This is an excerpt from the WPG response to the Refugee Integration Strategy Draft Consultation.
“Black, [Asian] and Minority Ethnic (BME) communities are generally considered to be at increased risk of poor mental health (Bhui and McKenzie, 2008; UK Department of Health, 2011; Fernando, 2012) and frequently have less confidence using available services (Rooney, 2013).”[1] Furthermore, Black, Asian and minority ethnic people living in Northern Ireland are at a heightened risk of discrimination and racist hate crimes in Northern Ireland.[2] Prejudice and hate crimes impart a significant psychological toll on victims. Any attempt to address the mental health needs of the Black, Asian and minority ethnic community in Northern Ireland needs to encompass a strategy to combat racism, particularly institutional racism in the health care system.
Some of the identified challenges to minority ethnic and migrant communities accessing mental health services include language barriers, discrimination, difficulty with GP registration and other aspects of accessing care and the stigma associated with accessing mental health services.[3] Further, the culture and power dynamics of psychiatry – a field dominated by white men – can be off-putting to BME people attempting to access care.
A report commissioned by Migrant Centre NI and the Black and Minority Ethnic Women’s Network found that a substantial minority (34.7%) of migrant women surveyed did not know or were unsure of what healthcare they were entitled to under their immigration status.[4] Though there is interpreter provision available through the NHS, in practice some women report that they are not always provided with interpreter services even upon request and 16.6% of BAME women surveyed report being unable to adequately express their needs to their healthcare provider. Black African and Caribbean Women rated their experiences of healthcare among the most negative of all respondents.
These women, compared demographically to the rest of the group, represented a lower proportion of English speakers, a higher proportion of refugee and asylum seekers, higher rates of unemployment, lower household income and lower levels of educational attainment. This is illustrative of the impact of systemic racism and anti-Blackness to account for even starker levels of health inequalities for Black African and Caribbean communities.
Refugee and asylum seekers reported additional health needs related to the trauma of persecution and fleeing their countries of origin which are not adequately addressed by local health providers due to lack of awareness, lack of resourcing, perceived discrimination, or the barriers outlined above. Women with no or low levels of formal education reported the highest levels of need compared to the group, particularly the need for interpreter provision, being able to communicate healthcare needs, comfort with exclusively seeing a female GP, comfort expressing women’s health issues and unmet healthcare needs, in particular, gynaecological and sexual healthcare needs. Women who took part in the survey made specific reference to community organisations who helped them to access care including GP registration and assistance with appointment scheduling, highlighting the importance of adequate funding and resourcing for organisations doing this work.
Health outcomes for Traveller communities in Northern Ireland are among the worst in the country, illustrating severe disenfranchisement and systemic neglect. A report completed by Strabane Access Youth Engagement commissioned by Migrant Centre NI found that health outcomes in Traveller communities were not only lower than those in the general population but also compared to those in other socially deprived areas.[5] 33.5% of all respondents surveyed reported their health as “poor” or “very poor.” 89.5% of respondents indicated that at least one person in their household has a disability or limiting long-term illness. Irish Travellers are nearly seven times as likely to die by suicide than the general population. From a gendered perspective, there are severe inequalities in maternal healthcare, with Traveller women experiencing significantly higher rates of miscarriage, stillbirth, neonatal deaths as well as maternal deaths during and shortly after pregnancy.
A conservative estimate of life expectancy gaps between Traveller women and settled women shows that Traveller women’s life expectancy is 12 years shorter. Barriers to healthcare include discrimination by GP surgeries to require proof of permanent address to register, inadequate or inappropriate public health outreach, awareness, and education to meet the needs of Traveller communities experiencing higher levels of illiteracy, anticipation of discrimination and a lack of cultural awareness on the part of healthcare providers. These barriers are embedded within broader social frameworks of systemic discrimination and socio-economic disenfranchisement of Travellers.
