Leeds Migrants JSNA

Leeds JSNA response from Migration PartnershipOverview

The Leeds Migration Partnership welcome the opportunity to contribute to the development of the Joint Strategic Needs Assessment for Leeds.

The 2011 census says 18.9% of the Leeds Population were from BME backgrounds and 86,000 (11.5% of the Leeds population) were born outside the UK (the majority (55%) of the non-UK-born population was concentrated in West Yorkshire).

In this context an accurate and reliable statement of needs and assets of migrant populations is increasingly important.

Leeds is the most linguistically diverse city outside of London with over 85 different languages spoken.

There are great examples of practical ways in which migrant communities can be included in Joint Strategic Needs Assesments, which have been developed with significant local input and expertise

The JSNA produced by Nottingham in 2012 is a particularly helpful example of how information on Asylum seekers and Refugees can presented simply and effectively.

Additional Sources of Information

National data on Migration and Asylum can be found at The Migration Observatory, Oxford.

Up to date information on Trends in Asylum Applications and the number of Asylum Seekers receiving support can be found in the policy section of the Refugee Councils website.

Migration Yorkshire continue to produce excellent local profiles on local migration populations.

The numbers of Asylum seekers being supported in Leeds is increasing and is currently around 650 according to confidential figures from G4S. according to confidential figures from G4S. They are predicted to rise to 750 by the end of 2015.

Figures relating to the numbers of destitute asylum seekers in Leeds can only be estimated using data from individual third sector organisations. Following the closure of the Refugee Council in Leeds, the Red Cross is the largest organisation supporting refugees and asylum seekers. They alone supported 152 destitute asylum seekers and refugees in 2014 (not counting indirect support) and actions relating to destitution were the 2nd most common actions taken by their caseworkers.

Recent national statistics have shown an increase in the number of young single males arriving in the UK from Syria, Sudan, Eritrea and Iran.

Forthcoming changes

With imminent changes to NHS charging and cost recovery policies, it will become increasingly important to understand and record the legal status of different migrant populations of Leeds.

The new NHS charging and recovery regime will also impact significantly on the way in which all migrant populations think and act in relation to health services, and unless clear information is available, there is the possibility of considerable confusion and distress.

West Yorkshire (and Leeds in particular) has also been highlighted as a national hotspot for trafficking and forced labour. These issues present very particular pressures on local services.

Key challenges

Leeds diversity and size makes it a magnet for dispersed migrant communities, increasing pressure on existing services.

Leeds is still perceived by many migrants as better place to access advice and support, based on historical provision. In actual fact, the withdrawal of contracts from several key providers (eg Refugee Council 2014, Refugee Action 2014) have produced a donut of services surrounding Leeds, with relatively few at the centre.

There is no one part of the council tasked with coordinating the development of health and social care services for Migrant Populations or asylum seekers and refugees across the sectors. Although all many partners remark on the impact migrant populations have on the delivery of services, there appears to be a lack of strategic direction shown in addressing these pressures. This has led, for example, to the continued marginalisation of small migrant groups such as Roma, with piecemeal attempts to address this, led by 3rd Sector Champions.

Basic ethnicity data is collected in different ways by NHS and Social Care providers across the city, with data sets which cannot easily be reconciled. Health and social care monitoring systems which do not account for migration/legal status will make planning for changes to charging/recovery particularly challenging.

Changes in Home Office operational guidance being rolled out in 2015 will mean a two tier system of support for asylum seekers: a fast-track for those who have claimed asylum at port of entry and delays in support for people who have not. This will inevitably increase the levels of destitution.

Both asylum seekers and refugees are different and distinct groups, with different rights and entitlements. Organisations helping asylum seekers should have a firm grasp of the different options available to people of different immigration status. Even organisations skilled in providing help and assistance to BME groups often struggle to provide effective services to this group, because of the uncertain legal status of some clients,

the multifaceted nature of the difficulties, and the uncertain methods of meeting these support needs when people do not have recourse to public funds.

For refugees and asylum seekers, what makes a real difference in achieving effective healthcare is social support and advocacy this enables people to understand what is going on around them, helps them to form links with the wider community, and to understand and demand their rights.

