Uncertainty about the number of migrant workers in Britain means that planning for demand on local NHS services may become increasingly tricky, writes Alison Moore
The arrival of large numbers of Eastern European migrant workers in the UK since the expansion of the EU in 2004 has led commentators, from councillors to chief constables, to warn of their impact on public services.
But one significant part of public services, the NHS, has remained largely silent on what these new populations mean for healthcare services in the UK, both in terms of the health needs of a new cohort - subtly different from much of the current population - and the cultural and language differences which may affect their access to services.
This may be partly due to the organisational make-up of the NHS; while local councillors are free to speak out on this issue, trust boards and chief executives are unlikely to do so in public. They also have nothing to gain from it.
NHS Alliance chief executive Mike Sobanja also suggests the fear of being thought racist may play a part, along with a 'get on and deal with it' approach to new challenges. He adds that the service may still not have a feel for the true extent of the impact and says frankly: 'I don't think a great deal is happening on the ground.'
Certainly HSJ found an unwillingness to discuss the issues among many in the NHS. Few primary care trusts or hospital trusts were willing to talk about the impact of migrants on local services and how their needs might differ, let alone whether their organisations were responding to these needs. A number of PCTs in areas known to have significant numbers of migrant workers would only say they were planning to look at the issues.
One public health doctor admitted they had no idea how many migrants were in their community or what their needs were. Other organisations simply did not return calls. There was frequently confusion between economic migrants and asylum and refugee seekers - despite the difference in health needs between the groups. Where managers did distinguish between the two, there seemed to be an assumption that as economic migrants are mainly young they would put little pressure on the healthcare system - a massive oversimplification of a complex picture.
One effect of rapid migration has been that the NHS - both nationally and locally - may be expected to care for more people with the same funding. Population projections by the Office of National Statistics play an important part in the distribution of NHS money. The current year's allocation is based on projections done before Eastern European states joined the EU and their nationals were more easily able to come to Britain.
Nationally, the projections for England for 2006 are now thought to be out by around 300,000 people. The ONS believes there were 50,763,000 people in England in mid-2006 compared with the projected population of 50,483,000. Some demographers suggest even the higher figure might be inaccurate as immigration and emigration can be hard to capture in estimates.
ONS national population projection team head Chris Shaw says the difference between predicted and actual population is due to three factors which were not fully allowed for in the original projections - the level of migration, an increase in the birth rate and fewer deaths than expected. Unusually, all these factors pointed in one direction - more people than predicted.
But as well as the NHS as a whole having to cope with more people than planned, individual PCTs may have experienced significant population shifts which are not reflected in their own allocations. Areas with anticipated rapid growth in housing get an additional adjustment, but these are not necessarily those with most migrants.
NHS Confederation primary care trust network director David Stout says the current allocation system is fine when the population is only changing slowly, but may need to be rethought if there is rapid change.
'Resource allocations to PCTs will take some time to catch up,' adds the NHS Alliance's Mr Sobanja. 'Movements of population have always been difficult for the NHS because the system works retrospectively.'
This can cause local problems. The Berkshire town of Slough, for example, has seen rapid population growth since 2004. Berkshire East PCT director of locality commissioning Donna Derby says: 'Slough prides itself on being multicultural. We would like the government to give us the funding but on the ground we do our best.'
It is difficult to be certain how many economic migrants there are across the country but even looking at the figures of those who have registered for employment in the UK gives a figure of nearly 100,000 in East Anglia since May 2004 and over 80,000 in both the Midlands and London.
Some of these workers may since have moved on - and others are self-employed - but they are indicative of what is likely to have been a significant increase in population in some areas, including some rural areas which have never experienced rapid migration before.
But what are the health needs of these groups? Most economic migrants are under 40 when they arrive and likely to be fairly healthy.
But one effect of having a larger cohort of 'young, fit and fertile' people in the country is increased demand for sexual health, maternity and abortion services.
Births in 2006 were 3.7 per cent up on 2005. There was a 10 per cent increase in the number of babies born to migrant mothers (not all of whom are from Eastern Europe, of course). Anecdotally, maternity units in areas with a large number of migrant workers have been under pressure.