It is also the case that, should an individual have a negative experience in accessing mental health care or any kind of health care, they will be unlikely to engage in the future. The lack of cultural competency on caring for BME people, widespread language barriers and the UK Government’s hostile environment policy have ensured that these off-putting negative experiences happen more often to people of colour accessing services, to the detriment of community health.
Members of the migrant community, particularly those without secure immigration status may be put off from accessing healthcare for themselves or their families during COVID-19 because of the continued operation of ‘hostile environment’ measures which have the NHS sharing migrant data with the Home Office. This impacts some of the most vulnerable women in society such as pregnant women, victims of trafficking and domestic violence and persons living with HIV.
The history of data sharing between the Home Office and the NHS differs across the UK. In England a 2016 Memorandum between the NHS, English Department of Health and Social Care and the Home Office previously allowed the Home Office to request confidential patient information for immigration enforcement purposes, including for minor immigration infractions.[6] This Memorandum was halted in November 2018 following condemnation from a Health & Social Care Select Committee inquiry and legal action taken by Migrant Rights Network, represented by Liberty.[7] UK wide data sharing continues between the NHS and the Home Office regarding migrants who have incurred a debt to the NHS.[8]
Migrant women and mothers are specifically targeted and harmed under the UK’s hostile environment immigration policies. Utilisation of the NHS to document and report patients’ immigration status discourages women to access care, important medical screenings and specialist services (including prenatal and antenatal care) or report domestic abuse.[9] Women not considered “ordinarily resident” in the UK, including those who are undocumented or are awaiting an asylum decision, do not have their maternity care costs covered under the NHS. Reports exist of asylum seekers being told that debts incurred to the NHS for maternity services will be used against them in decisions on the outcome of their asylum claims[10][10]. Xenophobic rhetoric targets migrant mothers specifically, with the UK government and media stoking fears of “heavily pregnant” migrant women using the NHS en masse despite no empirical evidence to support this. NISRA figures for 2019 show that just under 11 per cent of births were to mothers from outside Northern Ireland, the UK and Ireland; this figure has stayed relatively stable since recording began in 2009.[11]
NI legislation such as the Provision of Health Services to Persons not Ordinarily Resident Regulations (Northern Ireland) 2015 does not embed hostile environment practices in the same manner that equivalent English legislation does. However, data sharing related to migrants who have incurred debt to the NHS does apply to treatment received in Northern Ireland.
The Health Minister Robin Swann publicly said in a debate on 24 March 2020 that data on migrants/Asylum seekers accessing treatment for COVID-19 would not be passed on to the Home Office. At the same time, he also gave a (clearer) assurance that treatment would be free to everyone. This was later backed up by a response from the Minister to a written question from Gerry Carroll MLA (AQW 3899/17-22), which was answered in May 2020, almost two months after the question was first tabled. While these assurances are welcome, the atmosphere of fear created by the hostile environment policies means that this is not enough to ensure migrants will seek treatment. At no point has this information been widely publicised by the NI Executive or another public authority. A public information campaign would have allayed the fears of many migrants.
A different approach was taken in the Republic of Ireland where Simon Harris TD gave a clear, widely reported declaration at the start of the crisis that all people, documented or undocumented, could access health services in Ireland without their details being passed on the Department of Justice and Equality.
It is crucial that all persons in Northern Ireland, including migrants living here without immigration status, feel safe contacting health services to report COVID-19 symptoms and to seek advice. It is not enough to remove charging practices without also making it clear that no person’s data will be shared with the Home Office during the crisis. With the statutory basis for data sharing practices in Northern Ireland unclear and healthcare a devolved competence, it is within the power of the NI Executive to take action to address this issue.