Refugees and Asylum Seekers Meath Health Network Response for Leeds JSNA

This paper summarises the Leeds Refugees and Asylum Seekers Meath Health (RAS MH) Networks response regarding the health and well-being needs resulting from migration for Leeds Joint Strategic Needs Assessment (JSNA) highlighting the mental health needs of refugees and asylum seekers in city.

BackgroundIn July 2011, NHS Leeds commissioned Positive Action for Refugees and Asylum Seekers (PAFRAS) and Touchstone to undertake some participative research into: the way in which Refugees and Asylum Seekers (RAS) navigate their way into and through Mental Health Services of Leeds; how existing support systems can be made leaner and more responsive; and how the system might better respond to the needs of people in mental distress, but who do not meet the criteria for mental health interventions http://www.pafras.org.uk/wp-content/uploads/2013/01/Understanding_PT_2012.pdf. As a result the Refugees and Asylum Seekers Mental Health Network was established and continue to meet on a 6 weekly basis to share information, gather intelligence, build working relationships between mental health service working with RAS clients, to identify gaps, barriers and priorities for mental health services development regarding RAS clients across Leeds.

Current member organisations include: Solace, Freedom from Torture, Single Point of Access, Crisis Assessment Services, East North East Community Mental Health Team, Improving Access to Psychological Therapies, Psychological Therapies Services, Touchstone Community Development Service, Aurora, Womens Counselling Therapy Service, York Street Health Practice, PAFRAS, Refugee Council, Yorkshire MESMAC, Dial House, Regional Asylum Activism, West Yorkshire Finding Independence

Overview

It is important to note by the very nature of seeking asylum in another country Refugees and Asylum Seekers (RAS) often have issues impacting upon their health which is above and beyond other communities. Asylum seekers are recognised to have a high burden of need compared to other groups of migrants with evidence that their health deteriorates in the first 2-3 years following arrival in the UK. Asylum seekers tend to experience higher burdens of mental health problems and are amongst the highest risk categories for suicide in the UK. Furthermore many asylum seekers have experienced torture, persecution or rape which has a unique impact on mental and physical health.

In addition it is important to note much of the distress experienced by refugees and asylum seekers can be linked to the events that led them to flee their own country. However there is strong evidence that mental distress is also the result of difficult living circumstances experienced in the UK due to asylum and immigration policies. According to the Royal College of Psychiatrists, the psychological health of refugees and asylum seekers currently worsens on contact with the UK asylum system. Many people seeking asylum experience homelessness and severe poverty in the UK, putting them at risk of precarious and exploitative working situations and transactional relationships and abuse. The Joint Committee on Human Rights in both 2007 and 2015 stated their concern about the negative impacts of destitution on people seeking asylum.

In the last year Leeds has lost a significant amount of service provision to asylum seekers and refugees (Refugee Council and to a lesser extent Refugee Action); other services have seen on average a more than 50% cut in funding. Mental health and advice services are inextricably linked for this client group, therefore the cuts to advice services have a huge impact not only upon the mental health of RAS clients, particularly for asylum seekers who at risk of deportation, but also upon the mental health sector. Future increased demand is predicted as it is expected more asylum seekers will be dispersed to Leeds. During the last 10 years demand for mental health services for asylum seekers and refugees has exceed supply therefore is reason to conclude this will continue. Asylum seekers and refugees need long term therapy in a multi-agency model for the work to be effective. The lack of appropriate services leads to higher acute mental health care costs.The number of people waiting for a decision on their asylum claim for over 6 months is increasing. Almost 50% of cases pending an initial decision at the end of 2014 were over 6 months old. Increasing amounts of time spent living on asylum support (amounting to little more than 50% of income support for a single adult) combined with extended uncertainty on the outcome of their case can be expected to have detrimental impacts on both physical and mental wellbeing. The dispersal system, especially the forced relocation of individuals receiving Section 4, makes continuity of care very difficult. Some people are dispersed away from existing mental health support and are unable to access similar services in a new area. The table below is a summary of some of the key issues, needs gaps and barriers and some recommendations/possible solutions.

