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Migrants and healthcare: educating tomorrow’s doctors for a global challenge (Dr Anita Berlin)

Good Afternoon and welcome
to today’s lunchtime lecture. I’m Professor Paul McMillan, I’m one
of the lunchtime lecture committee. I’m your host for today. If you could first make sure
that you switch off your phones so that we don’t interrupt the lecturer. Welcome to any audience members who are viewing us online. We’re accepting Twitter feeds and also contact via Slido and so the Twitter feed
is given on the screen here and the event code for Slido is 5586. Our speaker today is Dr Anita Berlin from the UCL Primary Care
and Population Health unit. Today she is going to be telling us
about migrants and healthcare. Thank you. Thank you very much, I hope the microphone reaches the back. Hello and as Professor McMillan said
my name is Anita Berlin, I am senior lecturer here at UCL and
I also spent 20 years as a GP in London. I’d like to start with a story. Miriam is in her early 20s and a year ago she escaped from the
barracks where she had been conscripted in the African country
in which she had been born… She had been regularly beaten
and abused. She managed to get over a border into
Libya and across the sea and into Italy. In Italy, she slept in parks and one night she was raped
by a gang of men. Undeterred she continued
on her journey to Calais with the hope of reaching
London eventually where she was going
to seek out an old friend. From Calais by sheer determination
she managed to smuggle her way… Can you turn the microphone on? Is it on? Is that better? That’s better. Sorry. Miriam now arrived in London
but there’s no old friend. She sleeps on a park bench and after
days of no food and little to drink, she collapses in front of a church. She’s taken in
by one of the parishioners and the parish takes responsibility
for her for a little while. They try and register her with a GP. She’s not very well,
they try two practices. By now she is 29 weeks pregnant. They learn about the ‘Doctors
of the World’ clinic in Bethnal Green where they take her. There began the process of the social
and legal support for the asylum claim and they refer her to hospital for a
chest infection and her antenatal care. I’d like to leave Miriam’s story there
for a moment because I want to use that
as the context, or to build the context for
some teaching that we do here at UCL under the banner of
‘the global is local’. About two years ago we realised
that it was in urgent need of updating. For the purpose of this lecture,
I’m going to spend quite a bit of time looking at the context of the way
in which two crises have been framed, the NHS and migrants, look at the policy responses to these, some of the facts that underpin
the current situation in order to build a case
for what we did in the teaching. And pose some questions
about what more we could do. I’m going to interweave
three case studies into my lecture which are the ones
we used in our teaching. Of course, you must bear in mind
it is a composite – names have changed, details have changed in order to
protect people’s identity. In order to look at context, I think it’s important for us to realise
that one of our greatest challenges was how to teach a topic
that has become highly politicised. I’ll introduce the idea of framing. Framing and frame analysis
is used in the social sciences and in Media Studies extensively, and we all use frames. Frames are structures which we use
to hold and shape our view of the world. They are ways of communicating
predetermined messages. Individuals use them, organisations use them,
social groups use them, and they’re very commonly seen
reduced into logos and slogans. They are used to inspire, to motivate,
a call to arms, but they’re also used to manipulate, to divide and to deliberately deceive. We all use frames in order to help us
define issues or problems, to assign causal or responsible link, to make moral judgments and then align our moral judgments to
remedies we think would be appropriate. I want to apply the idea of frames
to the 2 key concepts here; which is the NHS and its relationship
with migrants. We are going to start with the NHS. The NHS is considered to be a model
of universal health coverage, which by definition
is free at the point of delivery without financial risk to the users. One of the main frames of the NHS is one of this positive
universal health care system, which is recognised that while we may
have an unequal society here in the UK, it’s a highly equitable way
of delivering healthcare. All the countries of the United Nations
have now signed up to promoting
universal health coverage as a goal within the
sustainable development goals. But we see an emerging new frame
for the NHS which is an organisation in crisis, a service on its knees
that is no longer affordable. Let’s turn to the framing of migrants. This is data from a study by Crawley
and colleagues in Coventry, published recently, where they looked
at all the printed press between January and May 2015, in the run-up
to the 2015 General Election and they identified
three clear frames: the benefits frame, where migrants are seen as contributing
to society and the workforce. The threat or the villainous frame, where migrants are challenging
our economy, our jobs and threatening our security. And the victim’s frame,
