Seminar on Somali people’s healthcare in Manchester NHS held 25th April 2009 Rusholme Health Centre Walmer Street, Rusholme, Manchester M14 5NP. This event was organised with the Robert Derbishire Practice, Manchester Refugee Health Promotion and many providers of services to the Somali Community.
We had three objectives:
- Increase the awareness of the NHS as a potential employer in the Somali Community
- Improve understanding of the Somali Community among staff in the NHS
- Improve understanding of the NHS and its services in the community and help people to articulate their views about their experiences to people who in a position to effect changes.
On Saturday morning we ran a seminar for NHS and social care providers, students and other interested people dealing with the Somali community’s attitudes and beliefs around:
1. Maternity and childbirth, with special reference to female genital mutilation.
2. Mental health and substance abuse, including Qat
3. Care of older people
4. Acute and chronic physical illness, and some discussion of German health services, which seem to be widely advertised in the Somali community.
We also had some discussion around immigration law and health with Paul Morris from South Manchester Law Centre.
Discussion on ‘General Health’ issues
31 participants in the discussion including health and social care professionals and community residents. Most participants were male and Somali.
The discussion began with the question: Why do Somali people travel to Germany for diagnosis and treatment?
People don’t know :
- what to expect from the NHS in the UK
- what services are available
- the processes they need to go through to access care
Getting past receptionists can be a hurdle that some people don’t manage to negotiate. Releasing such information in pamphlets will not reach some Somali people. It is an oral culture and the written word will not penetrate the community effectively.
Attitudes towards health care are very different in Somalia and don’t translate easily into the UK context. For example people don’t understand the long waiting time for appointments. There is no primary care system in Somalia. It is common practice to treat perceived minor health problems with herbal or traditional medicine and to take more serious problems directly to the hospital.
“Somalis like to pretend they know what is wrong and then they go to the GP to ask for treatment. It’s the wrong way round. We are in a hurry and we want something quick”
The same practices are reproduced in the UK promoting heavy use of A&E and under-use of the GP. In some cases, visiting the A&E does get immediate care. In others, hospital staff ask for a letter from the GP. This can slow things up or prevent treatment if the GP won’t provide the letter.
In Somalia, the expectation for ‘good’ treatment involves some form of medication. Going to the doctor and being told you don’t need any medication can be disappointing and feels to some as if the doctor is:
- not taking them seriously
- has not understood their problem
- is treating them as second class citizens
In these circumstances, trust cannot develop. It is trust that creates the conditions for the genuine exchanges that lead to better understandings and hence better service provision. In addition, seeing the same practitioner is important. Not a different one each time a visit is made;
“I can’t say who my doctor is. I see a different one all the time. What can I tell if I don’t know them and they don’t know me”
It was felt that getting treatment for mental health problems was especially difficult as doctors do not understand the ways in which Somali people interpret mental health. Many are not aware of the sometimes traumatic situations they have experienced. There are also instances when physical problems were diagnosed as mental health problems.
“She has been going to the GP for 10 years for joint problems. They say not suffering physically but it’s psychological. You have too many children, too much stress at home”
However, participants did not feel that this was always to case and some GP’s were able very good at distinguishing mental and physical problems. However, there is a lot of isolation, depression, PTSD, helplessness and this should be better recognised by health professionals. Somalis also sometimes don’t see that they can go to the GP for help with these issues
There are many stories around ‘Dr Paracetemol’. IE doctors who have a prescription already written for paracetemol before they have even told of their health problem. The Somalia participants in this discussion spoke of the tendency for Dr to over prescribe painkillers which are then stockpiled at home. In Somalia, tablets are not usually taken, injections and antibiotics are preferred:
“Give paracetemol, bad doctor”
This constitutes a further cultural difference whereby primary care in the UK does not meet Somali expectations for good quality care.
Difficulties in registering with the GP and working through interpreters have been problematic for some. In particular:
interpreters need a good level of medical/health knowledge if they are to translate effectively.
Doctors/NHS staff don’t always have sufficient expertise to work through interpreters.
“Drink lots of water…for all problems, drink more water”
Interpreter and patient may come from the same community. People may not accurately tell the GP their symptoms especially if they feel any shame or embarrassment. Issues of domestic violence, abuse, drug use etc may not be discussed.
“Some GP’s have worse language skills than us. They can come from anywhere”
This can lead to misdiagnosis and ineffective treatment. Most Asylum seekers and refugees don’t know that the NHS has a statutory obligation to give consultations in the patients own language, however long that takes. It is also promoting a culture in which Somali’s have lost confidence in the GP and while they don’t challenge them, they may not take note of medications prescribed:
“He has a cupboard full of painkillers he’s been prescribed. Just puts these with the rest!”
One key problem identified involved the short time GP’s allocate to appointments. If an appointment is normally 10 minutes long, then with the added complication of interpreting, this can mean only around four minutes for exchange of information.
