appendix 1)
already listed, plus two more countries added in 2007 (Bulgaria and Romania). The Workers Registration
Scheme is work related and should effectively be a sub set of National Insurance Number Registrations
(NINOs). As of 1 January 2014, Bulgarians and Romanians have gained the same rights to work in the UK as
other EU citizens. Migrant workers with an entitlement to work in the UK have the same rights and
protection14 as workers as the existing population. Migrant workers from Accession 8 countries have limited
access to benefits until they have worked in the UK for at least 12 months continuously.
15
Legislation governing immigration from outside the EEA has recently undergone extensive revision and in 2008
the Government launched the phased introduction of a points based system (PBS).15 Under this new system
migrants are required to pass a point’s based assessment before they are given permission to enter or remain
in the UK.
Imminent changes to these policies are also evident beginning with indications made during the Queen’s
Speech (2013) that the UK government will bring forward a bill that further reforms Britain's immigration
system. The bill will ensure that the UK attracts people who will contribute and deters those who will not by
limiting access to certain benefits in particular. The UK government has also been considering adopting
reforms similar to recent German immigration policy where unemployed EU migrants seeking work, with no
means of supporting themselves and have limited job opportunities, shall be given a limited window to find a
job before being required to leave. This will prevent recent migrants from immediately claiming benefits,
particularly among migrants who are unemployed, so that there is free movement to come to the UK and get a
job but not free movement to come and claim benefits. Residency may also be denied to individuals who have
not found a job after 12 months.
Under new tighter regulations that came into force on 1 January 2014, all EU migrants will have to wait three
months before they can claim jobseeker's allowance and other out-of-work benefits (housing benefit, council
tax benefit, access to local authority housing, income support, jobseeker's allowance and employment and
support allowance). Migrants will also then face a more robust residence test before any claim is approved.
This will include questions about their efforts to find work and English language skills. EU migrants will also
face having out-of-work benefits cut after six months unless they can confirm they are genuinely seeking work.
EU migrants found begging or sleeping on the streets can already be deported, but from 1 January 2014 they
have also been barred from re-entering the UK for a year - unless they find employment.
Currently, anyone with permission to live permanently or temporarily in the UK is offered free NHS care.
Potential changes such as new charges for migrants and overseas visitors using some NHS services in England
are being considered. This includes extended prescription fees, some emergency care and higher rates for
optical and dental services. GP and nurse consultations will remain free, and no-one will be turned away in an
emergency. In addition, employers paying less than the minimum wage will face a £20,000 fine per underpaid
worker.
These changes and welfare reforms will undoubtedly impact on the health and wellbeing of migrant groups
within the UK, particularly the most disadvantaged and vulnerable groups in greater need of care.
1.2. A IMS AND OBJECTIVES
1.2.1 AIM
The aim of the migrant health needs assessment (HNA) is to understand the health needs of migrants across
Coventry and to make recommendations to ensure that services are responsive to these needs through the
engagement of service commissioners and providers, migrant communities and promotion of community
assets.
16
1.2.2 OBJECTIVES
The objective of this health needs assessment is to:






Describe migration patterns in Coventry and the health needs of migrants
Raise awareness of the health needs and current health inequalities of migrants to inform and
influence commissioners
Determine what the gaps in information are and make recommendations to improve local
understanding of health needs
Review the suitability and accessibility of current services across the City and assess the
alignment with health needs
To make recommendations to improve health and access to health care for migrants
To engage and empower migrant communities and support community cohesion.
1.3 METHODOLOGY
1.3.1 HEALTH NEEDS ASSESSMENT
A Health Needs Assessment (HNA) is a systematic method for reviewing the health needs of a particular
population, leading to agreed priorities and resource allocation that will lead to improved health, improved
access to healthcare and reduce health inequalities. It also provides an opportunity to engage with specific
populations and enable them to contribute to targeted service planning and resource allocation. 11
Benefits of undertaking a HNA can include: Strengthened community involvement in decision making,
improved team and partnership working, professional development of skills and experience, improved
communication with other agencies and the public and better targeting and use of resources.
1.3.2 OVERVIEW
D ATA GENERATION Both quantitative and qualitative methods have been used to provide and to create a
current and real-life picture of the health needs of migrants in and services in Coventry, guided by the
elements inherent in the above HNA models. A number of epidemiological and health service data sources
were used to obtain a clearer picture of migrants’ health status. Evidence synthesis (literature review) and a
gap analysis (services review) were conducted to further complement the information collected.
S TUDY POPULATION Data was interpreted according to two categories in order to appropriately assess need:
Recent migrants (non-UK born) and established migrants (2nd or 3rd generation). Ethnicity data was used as a
proxy for established migrant groups. The use of ethnicity as a proxy for established migration is limited as
many established migrants or second and third generation members have integrated with host communities
and many hold British citizenship and record mixed ethnicities. It may not be appropriate to attribute the
diversity in health needs to migration alone and perhaps more appropriate to interpret differences in health
both to ethnic background and current environmental factors. Although the report aimed to assess need at all
levels, health needs of recent migrants were the focus of the report.
17
C OMMUNITY ENGAGEMENT CORPORATE ASSESSMENTS AND CO - PRODUCTION Service providers, voluntary sector
organisations and community champions across the City were engaged and relationships developed. It was
intended that an established community organisation within Coventry would be identified in order to coproduce and inform the health needs assessment from the perspective of the community; inputting their
expertise and local knowledge into each component of the needs assessment. Community representatives and
voluntary sector organisations were invited to workshops hosted by Voluntary Action Coventry (VAC). Time
and resources available limited the collection of qualitative data from individual community members but we
were able to engage with community champions who were migrants themselves and represented the views of
their particular communities. At the workshops, participants were asked the same questions across four main
themes:




Health: What do you think are the main health problems in migrant communities?
Barriers: What problems do migrant communities experience in trying to use health and social
services?
Community assets: What assets/strengths exist within communities that have positive impacts on the
health and wellbeing of migrant communities?
Improvements: What can the authorities do to improve health and social services for migrant
communities?
Questions had been circulated prior to the workshops (Appendix 2) to facilitate a more informed process and
open discussions were then held, addressing the above questions, during the course of each workshop.
Answers were thematically analysed and the main results are presented within relevant chapters under
thematic headings.
An advisory board, comprising a range of relevant stakeholders and community champions across the City, was
established to develop and refine final recommendations and support the progress of work addressing migrant
health needs and priorities (Figure 1.3).
1.3.3 UNDERTAKING A MIGRANT HEALTH NEEDS ASSESSMENT
There is an imperative need to produce a comprehensive up-to-date assessment of the health needs of
migrants, in response to the City’s growing migrant population. Coventry’s Health and Wellbeing Strategy has
identified migrants as a potentially vulnerable group, thus responding to health needs of this group will be key
in achieving the overarching aim to reduce inequalities and improve health among the most vulnerable groups
in the City. Addressing migrant health has also been emphasised by the West Midlands Strategic Migration
Partnership (WMSMP) and links well with Coventry’s role as a Marmot City. This HNA is also well-timed to take
into account and respond to the effects of welfare reform, EEA changes and NHS structural changes to ensure
we respond appropriately to the health needs of the City’s growing migrant population.
This HNA is aimed to inform a Coventry migrant health strategy and action plan, which will affect the local
migrant population, including host community members in terms of wider community cohesion; health and
social care professionals involved in services pertaining to migrants, as well as all voluntary sector
organisations and City services involved in work that may impact on migrants.
18
•City services
•Community services
communications
•Equality & Diversity
•Neighbourhood Action
•Education
•Housing
•Community Safety
•Coventry Law Centre
•Public Health
•Meridian Centre
•Clinical commisioning
group
•Public Health England
•Antenatal care
•UHCW
•TB Nursing & infectious
diseases
Healthcare
Community
Voluntary
and
Migrant
Champions
•Black Health Network
•Foleshill Womens Training
•New Communities Forum (NCF)
•Coventry Regugee & Migrant Centre
•Terrence Higgins Trust
•Redeemed Cristian Church of God (RCCG)
• Voluntary Action Coventry (VAC)
•Citizends Advice Bureau (CAB)
•Coventry Ethnic Minority Action Partnership (CEMAP)
●Carers Centre
●RCCC Coventry
●Young Migrants Rights
●Grapevine
Fig 1.3 Coventry migrant health stakeholder analysis
This HNA has been undertaken with support from the local Council. The Department of Public Health initiated
the project and is working closely with stakeholders and migrant communities to ensure the work is
representative and responds appropriately to the needs of migrants. A comparative assessment of work on
migrant health conducted in other regions in the UK has been included in Appendix 3.
19
1.3.4 MODELS USED TO DEVELOP THE HNA
Stevens and Raftery have described the common approaches to assessing population needs for health care
(Table 1.2), these are characterised as the Corporate, Comparative and Epidemiological approaches to
HNA.12.13 The Corporate approach “involves the structured collection of the knowledge and views of
informants on policies, services and needs”. Informants are the stakeholders in the issue being addressed by
the needs assessment. They might include clinical and social workers in primary care and secondary care,
health and social service managers, commissioners of services, experts in the field and service users. The
Comparative approach involves the comparison of levels of service provision between different localities.
These could be cross-national comparisons of the levels of service provision (e.g. comparing England with
other countries in Western Europe), or could be at a more local level. The Epidemiological approach to NA has
three elements: (i) determining the incidence and/or prevalence of the health or social problem; (ii) identifying
the effectiveness (and cost-effectiveness) of existing interventions for the problem; and (iii) identifying the
current level of service provision.
Table 1.2 Stevens and Raftery Model
Approach
Description
Epidemiological
1) Epidemiology of health condition & risk factors using available routine data
and future projections
2) Description of current services
3) Evidence of effectiveness & cost-effectiveness
Comparative
Compare levels of service & care between different (but comparable)
populations, localities, regions, countries
Corporate
Ask experts, users, policy makers and any other stakeholders what they view as
important and would like included
20
2. EPIDEMIOLOGICAL DATA
Key findings:









There is no single comprehensive source of data recording migration at a local authority
level.
According to the 2011 Census, 67233 residents (21.2%) are non-UK born
12% of Coventry’s residents are non-UK born and arrived since 2001
7.6% of the non-UK born population arrived in Coventry in the last 5 years.
Nearly 9% of households in Coventry do not have any person resident with English as their
first language
An increase of 30% in births in Coventry since 2001 is almost all due to births among the
most recently immigrated ethnic groups
The majority of new migrant communities have settled in Foleshill, St Michael’s, Radford,
Stoke, Hillfields, Tile Hill and Willenhall
Poland and India remain significant sources of new migration to Coventry, as well as
increases in National Insurance registrations from Latvian and Nigerian nationals
Coventry is currently providing support to around 360 documented asylum seekers and their
families
2.1 COVENTRY POPULATION
2.1.1 GENERAL
The population demographics of Coventry are provided in greater detail in the Coventry Annual Report of the
Director of Public Health.14 The resident population (all residents with a Coventry postcode, based on ONS
estimates) has increased by 4.7% between 2001 and 2011 (and 7.2% in the 10 years to 2012), and the
registered population (all people registered with a GP) has grown by 9.8% between 2001 and 2011 (8.8% in the
10 years to 2012). The registered population for Coventry was 359,230 in 2011, and is projected to rise to
371,766 by 2015. All age groups show steady increases in population growth, with particularly rapid increases
in the young adult population (15-29) after a dip in population growth in 2008.
Coventry has a younger population than the average for England, the average age of a Coventry resident is 34
years old compared to 39 years old nationally. The high proportion of 18-24 year olds reflects the fact that the
city has two successful universities; Coventry University and the University of Warwick. The percentage of
Coventry's population that is over 65 is 15%, lower than the national average. Life expectancy in Coventry is
increasing and the city currently has about 6,690 people aged over 85, a group that is expected to grow.
2.1.2 DEPRIVATION
According to the Index of Multiple Deprivation 2010, Coventry has become slightly more deprived between
2005 and 2008 relative to other local authorities. It is currently the 50th most deprived local authority with
income and employment deprivation being the most prominent in Coventry.
21
The deprivation pattern within Coventry has remained fairly static with higher indices of deprivation
concentrated in the North East (Figure 2.1). Thirty-five Lower Super Output Areas (LSOAs) in Coventry are in
the most 10% deprived in England and sixty-one LSOAs in Coventry are in the most 20% deprived in England.
Fig 2.1 Indices of deprivation in Coventry (2010)
2.1.2 ETHNICITY
2.1.3 E THNICITY
The city is ethnically diverse, with some 33% of Coventry's inhabitants coming from ethnic minority
communities compared to 20% for England as a whole. Asian and Asian British communities together make up
16.3% of the city's population of whom 9% have an Indian background. The next largest minority group is
made up of people with a 'White Other' background, who make up 7.2% of the population. Coventry's
population with a Black African background has grown to 5.6% - more than treble the English average (1.8%).
Measures of ethnicity and ethnic origin may be used as a crude indicator of established migration. However
this assumption is limited by the fact that there is no consensus on what constitutes an ethnic group and
membership is something that is self-defined and subjectively meaningful to the person concerned. Collecting
data on ethnic group is also complex because of the subjective, multifaceted and changing nature of ethnic
identification. Furthermore, because Coventry has had such a longstanding tradition of migration, this has
resulted in many Individuals being of mixed ethnicity. Many individuals actually tend to be the consequence of
inter-ethnic unions of their parents – resulting in people having more complex histories, and not all will
necessarily define themselves as belonging to a “mixed” category and will often self-define themselves as
“British.”.
2.1.4 L ANGUAGE
There are over 100 languages spoken in Coventry (Appendix 3).
22
2.2 MIGRATION DATA SOURCES
2.2.1 SOURCES OF DATA
There is no single comprehensive source of data recording migration at a local authority level. Accurate figures
on numbers of migrants, and therefore health impacting migrants, are hard to calculate with accuracy given
the complexity of definitions, diverse data sources utilised and failure to code ethnicity/migration status in
many health services (e.g. acute trusts). Therefore, information was extracted from a number of data sources
and triangulated to provide a picture of migration in Coventry. The data sources used and main limitations are
outlined below.
C ENSUS 2011 provides a fairly recent estimate of the proportion of non-UK born residents. However, available
information is not detailed and new questions (e.g. When did you arrive?) make trends difficult to examine.
N ATIONAL I NSURANCE N UMBER R EGISTRATIONS (NINO S ) Good source of data providing indication of new
registrations for employment, generally well-populated as NIN necessary to claim worker benefits but only
documenting migrants with employment and excluding spouses, children, immigrants with no formal
employment.
“F LAG 4” GP R EGISTRATIONS Records new registrations with GP when a person first comes to the UK but is lost
if person moves GP and will not capture migrants who do not register with a GP. In addition, a UK resident who
has been out of the country for 3 months will also acquire a Flag 4 registration.
B IRTH REGISTRATIONS Documents mothers born outside the UK but these may not necessarily all be migrants.
S CHOOL CENSUS DATA Records languages spoken at home and ethnicity of students but requests main language
spoken at home therefore cannot elucidate generation of migrants.
UKBA DATA ON ASYLUM SEEKERS Documents details regarding asylum seekers yet most of this information is
guarded by confidentiality laws and not shared with other organisations. No data on refugees is provided.
2.3 MIGRATION IN COVENTRY
The 2011 Census indicates that the current population of Coventry is 316, 960 – with an increase of
approximately 17, 000 within the last decade. Since 2001, the population demography of the City has changed
with a significant increase in the proportion of residents born outside of the UK.
According to the 2011 Census, Coventry as a local authority has experienced the greatest migration of non-UK
born groups arriving in England since 2001 - second only to London. Twelve percent of Coventry’s residents
were born outside the UK and arrived since 2001. Figure 2.2 shows that this proportion is the highest of any
West Midlands Local Authorities and is more than double the regional average (5.2%). This is thought to have
been driven by a number of factors, such as the expansions of the European Union in 2004 and 2007, the
dispersal of asylum seekers by the UK Border Agency from 2000, and the rise in non-UK nationals coming to
work in the City and surrounding area.
23
Fig 2.2 Percent of usual residents within Local Authorities in the West Midlands arriving in the UK
from 2001 to 2011.
24
2.3.1 HOW MANY MIGRANTS ARE THERE IN COVENTRY
The 2011 Census provides a clear indication of how many migrants are currently living in Coventry. According
to the 2011 census, 67233 residents (21.2%) are non-UK born (Table 2.1). Twelve percent of Coventry’s
residents are non-UK born and arrived since 2001, while 7.6% of the non-UK born population arrived in
Coventry in the last 5 years. This is a significant and rapid increase and is the highest proportion for any West
midlands Local Authority, comparing to 2.9%, arriving in the last 5 years, for the West Midlands Region.
Table 2.1 Summary statistics for Coventry and England and Wales according to Census 2011
(Source ONS Census 2011)
Coventry residents
Number
%
England + Wales (%)
Total
316960
100
56075912 (100)
Born in UK
249727
78.8
48570902 (86.6)
Not born in UK
67233
21.2
7505010 (13.4)
Number of years resident in UK in those not born in the UK
10+ years
28247
8.9
3680453 (6.5)
5-10 years
17397
5.5
1940425 (3.5)
<5 years
21362
6.7
1836044 (3.3)
All 16yr+ in household have English as main language
108756
84.6
21313812 (91.2)
At least one but not all people aged 16 and over in
household have English as a main language
6987
5.4
868431 (3.7)
No aged 16 and over in household but at least one
person aged 3 to 15 has English as a main language
1679
1.3
181729 (0.8)
None in household have English as a main language
11170
8.7
1002072 (4.3)
0-9 years
11494
3.6
1505980 (2.7)
10-19 years
17241
5.4
1525071 (2.7)
20-29 years
26473
8.4
2829409 (5.1)
30-44 years
9882
3.1
1304188 (2.3)
45+ years
2143
0.7
340362 (0.7)
Language
Age of arrival
25
Nearly 9% of households in Coventry do not have any person resident with English as their first language - this
is twice the figure for England (4.3%).Figure 2.3 illustrates the current population of Coventry by country of
birth. This provides an indication of more recent migration. From 2004, international migration has played a
significant role in sustaining the population of Coventry.
Fig 2.3 Population of Coventry by country of birth (Source ONS Census 2011)
2.3.2 BIRTHS TO NON-UK BORN MOTHERS
Total numbers of births in Coventry residents have increased from 3634 in 2001 to 4825 in 2011 (Table 2.2).
This equates to an increase of 32.8% since 2001, with almost all of that increase due to births among the most
recently immigrated ethnic groups. The proportion of births to non-UK born mothers increased from 17.4% in
2001 to 35.6% in 2011
Table 2.2 Coventry births by country of birth of mother
Africa
Asia
Europe +
Other
(incl
unmatched)
UK
Total
2001
101
374
124
34
2002
152
417
105
34
2003
210
463
113
30
2004
301
496
107
54
2005
376
508
111
38
2006
483
543
179
38
2007
494
636
263
47
2008
515
665
319
50
2009
540
656
384
48
2010
546
642
422
44
2011
528
704
430
57
2012
472
670
494
56
3001
3634
2927
3634
3005
3820
3046
4004
2854
3887
2994
4237
2950
4390
3095
4644
3050
4678
3094
4748
3106
4825
3039
4731
26
The regional average of births to non-UK born mothers on 2011 was 22.6%. Births to UK born mothers have
remained static (approximately 3000/year) for this period. Coventry has seen the most dramatic increase in
births to non-UK born mothers of all Local Authorities in the West Midlands. The largest proportion (45.4% of
births in 2009/2010) occurred in the most deprived quintile of the population (based on IMD 2007). There are
also significant increases in births to parents originating in Africa and Europe.
The profile of non-UK born mothers has also changed significantly from 2001 to 2011. The proportion of births
to mothers from the Middle East and Asia remains the largest in the City (14% in 2011), yet the most dramatic
rise can be seen in the proportion of births to Africa mothers, from 2.8 % in 2001 to 10.9% in 2011. A clear
increase in the proportion of births to European mothers from 3.2% in 2001 to 8.9% in 2011 has also been
recorded. Figure 2.3 below shows the percentage change in each group since 2001, showing the magnitude of
change, please note that groups making up smaller overall proportion of births can show greatest percentage
change over time. E.g. the overall proportion of births to African-born women have increased from 3.2 to 8.9%
but the percentage change in the number of births to African-born women has increased by 400% over the
period.
Fig 2.3 Percentage change in births in Coventry by parental country of origin, 2001-2012 (Source ONS)
2.3.3 CHILDREN AND YOUNG PEOPLE
In 2011, 27.7% of Coventry primary school children (Figure 2.4) and 23.1% of secondary school children (Figure
2.5) had a non-English first language. This compares with a regional average of 18.9% for primary pupils and
13.8% for secondary school pupils. Coventry had the third largest proportion of primary school children with a
27
non-English first language in the West Midlands and the highest proportion in secondary pupils in 2011. This
data provides an indication of new-migration as it is more likely that new migrants will have a non-English first
language as opposed to more established migrant groups.
The figures provide a visual representation of where in Coventry new migrant families may be settled if the
school is predominantly attended by children with non-English first languages. On examination of the figure it
would appear a great number of new migrant families are living in Foleshill, St Michael’s, Radford and Stoke.
This corresponds with data from the Coventry New Communities Study which places the majority of new
migrant communities in Foleshill, St Michael’s, Radford, Stoke, Hillfields, Tile Hill and Willenhall. This
information is important to know when planning service provision or targeted interventions.
In 2011, 40.1% of primary school pupils and 35.7% of secondary school were from a non-white British ethnic
origin. The regional average is 30.6% for primary pupils and 25.9% for secondary pupils. Coventry had the
fourth highest proportion of non-white ethnicity, in both primary and secondary schools, in the West Midlands
in 2011. These data must be interpreted with caution, as measures of ethnicity in a diverse population such as
Coventry may not reflect recent migration but provide an indication of more established migrant communities
(Figure 2.6).
Fig 2.4 Percentage of pupils with non-English first language in primary schools in Coventry in 2013.
(Source School census data)
28
Fig 2.5 Percentage of pupils with non-English first language in secondary schools in Coventry in 2013.
(Source School census data)
6.0%
9.1%
19.3%
63.4%
1.6%
0.6%
Mixed
Other Ethnic Groups
Black
Ethnicity Not Known
Asian
White
Fig 2.6 Ethnic origin of pupils in all schools in Coventry in 2013.
(Source School census data)
29
2.3.4 M IGRANT R EGISTERING FOR E MPLOYMENT
National insurance numbers (NINO) to overseas nationals provide an indication of migrants with employment
in Coventry. In 2011, 5740 NIN registrations to overseas nationals were issued. This figure has increased from
3250 in 2004. Poland and India remain significant sources of new migration to Coventry, as well as increases in
NIN registrations from Latvian and Nigerian nationals. The number of NIN issued to nationals from A8
countries in 2011 was 1610, which made up 29.4% of the total of NIN issued to overseas nationals. People
from Poland accounted for three quarters of the registrations along with other people from the new accession
states. Figure 2.8 indicates trends in NIN registrations and areas in Coventry where NIN registrations have
been more concentrated. This gives an indication of where recent migrant groups are working and have
settled. It appears recent migrant groups have consistently registered for NINs in St Michael’s, Foleshill, Upper
Stoke and Radford. This corresponds with the geographical distribution of non-English speaking primary and
secondary care school children.
6500
Wyken
Woodlands
5500
Whoberley
Westwood
520
535
450
4500
Wainbody
Upper Stoke
455
3500
1460
1695
365
1590
St Michael's
1095
2500
480
415
1165
410
355
1500
735
455
405
345
260
625
Sherbourne
Radford
Lower Stoke
Longford
425
380
Holbrook
Henley
Foleshill
830
595
675
Earlsdon
Cheylesmore
500
Binley and Willenhall
2008
2009
2010
2011
2012
Bablake
-500
Fig 2.8 National Insurance number registrations in Coventry by area.
(Source NINO registration data)
30
2.3.5 MIGRANTS REGISTERING FOR HEALTH SERVICES
Flag 4 registrations in Coventry in 2010 were approximately 25 per every 1000 of the resident population. This
represents 8441 new migrant patient registrations in 2010-2011.
2.3.6 ASYLUM SEEKERS
The number of people seeking asylum in the UK has reduced considerably recently. In 2007 there were 23,430
asylum applications in the UK compared to 84,130 in 2002. Coventry was formally made an asylum seeker
dispersal site in 2000 and the numbers of individuals claiming asylum have been decreasing with 360
individuals (asylum seekers and their families) receiving section 95 support (accommodation/subsistence) at
the end of 2012.
31
3. HEALTH AND WELLBEING
Main health issues identified:







Infectious diseases (including TB) and sexual health (including HIV and Hepatitis)
Mental health issues including drugs and alcohol abuse
Poor dental health (particularly among Roma groups)
Non-communicable diseases particularly in more established migrants (Diabetes in Asian
groups and hypertension in African groups)
Increased incidence of poor health behaviours such as smoking and obesity
Poor uptake of immunisation and screening Roma, Eastern European and African groups
Poor uptake of antenatal services.
It is estimated that over 80% of recent migrants in Coventry are aged between 15 and 44 years and tend to
have general health needs similar to individuals of equivalent age and sex as the indigenous UK population.
Issues of poor and cramped accommodation, low income, social isolation, abuse, racism and discrimination,
however, may have a negative impact on health. Health issues identified are based on best available health
service data and further informed by community champions, members of migrant communities and service
providers during workshops hosted together with Voluntary Action Coventry. Attendees were requested to
identify the main health issues they believed were impacting on migrant communities (Figure 3.1).
32
Fig 3.1 Sub-set of health issues identified at VAC workshop.
3.1 P RIMARY C ARE
The health of recent migrants is affected by three key determinants: their individual characteristics such as
age, sex and ethnicity; their country of origin and the circumstances for migration and the socio-economic
conditions of the host country or their current environment. The following health needs were identified in
primary care:









Infectious disease issues, particularly Tuberculosis (TB)
Mental health issues, including post-traumatic stress disorder (PTSD), the consequences of trauma
and rape, and isolation
Sexual health issues, including Sexually Transmitted Infections (STIs), Human Immunodeficiency Virus
(HIV) and unwanted pregnancies
Lack of, or incomplete, screening and immunisations – covering a wide variety of checks from
communicable disease, cervical screening, breast screening, hearing and eye checks
Poor dental health and difficulties in accessing dental care (particularly in Roma groups)
Poor nutrition and consequences such as vitamin deficiencies
Skin diseases and parasitic diseases
Behavioural health problems – alcohol and drug misuse, domestic violence, alcohol misuse, and a
higher prevalence of smoking (including Shisha).
Hypertension and diabetes are more prevalent in established migrant groups of certain ethnicities
(e.g. Diabetes in Asian groups) and diagnosed at earlier onsets. Hypertension and obesity have also
been raised as issues in recent and established migrant groups.
3.2 INFECTIOUS D ISEASES
3.2.1 HIV
The majority of residents accessing care in the Coventry region are of Black-African ethnicity, accounting for
approximately 77.8% of females accessing HIV treatment and care in 2010, and approximately 54.5% of males.
Primary infection of new HIV diagnoses in Coventry has been predominantly in Africa or the United Kingdom.
Figure 3.2 shows the count of new HIV diagnoses in residents of Coventry by world region of birth.
120
100
8
80
9
5
32
38
60
21
0
8
5
45
20
29
Other World Region
9
5
23
40
United Kingdom
12
58
43
43
50
35
Not Stated
10
7
43
Africa
31
13
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Fig 3.2 Count of new HIV diagnoses in residents of Coventry by year of diagnosis and world region of birth.
(Source HPA WM Regional Surveillance Project)
33
60
50
11
Other*/Not Known
40
Zambia
6
6
6
8
7
5
Kenya
12
7
30
6
5
20
Cameroon
6
5
31
24
10
23
18
Burundi
7
Malawi
28
19
21
2006
2007
12
17
South Africa
Zimbabwe
16
0
2001
2002
2003
2004
2005
2008
2009
2010
Fig 3.3 Count of new HIV diagnoses in residents of Coventry who were born in Africa by year of diagnosis
and country of birth, 2001-2010. (Source HPA WM Regional Surveillance Project)
Figure 3.3 indicates HIV diagnoses acquired in Africa diagnosed in residents of Coventry. The majority are from
Zimbabwe, followed by Malawi.
3.2.2 TB
Regionally, between 2002 and 2012, Heart of Birmingham teaching PCT had the highest number and rate of TB
case reports in the region, with an annual case rate of 81.9 per 100,000 in 2012. Other areas with rates
significantly above regional average in 2012 were Coventry Teaching, Sandwell, Wolverhampton and
Birmingham East and North PCTs (Figure 3.4).
Fig 3.4 TB rate by PCT, West Midlands
2012
34
Ethnicity was known for 97.4% of cases reported. Over half (54.9%) of cases were in people of Indian, Pakistani
and Bangladeshi ethnicity. Overall the highest rate (302.2 per 100,000) occurred in people of black African
ethnicity followed by Pakistani and Indian groups (Figure 3.5). Recent literature has shown that Eastern Europe
has one of the highest proportions of TB patients with multi-drug resistant TB (MDR-TB) globally; in some
countries more than 50 percent of people previously treated are living with MDR-TB. The highest proportions
of newly diagnosed people with MDR-TB in 2012 were in Belarus (32.3%), Kazakhstan (30.3%) and Kyrgyzstan
(26.4%).15 As Eastern European groups increase in Coventry, MDR-TB is an issue that requires attention. As this
increase has taken place recently, numbers of Eastern Europeans with MDR-TB have been difficult to establish.
They are also often routinely recorded as “White” and TB is particularly linked to drug use in these groups
which hinders patients from accessing services and provided detailed information.
Fig 3.5 TB rate by ethnic group, West Midlands 2012
In 2012, place of birth was known for 95.4% of all reported TB cases in the West Midlands. Of these 63.7%
were born outside the UK. About half of UK-born TB cases were of white ethnicity (52.9%). The second largest
group of UK-born cases in the West Midlands were the Indian and Pakistani ethnicity groups (32.9%) (Table
3.1). The majority of non-UK-born cases were in Indian and Pakistani ethnicity groups (58.7%) followed by
black African (20.6%).
35
Table 3.1 TB rate by country of birth and ethnic group, West Midlands 2012
Similar patterns have been reported in Coventry by TB nurses at the Coventry Walk-in Centre. Analysis of the
index cases from 2010 showed two key facts:
• In Coventry 73% of TB cases were non UK born and predominantly Black African and Asian individuals
• Geographically Foleshill and St Michaels electoral wards had statistically high rates of disease when
compared with the average for the City.
This is similar to the national picture where 75% of all notifications for tuberculosis are in individuals from
countries with a high burden of disease. Screening for TB is offered to asylum seekers, refugees and new
arrivals from abroad but there is strong local evidence that the screening could be improved. The new T spot
blood test for TB means that the identification of cases and latent disease is now easier and more effective.
3.2.3 HEPATITIS
In a local study 84% (250/296) of Coventry GUM clinic patients with new diagnoses of HIV were tested for HBV.
This showed that 6.8% of those tested between 2005 and 2010 were co-infected with HBV. All patients (100%)
co-infected with HBV had chronic infection. The majority (88%) of these co-infected patients were BlackAfrican and were born within Africa. The proportion of co-infection in Coventry newly diagnosed HIV patients
is similar to the UK estimate of co-infection of HBV of 3-10% of patients with HIV.
3.3 MENTAL H EALTH
Mental health issues identified ranged from anxiety and depression to suicidal thoughts and action and include
the impact of repeated racial abuse, stigmatisations and discrimination. These problems are then exacerbated
by social isolation, racism, language barriers, lack of access to English for speakers of other language classes as
well as lack of access to religious and cultural support and administrative processes in accessing work and
public services. Discussing mental health problems can be difficult enough in one’s first language, without
been compounded by cultural inhibitions and language barriers. The stresses of migration, separation of
families, poverty, unemployment, isolation and dis-empowerment impact on many migrants who may
experience one or two or all of these issues. The stresses impact on both mental and physical health yet a
number of barriers often prevent individuals from accessing support.
36
In consultation with the Meridian Practice, service providers and community representatives, mental health
issues in refugees and asylum seekers were emphasised as the mental health needs of this groups are acute.
This group experience abuse and mental and emotional trauma while in their country of origin, during their
flight to safety and when having to settle in a new country (including public hostility and the threat of
deportation).16 These experiences result in a range of symptoms and impact significantly on the individuals’
life. The main mental health issues identified are post-traumatic stress disorder (PTSD), depression, anxiety
and suicidal tendency:
“Depression, but when I’m sleeping sometimes…I’m shouting, I cry sometimes, I saw the
soldier come to kill me.” (Refugee)
Local research conducted at the Coventry Refugee and Migrant Centre identified the following factors as
significantly impacting mental health in asylum seekers and refugees:







Safety
Emotional effects (e.g. depression, loneliness)
Support
Family
Hopes for the future
Positive experiences of living in the UK
Negative experiences of the Home Office system.
Processes at the Home Office seem to have had major negative impacts on a number of asylum seekers and
refugees. The lack of clarity of the asylum process and sudden rejection and eviction of asylum seekers has led
to damaging emotional impacts:
“It’s hard when you don’t know what’s going to happen to you now – you think about it
every day.” (Asylum seeker)
This group experience serious emotional problems which frequently include suicidal ideation:
“I would really prefer to kill myself because my life is so bad.” (Refugee)
They consistently report feeling depressed and isolated:
“I’m just staying indoors, not going anywhere.” (Refugee)
This group face hostility on a daily basis and lack support and security in the UK which leads to further isolation
and mental health issues in individuals who fled persecution to seek safety in this country:
“I cannot go back because I face death, how can I go.” (Asylum seeker)
Recognition of the context and mental health needs of asylum seekers and realistic presentation to the wider
community is a necessary first step from which appropriate support systems need to be developed to address
the needs of this vulnerable group.
37
3.4 S ECONDARY C ARE
Current literature has shown that recent migrants aged 15 years and above have half the rate of hospital
admission as that of the general population of England. 17 Being able to migrate, and the population which tend
to migrate, implies that migrants are more often healthier than the general population, often termed the
“health-migrant effect.” However, there are also often differences in access to primary care, different
thresholds for referral to secondary care, and other barriers to access which may impact on migrants using
secondary care services less. It has also been shown that some migrants return to their home countries for
hospital care. However, based on local findings regarding barriers to primary care access, increased rates of
infectious diseases and reported un-booked maternity cases the following hospital services are likely to be
influenced:



Accident and emergency (A&E) – especially when registration with General Practitioners is low, partly
due to the nature of migrant worker employment, their lack of understanding of the process or by
barriers put up by the general practice itself. It is more likely to be the case that people report to A&E
departments following accidents and when experiencing acute medical illness
Infectious disease clinics – particularly TB, HIV and other blood-borne viruses, either referred through
from primary care or possibly presenting directly
Maternity – there is an increase in the number of births in Coventry, directly attributable to increased
rates in non-UK born mothers. The average age of migration also coincides with child bearing age.
3.5 N ON-COMMUNICABLE D ISEASES
3.5.1 T YPE 2 D IABETES
National data suggests that Type 2 diabetes is up to six times more common in people of South Asian descent
and up to three times more common among people of African and African-Caribbean origin (Table 3.2).18
According to the Health Survey for England 2004, doctor-diagnosed diabetes is almost four times as prevalent
in Bangladeshi men, and almost three times as prevalent in Pakistani and Indian men compared with men in
the general population. Among women, diabetes is more than five times as likely among Pakistani women, at
least three times as likely in Bangladeshi and Black Caribbean women, and two-and-a-half times as likely in
Indian women, compared with women in the general population. In the same survey, diabetes was generally
rare among those aged 16–34, but was highest among Indian men (2%), Black African men (1.7%) and Irish
women (1.7%).19 The risk of developing Type 2 diabetes can be reduced by changes in lifestyle and health
promotion messages could be developed to target these groups. 20
38
Table 3.2 Prevalence of self-reported, doctor-diagnosed diabetes in England by ethnic group
and sex (Modified from Diabetes in the UK 2010 Key statistics on Diabetes)
Minority Ethnic Group
Men (%)
Women (%)
Bangladeshi
8.2
5.2
Black African
5
2.1
Black Caribbean
10
8.4
Chinese
3.8
3.3
Indian
10.1
5.9
Irish
3.6
2.3
Pakistani
7.3
8.6
General Population
4.3
3.4
A local study conducted among women in Foleshill has shown that the crude prevalence of Type 2 diabetes
was 3.2% and 14.7% in Europeans aged 30–64 years and ≥65 years, respectively, and 10.9% and 36.5% in
similarly aged Asians, respectively.21 A prior local study had suggested similar differences between European
and South Asian individuals with prevalences of type 2 diabetes 3 times higher in South Asian men aged 35-59
years compared with European counterparts and prevalences up to 4 times higher in South Asian men over 60
years. In South Asian women aged 35-49 years the prevalence of Type 2 diabetes was nearly double that of
European women and nearly three times higher in women aged 60-79 years (Table 3.3). Consideration should
be given to the development and adoption of culturally appropriate targeted lifestyle interventions and health
promotion messages in these groups.22
Table 3.3 Prevalence of Type 2 diabetes in South Asian and European individuals in Coventry
(Modified from Diabetes in the UK 2010 Key statistics on Diabetes)
Prevalence
Men
Coventry Study
Age (years)
Prevalence
Women
European
S.Asian
European
S.Asian
25-34
0.5%
2.5%
0.5%
1.5%
35-59
3.5%
12.5%
6.0%
9.5%
60-79
6.5%
25.5%
8.0%
20.0%
39
3.6 P UBLIC HEALTH
3.6.1 S MOKING
According to local data, residents from White and White Other groups are more likely to smoke than other
ethnic groups. Smoking levels can be quite high amongst European Union migrant workers where prices of
tobacco products are cheaper. According to Coventry New Communities data 45% of Polish individuals were
smokers while 35% of Kenyan individuals smoked. However, reports have also indicated that paan and shisha
smoking may be a concern in local South East Asian migrant communities. Local public health programmes
need to target these vulnerable groups.
3.6.2 A LCOHOL
The harms caused by alcohol in Coventry are considerable. “At risk” groups include a diverse range of
individuals who are particularly susceptible to either the physical or psychological effects of alcohol and are,
thus, more likely than others to experience adverse outcomes of drinking. People living in higher levels of
deprivation tend to be more susceptible to higher levels of harmful drinking and alcohol-related harm because
they have fewer means of coping adequately with risk. Local data indicates that the majority of recent
migrants in Coventry live in deprived areas which would place them at higher risk for harmful drinking. In
consultation with professionals at the Meridian Practice, reports indicate that there are higher levels of
harmful drinking in asylum seekers and refugees often linked to mental health issues and stress. Harmful
drinking among East European migrant groups was also flagged at the VAC workshops. The evidence suggests
that risk is directly related to access to nutrition, health care, education and a social network – factors which
are all currently issues for migrant groups. Where any of these is inadequate, risk for harm in general is
heightened, including harm related to drinking.
3.6.3 N UTRITION
Local data suggest that residents from Indian and Pakistani ethnic groups are less likely than other ethnic
groups to eat 5 or more portions of fruit and vegetables per day. Issues regarding poor nutrition and diet were
raised at the community and stakeholder workshops, resulting in reported vitamin deficiencies particularly in
Roma groups and obesity in South East Asian and African groups. This may be partly due to income and
availability and social pressures which can impact an individual’s life such as racism, discrimination, poor
housing etc. Specific health concerns were raised for pregnant women and children with reports of poor access
to antenatal vitamin supplements and nutritional support for young children.
3.6.4 P HYSICAL A CTIVITY
Local research conducted among 250 children aged 8–9 years attending primary schools in Coventry indicated
that 77% White European, but only 35% South Asian children, met current national physical activity guideline
targets.23 The study also showed that South Asian children spend less time in moderate to vigorous physical
activity and more time in sedentary activities than White European children and with higher levels of afterschool activity in White European children compared with their South Asian peers. White European children
had significantly higher activity counts on weekdays compared with South Asian children. However, the study
indicated that when South Asian children are given the opportunity for either structured physical activity in a
physical education class or unplanned activity in a safe environment during school break times, they took as
much advantage of this time as their White European peers.
40
The low levels of physical activity found in a significant proportion of the children are of concern for future
health, but especially so for South Asian children in whom the risk of metabolic disease is so much higher.
Ethnically tailored interventions should explore whether physical activity can be increased in South Asian
children.
3.6.5 C HILDHOOD V ACCINATION
Only 68% of Nigerian individuals and 76% of Chinese individuals reported that their children had been
vaccinated as children. Poor vaccination uptake, in relation to a series of measles outbreaks in children within
Roma groups in Coventry, has also been reported. Cultural norms and different approaches in countries of
origin play a major role in influencing parental decision-making regarding vaccinating children. Insufficient
knowledge about vaccines and targeted diseases, lack of advice from health professionals and, at times,
suspicions regarding the motivations for such advice are common issues among many recent migrant groups.
3.6.6 P REVENTIVE HEALTH AND W OMEN ’ S H EALTH
Preventative health within the Roma community (estimated at around 6000 in Coventry) is of major concern
due to the lack of preventative healthcare in their countries of origin. Women’s health and particularly
maternity care is thought to be very poor in this community as it has been reported that many women do not
book in for antenatal care and often their first contact with the health system is on arrival at hospitals in
labour. Uptake of cervical screening in this group is also poor. Women’s health appears to be highly
stigmatised in this community.
3.6.7 D ENTAL H EALTH
According to the Coventry New Communities study only 43% of Roma/Romanian people were registered with
a dentist. Dental health has also been raised as an issue in this group during community and stakeholder
workshops. Only 50% of Polish people and 55% of Chinese people has registered with a dentist. Improving
access and information about these services may improve registration numbers.
3.6.8 D OMESTIC V IOLENCE
Domestic violence is an issue that appears to be more common than anticipated particularly among some
African groups. This was discussed at the community and stakeholder workshop. Domestic violence was also
emphasised as a factor that often inhibited women accessing health services.
3.6.9 H OUSING
Housing and overcrowding has been identified as a key issue at the community and stakeholder workshops.
Many families are living in multi-occupancy houses. The most overcrowded house that was reported had 32
people living in a 2 up 2 down house. This has critical implications for the transmission of communicable
diseases such as TB; mental health and sleeping quality which impacts on education and employment as well
as domestic violence. As well as overcrowding many of the houses are in a poor condition including damp.
Those families who overstay their visas (originally here on student visas) are routinely placed in hotels - often
single mums with 1 or 2 children living in one room. It appears many families are also only given short-term
tenancies, which results in them having to move frequently. According to data form the Coventry New
Communities Study, an average of 20% of Bangladeshi and Romanian people report more than 7 people living
in one household, while nearly 50% of Afghan, Bangladeshi and Romanian people have between 5 and 7
people living in one household.
41
3.7 INFANT MORTALITY AND LIFE E XPECTANCY
Local figures are too low to produce statistically significant data but nationally, babies with a Black Caribbean
or Pakistani background are twice as likely to die before reaching the age of one, than Bangladeshi or White
British babies. Local statistics on death rates are not available by ethnicity but at a national level it has been
estimated that Black African women who are asylum seekers have a mortality rate seven times higher than
White women.24
3.8 H EALTH ISSUES IDENTIFIED D URING W ORKSHOPS
At the community at stakeholder workshops participants were requested to identify and prioritise which
health issues they believed to be the most important to the communities they worked with and represented.
Findings from the workshops have supplemented each section above. The main results from the workshops
have been summarised and are presented below. The word cloud in Figure 3.5 visually depicts the frequency
of responses identifying the same health issues as significant in migrant communities.
Fig 3.5 Word cloud of health issues in migrant communities prioritised at
community and stakeholder engagement workshops.
42
4. HEALTHCARE AND SERVICES
Key points:






Migrants are entitled to treatment provided by a GP at no cost and registration of any
individual should on no grounds be denied
There are limited examples of health care commissioning specifically for migrant health
The majority of services and support for migrant groups is provided by voluntary and
community-led organisations
A number of issues around access to healthcare were identified, particularly regarding
language barriers and GP registration
Main problems in accessing services were due to language barriers; lack of understanding of UK
health systems, health issues and entitlement and available services; and cultural barriers
A wealth of community skills and strengths were identified that provide essential support that
mainstream services are not able to provide to migrant groups.
4.1 E NTITLEMENTS TO NHS CARE
An understanding of current health and social care entitlements for migrants is fundamental in assessing
service provision (full details in Appendix 4). Healthcare workers who do not fully understand eligibility criteria
may be putting unnecessary barriers for migrant workers to access healthcare, thus diverting them to
inappropriate services.
4.1.1 SERVICES FREE TO ALL
Treatment provided by a general practitioner (GP) is free of charge, whether registering as a temporary patient
(when a person is in the area for more than 24 hours and less than 3 months) or registering as an NHS patient.
A range of services are also currently free of charge irrespective of country of normal residence (Table 4.1).
Table 4.1 Services provided free of charge irrespective of country of normal residence
Emergency treatment

At any Accident & Emergency department, walk in centre or elsewhere (but not further emergency treatment
(e.g. operations) away from these locations or subsequent outpatient appointments)
Family planning
Treatment for communicable diseases

Including TB, Hepatitis, Mumps, Measles, Pandemic Influenza, Food Poisoning etc.
Treatment for sexually transmitted infections (including HIV)
Diagnosis, counselling and treatment in relation to HIV
Mental Health

Those detained in hospital under the Mental Health Act 1983 or treatment given for mental health problems as
part of a court probation order
43
4.2 CURRENT S ERVICES IN RELATION TO NEED
4.2.1 HEALTH SERVICES AVAILABLE TO MIGRANTS IN COVENTRY
There are limited examples of health care commissioning specifically relevant to the health needs of migrants.
There is insufficient reporting to assure equality of access to health care services and optimum health
outcomes for migrants. The recommendations in Chapter 6 of this report aim to provide guidance and next
steps to address gaps. Specific services were identified through workshops with stakeholders and community
representatives. Community assets were also identified and have also been included in this Chapter with the
aim of drawing attention to the range of support migrants need which is currently met by community-based
groups providing a potential platform from which further support could be developed.
C OVENTRY I NTERPRETATION AND T RANSLATION S ERVICES
The Interpretation and translation service in Coventry is jointly commissioned by Coventry City Council and
NHS England and is provided by Coventry Interpretation and Translation Unit (CITU). All the translators
employed by CITU are locals who are fully trained, accredited, Disclosure and Barring checked and work to a
Code of Conduct, which includes maintaining service users confidentiality as well as working within the City
Councils Equality and Diversity, Health and Safety Policies and Complaints procedures. Presently CITU employ
on average over 100 interpreters who work on a sessional basis.
CITU can provide an interpreter in around 45 languages/dialects in-house however, if required they can
provide more languages by accessing outside agencies. The service aims to fulfil any language requested by a
customer. The main languages spoken include: Albanian, Bengali, Czech, Dutch, Farsi, Gujarati, Hindi, Italian,
Kurdish, Latvian, Mandarin, Polish, Romanian, Somali, Tamil, Turkish, Urdu and Vietnamese. Over the past
three years the top five languages have for the most part stayed the same with slight variation with Polish
being the language most requested. The biggest difference has been an increased demand in Romanian over
the past few years with it now being the 2nd most requested language (Table 4.1). Between 2010 and 2013
CITU has seen a steady increase in the service users access the service from 25,257 in 2010/2011 to 26,694 in
2012/2013.
Table 4.2 Top five languages requested and spoken according to CITU records
2010/2011
2011/2012
2012/2013
Polish
Polish
Polish
Punjabi
Romanian
Romanian
Romanian
Punjabi
Punjabi
Arabic
Kurdish
Kurdish
Kurdish
Arabic
Urdu
44
Interpretation and translation services are used by a number of statutory and voluntary agencies, with health
services including general practice and Coventry and Warwickshire Partnership Trust being one of the biggest
users. The service is also used by a number of council departments including Social Care, Children, Learning
and Young People and Housing. University Hospital Coventry and Warwickshire (UHCW) provides its own
Interpretation and Translation service.
P RIMARY C ARE AND G ENERAL P RACTICE
 Meridian Practice is a medical centre specifically designed to provide eligible patients and asylum
seekers with access to high quality healthcare within Coventry City. The practice is open to new
patients who wish to register with us and can provide the relevant Home Office UK Border Agency
documentation. The practice aims to improve access to healthcare by developing an integrated
primary care service to meet the immediate health needs of asylum seekers and support transition
into mainstream practice if refugee status is awarded. The practice currently provides services to over
1500 patients, the majority of which are between 20-40 years of age, two thirds of which are women.
The practice has patients from all over the world with the predominant countries patients originate
from currently as Afghanistan, Iran, Iraq and the Democratic Republic of Congo.
 City of Coventry NHS Health Walk-in and Healthcare Centre are a GP-led service open to registered
and unregistered patients, with or without an appointment, based at the new City of Coventry Health
Centre. Not having to register is an important factor for refugees and asylum seekers who are afraid
to divulge certain personal details, which often acts as a barrier to accessing more formal healthcare
services. The Centre offers a wide range of services from stop smoking support to family planning
advice and contraception, to TB services and phlebotomy (complete list in Appendix 6). The Centre is
in addition to, and works alongside and complements other GP surgeries in the area and does not
replace their service. Patients can therefore use the centre as well as the services of their own GP,
however patients can register at the Centre should they wish. The service is provided on behalf of
Coventry and Rugby Clinical Commissioning Group.
M ENTAL H EALTH SERVICES
 A number of public sector and charity organisations providing mental health support are available to
migrant communities such as MIND, Coventry Rape and Sexual Abuse Centre, community mental
health teams (CMHT) improving access to psychological therapies (IAPT) and psychology services.
Individuals can refer themselves to these services or need to be referred by GP. However, the main
issues in migrant groups accessing mental health services are often culture driven, fear of stigma and
lack of awareness that services do exist and how they operate. A more targeted approach and
systematic, culturally-seneitive approach to mental health awareness and service provision for certain
migrant groups (particularly asylum seekers and refugees) may be warranted. At a Coventry Mental
Health for Migrants Seminar it was made clear that providers working in mental health were not
aware of other available services. This is a significant gap and there is a clear need to develop a
pathway or map of existing mental health services that is available to providers and the public in
formats that are understandable.
45
C ITY SERVICES
All general City Services impact on recent and established migrants, as for every citizen in Coventry. The
Coventry Strategic Asylum Seeker group brought together representation from Community Safety, Housing
and Community Cohesion to address issues relevant to asylum seekers and refugees. Specific services most
utilised by recent migrants in particular include:

Coventry Citizens Advice Bureau (CAB) advises people on their rights – this can include employment,
consumer, housing or relationship, but in the current climate, is largely dominated by debt and
benefits-related enquiries. CAB also works on social policy, and lobbies for changes in policy in order
to benefit the wider community. The service given is free, impartial and confidential. Salaried
“Caseworkers” provide advice in the specialist areas mainly through the service at the City Centre
Bureau. Coventry CAB currently employ 8 Debt Caseworkers and 1 specialist Welfare Benefits
Caseworker. The service also has 5 paid advisers who deliver a dedicated outreach service. Coventry
City Council core-funds the Bureau, but in total the bureau is funded by around 10 different streams
of income including the Legal Services Commission and Central Government. Coventry CAB is a
member of Citizens Advice, the national body.
V OLUNTARY SERVICES AND COMMUNITY GROUPS
 Coventry Law Centre is a charity employing Solicitors and paralegals to offer free legal advice and
representation in the areas of Community Care, Discrimination, Employment, Family, Housing,
Immigration and Asylum, Money and Debt, Public Law, and Welfare Benefits to the people of
Coventry. The Centre also collaborates with Grapevine (see below) and the Community Based
Champions Network in the Young Migrants Rights Project (Box 4.1)
The Paul Hamlyn funded, Young Migrants Rights project is a partnership approach between Community
Based Champions Network, Coventry Law Centre and Grapevine Coventry & Warwickshire. All three
organisations will be working to support between 35 -50 undocumented young migrants so that they
know how to access services which can assist and support them, particularly in respect of health and
education. The project aims to engage 200 young migrants in awareness-raising sessions focusing on
rights and entitlements.
Box 4.1 Young Migrants Rights project