a sort of semi voiceless group who are victims of inequality,
discrimination and worthy of our support
and compassion. The relationship between the NHS
and migrants is long and intimate, and it is usual to frame,
or it has been until recently, to frame the relationship
as a very positive one, as a benefit, largely through,
as we see here, it’s sustained through
a diverse workforce. We see this very inspiring image
from the 2012 Olympics Opening Ceremony. Preparing for this lecture, I did
a little bit of simple research myself using a tool called Google Trends. When I looked at internet searches
for immigration, UK immigration
and migrant crisis over the last five years, you can see that there are
broadly four peaks. The first peak corresponds with the 2015
election which is the Crawley’s work. The second peak was at the beginning
of September 2015. This happened to be the day before
our new teaching began. None of you will have forgotten,
I think, this image, of a child washed up
on the Turkish beach. Here we see very clearly
framing of a migrant as a victim. Impossible not to feel compassion, but very much a victim
on a foreign shore. The third peak,
and the little peaks afterwards, all coincide with the Brexit referendum
and the fallout thereof. The final peak was at the very end
of October this year which coincided with the dismantling
of the migrant camp in Calais, and on the day that most newspapers ran the burning of the camps
as a front-page story, the Sunday Express
chose to lead with this story. It’s not possible to work in the NHS
in London for 20 years, without knowing
that people come to the UK to take advantage
of our universal service. There are plenty of expats who come from
places like Torremolinos once a year asking for tests and hospital referrals. There’s no doubt there are package tours
in Nigeria for women to go to the States or come to the UK in the hope
of delivering their babies and perhaps with the promise of getting
a British Passport for their children. The point about this article
is not whether it’s true, but the fact it was chosen to lead on a day when there were other stories
about migration, and it is not a new story, it is recycled. The same story’s been run
either by the Express or The Mail, regularly since 2012. This is the context
in which we do our teaching and in which Miriam
is trying to find health care, where there’s a reframing of the
relationship between migrants and NHS, from a benefit in terms of a diverse workforce to a migrant patient
who is abusing the system and is directly responsible in some large way
to contributing to the crisis. So, we have a crisis on a crisis and we now have
this causal relationship. In addition to that, we need to take into account
in our teaching a policy environment, and the way in which policy towards
migrants and healthcare have changed. Policy makers are always at pains to address the mood, the popular mood with regard to
both migrants and the NHS. Both topics have featured in the top
three issues in popular surveys way back into to the 1980s. The fact that migrants feature
is not new, but it’s the moving of the concept
or the framing of the migrant, from a social problem issue of cohesion to one of a political problem
that needs a political solution. One of the challenges for policymakers is to have a constraining approach
to migration, but one that does not
actually constrain. This is one of the interesting things
that will happen following Brexit, constraining access
to a global workforce for the benefit. Two key policy areas
that were introduced with changes to the Immigration Act
in 2014-15, were firstly the NHS overseas
migrant cost-recovery scheme which applies
currently only to hospitals, and the immigration health surcharge
which is £200. It’s paid for now prospectively at the
point at which people apply for a visa, either to come to the UK to work, or for students who are going to be here
for more than six months. One of the key things here
is to recognise that although this was discussed, GP services remain free and without any restriction to anybody
living in the UK. So we have to ask ourselves, if we go back to Miriam, why could she not access a GP? Remember, when she was taken
by the good people of the church to the GP practice, she was an undocumented migrant; she hadn’t begun her journey
as an asylum-seeker, she had no papers. A very substantial proportion of
undocumented migrants living in London never attempt to access healthcare because of fears of
being reported to the Home Office, detention and possibly
subsequent deportation. Doctors of the World did a study
recently, where they identified that
of those who do approach GP surgeries about 60-percent of them
are denied registration, primarily because there are asked
for documents they don’t have, even though this is not a requirement
in the guidance from the NHS. Secondly, because of the number
of cultural and language barriers. Going back briefly
to the cost recovery scheme, it wasn’t introduced
without any thought. There are a number of exemptions,
which I won’t go through in detail, however, this is clearly a focus for
teaching for senior medical students prior to them becoming junior doctors. But what I would stress, is that there is considerable amount
