Refugees and Asylum Seekers in the United Kingdom’s Healthcare System: The National Healthcare Service and its Provisions for Underprivileged Populations

Introduction

The United Kingdom (UK) houses one of the most developed public healthcare systems in the industrialized world. Its services are free at the point of need for more than 58 million UK permanent residents, a vast majority of the population, and all emergency services are free of charge.[1] The NHS quite successfully provides primary services, such as visiting a general practitioner (GP) for cost-free checkups, but the complicated payment structure for more specialized services means that the system may not fully satisfy the health needs of all its residents. In particular, UK residents in lower income brackets cannot afford all necessary services. Barriers still remain with regards to accessing secondary and tertiary services, despite the mission of the NHS to reduce inequalities in healthcare access. Furthermore, residents who speak limited English may also find it hard to access clear explanations of NHS services beyond those services publically funded for all permanent residents. The refugee and asylum seeker population in the UK are a special subset of underprivileged migrants, often more economically constrained than other immigrant groups. An investigation into the services available to this group of forced migrants thereby reveals the obstacles to access that exist in the NHS, including demographics, services available, information dissemination, as well as linguistic and cultural barriers.

 

Forced Migrants in the UK Healthcare System

Overall, the NHS system functions in a decentralized manner, with regional operations divided between NHS England, NHS Scotland, NHS Wales, and Health and Social Care in Northern Ireland.[2] The basic services offered by GPs and the process of referral to specialists for more complicated cases are similar throughout all regions of the UK. However, depending on one’s region of residence, the local NHS branch may offer additional social care services such as mental illness support or rehabilitation. In particular, Northern Ireland and Scotland approach public healthcare using an “integrated” methodology, Wales has begun integrating its medical and social care systems in 2009, and England currently does not employ any type of mixed system.[3] Even so, the aggregate effect of making social services available through NHS is small, as the combined population of Northern Ireland, Wales and Scotland is around 10.1 million, while England’s population is around 53 million.[4] Much of the population resides in the Southeast, and so the lack of social care provided by NHS England limits the services available to underprivileged groups such as refugees and asylum seekers. It is important to also note that a much smaller, but still significant, private sector functions alongside the NHS, accounting for 9.5 percent of the UK’s healthcare spending.[5]

Although refugees and asylum seekers are not, by far, the largest segment of the UK’s population, they tend to be more vulnerable within the healthcare system due to linguistic and cultural barriers. For the purposes of this paper, the terms “refugees,” “asylum seekers,” and general “forced migrants” will be used interchangeably despite the significant legal differences; these groups of migrants often share socio-economic status and experience the healthcare system similarly. From 1990 to 2000, around 330,000 asylum seekers entered the UK’s borders from thirty-five countries around the world, and most settled in London and greater Southeast England.[6] Given such dispersion, the NHS in London and Southeast England may face additional pressure. This branch of the NHS also does not provide integrated social services. In areas of the UK that traditionally receive fewer asylum seekers, there may be fewer support systems to educate the new residents about their local healthcare providers and their NHS rights. Once forced migrants are granted asylum or receive refugee status, they are able to take advantage of all the legal protections granted to permanent residents and access basic NHS services at no cost.[7] If trends continue and the Brexit vote does not drastically alter UK immigration policy, the UK will continue to see a steady immigration of this particular underprivileged sector. [8] These changing international immigration and forced migration patterns are reflected in the NHS: that is, as the number of low-income, asylum seeker residents in the UK changes, so does the overall demand for inexpensive services as well as the cost borne by taxpayers.