'We have seen an increase in women coming to us from East European backgrounds who ask to talk over their pregnancy options and who request abortion treatment,' says chief executive of the British Pregnancy Advisory Service Ann Furedi.
'Demographic shift, such as an ageing population and now an influx of young, fit and fertile people coming to Britain to work, mean that healthcare needs of an area can change. In areas of healthcare that are unprepared for this change, this can be an issue.'
If migrants have children already or have families while they are here, that also has implications for child health services. Faculty of Public Health president Dr Alan Maryon-Davis says services are seeing additional children with congenital problems, birth defects and mental and physical disabilities. In some cases, these children have not been well served by health services in their home countries, says Dr Maryon-Davis.
Many Eastern European countries also have high rates of smoking, but language difficulties alone may mean migrants are unlikely to access smoking cessation classes unless they are tailored to them. A few areas are doing this - in Crewe, smoking cessation classes are organised with the local Polish Society.
Although economic migrants may not be as likely to have the severe mental health issues found among some refugees and asylum seekers, they may experience loneliness, anxiety and depression - occasionally compounded by excessive drinking - and have the same rates of mental health problems as any population.
Meanwhile many migrants will come from areas with a higher rate of communicable diseases than in the UK - several Eastern Europe states have high rates of drug-resistant tuberculosis - and may be living in cramped conditions once they arrive, increasing the chances of transmission. Immunisation boosters may also be due.
But for many, language and cultural differences will be the biggest challenge. In some cases, this may primarily arise from language difficulties, so it is surprising to learn how few PCTs and hospitals are providing translation of basic material on their websites.
Some are tailoring their public information. In NHS Highland - with a Polish community of 4,500 - leaflets are provided in Polish and translators are available at clinics where a large number of Polish patients are expected.
'Our hospital and community midwives have a range of literature to give to Polish women when they have their first appointment. These include leaflets about the routine blood tests, special screening tests and also more in-depth books in Polish such as a guide to parenting from birth to three years old. We also give out a guide to childhood immunisations in Polish. We have received positive feedback about this,' says NHS Highland midwifery manager Angela Watt.
In Norfolk - where there is a strong Portuguese community as well as a more recently arrived Eastern European one - the PCT has commissioned two interpreters to run sessions at GP surgeries. Medical practices also have access to a communicating/interpreting service and frontline healthcare professionals are given language cards so migrants can point to the language they speak.
But many Eastern Europeans are used to a different model of healthcare, one where the concept of a GP as gatekeeper to other services may not exist. They may be used to direct access to hospital services and a lower threshold for investigations than in the UK - more scans in pregnancy, for example.
Lack of information about the UK system can lead to inappropriate use of services. Dr Martin Shelley, past president of the British Association for Emergency Medicine and a consultant in Birmingham, says accident and emergency departments are seeing Eastern European patients who do not understand the UK healthcare system and may find it hard to register with a GP because of language difficulties. He describes it as 'adding to the pressure' facing busy departments.
In some cases, Polish patients have even returned home briefly so they can access specialist services more easily, says Richard Vautrey, deputy chairman of the British Medical Association's GPs committee and a GP in Leeds. Migrants may get some aspects of their health needs treated in their home country - dental services, for example - or may even get investigations carried out there and bring the results back, he says.
Some areas are trying to guide migrants through the UK system. Community development manager for Crewe and Nantwich borough council Claire Wilson says some migrants initially feel they are being discriminated against because they have to go through a GP for much healthcare. Some feel the NHS is an inferior system to the one they are used to.
The council, working with the local PCT, has been explaining the system and providing translations of literature and interpreters. Several thousand Poles live in the town, which now has a Polish pharmacist who was discovered working in a factory and offered English language training and support. It is also getting a Polish dentist.
In Reading, the PCT is working with various agencies, including the Catholic church - to inform the Polish community about the health system. It is also using health advisers from within the community, based on a scheme developed with its local black and minority ethnic community.
The NHS in Scotland - which has encouraged immigration from Eastern Europe under its Fresh Talent initiative - has a website describing the Scottish health service and how to access it, available in different languages. This covers subjects from the need to register with a GP before you are ill to where to go for marriage guidance. A similar guide is available in Wales.