of clinical judgment required in interpreting these exemptions. Most importantly, if your condition does
not appear in the list of exemptions, you will be asked to guarantee
you can pay, prior to your treatment beginning. However, if your condition is deemed
urgent or immediately necessary, which are clinical definitions, your treatment cannot be delayed
until such a time that you can guarantee that
you can provide the funds. It is important that students understand
how those clinical decisions are made. There are also a number of groups
who are exempted; those who are in the process
of seeking asylum, refugees with leave to remain, survivors of trafficking slavery, FGM and migrants who have arrived
due to domestic violence, who are all in the national
referral mechanism for migrants and modern day slavery. However again you should note,
that that extends only for 45 days, until the individual,
either decides to be repatriated or makes an asylum claim. Finally, this is very small number of
refused asylum seekers who are exempted, but it is a tiny number. You should also note that 50% of all asylum claims in the UK
are turned down. One of the important things
also for students to understand is particularly within the groups
of those who’ve been trafficked or who are victims of slavery, is that they may access health care but they may come with their masters and they may not often
be able to disclose that they have been held under duress,
they may not have a lot of insight, and careful history taking is actually an important part of
understanding the clinician’s role. Just some very quick figures. If this is the predicted total spend
for the NHS for this year, hundred and seventeen billion pounds, this large orange bubble, then the target for the recovery scheme
was less than half a percent – at 500 million, and it has already managed to generate
164 from the surcharge. However, the little green bubble
is what actually has been recouped from treatment costs. 250 million was billed. Only 125 million has been recouped, and the national audit office,
from where I’ve got these figures, predict that 50% that’s not repaid,
will never be repaid because the bills were given to people
who are never going to repay them. The other thing about this system
which the audit office note is that it requires
an enormous machinery to introduce charging and billing into a service that has never had
charging and billing, and therefore it requires
every acute hospital to employ an overseas visitor manager, to train them, and to make sure that the paperwork
and bureaucracy will flow so the billing can take place, which adds considerably. By this time you’re probably
beginning also to think that I’m beginning to sort of muddle
up different groups of migrants here. Let me try and unpack that a bit. We’ve talked about
the voluntary migrants, people who come here either
as students or to work, who have visas and extant passports. We’ve talked about those
who were forcibly displaced and who may be displaced
through conflict, environmental change,
border changes sometimes, violations of their human rights, who come under these categories
that I’ve talked of before. But there’s a growing number, and a grey area between
the recognised force displaced and those who are somewhere in between; the citizens of nowhere, a large group of destitute over stayers, perhaps students who come on a visa and find that their country now
is war-torn, they can’t return, exploited workers who have come
with poor work arrangements, whose passports or visas
are not renewed by their workers. In ‘Doctors of the World’ clinics
the largest single group that attends are Filipinos who have been brought
on domestic visas and who are let go by their employers
and have no passports or visas. The rejected asylum seekers
who still fear returning home are also are in this undocumented group These are essentially people
who are stateless and so where you see now that entitlement to patient-hood
is through a passport, you have to wonder what happens
to people who are ‘citizens of nowhere’. Just to put that on a global scale; 2015 saw the biggest movement of people through displacement ever. 65 million largely displaced internally, 21 million recognised by UNHCR
as refugees. This growing group of people who are
stateless, the citizens of nowhere. To put that in context in London, if we think about the way
this scheme was set up; there are in theory provisions for overseas visitors and students
and for migrant workers. There also is provision
for asylum seekers as long as they’re not refused, refugees and survivors of trafficking
and modern day slavery. I think you will agree it is easy to see
how anybody in any of those groups can slide into the undocumented group, and become potentially excluded
from a health service that in its inception
was intended to be universal. What has happened over the years… The UK has in the past
had a considerable reputation in taking in refugees
and asylum-seekers. There is considerable expertise
being developed by NGOs such as Doctors of the World,
Helen Bamber and ‘Freedom from Torture’
among others. This expertise has been in
recognising torture and the scars of trafficking, both physical and psychological and particularly expertise in
mental health and areas such as PTSD. That expertise has helped
