A total of 52 individuals participated in the research: 16 were one-to-one or group interviews; the remaining 36 participated in one of six focus groups. Respondents came from a wide range of countries (Table 1). Their ages ranged from 20 – 57; 31 were female, 21 male and most had been in the UK for at least 3 years (Tables 2 &3).
We have organised the findings by the 6 major themes that emerged from the analysis of both the focus groups and the interviews. These are discussed in turn.
Access to health care
Most asylum seekers arriving in Glasgow received written information from the health board telling them how and where to register with a general practice. In one site, an Asylum Support Nurse had been employed to contact asylum seekers, go over the registration process with them, conduct a health check then inform them which surgery to register with. As a result, most of these respondents (who were the 36 focus group participants) were registered with a GP and the prevailing theme that emerged here was one of feeling welcomed and cared for as a result of this process.
This positive experience was not shared by all asylum seekers. A few were concerned that they had been told to register with a GP who was not the nearest one to where they were staying. Others, particularly those who had arrived at the beginning of the dispersal process, had either received postal information or no information at all. Some thought that the information they had received had come directly from NASS rather than from the local NHS Health Board.
Many experienced difficulties getting timely appointments with their GP. Respondents often considered their symptoms as an emergency, e.g. flu symptoms, stomach pain, and wanted to be seen quickly. There was frustration when they had to wait several days for an appointment, especially when symptoms improved before the consultation. This was a particular issue when children were involved:
"... when you take the kid there she is crying but they would tell you to take her back home 'til tomorrow at ten o'clock. But when you take her tomorrow at ten o'clock the stomach [pain] has stopped." (F, Male, Somali Focus Group).
Some circumvented this problem by calling an ambulance or going directly to the hospital. One explanation for their response to such symptoms was their perception of the potential severity of outcome. In describing a situation where his child had flu-like symptoms and a blocked nose, one man said:
...at the hospital they will tell you it's not the right time to give him medication its only flu ... On our side flu is a big issue because the kid may die. If the kid cannot breathe normally then the kid will die." (H, Male, Somali Focus Group).
Most reported positive experiences regarding the care provided by their GPs, even when they re-told incidents where they felt care had not met their expectations, e.g. hoping for a referral to secondary care but instead receiving a prescription. However, GPs were often perceived as not being specialised, with this impacting on respondents' behaviour. For example if the problem was deemed to be an emergency or requiring a specialist, some would go directly to hospital. Others commented on the lack of continuity, seeing a different doctor each time they attended the surgery. This was a particular problem at a branch surgery where locums were often used:
"They [locums] are finding it difficult to understand. We have to explain everything and then they have to go deep into the file to give us medicine whereas Dr X will know automatically." (R16, Female, Sri Lanka, Interview).
However a few respondents expressed surprise when they discovered they could ask for a particular doctor if they wished and that they had a specific GP whose care they were under.
Many had experience of secondary care, as a hospital in-patient, outpatient or through accident and emergency departments. People again reported largely positive experiences, although there were problems accessing interpreters (see below). There was also surprise and disappointment at the length of waiting times both for hospital appointments and at accident and emergency.
"I had to wait six months for a hospital appointment. I asked about this because I was worried but the doctor said oh it's not a serious problem and that we should wait." (C, Afghani Female, Farsi Focus Group).
Most respondents had attended a dentist. However, the experience of finding and registering with a dentist was different to that with GPs. Several couldn't remember if the initial information packs had contained any information on dental services. Some got their information from their GP; some had received a letter telling them to register with a dentist, but others didn't know where it had come from. Some reported difficulty finding a dentist who would treat asylum seekers. There was little to suggest that respondents attended dentists for regular check-ups, instead appearing to use them when there was a clinical need.