Legislation has been passed in recent years to reduce the amount of cash benefits that an asylum seeker may claim to only 70 percent of basic income support, and also forbids this group from working for the first six months of their residency in the UK.[9] These limited financial prospects make it especially difficult for a transitioning family to spend money on services that may be seen as superfluous, such as those medical services intended to improve quality of life, but may not have life-and-death determinations. While the majority of refugees and asylum seekers face heightened risk for trauma due to the nature of fleeing regions of persecution and conflict, three countries in particular have seen significant increases in asylum applications to the UK in recent years. Time series datasets through 2016 have shown that the numbers of asylum seekers from Iraq, Bangladesh, and India have seen marked increases in recent years.[10] A closer look at these countries reveals them to be regions surrounded by increased religious conflict. Therefore, it is within reason to believe that refugees from these regions may suffer from psychological stress in addition to any physical illnesses they may have acquired prior to entering the UK. In particular, refugee women are less likely than others to seek job training to work outside the home and more likely to suffer from domestic violence.[11] Women in refugee populations may experience higher health risks, may be reluctant or unable to access care, and thus may need additional community support to access effective healthcare.

Indeed, research from the past several decades suggests that refugees tend to require more specialized health services. In one instance, a study conducted by the UK’s Home Office in 1999 on a sample of 4,000 Kosovo refugees airlifted into the UK noted that the vast majority of these new residents required long-term counseling for trauma.[12] The specifics of the Home Office’s research are unavailable to the general public, as the details were presented via confidential recommendations to Parliament.[13] Despite the fact that a later, unpublished study revealed that nearly half of the Kosovo refugees mentioned in the Home Office account felt that they were healthy, the question of asylum seeker and refugee care remains a difficult one.[14] The dearth of further data makes it difficult to gauge whether the Kosovo refugees sampled in the above study replied that they did not need extensive medical attention because they truly held different understandings of “medical need,” or if they did not understand their healthcare rights and were afraid that their UK residential status would be revoked. Despite the difficulties of this research, most studies conducted by UK authorities have consistently found the forced migration population to be at higher risk for physical, mental, prenatal, and social problems.[15] Yet even these studies are thought to understate health risks because forced migrants tend to seek official healthcare less often due to financial and social reasons. Services that many Western doctors view as essential to a patient’s long-term health, such as regular psychologist appointments for trauma patients, other cultures can deem excessive or unnecessary. Ultimately, the NHS’ provision of more niche services and its cost structure for secondary and tertiary health services mean that forced migrants tend to face higher barriers to access than other UK populations.

 

NHS Service and Payment Trends

Primary services are available to all permanent and temporary residents in the UK, although non-taxpayers may face higher costs for certain services than taxpayers. Treatment is not restricted by nationality and costs depend only on one’s term of stay in the UK. The NHS is generous in that even if a temporary resident in the UK cannot pay for emergency treatments or a hospital stay, healthcare providers are still legally obligated to perform lifesaving services.[16] Some GP and dental practices can refuse to accept a temporary resident onto their list of NHS patients, but again, only if the patient’s case is not a medical emergency. [17] Forced migrants do not often encounter these issues, since most are granted permanent residency status. Payment structures vary depending on the treatment sought and the patient’s immigration status. In cases where a patient receives lifesaving treatment but cannot continue paying until full convalescence, the UK government reserves the right to remove the patient back to his or her home country once their medical situation has stabilized. Non-residents who pay a “healthcare surcharge,” which varies depending on the length of one’s stay and country of origin, may see a reduced cost in NHS services during their stay when they apply for a UK visa.[18] Although specific regulations differ slightly by sub-region, these broad trends in payment schemes are seen throughout NHS system.

Services offered by the NHS vary in terms of payment coverage, which can be confusing to new immigrants and short-term residents. In many cases, GP services are widely advertised, while other basic healthcare programs such as dental services can cost patients extra and are not as thoroughly explained to forced migrants. The NHS makes a much more concerted effort to spread the knowledge of how to access a GP’s services by providing pamphlets advertising the service in more than thirty languages.[19] Yet the pamphlet, only four pages long, cannot thoroughly explain the NHS’ GP services. It may still be valuable to refugee populations because of the emergency contact information available: every asylum seeker granted residency in the UK is provided information with local contacts and directly assigned a GP before even arriving at a new area of residency.[20] The extent to which the NHS streamlines the process of connecting refugees to GPs clearly highlights that the NHS has taken successful steps towards completing its mission to provide basic healthcare services to UK residents of all nationalities. Even so, the support that forced migrants receive in introducing them to primary care is still quite limited compared to the detailed English resources explaining the NHS’ workings available to English-speaking immigrant populations.