to support people like myself in mainstream public services. However as we see the NHS contract, we see the need for these NGOs to start
providing care and filling gaps. Studies in Germany
and in the UK recently have argued that there is a very strong
economic and health case for treating proactively both forced migrants
and the undocumented migrants, and that delays in treatment pose a risk
to our public health, to all of us, but also increase social inequalities
in health outcomes by leading to preventable illnesses
and premature death. So, we go back to Miriam. Miriam now has attended
three antenatal appointments. She was found to have TB,
which is being treated, and as the midwife
and the obstetrician leave, the Overseas Visitor Manager arrives, and she’s just been told that she has
a condition called placenta previa, which will require her
to have a caesarean section and there may be some complications. The Overseas Visitor Manager
presents her with this price list and indicates the figure at the bottom, which is for people who have
caesarean sections with complications, and tells her she will be issued
with an invoice for £9,700,
once the baby is born. She’s devastated, she’s heartbroken, she doesn’t understand
why this has happened. It turns out that there’s been
very poor record-keeping and communication in the hospital and a health advocate
intervenes on her behalf. So, to summarise. There’s a double crisis, in which migrants are being framed
as a threat to the NHS and there’s a policy response which
requires a significant bureaucracy, sets targets which are low
and not being met, is poorly understood by commissions and it’s actively deterring people
who might develop high health needs and puts all of us at risk. You don’t want you or child
to sit next to somebody with open TB. So, where does this fit
into medical education? It was easy in medical education when we were preparing people
to work for a unit, a monopoly employer,
with the universally free access. Now things are more complicated. Education is taking place
in a new context, and there are new
service models emerging. One of our particular challenges is how
do we impress upon our future students, that they are the architects
of tomorrow’s health system. They are going to be designing
and stewarding the system that you, and your parents and your children
and grandchildren are going to be using. One of the questions they
need to ask themselves is, and this is a quote from Goric Ooms, who is a specialist in migrant law,
and he says “in an increasingly mobile world… how
are we going to provide health coverage on the basis of where we are living,” in terms of our human rights, and not just where we are
in terms of our citizens’ rights. I suppose a question I just briefly pose
to you, reflecting on Miriam’s case; how do you think we should frame
teaching for tomorrow’s doctors? We met with Doctors of the World who
have an education officer, we posed ourselves this question. Why is good access to healthcare
for vulnerable migrants important? We considered that there was
a duty of care to individual patients to at least follow the letter
of the policies, that there was also a wider
public health interest and there was also an important role in not adding to health inequalities. We also considered those issues
related to human rights and citizenship. We discussed whether to draw attention to the mechanics
of the cost recovery scheme. What we actually decided to do
is focus on the public health and the health inequalities issues by looking at individual
health care duties under the banner
of our Global is Local theme. We worked with outside agencies, in our case Helen Bamber Foundation
and Doctors of the World, who gave inspiring
and informative lectures. Then we broke students
into small groups, where we worked our way through
three clinical cases looking at the evidence
about migrant health and outcomes, and appealing to some of the human
skills in relation to communication, so, trying to engage them, their heads and their hearts,
in the learning about cases. What we actually were doing, I suppose,
is following a competency model, where you ensure that students
understand the key exemptions, the clinical aspects
of the cost recovery scheme, that they can then apply those, using their clinical judgment,
to case studies. Perhaps you could say job done,
to quote Lincoln, if you give people the truth,
they can be depended on to meet a national crisis. The great point is that you have
to bring them the real facts. The students have the facts
but is that enough? Let me introduce Jay. Jay was a member of a student
opposition group in an Asian country. He was arrested, tortured and held
in prison in shackles for two months. He was released suddenly and his parents
managed to get him on a flight to London and he was well briefed, he presented himself to an immigration
officer when he arrived and he was interviewed and told to report for a full asylum
screening interview a week or so later. He was met by an elderly aunt that his
parents had contacted at the airport. She was so alarmed by his condition, she took him immediately
to an A&E department where he was seen after a wait
by a very kindly junior doctor who took a lot of interest in him and took his history,
examined him carefully, found that he had long wounds
consistent with burns and he had infected wounds