There has also been a lack of clarity regarding access to the vaccination programme for people living in Northern Ireland without status. It appears clear from the regulations that there are legal entitlements to all persons to receive health services – including vaccines – relating to COVID-19 for free (with the sole exception of persons travelling for vaccination).[12] However, this is not always reflected in practice. There is evidence of individuals being informed that there are British citizenship requirements for vaccinations. This may be an isolated case but a systemic problem also relates to booking on the HSC COVID-19 online portal which asks questions regarding GP registration and place of residence.[13]
People who cannot answer yes to questions on GP and residence are then told that they are not eligible. Anyone who is told they are not eligible for the vaccine is then advised to email if they ‘still think’ they are eligible. The process is confusing and requiring people to follow up themselves is not appropriate. Online guidance on eligibility is also unclear stating the vaccine is available ‘If you live in Northern Ireland and are entitled to treatment by the Health Service’.[14] This statement is misleading as many migrants will not be eligible for all healthcare and others will pay fees, which may lead them to believe they aren’t eligible for vaccination. Further, there does not appear to be guidance on vaccine eligibility available in languages other than English.
A lack of clarity on access to vaccines will prevent people accessing the programme and undermines public health. Clear messaging is particularly essential for members of the migrant community who may have been restricted from accessing healthcare previously and who may have a fear of coming forward due to hostile environment practices. A clear public statement from the Department of Health is needed to confirm that all persons can access the COVID-19 vaccination programme, regardless of status and that no data on people accessing vaccines will be shared with the Home Office.
Article 12 of the International Covenant on Economic, Social and Cultural Rights provides the right of everyone to the enjoyment of the highest attainable standard of physical and mental health and includes steps which should be taken by states to achieve this.[15] The UN Committee on Economic, Social and Cultural Rights has clearly stated that this obligation also applies to migrants with or without status.[16] The right to health and wellbeing is also found in Article 25 of the Universal Declaration of Human Rights. Therefore, removing barriers to access to healthcare is an approach grounded in human rights.
[1] Institute for Conflict Research (December 2015)
‘Waking this thin line Report’ Black and Minority Ethnic (BME) Experiences of Mental Health Wellbeing in N.Ireland (conflictresearch.org.uk), https://bit.ly/2TYhkei
[2] BBC News Northern Ireland 12 June 2020 ‘Racism: More than 600 hate crimes reported to PSNI’, https://bbc.in/3qkQrgK
[3] Institute for Conflict Research (December 2015) ‘Walking this thin line Report: Black and Minority Ethnic (BME) Experiences of Mental Health Wellbeing in N.Ireland’, https://bit.ly/2TYhkei
[4] Austin, J. (2017) ‘Ethnic Minority Women’s Access To Quality Healthcare In Northern Ireland,’ Migrant Centre NI and Black and Minority Ethnic Women’s Network.
[5] Strabane Access Youth Engagement (2018) ‘The Needs and Issues of the Traveller Community in Northern Ireland,’ Migrant Centre NI.
[6]Memorandum of Understanding between Health and Social Care Information Centre and the Home Office and the Department of Health (came into effect January 2017, subsequently withdrawn)
[7] Liberty press release, Legal victory against Government’s hostile environment (November 2018)
[8]Department of Health & Social Care (March 2019) Overseas chargeable patients, NHS debt and immigration rules,https://bit.ly/3gRZmn4
[9] Equality and Human Rights Commission (2018) The lived experiences of access to healthcare for people seeking and refused asylum, https://bit.ly/2U1x5S4
[10] Coddington, K. (2020) Incompatible With Life: Embodied Borders, Migrant Fertility, and the UK’s ‘Hostile Environment, , Politics and Space, 0 1-14. https://bit.ly/3vV6X8u
[11] NISRA (December 2020) Registrar General Annual Report 2019, https://bit.ly/3wQLHSt
[12] UK Government (2020), The Provision of Health Services to Persons Not Ordinarily Resident (Amendment) Regulations (Northern Ireland) 2020, https://bit.ly/35JyOOi
[13] Get Vaccinated | COVID-19 (Coronavirus) Northern Ireland
[14] Am I eligible to use the vaccine service? | Guidance | COVID-19 (Coronavirus) Northern Ireland (hscni.net)
[15] International Covenant on Economic, Social and Cultural Rights (adopted December 1966)
[16] CESCR General Comment No. 14 (August 2013)
