Migration patterns

It is estimated that, in 2010, there were 47.3 million foreign-born residents in the European Union (EU), equivalent to 9.4% of the population (Vasileva, Reference Vasileva2011). Two-thirds (31.4 million) were born outside the EU; the remainder originated from member states, but are now residing in a different member state from the one of their birth. These figures, however, conceal the heterogeneity of patterns and rates of migration apparent throughout the EU, which are influenced by a range of social, economic, political, legal and cultural contexts. Migrants form a very heterogeneous group. They include those staying in a country not of their birth legally, who have come there for work or study or family reunion, but also those seeking protection (such as asylum seekers), and individuals without legal status (undocumented migrants). As a result, the experiences of migration, legal status within a country and access to welfare and health systems may vary significantly between different migrant groups (Gushulak et al., Reference Gushulak, Pace and Weekers2010; Anderson and Binder, Reference Anderson and Blinder2011). For example, undocumented migrants’ access to health care varies considerably between member states [see European Union Fundamental Rights Agency (EUFRA), 2011]. This has led the EU, in recent years, to develop a common framework and practices around immigration policy. Nonetheless, there remains variation between countries owing to national laws and policies, interpretation of those laws, ‘integration’ policies and practices (Messina, Reference Messina2011).

Table 1 summarises the overall recent migration experiences of the RESTORE partner countries. RESTORE countries are host to a range of migrant groups, who come from diverse socio-economic and cultural backgrounds and have various reasons for migrating to destination countries. Migration to specific countries is driven by the historical relationship between origin and destination countries (eg, colonial relations) and the status accorded to migrants in accessing health and welfare systems (Gushulak et al., Reference Gushulak, Pace and Weekers2010; Messina, Reference Messina2011; Salt, Reference Salt2011). Historical relationships explain the ties of Austria, The Netherlands and the United Kingdom to Turkey, Suriname and Pakistan, respectively. The changing geopolitics of Europe throughout the 1990s and 2000s has also resulted in economic migration from the EU8 countries and former Soviet states to all of the RESTORE countries. The EU is also a key provider of asylum for those seeking refugee status, with over a quarter of a million applications received in 2010 (Eurostat, 2011). The reception of asylum seekers, long established in England and The Netherlands, is a relatively recent phenomenon for Ireland, Scotland, Austria and Greece, whose migration histories in the last century have been defined by emigration until relatively recently. Greece, in particular, has experienced major shifts of migration, starting from the mid-1970s, resulting in the highest proportion of migrants in relation to its labour force in the EU in the 1990s (IOM, 2008).

Table 1 Immigration patterns in RESTORE countries 2010

^aOECD (2011), International Migration Outlook (2011).

^bEuropean Migration Network (EMN) (2011); OECD, (2011): 284, Maroukis (Reference Maroukis2009), Vollmer (Reference Vollmer2009), Van der Leun (Reference Van der Leun and Ilies2009), Kraler (Reference Kraler, Reichel and Hollomey2009).

^cMain citizenships of non EU-27 asylum applicants, Eurostat (2011) online data code migr_asyappctza.

^dThis figure is for the whole of the United Kingdom.

Although it is difficult to determine the actual numbers of undocumented migrants, an estimated 1.9–3.8 million people are residing illegally in the EU (in 2008, http://www.nowhereland.info/), with marked variation between countries (see Table 1). Greece has been a focus of irregular migration because of its border with Turkey, where over half (63%) of all detected illegal crossings into the EU took place [European Migration Network (EMN), 2011; OECD, 2011]. Once migrants have arrived in a particular country, they are faced with different health-care systems and rights within those systems. This is particularly apparent in relation to primary care, as illustrated when we compare the primary care systems, and in particular general practice, of the participating RESTORE countries.