around his ankles. He gave him antibiotics, told him
he didn’t need to come into hospital but he needed also painkillers,
to register with a GP, to be referred for follow-up
and further care. Jay and his aunt leave,
the doctor writes his notes and as he goes into the waiting room, he sees Jay being led away by the police
followed by his distraught aunt. He finds out later that the receptionist
had called the police believing it was her civic duty
to report an illegal migrant. Later, as Jay told this story to the
doctor doing his medico-legal report for his asylum claims, he said that the four hours
being interrogated in London was almost more traumatic
than two months in a prison at home because it was so unexpected. He thought he’d arrived in a place of
safety where he could trust authority. Some interesting work done
at the University of East London shows that the current climate
and the policy changes are turning a lot of ordinary people
in public facing roles into everyday border guards. This raises questions really about how
students going into the profession may understand
what is happening around them. A study recently published in Stamford showed that students using the internet
searching for news and for studying were unable to make a lot of sense
of what they were reading particularly in topics
that were politically charged. This study was actually done
before the recent issues surrounding the presidential elections, and so they were susceptible to bias and they were unable or they didn’t
regularly check for credibility. They were not good at distinguishing and we know that they were not as good
at distinguishing false news from fact. What I would suggest and what we
will be looking at in our teaching is moving to introduce a more
transformative approach which promotes critical thinking
in our students and gets them to consider
outside the box, a bit more and to develop themselves as advocates,
not just for people like Jay and Miriam, but also for the health system, that they are going
to have to advocate for, what type of NHS
or service that follows that. That’s it. Those are the two areas
that we would want to cover but I would like to say a bit about
my own research into institutions and how they frame their own missions. Universities have key and core missions, one is to generate knowledge
through research and the other is to share knowledge
through education. But they also have choices that they can
make about how they frame themselves in relation to the outside world. And so a question might be: what happens in a university that frames itself
to have a global mission, and does that global mission
have a potential local interpretation? I’d like to tell you very briefly
the last story about Suki. When Suki arrived at a ‘Doctors of the
World’ clinic, she was 18, she had a serious kidney infection. She’d been working in a takeaway and
a customer had brought into the clinic despite the protests of her manager. She had been here 4 years, hardly spoke
any English, didn’t know her address, she had no mobile phone,
no cash, no passport and she had actually been trafficked
into a massage parlour. Her grandmother thinking that she
was coming to the UK to be fostered, had paid a gang master. Suki, with the help
of the Salvation Army, that holds the contract for
looking after trafficked young people, managed to get to school, in a year, she learned English, passed 6
GCSEs, 3 sciences and maths included, and all she wanted to do
is go to university and she hoped that she would become
a pharmacist like her late grandfather. My reflection is, what might a global university
be able to do locally for somebody displaced and who has no social capital, who doesn’t know how
to get into a university, who has no financial backup, who could not raise the funds while
she’s waiting for her asylum claim. There is a loose alliance under the
banner of ‘Refuge in a moving world’ which is organised
by an impressive woman, who did a lunchtime lecture
about a month ago, Elena Fiddian-Qasmiyeh, that are looking at different
campaigning aspects, collaborations with organisations such
as CARA to support refugee academics, harness donations etc., increase access and improve information. I leave you with this thought, which is that some universities, including all the Scottish universities
have actually signed up to clear policies regarding
supporting potential migrant students. UCL as yet does not have a formal policy and maybe they are concerned
that their mission will be reframed, as Bristol’s was in the summer when
they announced the scholarship program and that they were giving out free,
I love the use of capitals, ‘FREE degrees at top universities
while Britons amass huge debts’, and then the REFUGEES, in capitals,
who are taking their places. I think the final quote goes to Dante, which is a question that I think I ask
myself as an academic in my teaching perhaps as a doctor too,
which is to reflect on, “the darkest places in hell
are reserved for those of us who maintain their neutrality
in times of moral crisis”. Thank you very much. With thanks to my colleagues. Thank you, Anita, for a very thoughtful
and thought-provoking presentation. We do have some time for some questions
and comments from the audience here. Gentlemen here,
I think we should have… You need to use the microphone.