Experience with interpreters
Interpreting was a major issue. In general, the provision of interpreters in primary care appeared to be well organised and fairly reliable. Respondents spoke of surgeries organising interpreters both for GP consultations and for appointments in secondary care. However, the provision of interpreters during in-patient stays was less reliable, with patients lacking interpreters at key points in their hospital stay, e.g. when waking up after an operation or during in-patient stays.
The first day in hospital was fine because there was an interpreter there for me. But I was in for four days and the next four days there were no interpreters. Doctors were asking me things but I couldn't understand and I wanted to ask them things but they didn't understand. (A, Iranian Female, Farsi Focus Group).
Data from one focus group discussion suggested that interpreting services are also required in pharmacies, to facilitate questions about medication names and regimens.
The use of interpreters was less common at the dentist compared with the GP. This appeared to be due less to a lack of provision and more to a perceived lack of need:
We don't need to talk to him, he checks our teeth. (R15, Female, Sri Lanka, Interview).
A number of respondents, particularly those from Sri Lanka, reported difficulties obtaining appropriate interpreters. Often, they were sent an Indian Tamil, which led to difficulties in communication due to the differences between Sri Lankan and Indian Tamil. Difficulties speaking English meant that this problem was not properly addressed.
There were times when respondents felt that interpreters were not fulfilling their duties appropriately, for example by not re-telling their story to the doctor correctly. Another respondent felt uncomfortable with interpreters within the consultation, arguing that you couldn't be sure that it was confidential. In one focus group, there was the view that interpreters were not trained to deal with health issues or medical terminology. Yet there was a demand for this service as evidenced by one respondent who explained that although his family could interpret for him, he preferred a professional who could help with medical terms.
An alternative view came from a respondent who was also an interpreter. He suggested that people expect their interpreter to act as an advocate. However, interpreters are trained to interpret literally. He suggested that clearer instructions were required, to reassure patients that interpreters are bound by a code of confidentiality but also that are unable to play an advocacy role.
Experiences of other health care staff
Respondents had experienced a range of other health care staff including health visitors, other nursing staff, receptionists and opticians. Most experiences were reported as positive:
They are all very very good. They are very patient and so far they are tolerant (R9, Female, Albania, Interview).
However, several respondents spoke of times when they felt discriminated against or treated badly because they were asylum seekers. One spoke of an incident he witnessed in secondary care when a consultant was derisory towards a patient for being an asylum seeker; another felt that a receptionist used to discriminate against asylum seekers when they were trying to make appointments. One respondent felt continually discriminated against, citing that health care professionals had stopped coming to his house when they found out they were asylum seekers. Others echoed this feeling of discrimination and isolation:
Sometimes you feel left out and think being an asylum seeker, you are different (E, Zimbabwean Female, Woman's Focus Group).
Asylum seekers who had been in contact with health visitors were particularly positive about the help and support they had received over a range of issues, both health and social. Health visitors instilled a sense of confidence and confidentiality, perhaps because they came to their homes. One respondent offered a note of caution over how much this professional group can be expected to achieve:
I've noticed people being seen by health visitors and are quite happy about them, about health visitors to go to them and see them because they think somebody is paying attention to me so they really appreciate that but then the problem with that is that they expect too much from the health visitor. ...... They don't understand that the health visitor's hands are often tied, they feel that is a disappointment. (R4, Male, Iran, Interview).
Barriers to care
Respondents rarely spoke directly about barriers to care, however several became apparent during analysis. The first was language, particularly in situations where there was no interpreter, e.g. when phoning the surgery to negotiate for an appointment. Access to medication was another barrier, with a number of respondents citing times when they were expected to pay for painkillers, such as paracetamol, over the counter rather then receiving a prescription. This was a significant cost for families where young children often needed childhood cold and flu remedies, particularly when the family had received an HC2 certificate and expected to be exempt from paying.
E:Then after she [GP] gave a prescription she said "You should go and buy this for yourself, because if I give you a prescription it is expensive. It is cheaper if you buy it yourself...." Some things you have to buy, what's the use of the medical certificate [HC2] then?
