Authors: Eyad Tuma / Editor: Nikki Abela / Codes: SLO12, SLO7, SLO9 / Published: 09/03/2023

Viktoria is a 13-year-old girl, brought in by her father with a 2 week history of fevers, joint pains and lethargy. It is difficult to get a detailed history, as family all speak limited English, having arrived from Ukraine only 3 months ago. Luckily, they brought an uncle who speaks good English to translate.  

She seems systemically well, with normal observations, so the clinician reassures the family, explaining that it is a viral illness, but advises to return or see their GP if symptoms persist.

Two days later Viktoria reattends – she has ongoing symptoms and the family are not satisfied. As the senior clinician, you have been asked to see her as she has reattended within 72 hours.

What is your approach? What additional things do you need to consider when assessing a potentially vulnerable migrant? Would you carry out any investigations? 

Here are some key points for assessing vulnerable migrants in the ED.

Definitions:

In this article I use the word “vulnerable” to imply an individual at risk for an enhanced need of special care, support, or protection because of age, disability, or risk of abuse or neglect. Migrants can also be vulnerable because of other factors which are not typical to what we see in the ED, for example, their migrant status – while in many cases can be protective, it may in itself make them more vulnerable (to things like exploitation, working rights, access to heal care and social care etc). Whilst there is no universally accepted definition for “migrant”, the International Organization for Migration defines a migrant as:

“An umbrella term, not defined under international law, reflecting the common lay understanding of a person who moves away from his or her place of usual residence, whether within a country or across an international border, temporarily or permanently, and for a variety of reasons.”

Language barrier:

GMC guidance is clear that clinicians should make arrangements to meet patients’ communication needs wherever possible. Use of a professional interpreter is always preferable as they provide a degree of assurance around quality, accuracy, and confidentiality. It is largely considered inappropriate to involve family members: e.g. where there are safeguarding concerns about the patient. The gov.uk website provides some useful information with regards to interpreting for migrants.  

Editor’s note: If your department doesn’t have one already, a video mobile interpreter (a.k.a. an interpreter on wheels has really changed the challenge of interpreting in my department) as it is so much easier to understand consultations like this. We also have sign language interpreters on tablet devices which I have yet to try – watch this space.

Vaccination status:

On arrival to the UK, migrant vaccination coverage can vary significantly, even among those seeking refugee protection, depending on their age and country of origin and what. Specifically low coverage in UK bound migrants is reported for diphtheria and tetanus. In patients presenting to the ED, we should be flagging this to the GP on discharge. 

Social circumstances / Reason for migration:

Vulnerable migrants, especially those of a lower socioeconomic background, may be living in overcrowded, cold and damp living conditions. Bear this in mind when considering their presentation to the ED. There are many reasons a family might have migrated, again, this might provide some clues to the reason for their attendance. Please be aware of potential safeguarding issues in these families, and the potential of human trafficking. Please discuss with an ED senior if you have any concerns. Your local safeguarding team can be a valuable resource.  Note that some individuals, particularly asylum seekers and undocumented migrants may be afraid of attending health care settings for fear of deportation. See: Rights to access healthcare (RCPCH guidelines).

Infectious diseases:

Consider broadening your differential diagnosis to include TB, HIV, hepatitis viruses, malaria as well as infestations e.g. head lice and scabies. Have a lower threshold for performing a chest x ray or specific serology tests. 

Mental health: 

Vulnerable migrants can be exposed to extreme physical and psychological difficulties. Consider screening for mental health issues during your clinical assessment and referring to appropriate teams such as CAMHS, mental health liaison or psychological support services. The ‘HEADSSS screening tool’ is a useful place to start for young persons.

Anaemia: 

Vulnerable migrant children are often anaemic. Consider screening for this in the ED if the patient is not yet registered with a GP, and you plan on discharging the patient home. 

Using a professional interpreter, you complete your assessment of Viktoria and are ready to discharge her home. Whilst the family are satisfied with your assessment, they are still uncertain about a few details, including registering with a GP. What information and guidance can you provide on discharge?

Discharge advice and support:

The healthier together website has translatable patient information leaflets which can be printed out, to facilitate safe discharge and safety netting. Vulnerable migrant families may also require guidance in understanding the NHS. 

This ‘how the NHS works’ infographic is a useful visual guide with links explaining how to access care such as GPs, dental care, mental health and what to do in medical emergencies. 

Registering with a GP:

Anyone can register with a GP (see NHS guide on registering). Practices are not required to ask for proof of identity, address or immigration status from patients wishing to register.  A practice cannot refuse an application on the grounds of medical conditions or any protected characteristics.   

Further reading / References:

  1. The international Organization for Migration (IOM)
  2. Government guidance on using interpreters for migrants: Language interpreting and translation: migrant health guide. Gov.uk.
  3. Knights F, Munir S, Ahmed H, Hargreaves S. Initial health assessments for newly arrived migrants, refugees, and asylum seekers. BMJ 2022; 377 :e068821.
  4. Deal A, Hayward SE, et al. Immunisation status of UK-bound refugees between January, 2018, and October, 2019: a retrospective, population-based cross-sectional study. VOL. 7, ISSUE 7, E606-E615, JULY 2022.
  5. Human Trafficking: At Risk: Exploitation and the UK Asylum System – A Report by UNHCR and The British Red Cross. 03 August 2022.
  6. RCPCH guidelines. Rights to access healthcare for migrant and/or undocumented children, 2020. Updated in 2022.
  7. World Health Organisation (WHO), Mental health and forced displacement, 2021.
  8. Adolescent mental health screening tool: Parish E. HEADSSS tool. 2018.
  9. Anaemia screening: Anaemia: migrant health guide, 2014. Updated in 2021.
  10. How the NHS works: a guide for migrants, 2022. NHS, UK Health Security Agency.
  11. Protected characteristics. Equality and Human Rights Commission.
  12. How to register with a GP surgery. NHS UK.
  13. Translatable patient information leaflets. Royal College of Paediatrics and Child Health (RCPCH).