There is some evidence that economic migrants from Eastern Europe have a high risk of deteriorating health. Researchers in Germany have suggested that lifestyle issues may be a factor in this. If economic migrants decide to stay in the UK long term - some research suggests around half may do so - there will be a need for education campaigns to change some of these lifestyle factors, such as smoking and a low level of fruit and vegetable consumption.
In the longer run, economic migrants may be more active users of the NHS, calling for services which are shaped to meet the needs of their communities. Public health departments already engage with health needs particular to a large South Asian population: this may extend to Polish or Slovakian communities. Ethnic monitoring may also need to be more sensitive to disentangle specific needs - most Eastern Europeans are currently classified as 'white other' or 'white European'.
Norfolk PCT recently held a migrant workers day where the PCT discussed and provided advice on issues such as diet, lifestyle, sexual and mental health and social care. The feedback the PCT had from its migrant community will lead to changes in its service-level agreements with providers to help ensure migrant workers are receiving appropriate care.
Migrant communities may need a voice in the running of the NHS. Heatherwood and Wexham Park Hospitals foundation trust has indicated it wants to involve more of the area's new migrants in its governance, although it is in the early stages of looking at how to do this.
As unwilling as the NHS may be to address an issue as politicised as migration, these growing demands on healthcare planning may leave it with little choice.
Elusive figures: the numbers challenge
Although the government's worker registration scheme recorded 683,000 Eastern Europeans living in the UK up to June this year, the number is likely to be higher as self-employed people do not have to register. It could be a million or more. There are also around 20,000 Romanians and Bulgarians, who face greater restrictions on working in the UK.
Those who have come to the UK to register are so far mostly young (more than four out of five are aged 18-34) with less than 10 per cent having dependants in this country - although more recent migrants seem more likely to have dependants.
More than 70 per cent are Poles, with Lithuanians and Slovakians the next most common groups. But this demographic profile may not be true of the self-employed.
This snapshot may already be out of date; migrants may bring their family to live with them once they are settled and may also start families here. Anecdotally, some are bringing older relatives to live with them once they are settled.
It is also very uncertain when - and if - migrants will return home.
However, it would be wrong to see immigration as solely about extra demands: at least 30,000 recent immigrants are thought to be working in the healthcare sector.
The worker registration scheme records more than 17,000 care assistants and home carers, 140 anaesthetists, 110 GPs and 70 health and social services managers.
Immigration criteria changes next year may increase the importance of EU unskilled workers in the UK as other unskilled workers will find it harder to enter.
NHS North West chief executive Mike Farrar sits on a cross-government migration impacts forum.'My role is to make sure we are dealing with both sides of the equation; the benefits of migration but also that we are able to deal with the health-related aspects that are more challenging.'
New polish experience
Luton has attracted a significant Polish population since 2004 - helped by its proximity to an airport and an existing Polish community.
The town's Lea Vale Medical Group has seen more than 2,000 Poles register as patients since then, out of a total patient population of 17,500.
The influx of these mainly young people has put additional pressures on its services, especially contraceptive and maternity clinics.
Lea Vale Medical Group consultant Nina Pearson says that, for its main town centre surgery, three-quarters of births are now to Polish parents.
As a women's and sexual health specialist, she sees many young Poles for contraceptive and pregnancy advice, although most of these pregnancies are planned, she says.
Polish women also tend to have babies earlier in life than UK nationals.
As a result, the practice has had to divert more nursing time to its baby clinics and increase capacity in family planning clinics and now has an extra half-time midwife attached.
It has also reorganised how it handles new patient registrations - which have run at 40-50 a week - and has recruited reception staff with Eastern European languages.
Although Poles who arrived soon after the 2004 EU expansion spoke excellent English, more recent arrivals are less likely to have good English and may need an interpreter, adds Dr Pearson. There is also now a Polish representative on the practice's patient group.
At one point, local doctors were concerned they were seeing a number of Poles with musculoskeletal problems, possibly linked to working long hours. However, this has now eased.
With the number of patients increasing by 10 per cent a year, there are also financial implications for the practice.