S:Mm yes, I experienced this ....
E (to S):You understand? (Zimbabwean and Moroccan Females, Woman's Focus Group).
Another barrier was access to specialists in secondary care. There were two issues: perceptions that the GP was not referring them to see a specialist and waiting times when they were. Several felt that there were situations where they would prefer to be referred to a specialist but where the GP was either reluctant or took other action e.g. prescribing medication. One respondent commented that he felt the GP actively avoided further referral. Many of the respondents also commented on the long waiting times to see a specialist, a view articulated most bleakly here:
I am very sorry, in this country one maybe die before he has received his appointment. (R10, Male, Algeria, Interview).
There was a view from some that this could be attributed to the fact that they were asylum seekers. However others, particularly those with a better command of English, took the view that waiting lists affected everyone in the UK.
I think it is a common problem for everybody. It's not that easy to get a specialist in this country, ... (R3, Male, Iran, Interview).
The waiting list was a bit unbelievable for me because the image we had under medicine in the UK was sort of different. Now I know why people refer to the private sector.......... So people on the NHS have just got long waiting lists, not just for me, for everybody. (R4, Male, Iran, Interview).
Needs/gaps in services
Data highlighted the need for better access to mental health/psychology services. Many respondents talked of extreme anxiety to the point of frequent panic attacks and feelings of sadness and loss. However many seemed unaware that any help could be offered for this and felt it was somehow inappropriate or hopeless to discuss such matters with the GP:
Sensitive health issues, such as rape and HIV, were unsurprisingly not discussed in this context but data from a related study (to be published separately) which interviewed health care professionals caring for asylum seekers suggests there are gaps in services here linked to both perceived low disclosure due to lack of trust and lack of specialist referral services.
Provision of appropriate health information was also an issue, with a lack of appropriately translated health information leaflets. There was also a lack of knowledge about health promotion and health screening programmes. Cervical screening was discussed in the woman's group, where there was confusion over the frequency over smears, fear and embarrassment over the procedure and a view that it was unnecessary when one felt well.
Few respondents knew about the provision of out-of-hours primary medical care, with only one respondent indicating that they had used the primary care emergency service out with routine surgery hours. Where medical care was required at night, respondents either attended A&E or called an ambulance. While we had no information on the clinical condition that required these visits, other than the patients' recounting of the event, some patients did talk about being admitted to hospital suggesting that their condition was of a more serious nature. In other situations, the patient was sent home again and told to attend their GP in the morning. This led to the following comment:
Sometimes at night the GP is not open so that is why we have to go to hospitals and they say you should wait until morning and be sent back, it's not good. I don't know, we could die if we wait until morning and something opens. (R8, Female, Turkey, Interview).
Comparison with health services in their country of origin
Respondents came from countries with health services ranging from the well developed and modern (e.g. Syria, Iran) to war areas where health care had completely broken down (e.g. Tamil-held Sri Lanka). A common feature to all these settings, however, was the absence of a primary care system impacting on their views of health care here, in particular expectations regarding access to specialists and a view that GPs were not specialised enough to deal with their problems.
Sometimes when the doctors or GPs aren't specializing in the thing, they just say you are OK. ....... They think that you are OK and you think that you are not OK. (R6, Female, Syria, Interview).
In general, all respondents compared the UK NHS favourably with health care systems in their own country, particularly where internal conflict had led to destruction of existing health care systems. Those from countries with more developed health systems were more cautious. While positive about health care in the UK, many were used to systems where one could access a hospital-based specialist immediately, albeit having to pay for that care.
Access to antibiotics was also raised as, in some countries, antibiotics were readily available on payment from a pharmacy. This led to expectations that antibiotics would also be readily available in the UK and disappointment when they were not prescribed.
...some people are not happy with the doctor because oh they didn't give us antibiotics... (R3, Male, Iran, Interview).
Thus, the type of health care system that they were used to clearly impacted on their expectations of health care in the UK.