Coventry Refugee and Migrant Centre (CRMC) are a local Charity with a mission to identify and meet
the needs of refugees and migrants in Coventry through the provision of projects and services which
support them to settle into local communities, ensuring effective integration and encourage migrants
to make a full contribution to the life of the City. The CRMC also chairs the Coventry Destitution
Partnership. Migrants are assisted with all aspects of beginning a new life in the UK, including
nationality and immigration issues through to housing, employment and learning about life in
Coventry. The team comprises 30 paid staff and nearly 100 volunteers and are currently receiving a 3
year Grant-Aid agreement from Coventry City Council to build on existing work and expand to include
outreach working within communities in need.
46

Foleshill Women’s Training Centre is a women only centre dedicated to helping all women in
Coventry and the surrounding areas through social, health and economic programmes. The Centre is
run by women, for women, and offer a women only space for accessing education, training,
healthcare and employment opportunities. The Centre provides services for all women in Coventry
including women from BME groups and new communities and aims to provide peer support,
prevention and intervention through a range of ongoing projects such as MAMTA (Box 4.2)
'MAMTA' - means "Motherly Love" in many South Asian languages and is a health project for black and
minority ethnic women. The aim of MAMTA is to empower these women to take control of their own
and their children’s health. One of the main aims of MAMTA is to work with health professionals on
improving child and maternal health, in Foleshill and its surrounding areas, through advice and
education. MAMTA support mainstream services, such as midwifery, health visiting, smoking cessation
in pregnancy and other services within the City Council and NHS Coventry in cascading key health
messages to the community. All the sessions are culturally sensitive, women only, and with language
support. MAMTA also supports women in surgeries by giving information on key health messages.
Box 4.2 MAMTA – a child and maternal health project



Black Health Network (BHN) is a community-based health promotion agency working to reduce
health inequalities and to ensure that all people from BME communities have access to quality health
care and a culturally sensitive system that works for people from all cultural and ethnic backgrounds.
BHN works closely both with BME communities and service providers to address issues in service
provision for BME groups. The Network works along the principles that professionals/people from
BME communities have the understanding, knowledge, interest, concern, and the expertise to make a
significant difference in the health care status of people from the same BME communities. Their
services complement existing services where necessary and they aim to provide expertise and
support to individuals and organisations that work with local/BME communities to improve health.
The Network is committed to responding to the need for a representative community-driven and
community-responsive voice in health care and health promotion.
Grapevine is a charity that traditionally provides support t0 people with learning disabilities but has in
recent years collaborated in the Young Migrants Right project and other projects to support young
migrant groups. Grapevine helps individuals build their skills and talents and finds places where their
contribution is needed. This empowers individuals and builds independence, protecting against
isolation and discrimination. Grapevine works with people and their families to get what they need to
deal with change, including recent migration and integration with the Coventry community.
Coventry Ethnic Minority Action Partnership (CEMAP) provides strategic representation on Ethnic
Minority issues across the City, helping to create a range of opportunities for Ethnic Minority groups
and organisations to come together, network, share ideas, discuss issues of mutual interest and
concern and develop best practice. CEMAP has engaged in and continues to carry out consultations
and research within the BME and New Communities in Coventry which has resulted in increased and
more focussed service provision. In addition a range of Empowerment and Job related training has
been successfully delivered to the BME and New Communities following the identification of training
needs. The charity works with people, organisations and agencies to improve the delivery of services
to Ethnic Minority Communities in Coventry.
47

Terrence Higgins Trust traditionally work in communities to promote better sexual health, particularly
among those groups at risk of contracting HIV and other sexually transmitted infections (STIs). They
are the lead provider of the national HIV prevention program - HIV Prevention England, and provide
information about HIV and better sexual health through posters, campaigns and leaflets. They target
large areas of the population by campaigns such as National HIV testing week, as well as more hard to
reach groups with strong engagement in migrant groups across the City.
4.3 B ARRIERS TO A CCESSING H EALTHCARE
Some migrants have indicated they understand entitlement to care in the UK and will access both primary and
secondary care services effectively, but for many others, problems in accessing services have arisen due to:



Language barriers
Lack of understanding of UK health systems, health issues and entitlement and available services
Cultural barriers.
4.3.1 L ANGUAGE B ARRIERS
The issue of language, including issues of translation and interpretation, was consistently identified as a major
barrier to accessing services by the majority of stakeholders and community representatives. This barrier was
strongly linked to other identified barriers, including a lack of understanding of the system
“I am convinced that all health and social problems in migrants in the UK are mainly due to poor
English” (Migrant community representative)
Levels of proficiency in English language usage among migrant and BME community members, in both spoken
and written forms, greatly influence the capacity with which communications within day-to-day social
Problems with language skills have cumulative effects. They reinforce, and are reinforced by, a lack of cultural
understanding between BME community members and those working within the NHS and its services. BME
community members may often have a limited knowledge of the culture of the British system, its history, its
processes, its mechanisms; and at the same time many of those working to plan or provide services may often
have a limited knowledge of the cultures, manners, customs and sensitivities of the BME communities who
they deal with in the course of their work. This can provoke a lack of trust. In addition, leaflets and other
advertising are often not available in people’s first languages, and so are dismissed.
“We do not understand the system and find it difficult to communicate. When we receive letters we
do not understand what they mean” (Migrant community member)
When migrants succeed in accessing a service, they can’t explain their needs or understand how things will
proceed, and they may be discouraged from proceeding by their experience of contact. An incident was
reported where a receptionist at a general practice refused to make an appointment unless the woman
seeking care told her what it was for but she could not do so in English as she had only recently arrived in
Coventry. Instances where children had been kept off school to translate for their parents have also been
reported.
48
Fig 4.1 Barriers to accessing care identified at community and stakeholder workshops.
“When approaching GP to register, they are reluctant and they turn you away because of the
language difficulties you may have. Interpreting is often not provided”
(Migrant community member)
These problems are exacerbated by difficulties experienced by some in accessing interpreters and by the nonrepresentativeness of the service provision workforce. Cases of patients discharging themselves from hospital
wards because no one explained what was happening to them in a language or manner they could understand
have been conveyed. Those providing services, as well as those accessing them, feel the consequences of
language barriers. There are knock-on effects on staff’s ability to offer appropriate and efficient services and
may have a profound effect on individuals accessing appropriate and timely health treatment or advice. This
has particular impact for mental health problems which are, not only culturally stigmatised, but
misinterpretation of symptoms could have a major impact on diagnosis and management. Limitations of
translators have been highlighted, particularly for Roma groups.
49
4.3.2 L ACK OF U NDERSTANDING OF H EALTH A ND H EALTHCARE
H EALTH S YSTEM
Lack of knowledge about the health system and processes, what help was available, and where to seek it was
highlighted as a major barrier to accessing services. Many migrants do not have general practitioner
registration in their countries of origin and are not even aware they need to register with a GP when they
arrive in the UK.
“It is really difficult to access services. The first problem is that we do not know much about any of
the services here.” (Migrant community member)
Many migrants and people from BME communities have different language skills, knowledge, contacts and
cultural awareness. It is in the interest of new arrivals that they are able to understand their rights,
entitlements and obligations. It is also in their interest, and the interest of the wider community, for them to
be able to communicate effectively. The sooner migrants can gain access to and understand how the
community works; the better community cohesion can be anticipated.
“People need information about different services. What is available for disabled people and how to
access mental health services.” (Migrant community representative)
H EALTH K NOWLEDGE
Issues regarding poor understanding of health issues were highlighted at both the workshops and stakeholder
meetings. Particularly knowledge and awareness regarding sexual health, cancer and screening, child
immunisation and healthy lifestyles was discussed. Cultural issues in some BME groups interfered with women
attending appointments for cervical and breast cancer screening. This was further challenged by an apparent
lack of female healthcare professionals. Many Roma people have very little knowledge and understanding of
preventive healthcare and healthy lifestyle choices in addition to poor uptake of child immunisation
programmes.
R EGISTERING W ITH S ERVICES
“The most disappointed situation was refuse in registration with GP. I just came to the UK; I was not
working these times and could not provide any pay slips or utility bills.”
(Migrant community member)
Community members have raised concerns regarding their difficulties in registering with GPs and other
services. The main reason was due to inability to show proof of address, often compounded by overcrowded
housing arrangements (some individuals cannot afford separate accommodation and often live with relatives
or friends and pay rent communally, with only one person in the household holding the proof of address).
4.3.3 C ULTURAL B ARRIERS
The lack of provision of culturally sensitive services was seen as another barrier to community members
accessing services. Culturally specific norms and restrictions about such subjects as sexual health,
homosexuality, domestic violence, drug and alcohol abuse, disability and mental health means that it is often
difficult to discuss these issues openly in front of other community or family members. It can also be
inappropriate for women to discuss certain sexual health issues with male health staff. This can lead to
50
individuals not accessing services and these issues being hidden and not managed appropriately. Particularly
mental health issues, learning disabilities and other disabilities were flagged as very sensitive issues in many
recent migrant groups (Roma, Polish and African communities) as well as in asylum seekers and refugees.
4.4 COMMUNITY PARTICIPATION AND ASSETS
One of the Marmot Review’s25 key messages on challenging health inequalities is that
“Effective local delivery requires effective participatory decision-making at local level. This can only
happen by empowering individuals and local communities.”
The asset approach provides an ideal way for councils and their partners to respond to this challenge in valuing
the capacity, skills, knowledge, connections and potential in a community. Among other aims, asset based
working promotes well-being by building social capital, promoting face-to-face community networks,
encouraging civic participation and citizen power. High levels of social capital are correlated with positive
health outcomes, well-being and resilience. Professional staff and councillors have to be willing to share
power; instead of doing things for people, they have to help a community to do things for itself. Working in
this way is community-led, long-term and open-ended. A mobilised and empowered community will not
necessarily choose to act on the same issues that health services or councils see as the priorities. 26
Through the community and stakeholder workshops, assets and strengths within migrant communities were
identified. The process of community-led asset mapping was conducted in five steps as currently described:26
1) Engage with core community champions
2) Contact individuals or groups active in the community of interest (formal and informal networks)
3) Through workshops or face-to-face interviews collate the assets and strengths of individuals in the
community
4) Identify the assets of local groups and volunteers
5) Map the assets of the agencies including the services they offer.
There are many local circumstances where the process of the asset mapping exercise itself can help stimulate
and motivate change – this was aimed for during the community and stakeholder workshops conducted in
Coventry as part of this work.
These instances include when:





A community is fractured, has no sense of its own abilities and no belief that it can change
There are no community associations or where those that do exist are exhausted, have a low
membership and are dominated by public agency agendas
Agencies only see the community as a source of problems and needs and cannot see where solutions
can come from
A group of people who organisations see as dependent – for example, people with learning
disabilities – can challenge attitudes and empower themselves
Communities and staff both want to change things and need to see the world differently in order to
discover how they could change.
51
By raising awareness and making visible the things that are undiscovered or unused, the ways people perceive
each other and their environments can improve. Mapping assets is an important step in collecting information
about needs and available resources and services.26
4.4.1 W HAT D O T HEY H AVE : E XPERTISE O F L OCAL C OMMUNITY
In collaboration with community groups during the workshops a number of vital skills and areas of expertise,
unique to local community members, were identified. These strengths are presented in Figure 4.2 Local
community groups and individuals are able to provide information and support in a language and way that
external services may not be able to. Community groups are trusted, empathetic, understanding, passionate
and familiar. They have skills and expertise regarding their community and are a powerful voice and leaders for
their members. Community involvement also had the effect of empowering citizens and building networks and
relationships. Throughout the workshops, many assets were identified, reflecting on the significant positive
contributions these groups and individuals were making to the health and wellbeing of migrant communities.
Figure 4.2 Expertise of local migrant communities
4.4.2 W HO A RE T HEY : E XISTING V OLUNTARY A ND C OMMUNITY G ROUPS
The assets and strengths of the community are channelled through community groups and organisations.
These groups also maintain health advocacy for their communities and have served as a vital platform from
which support for health and wellbeing have been driven. Barriers to accessing services in migrant groups are
often due to a lack of knowledge about services or a lack of cultural understanding by traditional service
providers. Community groups and hubs are ideally placed to overcome both of these barriers.
There is a wealth of excellent projects and support services currently provided by community groups that was
identified during the workshops. Some examples are listed below (and additional details on services voluntary
organisations are providing to migrant groups are described in section 4.2):

FWT: MAMTA; Peer-worker programmes; Women’s self-led group; Healthy lifestyles workshops for
BME women; Antenatal classes; health champions programme for BME women and Digital literacy
courses for women.
52