Role and position of general practitioners (GPs) in primary care

The organisation of primary care in the participating RESTORE countries differs (see Table 2). In The Netherlands, Ireland and the United Kingdom, GPs have a central role as gatekeepers to secondary care (Government of Ireland, 2001; de Maeseneer, Reference De Maeseneer, Moosa, Pongsupap and Kaufman2008; Schäfer, Reference Schäfer, Kroneman, Boerma, van den Berg, Westert, Devillé and van Ginneken2010; Van Weel et al., Reference Van Weel, Schers and Timmermans2012). They generally work in group practices with more than one GP and a team of primary care professionals, in particular practice nurses, but also other professional groups, sometimes including psychologists or social workers. GPs deal with the entire spectrum of medical ailments. They take part in prevention and manage chronic illness. In Austria, the health-care system ensures free access to a GP of choice and to most specialist services. GPs are not gatekeepers. Here GPs usually work in single-handed practices that they own. In Greece, GPs still represent a small proportion of the total number of Greek physicians and GPs are less acknowledged compared with other medical specialties (Lionis, Reference Lionis2000; Reference Lionis, Symvoulakis and Vardavas2010; Liangas and Lionis, Reference Liangas and Lionis2004). In this respect, general practice in Greece is yet to become integrated, such as in other European countries.

Table 2 Primary care system and GP services in six European countries

^aKringos (Reference Kringos2012).

^bBoyle (Reference Boyle2011), Economou (Reference Economou2010), McDaid et al. (Reference McDaid, Wiley, Maresso and Mossialos2009), Hofmarcher (Reference Hofmarcher and Rack2006), Schäfer (Reference Schäfer, Kroneman, Boerma, van den Berg, Westert, Devillé and van Ginneken2010).

^cWendt (Reference Wendt2009: 437).

^dReibling and Wendt (Reference Reibling and Wendt2012: 500).

In all these settings, GPs are primarily responsible for the provision of comprehensive and continuing, person-centred generalist care to every individual seeking medical care (European Academy of Teachers in General Practice (EURACT), 2007; Royal College of General Practitioners, 2007; World Organization of Family Doctors (WONCA) Europe, 2011).

Migrants’ health issues

Despite the heterogeneity of migrant populations described earlier, migrants share commonalities in health problems and needs (Gushulak and MacPherson, Reference Gushulak and MacPherson2006). Although migrants entering Western Europe are often healthier than native-born residents (the healthy migrant effect (Razum et al., Reference Razum, Zeeb and Rohrmann2000), once arrived in the host country, their health status often deteriorates. Migrants often rate their health as worse compared with natives of the same socio-economic status (Nielsen and Krasnik, Reference Nielsen and Krasnik2010). The most vulnerable groups of people, for example, those seeking protection/asylum, refugees, undocumented and low-income migrants, particularly, experience worse health than other people (Schoevers et al., Reference Schoevers, van den Muijsenbergh and Lagro-Janssen2009). Robust data on the health of migrants are only available for a few European countries, for example, the United Kingdom and The Netherlands (Rafnsson and Bhopal, Reference Rafnsson and Bhopal2009), and similar ethnic minority groups living in different European countries differ in mortality rates, possibly reflecting local context (Bhopal et al., Reference Bhopal, Rafnsson, Agyemang, Fagot-Campagna, Giampaoli, Hammar, Harding, Hedlund, Juel, Wild and Kunst2011). However, it is clear that, overall, cardiovascular diseases, being overweight and diabetes mellitus are much more prevalent among migrant groups, especially those originating from South Asia, Africa and the Caribbean (Vandenheede et al., Reference Vandenheede, Deboosere and Kunst2009; Rafnsson et al., Reference Rafnsson, Bhopal, Agyemang, Fagot-Campagna, Giampaoli, Hammar, Hedlund, Juel, Primatesta, Wild and Mackenbach2013). Although genetically based differences in morbidity patterns may contribute to this high incidence, there is also growing evidence of the relationship between migration-related social problems and chronic stress and the rapid development of metabolic diseases such as hypertension, overweight and diabetes in migrants (Schulz et al., Reference Schulz, House, Israel, Mentz, Dvonch, Miranda, Kannan and Koch2008; Pyykkönen et al., Reference Pyykkönen, Räikkönen, Tuomi, Eriksson, Groop and Isomaa2010; Agyemang et al., Reference Agyemang, Goosen, Anujo and Ogedegbe2011). This migration-related stress is also responsible for the high prevalence of mental health problems among migrants (Carta et al., Reference Carta, Bernal, Hardoy and Haro-Abad2005), in particular people seeking protection/asylum and undocumented migrants (McMahon et al., Reference McMahon, MacFarlane, Avalos, Cantillon and Murphy2007; Schoevers et al., Reference Schoevers, van den Muijsenbergh and Lagro-Janssen2009; Craig, Reference Craig2010; Murray and Davidson, Reference Murray and Davidson2010; Vijayakumar, Reference Vijayakumar and Jotheeswaran2010). It is even more visible in countries such as Greece that are struggling with the financial crisis where control measures to protect public health have taken under pressure without proper design and consensus with stakeholders (Nikolas, Reference Nikolas2012).