One key issue in sorting out any recurring problems is that people do not know that they can complain about their treatment, or how to make a complaint
Because of such problems and the mismatch of expectations and service provision, 2001/2002 saw Somalia people travelling to Germany for diagnosis and treatment. Several participants in the discussion had done this themselves, recounting prior years of pain and suffering before taking the decision to go. For some, the experience had been effective. The German health system was described as:
- Highly professional
- Quick access to specialist care – in some cases only days after initial appointments
- Full extensive check ups
- Use of technological equipment for scans etc
- Written, inclusive reports
In general, these people felt they had received a much better service than that experienced in the UK. German medics also advertise on Somali TV. When a Somali becomes ill, then others in their community who have heard of stories about Germany (and Holland and Scandinavia) advise them to go to Germany to get treatment, rather than progress through the UK system. There is a fear that they will not get the right treatment and that health problems will then deteriorate:
“The standard of care is not as good as it should be in the UK”.
“When I go to the GP here they tell me I’m OK. When I go the Germany I get lots of treatment”
“At the café, one boy got shot. We waited 30 minutes for ambulance. Too late, gone”
On return to the UK, they felt that the written reports and prescriptions gained in Germany were not taken seriously by UK doctors. Some had then gone to private practitioners and reports of these experiences were negative when people thought they had been persuade to have expensive and sometimes unnecessary treatments/medications. One person said he had accumulated £12,000 in debt because of this. One Somali doctor participant in the discussion told of how they had been involved in one case where a person had been diagnosed by a private German doctor who had set up in business in the UK. The private practitioner had diagnosed dysfunctional liver and high cholesterol requiring expensive medication and treatment. On examination by the Somali doctor, no health problems of this kind were detected.
Seeking medical attention in other countries was not seen as unique to the Somali communities in Manchester. The Kurdish go to Germany. People from Angola go to Portugal or Spain.
Not all participants felt that the German health system was superior to the NHS. Asylum Seekers were given a full medical check once they arrived in the UK (although they may need to travel a long way for this). Hospitals were well equipped and UK GP’s and consultants operated with considerable expertise.
“The NHS can give excellent service, depends on your condition and good staff. I got the best service in the world”
It may be that the German treatment is not better, but that they have a more efficient system. One German student participant stated that, in Germany, patients can choose their doctors freely across the country and that this operated as a lever for quicker, high quality care. It was felt that while similar choice is theoretically possible in the UK, in practice moving GPs, especially as an asylum seeker, could be very difficult especially when popular GP surgeries were always full and travel to GP surgeries was difficult.
Waiting times were acknowledged to be too lengthy in the UK. Also NHS staff can hold much expertise and knowledge but this does not stand instead of good communication skills which are also needed. NHS staff can be seen as cold, officious with a bad attitude. Instead what is needed is a feeling of warmth and welcome:
“Pleasantness doesn’t cost anything but it doesn’t come with qualifications but it’s important and can make a huge difference to a patient. If the GP doesn’t seem to care, then you want to go elsewhere”
Most agreed that mistakes and misdiagnoses can happen within any health system as any health system is based on human decision making.
There were arguments that Somali/Asylum seeker/ Refugee problems of access to healthcare are not so different from those experienced by British people living in disadvantaged communities. In isolation, this is often the case (including issues of lack of knowledge of services and lack of cultural understandings). However, it was felt that the complex and multiple problems experienced by Somali asylum seekers and refugees did make their case different:
“asylum seekers and refugees help to put a magnifying glass to problems. The NHS should be grateful to us for, glad that they are starting to see what is really happening”
Many participants felt that Somali communities in Manchester can take more responsibility for promoting better health care. Further discussions about experiences and health outcomes could help to set an agenda for shared knowledge and change of attitudes and expectations. In general, the daily experiences of Somalis and how these affect their health are not part of the world of health care staff.
Recommendations discussed were:
- Basic information on how the NHS works, where to go, what services are available should be given in oral as well as written forms
- Educate Somali people to understand that sometimes no treatment is appropriate
- Facilitate further join discussions between health and social care professionals and Somali people to enhance cultural understandings between them
- Mental health issues related to past experiences as well as current experiences of poverty and (for some) destitution should be taken into account in GP consultations. Attention to the whole person is of great importance and not just treatment for expressed symptoms
- Treatment for Somali people/and asylum seekers and refugees more generally is not set as a specific performance target for NHS staff. Unless this is the case, good quality treatment for Somali people will not be prioritised: “It’s not what matters that counts, it’s what is counted that matters!”
- The Somali community has many people with high degree of medical, health and care skills. They should be welcomed into the NHS to provide these skills in a work environment (employed or as volunteers). “This is my home now. I should be concerned with what happens here. I should contribute to making all our lives better here”
- The Somali community should be made aware of the potential problems of getting private medical attention
- Need to get the NHS to do more outreach work. Go out to venues where Somalis live/ congregate so that currently neglected local needs are recognised
- Need to build bridges from NHS professionals to Somali health professionals: “There are a lot of Somali doctors but we are not building bridges to them”
- Complaints procedures need to be more transparent and accessible.
- Somali’s need to talk to people from other minority communities to share experiences and understandings. Individual problems can be easily dismissed, but the collective voice is much harder to ignore.