Crisis

Needs, Gaps, Barriers

Crisis pathway is the only method of access to mental health services for some RAS clients in particular destitute asylum seekers Existing barriers to primary care (see primary care section) results in late referrals or rapid escalation towards crisis services. Waiting lists for the majority of services may lead to crisis services/inpatients setting when early intervention prevents deterioration and reduces costs Potential increase of crisis pathways for RAS not only due to gaps in pathways but the predicted impact of the Immigration Act 2014 due to confusion and fear of healthcare charging

Recommendations/solutions Preventative work heavily reliant on ability to access specialist workers (e.g. Solace, PAFRAS mental health worker, Refugee Council Therapeutic Case Worker) Review of all crisis services in order to ascertain if needs of RAS are being met Increase numbers of therapeutic case workers combining mental health support and advocacy provision (e.g. Refugee Council, PAFRAS mental health worker) to support clients and reducing crisis pathways

Data


An effective strategic response to RAS is impeded by poor or non-existent data/intelligence within NHS. Gathering data on ethnicity does not effectively identify refugees and asylum seekers. Gathering RAS data post Immigration Act 2014 is problematic e.g. fear of charging, fear of being reported to authorities

Recommendations/solutions More robust data collection across statuary mental health services in line with their Equality Act (2010) duties will facilitate analysis of services and support the identification of effective and ineffective mental health interventions.

Inpatients


Risk to loss of NASS support when inpatient

Risk of loss of residence

Potential discharge to homelessness prolonging inpatient stay

Immigration Act and implication on access to healthcare


Changing entitlements to healthcare services is of great concern. Service providers often lack understanding of accessibility for asylum seekers under present conditions. The concern is this will increase amongst service providers and amplify clients confusion. As a result increasing crisis pathways.

Recommendations/solutions There should be clear monitoring of healthcare providers (both primary and secondary care) to ensure that individuals are not refused the care they need.

Clear avenues for complaints against bad practice need to be identified. Increase provision within advocacy services to support clients Ensure all services are provided on what care you can get rather than what care you cant get basis, as advocates in the Demos/Doctors of the World report.

Language and Interpreters


Inconsistencies in the ability to access interpreters speaking appropriate language/dialectic

The need for clients to complete assessments and paperwork reduces therapy time

Very few voluntary sector mental health and counselling services are able to fund interpreters

Lack of knowledge and skills for working therapeutically with interpreters in voluntary and statutory services

Language line clients have reported experiencing difficulty using this service

Short appointment times at GP surgeries combined with language barriers can result in mental health issues remaining undisclosed, wrongly diagnosed or ignored English language lessons and the barriers to accessing these classes need to continue to be worked upon

Recommendations/solutions Longer therapeutic sessions required when working through interpreters

The ability to maintain a consistent interpreter would enable the trust building process and support therapeutic interventions Mental health services to employ more people that reflects the local BME population and the language diversity of Leeds.

Mental Health and Advocacy


Therapeutic care without adequate advocacy support is ineffective. Clients basic needs (housing, food and asylum support) must be met in order to focus on mental health interventions

Recommendations/solutions More advocacy support needed to help clients with practical matters such as housing, asylum process, engaging with communities etc. Commissioning integrated mental health and advocacy services e.g. PAFRAS and Refugee Council therapeutic case model (combining mental health support and advocacy provision) to case coordinating/navigate clients through services) Co-location of third sector mental health and advocacy services. Having organisations within the same building facilitates access, effective engagement and co-working

Pathways


Mental health pathways for refugees and asylum seekers are less established in comparison to generic population and settled communities. Refugees and asylum seekers mental health needs are multifaceted, pathways are more complex, and barriers more prevalent and problematic to overcome. In addition to this the majority of the pathways leads to Solace is not NHS/statutory funded see specialist services below

Recommendations/solutions More representation from mental health service providers (especially statutory / secondary mental health) at Refugees and Asylum Seekers Mental Health Network to share information and overcome barriers.

An accessible method of sharing up to date mental health and advocacy service provision information across sectors

Primary Care


Asylum seekers experience more barriers when accessing GP surgeries: difficulty registering, unwelcome atmosphere, obstructive receptionists / administrators

Recent Department of Health secondary legislation relating to charging migrants for healthcare proposes to introduce standardised collation of immigration data from new patients at primary care level. This could further dissuade patients from accessing primary care.