In general, health problems often overlap with deprivation and poor living conditions, highlighting the relationship between poverty, poor health and lack of access to health care (Stanciole and Huber, Reference Stanciole and Huber2009; Pieper et al., Reference Pieper, Clerkin and MacFarlane2011). For migrants, the social determinants of health are not favourable.

Migrants’ access to health care and the importance of language and cultural barriers

Documented or regular migrants and asylum seekers in all RESTORE countries are entitled to some form of health-care insurance that covers most of the costs in primary care and of at least basic treatment for acute diseases and antenatal care (Stanciole and Huber, Reference Stanciole and Huber2009). Although the right to medical care for all is an acknowledged human right (UN economic saCRC, 2000), and medical professionals are bound to deliver all necessary medical care irrespective of finances or legal status [World Medical Association (WMA), 2006], undocumented migrants in all six RESTORE countries face financial and administrative barriers in accessing health care (Chauvin et al., Reference Chauvin, Parizot and Simonnot2009; Karl-Trummer et al., Reference Karl-Trummer, Metzler and Novak-Zezula2009). In most countries, they have no right to health insurance and are required to cover the costs of health care themselves, although some form of ‘emergency’ care is provided for and, in some situations, health-care workers can get some reimbursement if the migrants are not able to pay. Since 2001, in Greece, migrants’ access to emergency care until stabilisation is available, although the hospital director was obligated to inform the authorities about all migrant users (Law 2910/2001, Article 51). Since 2005, the hospital director no longer has to inform the authorities of the migrant health-care users (Law 3386/2005, Article 84). Therefore, although undocumented migrants experience many health problems (Schoevers et al., Reference Schoevers, van den Muijsenbergh and Lagro-Janssen2009), they make far less use of health-care services, including primary care than do native-born residents or other migrants (Schoevers et al., Reference Schoevers, Loeffen, van den Muijsenbergh and Lagro-Janssen2010; de Jonge et al., Reference De Jonge, Rijnders, Agyemang, van der Stouwe, den Otter, van den Muijsenbergh and Buitendijk2011).

Despite their entitlements to health care, many documented migrants have also been found to have inadequate access to health services. This is a common feature in the six described European countries (Rafnsson and Bhopal, Reference Rafnsson and Bhopal2008). This is because of other kinds of barriers to access, which occur at three different levels: the patient, the provider and the system. At each level, language and cultural differences play an important role (Huber et al., Reference Huber, Stanciole, Bremner and Wahlbeck2008; Pieper et al., Reference Pieper, Clerkin and MacFarlane2011). At patient level, access is hampered by lack of knowledge of the health-care system and this is compounded by language and cultural barriers. At provider level, weak communication skills and lack of cultural competence act as a barrier. A Dutch study showed that GPs communicate differently with migrants compared with non-migrants in that consultations with migrants were shorter, the GPs were more verbally dominant and migrants less demanding (Meeuwesen et al., Reference Meeuwesen, Harmsen, Bernsen and Bruijnzeels2006). In addition, and surprisingly, although GPs emphasise that language and cultural differences are a major problem from their perspective, they rarely make use of available, formal interpreters in routine practice (Crowley, Reference Crowley2003; Greenhalgh et al., Reference Greenhalgh, Robb and Scambler2006; MacFarlane and O Reilly-de Brun, Reference MacFarlane and O'Reilly-de Brún2009b; Meeuwesen and Twilt, Reference Meeuwesen and Twilt2011; Papic et al., Reference Papic, Malak and Rosenberg2012).

Finally at the system level, health-care facilities are not adapted for migrants with particular problems in terms of poor availability of translated health information materials and poor organisational practices and resources to support the use of formal interpreters (Greenhalgh et al., Reference Greenhalgh, Robb and Scambler2006; MacFarlane and O'Reilly-de Brún, Reference MacFarlane and O'Reilly-de Brún2009b). Furthermore, not all health systems have resources for paying formal interpreters or, as is the case in The Netherlands, such resources have recently been withdrawn.