Secondary and tertiary treatments, such as visiting an ophthalmologist or undergoing long-term continued care for a disability, are judged on a case-by-case basis to determine both the level of emergency and the amount that the patient must pay.[21] The specifics of payment and services included under a resident’s care package are difficult to track, which presents challenges especially for asylum seekers who speak and read limited English. For instance, “non-emergency dental visits,” which describe the majority of dental visits, are priced in bands of ₤19.70, ₤53.90, or ₤233.70, though pregnant women and children below eighteen years of age receive free dental services.[22] The lowest band covers basic diagnosis and polishing, with the occasional x-ray, while the highest band may include procedures such as crowns and denture setting.[23] While basic dental services are priced within an acceptable range for most working adults, for many underprivileged families the cost may be seen as an excessive luxury. Although the NHS may evaluate that some patients may not necessarily need dental care as part of a free health service package, it is still a significant addition to improving quality of life. Hence, it is important that the NHS consider improving forced migrant access to at least basic dental services, even if normal dental care is not considered a life-saving procedure.

Moreover, all permanent residents in England are entitled to free maternity care, and refugees are exempt from all NHS charges when they seek medical care under these conditions.[24] However, the general pamphlet on GPs distributed to asylum seekers only notifies them of basic contacts for medical needs, and does not specifically address the issues of maternity care. A GP may be able to guide a pregnant refugee woman if she happens to come in for an appointment during her pregnancy, but the healthcare system will not be able to provide adequate support for pregnant asylum seekers who do not go in for checkups at all. The NHS, then, fails to adequately support those forced migrant women who hope to start families in the UK Without government-spearheaded programs, few avenues for learning about the intricacies of the healthcare system are available for refugees with limited English proficiency, as most regulations regarding more complicated medical treatments are written in English.

In terms of mental health care, NHS needs to take further steps to deliver high-quality services to all its residents, particularly refugees. For instance, data for England reveals that for every quarter from 2010-2016, British mental health services provided early intervention services only to an average of around 7,500 patients at risk for psychosis.[25] Unfortunately the figures do not detail the age, gender, or income backgrounds of the patients receiving the intervention services. They do suggest that the use of mental health services is quite low; psychiatric services may be one of the more fringe services provided through the NHS. However, many refugees suffer from psychological issues such as severe depression, PTSD and anxiety, which may create a higher demand for services to deal with mental illness than in the general UK population.[26] The free services provided by the GP may treat physical problems, for example by immunizing children, but may not adequately deal with mental ones such as the aftereffects of problems of prevalent domestic violence or long-term isolation.[27] Forced migrants constrained by both difficulties in accessing information and by the fact that mental health services may be less developed in general. Overall, then, then healthcare system may not adequately provide for the needs of underprivileged populations.

 

Trends in Healthcare Access and Societal Attitudes

Despite the NHS’ dedication to providing universal basic healthcare, trends of unequal access prevail. In particular, Stephen Morris, Matthew Sutton, and Hugh Gravelle undertook a study using data from the Health Survey for England from 1998-2000 to test how socio-economic positions affected healthcare access. The study revealed that health consciousness in the UK increases with higher education levels and is not positively affected by income.[28] In general, the data revealed that income did not have a marked effect on a patient’s propensity to visit their GP, while having higher education was correlated with a higher propensity to access healthcare.[29] For instance, all income categories were associated with a negative propensity to consume healthcare services, with skilled non-manual workers experiencing a -0.006 marginal effect on number of GP consultations and unskilled manual workers -0.001.[30] Conversely, residents with an A level education or equivalent saw a marginal improvement of 0.014 in terms of propensity to utilize GP services.[31] In light of the NHS’ mission, the fact that the data reveal propensity to access primary healthcare in the UK is not positively dependent on income underscores that the NHS is making significant steps towards reducing barriers to accessing basic healthcare and inequities between the rich and poor. These findings prove important in revealing that refugees and other underprivileged migrants more easily access healthcare in the UK than in those countries where healthcare is income-dependent. Even so, this does not discount other barriers to access. The education bar revealed by the Health Survey for England data suggests that a central factor in determining one’s propensity to utilize healthcare effectively is one’s ability to understand the importance of long-term healthcare. Asylum seekers are less likely than other groups of immigrants to have received a formal education or schooling in English. The result is that they may be less comfortable with seeking out more information regarding their health options beyond the bare minimum introduced to them through government advertising. These sentiments are echoed by research conducted by Maria Goddard and Peter Smith, which reveals that socio-economic status is associated negatively with one’s propensity to undergo preventative screening for disease.[32] In general, women and people of ethnic minority descent are less likely to seek out secondary or tertiary levels of medical care.[33] These higher-level services tend to refer to those that require a specialist reference from a GP, such as cardiac surgery or plastic surgery, and are thereby more likely to incur additional fees, which may be unaffordable to many refugee families who may be living off of government subsidies for months after moving to the UK. Hence, the general patterns of healthcare seeking activity once again underscore that the NHS is less successful in providing specialist services than basic services, except when more complicated services are required in cases of emergency.