Recommendations/solutions Establishment of specialist GP surgery - York Street health Practice has supported asylum seekers access to GP Mental health worker within PAFRAS plays a vital role in coordinating clients to access mental health support

Housing providers under the COMPASS contracts have agreed to ensure that all new arrivals are registered with GP practices. Councils should monitor this, identify which practices are receiving more patients from asylum seeking and refugee backgrounds, and provide further support and training to staff.

GPs are important advocates to people in the asylum process, and an intervention from a healthcare professional is crucial to ensuring that victims of torture are not detained and that some refused asylum seekers with health needs are able to access financial support. Care must be taken to ensure primary care services are as open as possible to people in the asylum process. Training GP receptionists / administrative staff to support effective engagement with RAS clients

Psychological Therapies


A key indicator for Leeds Joint Health and Wellbeing Strategy is the number of people who recover following use of psychological therapy, however recovered based therapy interventions is hindered when working with refugees and asylum seekers for the following reasons: Refugees and asylum seekers needs are more complex Social stressors i.e. individuals and families being in the asylum system for many years, inability to meet basic needs, lack of autonomy, living with uncertainty about their future and in constant fear of detention and deportation

RAS clients often experience Post Traumatic Stress Disorder (PTSD) however this is often not post as many still have ongoing complex traumas e.g. threat of deportation, asylum process and Home Office procedures and establishing safety hindering. Formal therapy is time limited and often based on western modalities. Due to the nature and complexity of their needs RAS may not be able to focus or engage in the trauma evidenced based therapies About a third of all asylum seekers and refugees have experienced torture and suffered from multiple traumas. Primary Care IAPT addresses single trauma consequently many referrals are deemed inappropriate/ RAS clients group being less likely to be referred or accepted for NHS psychological therapies

The need for advocacy services to meet their specific needs is often difficult to obtain. Services specifically providing psychological therapy cannot provide fully the advocacy that is required and this can impact on the potential gains from time limited therapy.

A limited number of sessions is rarely effective in meeting the complex needs of RAS clients, longer intervention is often required. A 12 / 20 session model is not enough for most of this client group (especially for those who do not speak English)

When using interpreters therapy session can be significantly impeded because due to the need to complete lots of paperwork taking up much of a therapy session.

This can lead to the majority of referrals for mental health referral pathways in primary and secondary health being referred to specific services that address RAS needs such as Solace who receive no statutory funding. With further cuts in funding throughout all sectors this can lead to fewer resources to meet needs.

Recommendations/solutions

An example of good practice is Touchstone IAPT as sessions with interpreters are doubled in length and this service is also able to be more flexible regarding number of sessions where interpreters are involved

Exploring alternatives / more flexibility in therapeutic models available and the use of alternative indicators (i.e. less recovery based and more stabilisation). Exploring models which facilitate psychological therapy potential to stabilise people in the asylum process reducing suicide risk and crisis pathways Longer appointment times when working with interpreters is good practice Access to longer interventions More effective integration of advocacy with mental health provision

Secondary Care


Access to secondary mental health services is not straight forward.

Clients are being referred to multiple services compounding mental ill health. Clients are exasperated by the need to repeat their journey and story when re-referred to services; reducing trust in mental health provision diminishing their recovery.

The Immigration Act 2014 introduces new incentives and sanctions for secondary care providers to ensure they recoup charges from chargeable patients. This may start to have an affect on patients willingness and ability to access secondary care.

Recommendations/solutions

Getting RAS mental health needs recognised and correctly referred to the correct service is essential Effective sharing of information across services to improve mental health pathways and reduce reliance on clients to re-live journey and story

Specialist services


Solace plays a vital role in the mental health provision to RAS clients in Leeds. Many statutory mental health services refer clients on to Solace as they are able to provide therapeutic care which addresses the needs of refugees and asylum seekers and are able to offer more effective periods of intervention (not limited to e.g. 6 sessions), however cuts in funding, lack of NHS funding and high demand has impacted on Solace ability to meet service demand resulting in reduction of service and waiting lists In addition

Recommendations/solutions Specialist RAS mental health service Solace are financially supported by NHS/statutory funding, enabling increased capacity to support refugees and asylum seekers mental health needs effectively and presenting a viable cost effective approach to Leeds RAS mental health sector PAFRAS Mental Health Worker and Refugee Council Therapeutic Case Worker plays a significant role in facilitating access to mental health services for RAS clients and these roles should continue to be funded

