The latest figures estimate that in 2009 11% of the UK population had been born abroad,1 representing an increase on the 8% recorded during the 2001 Census.2 India, Poland, and Pakistan were the top three most common countries of birth for migrants living in the UK in 2009, but in London the largest groups among those born abroad were African-born (just under a quarter in both inner and outer London) and European-born (a quarter in inner London and a fifth in outer London).1 The largest number of new long-term migrants over the last 5 years has come from the European Union (the majority from the original EU-15 countries).3
Most migrants have come to the UK to study or work,3 but some are more vulnerable, such as those who are seeking asylum, unaccompanied children, and those who have been trafficked. Although the majority of migrants have few health problems, some will have health needs that are different from those of UK-born patients.4 There are many influences on health and these can include exposures and experiences in someone's country of origin, during the migration process itself, as well as their living conditions once they have arrived in the UK. In addition, cultural practices and ethnicity can influence health throughout someone's life
CONSULTATION RESOURCES
When a migrant patient presents for treatment within a primary care practice it can be difficult to understand what health issues are relevant to that patient without knowing more about their background and the country they have come from. It is not just the practitioner who can be facing an unfamiliar situation; some migrants may have come from countries with almost non-existent health systems or systems that are very different in the way they operate to the UK GP-led system. A migrant's expectations of healthcare in the UK can be influenced by their experiences of the health system in their country of origin; understanding this can reduce confusion during the consultation.5
Information and resources to help practitioners to care for migrant patients, including country-specific information, have now been brought together in an online resource called the Migrant Health Guide (www.hpa.org.uk/migranthealthguide). The guide was launched by the Health Protection Agency in January this year, and covers a range of relevant topics including infectious diseases as well as other health concerns such as anaemia, dental care, and mental health. The guide indicates which tests are recommended for particular countries of origin. It also explains the entitlements to NHS care and contains links to downloadable materials, such as translated patient information leaflets and language resources
The guide has been designed for use during a standard consultation period, with key messages at the top of each page that can be accessed quickly, and more detailed information lower down the page if time allows. It is endorsed by both the Royal College of General Practitioners and the Royal College of Nursing.
INFECTIOUS DISEASES
The greatest burden of infectious diseases (such as tuberculosis [TB], HIV, and malaria) diagnosed in the UK falls on people who were born abroad, and sometimes opportunities for diagnosis within primary care can be missed. A survey of newly-diagnosed HIV-positive Africans attending treatment centres across London (2004-2006), 50% of whom presented with advanced HIV disease (CD4 cell count <200 cells/μl at diagnosis), found that in the year prior to HIV diagnosis 76% of patients had seen their GP.6
Opportunistic testing for HIV in primary care and the normalisation of this process will hopefully help to reduce some of these missed opportunities for diagnosis. However, this process needs to be ongoing, as between one-quarter and one-third of HIV-positive African residents in the UK, and nearly half of HIV-positive African men who have sex with men, may have acquired their HIV infection in the UK.7
Exposures in a person's country of origin can continue to influence health even after they have settled in the UK. This can take the form of chronic infections such as TB, or exposures during visits ‘home’ to visit friends and relatives. Migrants visiting their country of origin have a different risk profile to other travellers as they typically stay for longer periods of time and live within the local community.8 In addition they can sometimes underestimate their risk of acquiring infections, such as malaria because they may have previously developed some resistance to the disease and do not appreciate that this rapidly wanes after leaving a malaria risk country.
It can be helpful to ask opportunistically about forthcoming travel plans during consultations for other reasons, and to encourage them to come for pre-travel advice before they go abroad as they might not be aware that this service is offered in the UK or of its benefits.
GPs' EXPERIENCES OF USING THE MIGRANT HEALTH GUIDE
At a recent training day for GPs in East London, a GP commented that she had found the Migrant Health Guide particularly useful when treating a family from Somalia because it gave her information about the background situation in that country, as well as information on which health issues were relevant to women and children. She said:
‘It's very helpful to have so much information in one place, which I can quickly access during a consultation, thereby reducing the need to bring the patient back. The links to other resources are also very useful.’
The Countries A-Z is the largest section of the guide and provides country-specific information, derived from global prevalence data and the latest national guidance on a range of topics including infectious diseases and nutritional deficiencies, and also health system indicators, such as the proportion of women estimated to have undergone cervical cancer screening. A GP from Tower Hamlets said:
‘I appreciate the intuitive layout of the website … Our healthcare assistant often uses it in new patient checks to alert us and the patient to possible specific health needs; for example, screening for particular infections.’
PROVIDING INDIVIDUALISED CARE
Each patient also has their own set of health beliefs which may or may not reflect those of their culture, so exploring this with the individual can be important. Where language is a barrierthis may be necessary through an interpreter. In this situation it can be helpful to refer to the agreed principles of good practice which are outlined on the UK Screening Portal website.9 These include the importance of using short, specific, clear sentences when communicating, and of addressing the patient rather than the interpreter.
Many healthcare workers in primary care may find information of relevance to their work in the Migrant Health Guide; this could include practice nurses running vaccination clinics or healthcare assistants performing new patient checks. Having robust information about the country of origin of all patients in your practice may be useful in ensuring that some aspects of care (such as targeted screening of HIV or TB or vaccine updates) can be comprehensively covered.
The NHS registration card records country of origin, but this is not always translated into the electronic patient record. Modification of the electronic patient record to record and display this information would be a useful approach to facilitate prompts to use of the Migrant Health Guide and of clinical pathways, and to audit practice.
Acknowledgments
We'd like to thank Dr Angela Burnett, GP at the Greenhouse Practice in Hackney and lead doctor at Freedomfrom Torture (formally the Medical Foundation for the Care of Victims of Torture), and Dr Keith MacDonald, GP at Health E1 Practice in Tower Hamlets for their comments.
Notes
Provenance
Commissioned; not externally peer reviewed.
- © British Journal of General Practice 2011