Yet, specialist services tend to improve the productivity of underprivileged residents than standard GP visits when conditions are more serious than a GP can handle. Consider, for instance, someone who may need a hip replacement—a non-fatal, non-emergency medial situation. As seen in the example of the band prices in dental treatments, the more specialized the treatment, the more expensive the individual copay. General trends in healthcare access in the UK suggest that a typical refugee family with limited funds may not be able to pay for the procedure, which requires surgery and recovery. Although the procedure could bring benefit by perhaps allowing one more adult to seek a full-time job outside the home, the family must forgo the surgery because the NHS does not provide a feasible financial avenue for them undertake the procedure.

Furthermore, attitudes adopted by existing local communities may discourage asylum seekers from seeking more specialist forms of healthcare. Refugees and asylum seekers tend to face significant uncertainty in their residential situations. Although it is possible for approved asylum seekers to eventually gain legal, long-term residency status, the complicated paperwork of asylum procedures leaves some residing in the country illegally after failing to complete the necessary documents, which increases the potential of deportation.[34] They are often subject to othering by local and international media, which frames their existence as irregular or charity cases.[35] Then, communities become unwilling to share public resources with these migrants, as they are rarely seen to be contributing positively to the community. As the UK prevents refugees from working during the first six months of residence, the public resents refugees for using social service, including healthcare, without paying the taxes that support the system. Moreover, some refugees who have escaped conflict zones with collapsed medical services have higher risks of diseases such as HIV/AIDS and hepatitis.[36] Therefore, public health services may see containing the diseases and dealing with the mental health issues brought by refugees as an excessive drain on a system built to serve lawful taxpayers. Due to the othering of refugees in public opinion, the UK government may be less likely to improve information dissemination regarding NHS services available to asylum seekers. Societal impressions of the forced migrant population also decreases the likelihood that the NHS’ copay for secondary and tertiary medical procedures will become more affordable. Moreover, the hostile environment does not encourage refugees with questions about their rights and privileges to seek more support. Medical access for asylum seekers is thus constrained by the biases that local communities may hold towards refugee groups.

Thus, the UK healthcare system is strained by the public image of the refugee community, the community’s heightened need for healthcare services, and the difficulty that asylum seekers may have in determining avenues to seek medical help. The public image of refugees creates a tense environment for healthcare providers, who feel pressure to reduce costs and not to “waste” taxpayer funds on forced migrants’ health problems. Moreover, the public has begun to display nationalist sentiments echoing those of the UK’s former Minister of State for Health, who infamously said that the “NHS is a national institution and not an international one.”[37] These negative feelings create an oppressive atmosphere for asylum seekers hoping to access healthcare, and dissuade public institutions from implementing costly community support programs. As seen from the recent heated discussions of the Brexit vote, feelings of negativity and hatred towards low-income, foreign national residents reach far beyond healthcare alone, to UK politics as a whole. Given such a political climate, the pathway to improving the health of underprivileged migrants needs to combine improvements to information dissemination on services provided for free to NHS care recipients, reductions in the copay for specialist services, and improving community sympathy for refugees in order to decrease the “othering” of their communities.

