Leeds JSNA response from Migration Partnership

Overview
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 2 nd 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.

Leeds Multi Agency

Meeting Jan15 report.docx

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 3 rd 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
the
the
not

uncertain legal status of some clients,

multifaceted nature of the difficulties, and
uncertain methods of meeting these support needs when people do
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.
Background
In 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/wpcontent/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
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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
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support and advocacy provision (e.g. Refugee Council, PAFRAS mental health
worker) to support clients and reducing crisis pathways

Data
Needs, Gaps, Barriers
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
Needs, Gaps, Barriers
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

Needs, Gaps, Barriers
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

Needs, Gaps, Barriers
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
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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

Needs, Gaps, Barriers
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
Needs, Gaps, Barriers
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
Needs, Gaps, Barriers
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
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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
Needs, Gaps, Barriers
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
Needs, Gaps, Barriers
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
Needs, Gaps, Barriers
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
Needs, Gaps, Barriers
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.
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Training RAS support services in mental health awareness and support

services

Transport
Needs, Gaps, Barriers
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
Needs, Gaps, Barriers
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.

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