CRMC: Men’s and Women’s groups; Gardening sessions; Crisis support and Referral support.
Country-specific groups such as Ghanaian and Somalian organisations which provide a hub for
migrant from these countries to socialise and meet others, become part of a community and get
information on health and support services. These groups are strong health advocates and provide
support at a personal level often accompanying members to the hospital for cervical screening and
assisting members in responding to letters from GPs.
Faith-based groups providing services at local churches.
BHN: Sport-based events including health promotion messages and action.
These groups provide services and support that traditional services are often unable to. It was evident that
these groups were well-engaged with their communities, trusted and committed to caring for members.
During the workshops it was raised that many in social services and GPs were not aware of these third sector
organisations and community groups and did not refer people to them, and that there was a need to have
representatives on different health community panels.
These groups are predominantly charity funded which renders their futures as uncertain. They are linked to
infrastructure and have resources in terms of skilled and hard-working volunteers representing migrant
groups. Being part of these groups and providing services to others empowers volunteers and helps the
community and although no objective measures of impact on health and social outcomes are available it is
clear these groups provide vital support which benefits many. The expertise available within the community
groups presents the Council and other stakeholders with an opportunity to build and develop capacity, skills,
and potential in a community while engaging with members. By working together with community groups and
supporting their services a strong City-wide partnership based on existing strengths and assets would build
social capital, encourage community cohesion and ultimately promote health and wellbeing.
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5. EVIDENCE OF EFFECTIVENESS
5.1 COMMUNITY ENGAGEMENT
The National Institute for Health and Clinical Excellence (NICE) Public Health Guidance No.9 (Community
Engagement to Improve Health) emphasises the value of community outreach health projects undertaken in
partnership with the voluntary sector and local migrant organisations. 27 The guidance also highlights the
challenges associated with the short-term nature of many projects. While evaluations are overwhelmingly
positive and indicate significant health gains, the majority of projects run for between one and three years,
with a risk that the health improvement will be lost once they finish. A summary of evidence based
recommendations underpinned by dedicated long term funding include:



Peer educators programmes
Specialist health visitor / health worker, community development worker posts
Information to cover the key topics identified by migrants themselves including information to
support them to access healthcare, to help them to understand medication and health and safety at
work information and training supported with interpreters
5.2 MENTAL HEALTH
National Institute for Health and Clinical Excellence (NIHCE) Clinical Guidelines for managing Depression and
Anxiety in primary secondary and community care make reference to the following key priorities 28,29:




Screening in primary care and general hospital settings for depression in high-risk groups e.g. asylum
seekers
Watchful waiting for patients with mild depression who may recover with no intervention, a further
assessment should be arranged (within 2 weeks)
Guided self-help for patients with mild depression, healthcare professionals should consider
recommending a guided self-help programme based on cognitive behavioural therapy (CBT)
Appropriate prescription of medication and parallel support
5.3 INFORMATION
Evidence gathered from national focus groups and relevant literature regarding key information requirements
for new migrants highlighted twenty information subject areas to be included in local information resources
and they are summarised in Table 6.1. It is recommended that these topics should be covered and information
provided through appropriate channels e.g. Welcome packs, community events, community representatives.
Table 6.1 Major information areas relevant to new migrants
Getting a job
Discrimination
English language learning
Racial harassment
School places
National insurance and tax
Rights at work
Welfare benefits and social security
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Family services: Where to get advice and information
Rights to bring your family to the UK
Adult education and training
Housing in the UK
Interpreters
Money, bank accounts, credit debt
Trade unions
Doctors
Rights to live and work in the UK
Housing –overcrowding and repairs
Homelessness
5.4 A NTENATAL AND POSTNATAL SERVICES
The National Health Service Implementation plan for reducing health inequalities in infant mortality recognises
the importance of good quality early years NHS services such as maternity and health visiting can offer to
ensure a crucial opportunity to nip in the bud health inequalities that will otherwise become entrenched and
last a lifetime.30 The good practice guidance outlines actions for both commissioners and providers in the
development of local services. In order to reduce inequalities in infant health, the guidance recommends the
following:



Giving priority to evidence based interventions that will ensure improved access to maternal care and
improving services for Black and Minority Ethnic (BME) groups
Improved reporting on maternity and paediatric activity (including breast feeding rates, infant
screening and immunisations).
Provision of high quality primary care, midwifery, obstetric, neonatal and health visitor care including
proactive identification of ‘at risk’ women, provision of maternity care in community settings,
promotion of early access to maternal care, antenatal screening help with nutrition for women on low
incomes and neonatal screening
55
6. RECOMMENDATIONS
Main recommendations:








Improve access and address entitlement to health services
Address language barriers, interpretation and translation issues
Improve health intelligence and recording of information across sectors to capture data on
migration status and origin to better identify needs and target services
Promotion of access to specific services
Ensure implementation of evidence-based, national protocols and guidance
Address cultural barriers and develop cultural competence within health and social care workforce
Evaluate and audit and current work streams to ensure vital services for migrant groups remain
accessible and operational
Promote and support sustainable solutions and community assets
Migrants and their families are entitled to the same high quality health care services as the rest of the local
population, i.e. to provide them with accessible and high-quality care (preventive, curative and palliative), as
well as health promotion and education. Migrants may require additional services, such as interpretation and
translation services, and support to ensure they also gain the maximum health benefit and equality of health
experience.
Migrants and migrant communities should consistently be engaged and involved in taking forward the
recommendations outlined in this report.31 To ensure this is made possible, a variety of communication
channels and platforms to facilitate easy access of this report and related outcomes need to be put in place to
enable maximum participation. The involvement of local communities is vital for reducing barriers between
health services and migrant service users. 32
A wide range of assets within migrant communities in Coventry are evident, providing strong support networks
and powerful platforms from which to impact on health. These channels require sustenance and incorporation
into an integrated approach to improving migrant health.
These recommendations have been supported by those who contributed to this report and stakeholders,
service providers and members of migrant communities who were involved in the engagement workshops and
meetings. Development of a Migrant Health Task and Finish Group could ensure recommendations are
advanced and continue advocating for the improved health and wellbeing among migrant groups.
6.1 A CCESS AND ENTITLEMENT TO H EALTH S ERVICES
Providing equitable health services involves making sure that access to services and the quality of services
does not differ between groups. Access and quality have different implications yet a great deal of overlap. Of
particular relevance to migrant health in Coventry is the influence of quality of service on access of services:
poor quality or poor experience of a service results in loss of confidence in services and consequently fewer
people accessing services. A number of poor experiences of health services by migrants in Coventry were
highlighted in previous chapters.
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6.1.1 ENTITLEMENT TO HEALTH SERVICES
Regarding entitlement of primary health system use, varying reports across GP practices in Coventry were
reported. Particularly regarding undocumented migrants, there appears to be poor coverage for these groups.
Current UK rules governing entitlement to health services stipulate that anyone can register with a GP practice
(without proof of identification) yet practices are allowed flexibility in decisions to accept/refuse patients onto
their register. Rules emphasise that this decision may not be based on the grounds of race, gender, social class,
age, religion, sexual orientation, appearance, disability or medical condition. Isolated cases reported in
Coventry have however indicated that patients were refused on unreasonable and discriminating grounds e.g.
because of inability to speak English.
After consultation with GP practice representatives it is evident that practices are not clear on the guiding
principles of entitlement and access to health services by migrants and that no systematic approach is
employed within practices and across practices in Coventry.
The following recommendations aim to address these issues:




Information regarding entitlements to health services and current policies need to be disseminated
to both migrants and healthcare workers
Inconsistencies regarding freely available services and health service entitlements need to be
clarified for both migrants and healthcare workers to avoid fears regarding costs of treatment as a
hindrance to access for migrants and confusion for healthcare workers
To review the process currently used by migrant workers when registering with a GP practice with
the aim to improve access to primary care services.
A single, systematic approach and registration protocol to accepting and offering treatment to
migrants needs to be developed, disseminated and implemented across GP practices in Coventry to
ensure equitable access across the City. It is recommended that the approach be developed in
collaboration with practices to ensure engagement and adoption and allow for the resolution of any
challenges to implementation.
6.1.2 ACCESSIBILITY OF HEALTH SERVICES
The accessibility of health services depends on geography location of services, available transport and service
capacity to cope with demand. Based on the available data, an indication of where many recent migrants live
has been established. These areas fall among some of the most deprived areas of the City and while the many
of services available to migrants seem to be placed in these areas; many are not and migrants struggle to
access them. Fragmentation of health services was highlighted by many stakeholders, for example, the Walk-in
Centre does not have an X-ray machine and according to TB nurses many people diagnosed with suspected TB
and then referred to UHCW for a confirmatory X-ray investigation are not able to travel to the hospital and the
diagnosis is never confirmed and the patient cannot be started on treatment. Practical issues such as these,
need to be addressed as often simple solutions may have substantial benefits.
Issues regarding capacity also need to be addressed, for example, the Meridian Centre has long waiting lists
and to offer the care and support needed by many asylum seekers and refugees would greatly benefit from
additional administrative support to facilitate longer consultations. Health and social care integration
57
Access to services providing health promotion and education is limited in these areas and while services may
be available, they are often not culturally responsive, for example, swimming sessions for women only
provided only in the late evening when women need to be at home and don’t feel safe travelling. Again,
simple re-organisation of infrastructure to best use available services would be beneficial. Greater partnership
working would also facilitate improved access, for example Information about health services and social care
could be explained to migrants in greater detail by community groups – thereby bringing together healthcare
or the GP with the third sector and communities, leading to greater accessibility, understanding and
responsiveness of services.
Recommendations include:


To review and map all services to include details such as location, opening times, effectiveness and
uptake
Re-organisation of service delivery in response to community needs
6.1.3 HEALTH INFORMATION AND LITERACY
Health information and literacy is in a major determinant of access – access to services id dependent on the
availability of information for patients about health and health system.31 Health literacy is unequally
distributed in migrant groups in Coventry as many are still socially excluded and less well-educated and are
known to be at a disadvantage concerning health literacy. Health inequalities in these groups are often linked
to inadequate knowledge about health problems and services available. Cultural and language barriers impact
on health knowledge and service uptake and need to be taken into consideration.
The following recommendations aim to address these issues:




Targeted, outreaching approach to improving health literacy for migrants is urgently needed,
particularly in sexual health, maternal and newborn health, mental health and risk factors for noncommunicable diseases
Review current provision of health material in highlighted health areas most prioritised for current
migrant health needs and ensure material is translated in major languages currently spoken within
migrant communities
Review topics currently covered in Coventry welcome packs, ensure availability of universal pack for
all new arrivals (currently this is selective) and ensure necessary information in appropriate languages
is provided
General and specific information on each service could be provided, in appropriate language and in a
culturally appropriate manner, and in suitable media (some members of the Roma community cannot
read). This might include websites, leaflets, video, CDs or audiotapes, distributed or lent through front
line service offices, libraries, community organisations or outreach teams, or it might be regular
ongoing training presentations in the local community in various languages, by or with community
organisations or own language outreach teams.
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6.2 L ANGUAGE BARRIERS , INTERPRETATION AND T RANSLATION
One of the greatest challenges to both the accessibility of health services and the quality of
services/experience is the presence of language barriers. These often lead to inaccurate/delayed diagnoses,
lack of compliance to therapies, miscommunication regarding follow-up, lower levels of patient safety and
lower satisfaction levels for both healthcare worker and migrant – as well added costs incurred. Where
language barriers have impacts on quality of healthcare and patient safety, measures need to be taken to
reduce them.
Regarding translation, a number of reports of informal face-to face interpretation have been made. In most
instances children were kept off school and used as translators, putting the child in a difficult and perhaps
traumatic situation as well as the adult in an awkward situation. Other informal interpreters such as nurses
and cleaners have been drawn into consultations again disrupting patient confidentiality. Informal translation
runs high risks of inaccurate communication of information with impact on diagnoses and management. Issues
regarding the use of informal multilingual interpreters also highlight the importance and need for trained
interpreters who are qualified to work with patients in health settings within varying cultural norms.
Recommendations include:






Increase resources for professional face-to-face interpretation
Increase capacity of professional interpretation by telephone
Matching of bilingual professionals to geographical areas most in need of interpretation
Consider the development of cultural mediators – health or social care workers proficient in various
languages but also able to mediate actively between patients and healthcare workers. A sustainable
extension of this concept could allow training of community members to engage in these roles (e.g. of
members of the Roma community in Leeds who are engaging in this system)
Translator protocol and portfolio of services available across primary and secondary care
Council could consider providing English classes to recent migrants which would empower individuals,
improve communication, access and health independence.
The need for interpreters and translators has been raised by both primary and secondary care and a cross
agency joint protocol should be developed and agreed to address these needs. Consideration should also be
given to supporting opportunities to employ or fast track bilingual health care workers. There is also a role for
health advocates in hospital who are needed not only for translating languages but also for interpreting
cultural differences.
6.3 H EALTH INTELLIGENCE
Public, private and voluntary organisations in Coventry should agree a process for sharing current intelligence
to improve our understanding of migrant worker’s health needs, thus aiding commissioning and monitoring
the improvements to meet these needs.
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6.5 P ROMOTING A CCESS TO S PECIFIC S ERVICES
It is clear that access to a number of services is poor and this calls for targeted approaches to ensure services
respond to specific and most important current health needs of migrant groups.
The following recommendations aim to address these issues:




Address any issues pertinent to access to interpreters, culturally appropriate consultations, the
opening times of surgeries and facilities and the geographical spread of appropriate services
Review current maternity services provision among migrant and BME groups across Coventry with the
aim to ensure that there is a proactive outreach service available that targets “at risk” women. To
routinely monitor access by ethnicity.
To review access to mental health services, including drug and alcohol services, in the community,
primary and secondary care with the aim to ensure timely access that meets ethnic needs and
addresses cultural and language needs
To improve access to public health programmes (smoking, obesity, sexual health, drugs and alcohol
misuse) they need to be designed to address cultural and language differences - the use of
community-led solutions and groups may provide the best channel for communication and provision.
6.6 P ROTOCOLS AND G UIDANCE
There is a clear need to ensure there are agreed protocols in place between all agencies to clarify roles and
responsibilities in the provision of health services among migrant groups in the City, for example, the
commissioning of translators and interpreters in acute settings (UHCW) is currently unclear, resulting in
ineffective service provision.
Recommendations include:


To ensure the full implementation of national plans and strategies reducing health inequalities and
managing mental health conditions
To develop and agree a joint agency protocol on the use and availability of interpreting services.
6.7 CULTURAL B ARRIERS AND CULTURAL C OMPETENCE
Healthcare workers and service users may differ widely in their understandings of health and illness in general,
as well as expectation regarding appropriate health behaviour. Groups from varying socioeconomic,
generational and cultural backgrounds often perceive health differently. It is important to note however, that
migrants typically live between two cultures – that of their country of origin and that of the new host country.
In addition, healthcare workers also have their own culture, thus acknowledging both sides is important when
planning how best to achieve cultural sensitivity in health service development.
Migrant cultures are often complex and not always generalisable but all people are likely to appreciate
healthcare workers who know and respect their traditions and show and informed interest in their country of
origin. Although there is variety of cultural and ethnic groups in Coventry, large communities from particular
countries have settled in the City – thus it is possible for service providers to focus on the needs of particular
groups.
60
Recommendations include:







A City-wide commitment to valuing and respecting diversity ( a sensitivity to diversity) needs to be
prioritised and upheld at both individual and organisational levels
Cultural competence should be integrated into all aspects of health and social care
Systematic training and the dissemination of knowledge and development of skills and attitudes in
cultural competence and social contexts in which the City’s migrant communities come from and live
currently - for healthcare workers, policy-makers, managers, researchers, community and social
workers
To ensure all staff receive training in the skills to work with interpreters
To ensure Equality and Diversity training programmes address the issues that concern migrants with
the aim of improving knowledge and understanding and reduce discrimination and prejudices
Develop genuine respect for other cultures across the health system and an awareness of differing
health behaviours across cultures
Diagnostic criteria developed for in a western context may not be appropriate for use in certain
cultures – while altering the way existing diagnostic methods are applied or developing new methods
of diagnosis or management may not be feasible at this stage, methods to supplement these issues
such as “cultural interviews,” particularly during mental health consultations need to be adapted.
Providing more culturally sensitive services, employing advocates who understood various migrant cultures,
educating service providers more fully about culturally sensitive issues, and beginning to raise these issues
with the community through third sector organisations would ensure a strong start in Coventry’s commitment
to respecting and responding to diversity.
6.8 E VALUATION AND A UDIT
An evaluation of current work streams and projects that are currently being commissioned to ensure resources
are being used effectively and efficiently and make the case for mainstream funding where there is evidence of
improved outcomes could be considered. This could ensure there is no restriction of access to primary care
walk-in centres.
6.9 S USTAINABILITY AND COMMUNITY ASSETS
Issues regarding the adoption of targeted service-provision or population-wide approaches have both
advantages and disadvantages. In the City, separate service provision for migrants is apparent to some degree
e.g. Meridian Health Centre which concentrates and ensures appropriate expertise and culturally sensitive
staff are available to assist migrants and asylum seekers. However, these separate services may be harder to
access for many migrants and not offer a full range of services. Migrants are dispersed quite widely across the
City with varying groups and varying needs. Thus, population-wide adaptation of services to diversity is
preferable. As described in previous chapters, Coventry is a highly diverse population with a growing need for
culturally responsive services across the City.
61
The following recommendations aim to address these issues:


Existing or potentially effective voluntary and community-led interventions should be sought after,
acknowledged and incorporated into policy – These groups often carry out essential tasks of providing
services for groups not provided for, with excellent accessibility and engagement with migrant
communities
Coventry City Council and Public Health could consider evaluating current community work streams to
ensure resources are being used effectively and efficiently and make the case for mainstream funding
where there is evidence of improved outcomes.
An ideal system would be to combine the strengths of community groups and voluntary organisations with the
resources, sustainability and accountability of the public health system. Good practices alone are not enough –
they need to be embedded in policy.
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7. CONCLUSIONS
Migrants contribute to economic prosperity, diversity and tolerance within Coventry – the contributions of
which are visible in the City. National evidence suggests that public services would struggle without the
contribution of migrant workers to fill skilled and unskilled labour shortage gaps - including those in health and
social care. These positive elements of migration are often overlooked (particularly in the media) and need to
be emphasised and celebrated in order to tackle and disband discrimination and develop a culture of
respecting diversity in the City.
This assessment has utilised best available evidence to provide a platform from which further work may
progress. Information from national and local research suggests that migrants currently experience
inequalities in health leading to poorer health and wellbeing outcomes. The inequalities are exacerbated in
part by language difficulties, problems in accessing work and other public services, lower incomes, poor
housing, as well as the negative impact of intolerance and discrimination.
The Council, working in partnership with other public, voluntary and community-led services has a clear role in
reducing health inequalities and evidence-based, sustained action must be taken to overcome existing health
inequalities. The development of a Migrant Health Task Group would be well placed to advance these
recommendations and continue advocating for the health and wellbeing of migrants.
During this work; stakeholders, voluntary organisations, community groups and community members have
come together to drive this work with the aim of improving health and wellbeing in local migrant and BME
communities. The commitment, energy and passion with which these groups and individuals have contributed
are sure signs that, not only is this an important cause but also that the strengths and skills necessary to
achieve improvements are locally available and highly commendable. Changes to support delivery of these
recommendations and improvements should be integrated into mainstream health services, embedded into
policy and sustained by local communities.
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ACKNOWLEDGEMENTS
The Public Health Department of Coventry City Council has led the production of this Health Needs Assessment
of Migrant Health with strongly supported by Coventry City Council. The author was supported and advised by
a working team within Public Health: Sam Hewitt, Olivia Taylor, Tanya Richardson and Khadidja Bichbiche with
overall guidance and support from Jane Moore and Cllr Gingell.
The author of the report is indebted to people from a number of organisations across the City and the West
Midlands. All have freely given up time and offered support, advice and expertise. The list below details those
who contributed to the provision of data and provided comments to inform the final version of this report.
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
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Sam Hewitt who contributed information to the section on entitlements to NHS care and the
provision of translation services in Coventry
June Morley for her valuable expertise and the provision of New Communities data
Dr Allison Callaway for her time, knowledge and provision of information on the needs of asylum
seekers and refugees and wonderful compassion on this issue
Helen Shankster for sharing population data and information
Anne Hartley for data analysis and data mapping
Harjeet Matharu and VAC for their dedicated support and for hosting and organising the community
and provider workshops
All those present at the Coventry Mental Health for Migrants Seminar (20 June 2013) who shared
their knowledge, data and experiences – in particular Ric Bowl, Dr Alexandra Cooper and Dr Simon
Goodman
Farhana Darwich and Dave Newall from the West Midlands Migration Strategic partnership for their
advice and expertise
Diane Steiner on her invaluable advice on migration data sources
Sally Greatrex for her wholesome inspiration and initiation of this work
Inger den Haan, Noreen Bukhari and Luda Ruddock for their expertise and incredible inspiration
Debbie Crisp for her valued insight on TB in Coventry
Colleagues from a number of regions across the country who provided local insights and shared
information (including PHE Birmingham, Public Health Devon and NHS barking and Dagenham)
A special word of thanks is extended to all the stakeholders, community and voluntary groups and committed
individuals who attended the workshops and provided valuable input throughout the process of the needs
assessment – without you this work would not have been possible.
64
APPENDIX
A PPENDIX 1: A CCESSION 8 C OUNTRIES
Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Slovak Republic, and Slovenia plus Malta and
Cyprus (not Accession 8 countries) and in 2007 two more A8 countries were added i.e. Bulgaria and Romania.
65
A PPENDIX 2: C OVENTRY MIGRANT H EALTH CONSULTATION
QUESTIONNAIRE
Name of Provider/Organisation:
Postcode:
How many communities do you work with?
Please state the communities (according to country of origin) that you work with:
Please describe the service/s you provide?
1) What do you perceive to be the biggest health problems in this migrant community(s)
(please insert name of community, add specific health problem and add further communities if
necessary)?
2) How aware are the community(s) that you work with of available health services (please
insert name of community, tick awareness as appropriate and add further communities if
necessary):
3) How aware are the community(s) that you work with of available social care services
(please insert name of community, tick awareness as appropriate and add further communities if
necessary):
4) Please specify any issues regarding health services and access to services (by community)?
5) What other issues impact the lives of migrant community(s) you work with (e.g.
education, housing)?
6) What assets/strengths are you aware of within migrant community(s)?
7) What improvements/recommendations would the community(s) suggest to improve daytoday living in Coventry (by community)?
66
A PPENDIX 3: C OMPARATIVE ASSESSMENT OF R EGIONAL MIGRANT HEALTH
NEEDS AND RECOMMENDATIONS
Title
Region
Health Needs
Assessment of Migrant
Workers in Devon
(2010)
Devon
Nottingham Joint
Strategic Needs
Assessment: Asylum
Seeker, Refugee and
Migrant Worker (2010)
Nottingham
Main conclusions
 Recommendations cover interpretation issues,
intelligence, access to services, training, protocols and
evaluation. The report also emphasises the importance
of engaging and involving migrant workers in taking
forward the recommendations.






Report documents the difficulties migrant experience in
accessing healthcare services due to a number of
barriers, including poor understanding of the role of the
NHS, language and healthcare entitlements, particularly
in accessing mental health services which may be a
priority in this population
Lack of interpreting services to cover out of hours
services
Poor ethnicity recording amongst some services
High rates of communicable diseases (HIV, TB,
Hepatitis)
Lack of a standardised approach to assessing individuals
for social
High smoking rates amongst some EU migrant groups.
Minority Ethnic Health
and Well Being: Needs
Assessment in Dumfries
and Galloway (2005)
Dumfries and
Galloway
Key recommendations include:
 Provide mandatory training on best practice regarding
language support, and what the processes are within
the organisation to ensure interpreting and translation
services are provided
 Implement a policy whereby all patients or service
users are asked a question at point of contact regarding
their access and support needs. This will not only allow
language support to be provided but also other
arrangements such as longer appointment times
 Training for reception staff in all service areas.
Migrant Health Scoping
Report: East of England
Regional Assembly
Strategic Migration
Partnership (2010)
East of England
Issues raised included:
 Poor registration ad issues with access to primary care
services
 Biggest barrier to accessing services was issues with
translation and interpretation
 Increased need for maternity care in this group
 Mental health issues linked to migration
 Unaccompanied asylum seeking children
 Robust and comprehensive data regarding new migrant
communities was limited
67
Understanding the
health needs of
migrants in the South
East region (2010)
South East
Recommendation covered the following areas:
 Provision of better information about the range of
health services for migrants
 Improved understanding of roles of health and social
care in meeting needs of migrants
 Improved health intelligence documenting variables
relevant to migration
 Joint working to ensure range of social issues addressed
 Language and translation issues.
Health Needs
Assessment of the
Nepali Community in
Rushmoor (2010)
Hampshire
Priority areas as follows:
 Patient education and enablement
 Safe access to services
 Further research on health in this community and
prevalence of diseases
 Specific service developments including TB nurses,
substance misuse and immunisation.
An effective health
response to meeting
the needs of migrants
in Yorkshire and the
Humber (2008)
Yorkshire and
the Humber
Key health issues identified:
 The impact on community health services which are
already struggling to serve poor and disadvantaged
communities
 The need to establish new forms of service that have
strong links with other agencies such as housing,
advice, employment
 The need for specialist language services and skills in
working with fast moving transient populations
 Skills in working with diverse cultural groups who may
have very different views about health and health
services.
Health and Social Care
Needs Assessment of
Eastern European
(including Roma)
individuals living in
Barking and Dagenham
(2010)
Barking and
Dagenham
Recommendations focussed on:
 Language barriers
 Working with the third sector
 Training and supporting receptionist staff
 Specific inequalities experienced by the Roma
community
 Trauma and associated impacts among people from
Albania and Kosovo
 Mental health, healthy lifestyles and health promotion
Migrant Health in North
East England (2011)
North East
Key recommendations:
 Information on migrant numbers needs to be better
used by commissioners
 Support facilitative role of The Migrant Health Group
68