 

Problems with Adapting: Case Studies

In a 2006 study conducted in Glasgow, fifty-two asylum seekers from several countries, including Morocco, Somalia, Sri Lanka, and Russia, were interviewed regarding their healthcare experiences.[38] The intent of the study was to encourage refugees, through a series of focus group interactions and individual interviews, to overcome the general shyness of forced migrant populations to share their experiences with social services. The results reveal that while thirty-six of the participants felt comfortable with the way their Asylum Support Nurse registered them with their general practitioners (GPs), a small sample were frustrated.[39] Some felt that they were assigned GPs far from their homes, which made appointments very inconvenient and inaccessible.[40] Others felt confused that the UK’s medical system did not grant immediate appointments for illnesses that some refugees viewed as emergencies, such as stomach pain and flu symptoms, especially in children.[41] This study highlights that, for refugees who are able to access GP services, NHS support is regarded positively, but some cultural differences exist in the understanding of illness. Indeed, in many situations, asylum seekers come from impoverished regions of the world, often without stable housing or medical facilities, where common illnesses can become life-threatening. Conversely, illnesses such as HIV and cancer, which would meet with more medical attention in developed countries, may not be diagnosed in the countries from which refugees flee. Many participants of the study also felt discouraged by the NHS because the waits for hospitalizations were sometimes as long as six months for health problems that greatly worried them, but that GPs thought were relatively unserious.[42] The situation is complicated by the fact that interpreters for forced migrant populations remain in high demand without sufficient trained supply. Furthermore, dialects of languages that vary between countries, such as Sri Lankan Tamil and Indian Tamil, can present difficulties even when an interpreter is available.[43] Lacking effective communication resources, the minute confusions that refugees may find it difficult to understand how the NHS prioritizes patient cases, which can lead them to feel less valued than other permanent residents. Thus, the difference in understanding of what constitutes a “medical emergency” may mean that refugees are less inclined to continue regular health checkups once they find the system inconvenient and confusing.

The quality of care provided to refugees also deserves further questioning. NHS staff shortages in high-volume regions such as east London have led to situations in which underprivileged patients, including refugees, are signed on under a temporary patient registration, which only allows treatment for up to fourteen days.[44] Then, especially in regions with high NHS patient volume, refugees and other underprivileged populations tend to be seen as less important than “normal” permanent residents. The situation with NHS staff shortages may not occur in regions with less traffic, but serves as an example of how forced migrants tend to be the first to be cut in a public service system.

Case studies of Somali refugees in the UK further highlight the limitations that forced migrants face, many of which divert resources away from a family’s ability to access adequate healthcare. Two separate case studies of Somali refugees in East and South London drew connections between physical, mental, and healthcare needs. A 2001 study of Somali refugees led by Nasir Warfa drew connections between housing frustrations and mental health. The qualitative study intended to use the Somali refugee community to analyze how residential mobility affects forced migrants who already suffer from a variety of external stressors.[45] In this study, it was noted that Somali refugees tend to replicate their ancestral nomadic habits in London by moving between several similar public housing properties many times within a few years before settling down permanently.[46] Unlike typical nomadic movements, where there are few legal restrictions, this instance of house hopping led to increased frustration for the Somali community in London because families tended to cross Primary Care Trust boundaries. Such movement requires that each refugee reregister with a new health service agency in every new location.[47] The additional paperwork led to longer wait times and made it more difficult for the migrants to receive stable healthcare, which could exacerbate any existing mental or physical illnesses. These findings suggest yet another cultural disconnect that may affect forced migrants who move to the UK, now expected to navigate a foreign bureaucracy of property rights and residential identification. This presents another structural barrier to healthcare access, exacerbated if refugee families are not notified of the requisite transfer paperwork needed once a family moves to a new location.