Staff Training


Mental health services lack knowledge and understanding to work effectively and meet the needs of RAS Gaps within refugees and asylum seekers support services knowledge and understanding around RAS mental health needs and service provision

Recommendations/solutions Training mental health service providers to increase understanding of the needs of refugees and asylum seekers, asylum process and its relationship to therapeutic work, impact of torture, working effectively with interpreters etc. Training RAS support services in mental health awareness and support services

Transport


A key barrier for asylum seekers accessing healthcare provision is transport. Clients in the asylum process often are unable to obtain the bus fare to travel to attend appointments resulting in an increased number of DNAs (do not attend) and impeding interventions.

Recommendations/solutions Provision of bus fares, co-location of services and/or increased understanding of this barrier amongst mental health service providers with the aim to explore alternative arrangements would increase engagement

Other


Limited understanding of the UK health system, and in particular the role of the GP

Differing health seeking behaviours and expectations of healthcare services

Language and cultural differences

Mental health stigma

The relationship between physical and mental health parity of esteem is not fully incorporated within healthcare provision.

There has been an increase in the number of new refugees falling into destitution after receiving status due to delays in accessing mainstream benefits.

Recommendations/solutions Increasing understanding amongst migrant, refugee and asylum seeker communities of the UK healthcare system and mental health.

Supporting communities to have conversations about mental health and UK system in community languages in partnership with community leaders echoing the Migrant Access Project / Talking Your Language / Train the Trainer style models

Refugees and Asylum Seekers Mental Health Network require increased membership from statutory services and an effective method of escalating gaps, barriers and solutions to commissioners and decision makers.

1

Leeds Multi Agency meeting Jan 2015

Table 1 Total service users @31.12.14

Leeds

S95

S4

Total

Singles

Family

Singles

Family

203

331

74

42

650

Cases

104

Cases

18

122

Table 2 Properties and People by postcode.

Post Code Figures

Properties

People

LS9

59

190

LS7

24

84

LS11

29

109

LS8

45

148

LS6

17

87

LS10

1

4

LS12

1

3

LS16

2

9

LS28

3

9

LS4

3

11

Table 3 Move in

Nationality

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Total

Eritrea

8

6

7

2

11

6

3

11

15

18

13

15

115

Iran

12

10

5

6

11

1

10

8

12

10

3

8

96

Pakistan

9

9

4

11

1

3

11

3

2

6

2

61

Sudan

2

4

8

1

3

7

3

6

6

6

5

8

59

Syria

5

4

4

2

2

3

3

2

2

11

1

8

47

Nigeria

2

13

6

5

3

2

3

1

35

Zimbabwe

2

2

2

2

2

2

2

2

5

21

Afghanistan

1

1

1

5

1

1

4

1

1

5

21

Albania

1

4

2

9

1

17

China

1

4

1

5

3

3

17

Others

8

18

20

3

22

20

22

12

27

14

9

18

193

Total

46

50

64

36

78

47

49

58

74

68

43

69

682

Singles 415 Families 267 (104)

Table 3 Move outs

Nationality

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Total

Pakistan

9

14

5

18

6

2

9

10

1

4

2

80

Eritrea

4

4

2

2

8

2

5

4

8

14

14

67

Iran

4

3

4

4

5

7

7

12

2

5

8

61

Syria

1

1

1

6

6

3

3

2

8

3

2

36

Sudan

1

1

2

4

2

1

3

10

5

5

34

Nigeria

10

5

8

2

3

4

32

China

1

2

7

5

4

5

4

28

Zimbabwe

1

2

2

3

2

3

3

4

20

Somalia

1

2

4

3

4

14

Egypt

7

2

2

11

Others

9

15

17

8

16

13

12

9

13

9

15

9

145

Total

27

40

46

35

59

50

44

28

44

43

58

54

528

Singles 261 Families 96 (267)

Future procurement

We are expecting numbers to continue to rise and following discussion with the Home Office and partners expect the numbers in Leeds to increase to over 750 by the end of 2015.

Documents

Leeds Migrants JSNA