A lead responsibility for migrant health should be
established
Commissioners should review commissioned services
and their adequacy in areas identified by report
Public Health bodies should ensure that public health
work on issues such as smoking, alcohol and obesity
makes appropriate provision for migrant populations
Health and Wellbeing boards should consider the
health needs of small and vulnerable groups such as
asylum seekers and trafficked people.
69
A PPENDIX 4: L ANGUAGES S POKEN B Y COVENTRY S CHOOL P UPILS
A range of first languages are spoken by Coventry school pupils, which provides an indication of the range of
nationalities of Coventry residents (but note that some languages such as English, French and Arabic are
spoken in a range of countries):
Language
Total pupils
English
Panjabi
Urdu
Polish
Bengali
Gujarati
Somali
Tamil
French
School
Arabic
Swahili/Kiswahili
Shona
Persian/Farsi
Kurdish
Romanian
Hindi
Albanian/Shqip
Chinese
Malayalam
Tagalog/Filipino
Russian
Latvian
German
Slovak
Dutch/Flemish
Pashto/Pakhto
Ndebele
Portuguese
Yoruba
Lingala
Czech
Serbian/Croatian/Bosnian
Other
Not Known #
Primary
School
28016
70.6%
6.0%
3.6%
2.1%
1.8%
1.3%
1.1%
1.2%
1.2%
Primary
0.9%
1.0%
0.5%
0.6%
0.5%
0.3%
0.3%
0.3%
0.2%
0.3%
0.2%
0.3%
0.2%
0.2%
0.2%
0.2%
0.2%
0.2%
0.2%
0.2%
0.2%
0.2%
0.1%
2.4%
1.3%
Secondary
School
20766
76.0%
5.5%
2.6%
1.5%
1.3%
1.4%
1.0%
0.7%
0.6%
Secondary
0.6%
0.4%
0.5%
0.4%
0.2%
0.2%
0.1%
0.1%
0.2%
0.1%
0.1%
0.1%
0.2%
0.2%
0.2%
0.2%
0.2%
0.2%
0.1%
0.1%
0.1%
0.1%
0.1%
3.6%
0.9%
Special
School
804
79.4%
4.0%
5.0%
0.6%
0.6%
1.1%
1.1%
0.6%
0.7%
Special
0.4%
0.2%
0.2%
0.0%
0.1%
0.2%
0.1%
0.0%
0.0%
0.1%
0.0%
0.1%
0.4%
0.1%
0.2%
0.0%
0.0%
0.0%
0.2%
0.0%
0.1%
0.1%
0.2%
1.7%
2.0%
All Schools
49586
73.0%
5.8%
3.2%
1.9%
1.6%
1.3%
1.1%
1.0%
1.0%
Schools
0.7%
0.7%
0.5%
0.5%
0.4%
0.3%
0.3%
0.2%
0.2%
0.2%
0.2%
0.2%
0.2%
0.2%
0.2%
0.2%
0.2%
0.2%
0.2%
0.2%
0.1%
0.1%
0.1%
2.9%
1.2%
70
A PPENDIX 5: LIST OF BILATERAL HEALTHCARE AGREEMENT COUNTRIES AND
EEA MEMBER STATES
EUROPEAN ECONOMIC AREA COUNTRIES (EEA):
Austria, Belgium, Bulgaria, Cyprus (Southern), Czech Republic, Denmark, Estonia, Finland, France, Germany,
Greece, Hungary, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Poland, Portugal, Republic of
Ireland, Romania, Slovakia, Slovenia, Spain, Sweden, UK, plus Iceland, Liechtenstein and Norway. Switzerland
by special arrangement
NATIONALS OF, AND UK NATIONALS IN, THE FOLLOWING COUNTRIES:
Armenia, Azerbaijan, Belarus, Bosnia, Croatia, Georgia, Gibraltar, Yugoslavia i.e. Serbia & Montenegro,
Kazakhstan, Kirgizstan, Macedonia, Moldova, New Zealand, Russia, Tajikistan, Turkmenistan, Ukraine,
Uzbekistan.
RESIDENTS IRRESPECTIVE OF NATIONALITY OF THE FOLLOWING COUNTRIES:
Anguilla, Australia, Barbados, British Virgin Islands, Falkland Islands, Iceland, Isle of Man, Jersey, Montserrat,
St. Helena, Turks and Caicos Islands
71
A PPENDIX 6: E NTITLEMENTS TO CARE
6.1.1 MEDICAL GOVERNANCE AND TREATMENT
Anyone can approach a GP practice and apply to register on its list of NHS patients. The practice may choose
to accept or decline their application. An application may be refused if the practice has reasonable grounds for
doing so, but a practice is not able to refuse an application on the grounds of race, gender, social class, age,
religion, sexual orientation, appearance, disability or medical condition. The patient can be asked to complete
a GMS1 form as part of their application to be registered with a practice.
Practices are not required to request any proof of identity or of immigration status from patients wishing to
register. Some GP practices will however also ask to see proof of identity, such as passport, driving licence,
Application Registration Card (ARC), IS96 or a Home Office letter with the patient's name and date of birth, and
proof of address, such as a recent utility bill (gas, electricity, water or landline phone bill) or council tax bill.
Note that not having these documents should not be a reason to refuse registration.
Where a patient applies to register with a general practice and is subsequently turned down the GP must
nevertheless provide, free of charge, any immediately necessary treatment that is requested by the applicant
for a period of up to 14 days (this can vary according to circumstances).
If a GP refuses to register a patient they are obliged to notify the applicant, within 14 days of its decision, in
writing of the refusal and the reason for it.
If a person goes to a GP for treatment whilst visiting the UK and is treated as a private patient then any
prescription would also be private and would have to be paid for privately. If a GP accepts a person as an NHS
patient (either full or temporary) and gives the patient an NHS prescription (FP10) then normal charging rules
apply.
6.1.2 DENTAL SERVICES
As with primary medical care dentists providing NHS care are self-employed contractors with Public Health
England. They cannot turn down an applicant for NHS treatment on the grounds of race, gender, social class,
age, religion, sexual orientation, appearance, disability or dental condition. In applying to become a NHS
patient of a particular dental practice there is no formal requirement to prove identity or immigration status.
Where a person has difficulty in finding a dentist willing to provide them with NHS dental care they should get
in touch with Public Health England to discuss what assistance might be available locally.
NHS dental charges are levied on all those who are taken on as NHS patients unless the treatment is free
(certain NHS dental treatments are free) or the patient is exempt or partially exempt from charges on age,
pregnancy related, or income grounds. Further information is available from NHS choices.
6.1.3 HOSPITAL TREATMENT
Entitlement to free NHS hospital treatment is based on 'ordinary residence' in the UK, not nationality, being
registered with or referred by a GP, or payment of UK taxes or national insurance. Ordinary residence means,
broadly, living in the UK on a lawful and properly settled basis. Some people who are not considered ordinarily
resident in the UK ('overseas visitors') are exempt from charges for NHS hospital treatment under the current
Regulations, but all other patients will be charged for treatment, except that treatment that is 'free to all',
outlined above. Prescription charges may apply for out-patient or day patient treatment.
72
Assessments regarding eligibility for hospital treatment lie with the NHS body providing treatment and most
have Overseas Visitors Managers to do this. They make their assessments in line with the Regulations and
based on evidence provided by the patient.
Anyone who is taking up permanent residence in the UK is exempt from charge. The person should expect to
be asked to prove that they are legally entitled to live in the UK and show that they have moved here
permanently rather than just visiting.
If the person does not have an automatic right to take up permanent residence but has applied to the Home
Office for leave to enter/remain on a settled basis, they will be charged for any hospital treatment up to the
point their application is granted or until they accrue 12 months lawful residence in the UK or are considered
ordinarily except that treatment that is ‘free to all’, outlined above resident here.
All asylum seekers in England who have not had their claim refused (including those who have an appeal
outstanding) are entitled to free secondary health care. Those who have had their claim refused but are
receiving section 4 or section 95 support from the UK Border Agency are also entitled to free secondary health
care.
Eligibility for dental secondary care is as per general eligibility for NHS medical treatment in hospitals.
6.1.4 SPECIAL GROUPS
V ICTIMS OF HUMAN TRAFFICKING
The 2011 NHS Regulations provide an exemption from charge category for Victims of human trafficking.
R EFUSED ASYLUM SEEKERS
Registration with primary care in England, Wales and Scotland as outlined above applies to refuse asylum
seekers as for any other patient regardless of immigration status. In England only those refused asylum
seekers that receive section 4 or section 95 support from the UKBA are entitled to free secondary health care,
but all refused asylum seekers can continue, free of charge, with any course of treatment already underway
before their application was refused.
V ISITORS FROM BILATERAL HEALTHCARE AGREEMENT COUNTRIES AND THE E UROPEAN E CONOMIC A REA (EEA)
People who are visiting the UK from a country which has a bilateral healthcare agreement with the UK are
exempt from charges for NHS hospital treatment in England, if the treatment is needed promptly for a
condition that arose, or acutely worsened, after their arrival in the UK.
Furthermore, people from European Economic Area member states and Switzerland are also exempt from
charge for treatment for chronic conditions, including routine monitoring, but must show a valid European
Health Insurance Card (EHIC) or a Provisional Replacement Certificate. In neither case is pre-planned
treatment included free of charge without special, prior arrangement.
In the UK, the EHIC provides access to free medical treatment which is seen, by a medical professional in the
UK, to be clinically necessary and needed before the patient’s planned return to their home country. Visitors
are also covered, with an EHIC, for the treatment and routine monitoring of pre-existing conditions.
The UK has recently put infrastructure in place to allow NHS trusts to submit EHIC and treatment details to the
Department for Work and Pensions. This enables the UK to claim back the cost of the treatment provided
from the patient’s home member state. As this system is currently being trialled for primary care, submission
73
of these data is not currently required by GPs. GP practices are however, still requested to ask to see the card
when a patient from an EEA member state requires treatment.
The card does not provide cover for the cost of medical treatment where that is the reason for the patient
being in the UK. Residents of EEA member states should speak to the authorities in their home country if they
wish to come to the UK specifically to receive treatment.
A list of bilateral agreement countries and EEA member states is included in the appendix.
6.1.5 DATA SHARING - SECTION 55 DATA PROTECTION ACT
Health professionals are under no obligation to share personal medical data on patients, even if requested by
other government agencies. In some circumstances, doing so could be a violation of a health professional's
obligations under the Data Protection Act and duty of confidentiality. The NHS can however share information
about overseas debtors with the UKBA. Overseas visitors are informed as a condition of receiving treatment
that information may be disclosed to the UKBA if the patient does not pay for any treatment received and that
this may prevent them from being able to enter the UK at a future date.
74
A PPENDIX 7: C OVENTRY I NTERPRETATION AND T RANSLATION SERVICES
Many different communities have settled in Coventry in recent years. The largest numbers include
representatives from Polish, Nigerian, Somalian, Cameroonian, Chinese and Roma communities. There are
over 100 languages currently spoken in Coventry. Language Interpretation is the facilitating of oral or signlanguage communication, either simultaneously or consecutively, between users of different languages.
Translation is the transferring of test from one language to another, conveying a clear and concise message.
The legal framework for using interpreters is detailed in Box 1.
Race Relations Act 1976 Section 71
 Places a duty on local authorises to eliminate unlawful racial discrimination and to promote equality
of opportunity and good relations between people of different racial groups
Mental Health Act 1983 section 13
 Requires an Approved Social Worker to interview in a ‘suitable manner’ which means that due regard
should be given to a person who does not speak English or for whom English is a second language
The Children’s Act 1989 clause 22 (c)
 Places a duty on local authorities in relation to looked after children, to give due consideration to the
child’s religious persuasion, racial origin, cultural and linguistic background
Box 1 Translation service utilisation legal framework.
The role of the interpreter is to:




Facilitate communication between the practitioner and the service user
Ensure that each person’s reactions and feelings are made explicit and difference in culture, race and
relationships are understood
Ensure the practitioner is aware if the service user is failing to understand words/ concepts
Ensure that if written text is given to the service user, the interpreter should check they can
understand it
The interpreter is not authorised to act as an advocate or representative for the service user.
75
A PPENDIX 8: LIST OF S ERVICES P ROVIDED BY COVENTRY W ALK - IN AND
H EALTHCARE CENTRE





























Clinics and services that are available in the centre are:
Alcohol and drug misuse service
Anticoagulation monitoring*
Breast feeding advice
Cervical screening*
Child health surveillance*
Chlamydia screening;
Contraceptive services and pre-conceptual advice*
Counselling*
Diabetes services
Health screening
Heart failure
HIV screening*
Intra-uterine contraceptive device fitting*
Learning disabilities
Lifestyle advice and disease prevention
Long term mental health support
Maternity care
Mild to moderate depression intervention
Minor injuries
Minor surgery*
Osteoporosis
Phlebotomy
Sexual health
Smoking cessation support
Supporting people with long-term mental health problems
TB screening*
Vaccinations and immunisations*
Wound management.
* Services requiring prior appointment
76
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