In addition, in a 2005 study of 143 Somali refugees in urban settings further investigated the effects of shortages in other services on medical care. Most participants in the study kept in frequent contact with refugee services and had accessed GPs or psychiatrists at some point before the interviews, though they collectively shunned community mental health nurses and social workers.[48] Many also did not have steady accommodation or food sources, stressing both their mental and physical health.[49] On the one hand, it is clear that the refugees in fact welcome government services that are free or affordable. On the other, the refusal of any of the participants to make use of more “informal” services such as the community nurses and social workers suggests that the Somali refugees in particular prefer services that they feel are more legitimate. These findings highlight that official government programs explicating available NHS medical services or potential food and shelter subsidies are likely to be welcomed by refugee communities. The experience of Somali refugees also reinforces that a lack of suitable shelter and other physical amenities can put extra stress on a refugee’s mental and physical health, thereby straining the NHS even more. Government-sponsored programs could likely succeed in educating forced migrants about their options in order to increase access to healthcare and other social services.

The unequal treatment of forced migrants in the healthcare system is particularly apparent in childbirth and maternity care. A 2002-2003 study conducted by Lesley Briscoe and Tina Lavender from Liverpool and Manchester, respectively, interviewed four women about their childbirth experiences. Despite the small sample size, the study aimed to qualitatively describe a forced migrant’s experience with maternal care. The study revealed that the experience varies dramatically with her perception of “self” and a woman’s own autonomy over childbirth.[50] In particular, one participant was pregnant as a result of rape in her home country of Rwanda. This experience had grave implications for her willingness to think face the realities of childbirth and maternity care.[51] This example sheds light on the difficulty of providing maternity and prenatal care for expecting refugee or asylum seeker mothers. It is not just sufficient that a service be affordable for expecting mothers: it must also be provided in a manner appropriate for cases of trauma.

Furthermore, as this paper has already discussed, language and cultural barriers can hinder communication. In one case, parents could not understand the correct way to prevent a baby’s death via cot-related sudden infant death syndrome, or understand the results of her own blood work.[52] Although NHS maternity care is intended to serve to all permanent residents, the system does not adequately support the changing cultural composition of the UK population. Due to the dearth of qualified translators, gesticulation is often used as a form of communication within the birthing chamber, but many complicated situations cannot be sufficiently explained. For instance, in the case of one woman interviewed, her situation required a Caesarian section while her culture taught her to think that any type of surgery during childbirth would lead to the death of the mother.[53] Understandably, her delivery was incredibly traumatizing and stressful. Cultural dissimilarities, different understandings of medicine, and language barriers make it difficult for underprivileged mothers to adequately prepare their families for the delivery and subsequent care. Research has revealed that postnatal depression can affect up to 42 percent of refugee women, compared to the normal range of 10-15 percent of new mothers, potentially due to experiences of sexual violence.[54] NHS medical staff are not trained to converse with the expecting mothers about emotionally traumatizing experiences and are thus unable to provide sufficient support to new mothers with postnatal depression. These case studies reveal that NHS standard operating procedures do not provide adequate care for expecting refugee mothers, because they insufficiently prepare healthcare workers to deal with other cultures.

Furthermore, systematic failures by the state to provide refugees with support for health services that may be deemed more cosmetic enacts new barriers to healthcare access within the NHS. In terms of dental care, the 2006 Glasgow study detailed previously found that while most of the participants had visited a dentist, they had a much more difficult time finding information about dentists. As seen in previous studies, many asylum seekers interviewed in Glasgow did not receive centralized guidance on finding a dentist, and many dentists did not wish to treat refugees in their practice.[55] Compared to GP needs, NHS dental services see significantly fewer patients with medical emergencies. Hence, it is understandable that local NHS divisions may choose to use fewer funds to provide special avenues for refugee populations to access a segment of healthcare that, seen from an administrative standpoint, could be potentially less essential to life. Even so, these minute differences in treatment reveal that asylum seekers face significant barriers to access in the NHS system. Unlike many other immigrant populations, asylum seekers may not speak or read good English, and thus may disproportionately rely in government provided resources to educate themselves about their healthcare rights. The lack of follow-up in healthcare services with lower priority can be crucial in determining whether a refugee may choose to use that service or not.