One very serious implication of these barriers is that family members and friends, including children, are often used as interpreters as a pragmatic response by migrants and GPs to address the language and cultural differences between them (eg, Greenhalgh et al., Reference Greenhalgh, Robb and Scambler2006; O'Donnell et al., Reference O'Donnell, Higgins, Chauhan and Mullen2008; MacFarlane et al., Reference MacFarlane, Singleton and Green2009a).

Migrants make less use of public health facilities, screening and preventive programmes, antenatal services and homecare provisions (de Graaff and Francke, Reference De Graaff and Francke2003; Alderliesten et al., Reference Alderliesten, Vrijkotte, van der Wal and Bonsel2007; Denktaş et al., Reference Denktaş, Koopmans, Birnie, Foets and Bonsel2009; Norredam et al., Reference Norredam, Nielsen and Krasnik2009; Vermeer and van den Muijsenbergh, Reference Vermeer and Van den Muijsenbergh2010) than the general population. Use of general practice care and of emergency services, on the other hand, is generally higher among migrants, even when compared with native patients of the same socio-economic level and health status (McMahon et al., Reference McMahon, MacFarlane, Avalos, Cantillon and Murphy2007; Uiters et al., Reference Uiters, Devillé, Foets, Spreeuwenberg and Groenewegen2009). This has been related to inadequate access to other services. Another explanation is that, because of communication problems, cross-cultural consultations more often end without mutual understanding being reached, leading to poorer compliance and less patient satisfaction (Campbell et al., Reference Campbell, Ramsay and Green2001; Harmsen et al., Reference Harmsen, Bernsen, Meeuwesen, Thomas, Dorrenboom, Pinto and Bruijnzeels2005; MacFarlane et al., Reference MacFarlane, Dzebisova, Kanapish, Kovacevic, Ogbebor and Okonkwo2009c; MacFarlane and de Brún, Reference MacFarlane and deBrún2010). As a result, in health-care systems with low-threshold access to general practice, the migrant keeps coming back in an effort to resolve his health and social care needs.

There are indications that not only the access but also the effectiveness of care in some fields is lower for migrants (Huber et al., Reference Huber, Stanciole, Bremner and Wahlbeck2008; Lanting et al., Reference Lanting, Joung, Vogel, Bootsma, Lamberts and Mackenbach2008; Denktaş et al., Reference Denktaş, Koopmans, Birnie, Foets and Bonsel2009). Several factors are responsible but, again, there is evidence that language and cultural barriers play a decisive role here (Smedley et al., Reference Smedley, Stith and Nelson2003; Joint Commission, 2006; Sievers, Reference Sievers2012). Lack of a common language is one of the major factors that limits the use and effectiveness of health care because it jeopardises effective communication between ethnic minority patients and health-care personnel (Scheppers et al., Reference Scheppers, van Dongen, Dekker, Geertzen and Dekker2006). Ineffective communication enlarges cultural differences as experienced by professionals and patients, leading to even less mutual understanding (Baraldi and Gavioli, Reference Baraldi and Gavioli2012). GP registrars, in particular, have mentioned their concerns about their reduced ability to deliver good-quality holistic general practice care in such consultations (Pieper and MacFarlane, Reference Pieper and MacFarlane2011).

Adequate person-centred communication is a cornerstone of good clinical practice. Key features of patient-centred communication in general practice are: providing room for the patient's story; attention to the context as well as the problems of that person; an emphasis on a dialogue between patient and health-care provider; exploring emotional cues and showing empathy; adjusting information and advice to the persons’ context, and framing it in a positive way; and involving patients in decisions on management of illness (Stewart, Reference Stewart2005; Zandbelt et al., Reference Zandbelt, Smets, Oort, Godfried and de Haes2007). If communication is hampered, patients and professionals are less satisfied, and the health outcomes for patients are less positive (Turner et al., Reference Turner, Deyo, Loeser, Von and Fordyce1994; Stewart et al., Reference Stewart, Brown, Donner, McWhinney, Oates, Weston and Jordan2000; Di Blasi et al., Reference Di Blasi, Harkness, Ernst, Georgiou and Kleijnen2001; van Os et al., Reference Van Os, van den Brink, Tiemens, Jenner, van der and Ormel2005; Pieper and MacFarlane, Reference Pieper and MacFarlane2011).