It’s the gentleman in grey. Firstly, thanks a lot for the talk,
it was really interesting, but what struck me was amongst all of
that complicated picture you presented, one very practical problem
that seemed to emerge was that individuals weren’t able
to access health care essentially because of their migrant status but it was because they were being asked
for documents they didn’t have. I just saw that as a really simple
problem which could be solved but doesn’t seem to be being solved. Can GPs not have it in their…. It’s bad organisational practice and it’s not properly promoted and so, for example, one option would be that GP practices are subjected
to regular CQC inspections. It should be part of that to ensure
that reception staff know that there is not a legal requirement to ask for proof of an address
or a passport in order to register, and in fact, homeless people should be registered
using the practice address as their postal address,
if they have no postal address. It can be got around and there’s 60% who don’t register but 40% do register
and they understand that responsibility and there’s some practices who go out of
their way to register homeless people. Very good point. Do we have another question
from the lecture theatre? The lady here. Thank you for your presentation. The diagram showing the surcharge, why is it that they still ask money
from people who can’t pay and if so much of it isn’t paid back why
isn’t the message still being received, it’s futile? Well it was only introduced a year ago
and they’re still running it. The Overseas Business Managers
are all new to their jobs but you’re not exempted
because you can’t pay. If you don’t have one
of those conditions, then you have to pay. If you’re not in a recognised group
or don’t have one of those conditions, in other words
if you’re undocumented you can’t demonstrate you are entitled,
that you have entitlement, you have to pay
or leave the hospital. People have the treatment, especially the immediately necessary
urgent treatment, then they’re billed afterwards. Can you see,
it’s a sort of vicious circle and one of the problems is that
on the bottom of the invoices it says if you do not pay within,
and there’s a specific time period, this will be notified
to the Home Office. What a deterrent is that? Well, I have two questions. The first one is, how climate change
will rise to this challenge? Second, how a wider social rights approach
to policy is needed to bring a better environment
to tackle this issue? Both I think, we don’t know and one of the problems with
displacement due to climate change is that people are simply moving out
of uninhabitable areas and that doesn’t have the same sort
of provable, for example, in order to demonstrate torture, the definition of torture has changed
repeatedly over the last decade or so to make the definition
more and more narrow and so how do we actually say people
are actually displaced and are in need of shelter
because of climate change. It is going to become complicated. We’ve already seen people
migrating through lack of water so that is going to become
increasingly so. Why don’t we use a social rights model? Well in a way,
that was what underpinned… The most interesting is talking to
my 95-year-old father who said to me; don’t forget that the Labour government
came in after the war came on a popular vote. It was a popular vote
against the officer classes by the troops who had been conscripted
into the government and they generated
a completely social program, the whole welfare state
was based on a popular uprising. So, one of the questions maybe is… this may be the most optimistic, that we
might get a concern for social rights emerging out of our current, more negative, popular framing
of social relations. Does that answer your question? It has to be wanted,
it’s very hard to promote it directly. I’m sorry
but I think we need to close now because there’s another class
coming in and so thank you all very much
for attending today and to our audience online. Remember that there is
another lunchtime lecture next Tuesday, and if you could remember to fill in
the evaluation form on your way out. Thank you very much,
and thank you.

Reynold King

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