 

Conclusion

Despite the many successes of the UK public healthcare system, there are still elements that must be improved so that underprivileged populations can more equally access services. The NHS has made concerted efforts to educate forced migrants about the free primary care system and has done well in providing free, lifesaving care in emergency situations. However, the quality of services can suffer in areas like London, where staff shortages are the norm, and, across the country, access to higher-end, more specialized services is almost completely determined by the patient’s ability to pay. For forced migrant populations in particular, the lack of translators and training for medical personnel on cultural sensitivity hinders access to quality care. This analysis brings to the fore the existing strengths and weaknesses of the NHS, as forced migrants are an extremely underprivileged subclass of those on the lower end of the socio-economic spectrum and are disproportionately affected by the inequalities in information access within the NHS. Increased training in cultural sensitivity and reduced costs to expensive treatments are necessary not only for the UK’s refugee community but also for the country’s growing population of economic migrants. As immigration brings more cheap labor from Eastern Europe into the UK, many low-wage economic migrants who receive permanent resident status will share many of the barriers to healthcare access faced by forced migrants. It is also especially important that the government consider the cost-efficiency of the healthcare system, given the economic turmoil brought on by the Brexit vote. In order for the NHS to successfully fulfill its mission of providing healthcare to UK residents, the system must be streamlined to improve access and improve equity for treatment access across all populations, no matter their income, education, or grasp of language.

 

 

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[1] Josh Chang, Felix Peysakhovich, Weimin Wang, and Jin Zhu, The UK Health Care System (New York: Columbia University, 2015), accessed August 16, 2016, http://assets.ce.columbia.edu/pdf/actu/actu-uk.pdf, 2.

[2] Chang et al., The UK Health Care System, 3.

[3] Chris Ham, Deirdre Heenan, Marcus Longley, and David R. Steel, Integrated care in Northern Ireland, Scotland and Wales: Lessons for England (London: The King’s Fund, 2013), accessed August 16, 2016, http://www.kingsfund.org.uk/sites/files/kf/field/field_

publication_file/integrated-care-in-northern-ireland-scotland-and-wales-kingsfund-jul13.pdf, 2, 25.

[4] Ibid.

[5] Chang et al., The UK Health Care System, 2.

[6] Derek Summerfield, “Asylum-seekers, refugees and mental health services in the UK,” Psychiatric Bulletin 25 (2001): 161.

[7] “Settlement: refugee or humanitarian protection,” Gov.uk, accessed August 16, 2016, https://www.gov.uk/settlement-refugee-or-humanitarian-protection/overview

[8] “Quarterly asylum statistics,” Refugee Council, published May 2016, accessed August 17, 2016. http://www.refugeecouncil.org.uk/assets/0003/7961/Asylum_Statistics_May_2016.pdf, 1.

[9] Rosemary Sales, “The deserving and the undeserving? Refugees, asylum seekers and welfare in Britain,” Critical Social Policy 22, no. 3 (2002): 464.

[10] “Quarterly asylum statistics,” 1-2.

[11] Taylor, “Asylum seekers,” 768.

[12] Summerfield, “Asylum-Seekers,” 161.

[13] Ibid.

[14] Ibid.

[15] Keith Taylor, “Asylum seekers, refugees, and the politics of access to health care: a UK perspective,” British Journal of General Practice 59 (2009): 767.

[16] “NHS charges for people from abroad,” Citizens Advice, published 2016, accessed August 16, 2016. https://www.citizensadvice.org.uk/healthcare/help-with-health-costs/nhs-charges for-people-from-abroad/.

[17] Ibid.

[18] “Pay for UK healthcare as part of your immigration application,” Gov.uk, accessed August 16, 2016, https://www.gov.uk/healthcare-immigration-application/overview.

[19] United Kingdom Department of Health, Introduction to the National Health Service, 5651, London, UK, n.d, http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4122587 (accessed August 17, 2016).

[20] Ibid.

[21] “NHS services and treatments,” NHS, accessed August 16, 2016, http://www.nhs.uk/chq/pages/Category.aspx?CategoryID=68.