- Need to get key decision makers to come to events such as this. Health care and social care commissioners. They need to attend discussions with Somali people.
- Empowerment of people in Somali community is a priority so that they can take responsibility for informing the NHS of changes that need to be made. This could happen in the context of a Somali health forum
Mark Carrol’s notes – why do Somali people not use the NHS?
- 1.Home system is different – no GPs so everyone goes straight to hospital
- 2.Language barrier
- 3.“Mistrust” that GPs don’t give the right treatment
- 4.German clinics opening in Manchester – what is the NHS doing about this?
- 5.Need for immediate treatment (e.g. medication, x ray, scans) – German health system can provide that whereas NHS requires referral
- 6.Psychological barriers – Somali community prefer to be given something rather than simply health advice (what is treatment – GP medicating a problem versus health advice and / of self treatment)
- 7.Primary Care education – sessions on getting the right treatment with Somali people?
- 8.Service depends on your condition and your individual GP
- 9.Clinical investigations not up to European standards – are NHS diagnostics good enough (NB contrast with comments from German nursing student – German system is different and not necessarily better)
- 10.GPs not given enough funding / time to do what they want with patients
- 11.Self medication / sourcing medication from other countries
- 12.Appropriate use of qualified professional interpreters – current interpreters may not be trained (dangers of using family members), not from that country, not professional
- 13.Need to increased GP consultation time – address complications of population and particular patients
- 14.PCT could agree target for seeing specific communities for longer per consultation
- 15.Role of the Single Equality Scheme
- 16.Need to see the same GP when you attend your practice (NB Practical problems this creates with popular GPs in terms of waiting times for appointments)
- 17.Full health check for refugees / asylum seekers in the UK
- 18.Role of the Somali community working with NHS to provide interpreters for free or reduced cost to address high cost / availability of interpretation
- 19.How is the local community communication structure replaced? (E.g. from Alistair Cox of the void left in central Manchester when the LAGs were disbanded)
- 20.Getting past reception to see the GP, obtaining a referral from the GP.
- 21.GPs role in psychological care and comfort not just prescribing medication and treatment
- 22.Cost of private healthcare when Somali patients go to Germany – does paying for care necessarily mean it is better and are people better?
- 23.Potential for volunteers in each community to work with the NHS e.g. Somali PALS Linkworker / Somali Health Linkworker
- 24.Use of information – value of spoken word rather than written information
- 25.Issue is the amount of time available with your GP not their knowledge
Women’s Group Notes
The conversation began around women’s health and childbirth, but then broadened into health generally.
St. Mary’s Hospital was generally felt to be good, but one woman had a bad experience after a Caesarian Section.
However, there was a feeling that if you went every year to have a baby they would get fed up, and that having too many babies was frowned on – ‘They think we don’t pay tax, and that we should not be having so many babies.’ They felt that they might be seen as a burden. When asked whether they would want their daughters to have many children, they were not so sure.
People were happy with the service they get at Rusholme Health Centre.
One woman spoke about racist attitudes of a GP receptionist, who spoke kindly and considerately to an elderly white man, but whose who demeanour changed when faced with an elderly Asian lady and then the Somali lady herself (this lady speaks excellent English, and gave as good as she got!)
A discussion followed on racism generally and how it affected their confidence about going out, taking their children to the park. Several women said that they did not feel physically safe going out, and so stayed at home. They said they know many women who keep their children at home rather than risk racial abuse outside. Asked whether they would feel safe if special sessions for families with young children were arranged at Platt Fields, they responded positively.
One woman said that if she needs to call a doctor at night, he will not come out to her because she lives in Moss Side and he does not feel safe.
Asked about health care, and why they go to doctors in Germany, the women expressed considerable dissatisfaction with health services in the UK.
They spoke of several cases, very well known in the community; on two occasions ambulances had been called and not taken the patient’s condition seriously. One man subsequently died of a heart attack, and the other patient turned out to have TB spine. These cases, and others, are very well known in the Somali community, and have a profound effect on Somali people’s confidence in the NHS. A complaint had been lodged about the man who died, but a year later his family have heard nothing.
They also spoke of general inefficiencies, e.g. test results not being sent to the GP, mistaken identities.
There were concerns about the quality of interpreters, and their ability to interpret medical jargon.
‘Doctors don’t take notice of us, don’t read body language.’
They felt that their culture is not understood – for example, it is normal when someone is ill for a lot of people to visit them. If they do that in a UK hospital they get told, very rudely, that they must leave.
There was a general feeling that they do not get listened to by some GPs, who simply prescribe Paracetamol.
Asked why people go to see doctors in Germany, they said that they use the health service in the UK first, but that they are told that there is nothing wrong with them. Because they feel that there IS something wrong, they go to Germany where they see doctors who take time, are patient and listen to them, perform tests, and make them feel better.
They felt that there is a need for bridges between the NHS and the Somali communities, and more Somali people working in the NHS.
The women all agreed with the statement that mistakes are made, because we are all human, but they feel as though they are treated badly because they are refugees or because they are Somali.
Cath Maffia