We found that international migrants, most of whom were recent arrivals to the UK, posed a significant workload to this service and were a diverse group. There were two distinct groups of migrants at this service. First, the dominant presence in the cohort of Australians, New Zealanders, and EU citizens, coming in on work and study visas, which reflects current national gross in-migration data . These individuals were significantly less likely to be registered with GPs (ANS: 32% registered). Second, the smaller RGC group, who despite obvious barriers to care such as language, were significantly more likely to have GP registration (58%) and to have made prior contact with a GP about the current illness before attending the A&E/Walk-In Centre. Registration and/or contact with GP services did not influence mode of access to hospital services, with equal rates of self-referral to this A&E/Walk-In Centre across nationality groups, suggesting that there are other factors involved in use of health services that may differ between migrant groups.
Few studies have sought to gain numerical data on use of GP and acute services by recently arrived migrant groups, despite the need for evidence to inform service delivery at this time [7, 8]. Our study is of interest to service providers as it considers the diversity of international migrants using this type of service. Additional workload in specifically London A&E Departments from temporary visitors such as tourists and commuters who present without GP registration has previously been described ; our survey has enabled us describe the impact on such services of a more diverse migrant population. Although these snap-shot surveys have limitations, our response rate was considered high in what is a difficult context to collect data and we are confident that these findings reflect the day-to-day experiences of this service and are likely to be generalisable to other inner-city London units. There are few studies in this area adopting a self-completion questionnaire approach that are useful for comparison. Not collecting data on migrants presenting via ambulance could have biased the results in favour of higher presentation rates of more affluent migrant groups (ANS or OM groups), though this is unlikely to have had a significant impact on key findings. The absence of interpreters in the department to administer questionnaires meant that some patients for whom a translated questionnaire was not available may have been excluded from the study. However, patients presenting to this service who did not speak English largely arrive with a friend or family member to interpret for them, and who we are aware supported patients in the completion of survey forms. In addition, we translated the questionnaires into the dominant languages of presenting patients to this hospital, so feel confident that we will have captured the majority of presenting migrants.
We and others report that only around 50% of the cohort resided within the hospital catchment area ; additionally, we found that overseas-born patients as a group are over-represented at the service in comparison to local data . This over-representation likely reflects the large number of recent arrivals and temporary migrants using this service, who will not have been accounted for in local estimates. A&E Departments may be an additional attraction for migrants who may not be entitled to register with a GP free of charge, or may perceive that they are not entitled, because they are freely accessible to all and health staff will address both emergency and non-emergency health needs. One other national UK study at open access Genitourinary Medicine clinics reported an increase in workload from migrant populations comprising asylum seekers and irregular migrants , but did not consider other categories of migrants.
Patients from the ANS and OM group were younger, had higher socioeconomic status (paid jobs), and likely a better baseline health status – all of which are factors known to impact on mode of access to primary and secondary care [10–12]. Some may not have been entitled to register permanently with a GP because of their recent arrival or temporary status. This may be a specific issue for GPs in high migrant areas who are concerned about the impact of temporary migrants on practice targets; the new GP contract has largely removed financial incentives for GPs to register temporary patients . We hypothesise that some patients from these groups could feasibly have been using this service as their source of primary care in the absence of GP registration, and that this could explain their high attendance. Previous studies have shown a range of rates of non-emergency attenders at UK A&E Departments (6%–80%), which is deemed detrimental as it adds to waiting times, degrades the quality of care such services can deliver, and increases costs ; however, none have addressed migration status. Although not advertised, the presence of GPs at the attached the Walk-In Centre at this survey site (patients are triaged to the Walk-In according to needs after initial registration at the A&E Department) could have attracted an additional number of migrants aware of this option. Walk-In Centres, designed to address issues of access and unmet need in primary care, have been shown previously to benefit mainly white, middle class patients in terms of improved access ; our data perhaps suggest that such GP-led services could disproportionately attract certain migrant groups with low GP registration rates.
GP registration rates had little bearing on subsequent mode of access, with equal rates of self-referral to this service across all groups, which suggests that accessing appropriate primary health care is more complex than finding and registering with a GP. Greater GP use among the RGC group, despite obvious barriers such as language, mirror recent studies investigating GP registration among refugees and other RGC migrants [14, 29] and may reflect local initiatives to facilitate registration amongst minority groups. However studies show that additional barriers, associated with ethnicity and communication problems, may operate at the service provider level in terms of access to appropriate quality care to meet needs once inside the system [10, 12]. Although it was outside of the scope of our survey to assess reason for attendance, these factors have previously been associated with increased use of acute services by more vulnerable migrant groups [14, 18, 19].
Our findings have implications for resource allocation in terms of enabling inner-city London services to cope with increasing rates of in-migration to the UK. Initiatives that encourage migrants with low registration rates to register with and use GPs could alleviate pressures on acute services. We need to assess how best to deliver appropriate quality care to more vulnerable groups beyond merely facilitating GP registration. Models of best practice, considering the approaches of other European countries , need to be explored to elucidate how best to deliver primary care to migrant groups, whilst consideration must be given to the impact of temporary migrants on GP practice targets and resources.
Recent attention on the impact of 'foreign born' patients on the NHS, and the tightening up of charging systems for non-eligible migrants [7, 8], has not considered the diversity of this group. Focus on the burden of asylum seekers, particularly from resource-poor African countries, misses the significant number of migrants from wealthier countries (eg, USA, Europe) who may pose similar organisational and charging dilemmas. Our data suggest that recent proposals to exclude or charge non-eligible migrants at GP services [7, 9] could have a detrimental impact on free A&E Departments in terms of an increase in presenting migrants.