[22] “How much will I pay for NHS dental treatment?,” published June 5, 2014, accessed August 9, 2016, http://www.nhs.uk/chq/Pages/1781.aspx.

[23] Ibid.

[24] Entitlement to free NHS maternity care for women from abroad (Scotland, Wales and Northern Ireland) (London: Maternity Action, 2015, accessed August 16, 2016, http://www.maternityaction.org.uk/advice-2/mums-dads-scenarios/3-women-from-abroad/entitlement-to-free-nhs-maternity-care-for-women-from-abroad-scotlandwalesnorthern-ireland/.

[25] “Mental Health Community Teams Activity,” NHS England, accessed August 17, 2016. https://www.england.nhs.uk/statistics/statistical-work-areas/mental-health-community-teams-activity/.

[26] Angela Burnett and Michael Peel, “Asylum seekers and refugees in Britain: Health needs of asylum seekers and refugees,” BMJ 322 (2001): 545.

[27] Burnett and Peel, “Asylum seekers and refugees in Britain,” 546-547.

[28] Stephen Morris, Matthew Sutton, and Hugh Gravelle, “Inequity and inequality in the use of health care in England: an empirical investigation,” Social Science & Medicine 60 (2005): 1253, 1260.

[29] Ibid., 1260.

[30] Ibid.

[31] Ibid.

[32] Maria Goddard and Peter Smith, “Equity of access to health care services: Theory and evidence from the UK,” Social Science & Medicine 53 (2001): 1155.

[33] Joy Adamson, Yoav Ben-Shlomo, Nish Chaturvedi, Jenny Donovan, “Ethnicity, socio-economic position and gender—do they affect reported health—care seeking behavior?,” Social Science & Medicine 57 (2003): 895.

[34] Natalie J. Grove and Anthony B. Zwi, “Our health and theirs: forced migration, othering, and public health,” Social Science & Medicine 62 (2006): 1933.

[35] Ibid.

[36] Ibid.., 1937.

[37] Taylor, “Asylum seekers, 765.

[38] Catherine A. O’Donnell, Maria Higgins, Rohan Chauhan, and Kenneth Mullen, “‘They think we’re OK and we know we’re not’. A qualitative study of asylum seekers’ access, knowledge and views to health care in the UK,” BMC Health Services Research 7 (2007): 4.

[39] Ibid., 5.

[40] Ibid.

[41] Ibid.

[42] O’Donnell et al., “They think we’re ok,” 7.

[43]Ibid., 6.

[44] Sally A. Hull and Kambiz Boomla, “Primary care for refugees and asylum seekers: If the NHS stops free care for all groups, charities may offer the only safety net,” BMJ 332 (2006): 62.

[45] Nasir Warfa, Kamaldeep Bhui, Tom Craig, Sarah Curtis, Salaad Mohamud, Stephen Stansfeld, Paul McCrone, and Graham Thornicroft, “Post-migration geographical mobility, mental health and health service utilisation among Somali refugees in the UK: A qualitative study,” Health and Place 12 (2006): 505.

[46] Ibid., 505-508.

[47] Warfa et al., “Post-migration geographical mobility,” 508.

[48] P. McCrone, K. Bhui, T. Craig, S. Mohamud, N. Warfa, S. A. Stansfeld, G. Thornicroft, and S. Curtis, “Mental health needs, service use and costs among Somali refugees in the UK,” Acta Psychiatr Scand 111 (2005): 354.

[49] Ibid., 355-356.

[50] Lesley Briscoe and Tina Lavender, “Exploring maternity care for asylum seekers and refugees,” British Journal of Midwifery 17, no. 1 (2009): 18.

[51] Briscoe and Lavender, “Exploring maternity care,” 18-19.

[52] Ibid., 19.

[53] Ibid., 20.

[54] Catherine H. Collins, Cathy Zimmerman, and Louise M. Howard., “Refugee, asylum seeker, immigrant women and postnatal depression: rates and risk factors,” Arch Women’s Mental Health 14 (2011): 3, 8.

[55] O’Donnell et al., “They think we’re ok,” 6.

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