Delivering health services in an era of superdiversity: new - - PowerPoint PPT Presentation

Delivering health services in an era of superdiversity: new challenges or old problems?

Dr Jenny Phillimore Institute for Research into Superdiversity Institute of Applied Social Studies The University of Birmingham

Introduction

 Superdiversity and welfare provision  Superdiversity in the West Midlands  Old problems and new challenges in health

provision

 Newness and novelty  A tentative way forward

Superdiversity

 “Diversification of diversity” (Vertovec 2007  Speed – 9% to 13% born overseas  Scale – census – 3.5m rise in population 56%

are migrants

 Spread – now urban and rural i.e. Boston

highest increase in AoW (11.4%)

 Complexity – gender, status, age, reason for

migration, class, faith.......

 Fragmentation – from many migrants from a

few countries to a few from many

 Super-mobility

Superdiversity and access to welfare

 Emergence of superdiversity and global

neighbourhoods

 Social scientific and policy challenges (Vertovec

2006)

 Viability of MC approaches to welfare delivery

questioned (Ahmed & Craig 2003)

– Politically (backlash, alleged loss of social solidarity) – Financially (austerity cuts) – Practically (weakness of ethnicity approach)

 Need for new models (Vertovec 2006)  Focus on health provision in W. Midlands

The West Midlands

SD, migration, and health in West Midlands

 Central region, 2nd biggest urban area, high

deprivation and rural remoteness

 Birmingham to become majority/minority city  Migrants from 187 countries – old and new

migrants, clustered and fragmented (table)

 High levels of deprivation, exclusion, poor

health outcomes and highest infant mortality rates in Europe

 Is there a crisis in welfare delivery?  Are there new challenges for providers?

Numbers Categories of migrant Pakistan 5585 Family/marriage, economic migrants, students, asylum seekers India 4559 Family/marriage, economic migrants, students, asylum seekers Poland 4172 Economic migrants (A8), students China 2514 Economic migrants, students, asylum seekers, family reunion/marriage Bangladesh 1551 Family/marriage, economic migrants, students, asylum seekers Romania 1351 Economic migrant (A2), students Afghanistan 1180 Asylum seekers, family reunion Nigeria 1118 Economic migrants, students, asylum seekers, family reunion/marriage Somalia 1047 Asylum seekers, family reunion France 860 Economic migrant, asylum seekers with French citizenship Germany 782 Economic migrant, asylum seekers with German citizenship Slovakia 685 Economic migrant (A2), students Iran 684 Asylum seekers, students, family reunion Malaysia 660 Family/marriage, economic migrants, students, asylum seekers Iraq 507 Asylum seekers, family reunion Saudi Arabia 485 Economic migrants, students, family/marriage, asylum seekers USA 481 Family/marriage, economic migrants, students Netherlands 431 Economic migrant, asylum seekers with Dutch citizenship Philippines 429 Family/marriage, economic migrants, students, asylum seekers Jamaica 413 Economic migrants, students, family reunion/marriage Others 11824 Various Total 41318

Methods

 No reliable/complete socio demographic data  Need to generate findings with policy relevance

to improve services

 Four research projects focusing on different

aspects of health (MH, maternity, primary care)

 Move from ethnicity sampling to SD sampling  Selection on the basis of difference  Questionnaires and interviews by community

researchers with new migrants

 Interviews with health professionals

Old problems New challenges Migrants

Language

Initially Difficulty identifying translators/ interpreters for “new” languages”

Transiency

Populations tended to be more fixed Break in continuity of care

Pressure on services

Initially Pressure of numbers means limited General Practitioner spaces Over-use of A&E

Rights and entitlements

Free access to NHS – assumed in the UK legally End of free access - health problems neglected until acute Others incorrectly denied free access

Inability to understand institutional culture

Initially “Misuse” of services

Cultural needs not met

Initially but later specialist services developed For “old” migrants but not new

Destitution

No In hiding and no income so health seeking is restricted

Isolation

No Fragmentation means lack of critical mass

Old problems New challenges Providers

Languages

Initially but eventually interpretation and minority staff and development of expertise Problems accessing appropriate translation/ interpretation plus reduced budgets

Transiency

No Inability build relationships with patients, new patients requiring intensive intervention

Lack of data

Yes Yes

Lack of knowledge

Initially but over time knowledge acquired Constant newness and novelty mitigates against development of knowledge

Outsourcing of immigration control

No Health providers have role in restrictionalism and expected to deny those who can’t pay

Destitution

No Charges for those with NRPF

Multiple problems

To some extent New levels of complexity as immigration status interacts with ethnicity, language, culture etc

Discussion: newness and novelty

 Novelty

– Novel language, culture and systems for migrants – Novel languages, cultures, immigration rules and roles, and entitlements for professionals – Novel encounters with diversity in rural (& urban) areas – Novel combinations of problems with no clear solution

 Newness

– Lack of established community with collective knowledge to support or guide migrants – Patients always new when high levels of transiency: require extra time and admin costs – No opportunity to develop knowledge or expertise

Discussion

 Scale of arrivals exceeds all previous experience  Superdiversity treated as a problem to be

controlled at borders rather than a condition

 No funds, time or training to adjust  NHS restructuring and austerity cuts leading to loss

• f expertise around old problems

Consequences:

 Migrants: over-use, misuse or don’t use system  Professionals: overwhelmed, confused and

powerless and sometimes resentful

What to do?

 Need to acknowledge new reality of SD  Not practical/possible for professionals to

acquire comprehensive cultural knowledge or identify interpreters for all

 Move from multicultural mindset to

interculturalism – make no assumptions

 Train all new professionals in intercultural

communication

 Educate children about institutional cultures  New health intermediary role  Invest to save????

Conclusion

 Social policy challenges associated with SD  Repeating all of the old problems  Experiencing many new problems associated

with “super”- diversity, scale, speed and spread, complexity and fragmentation

 Much work is needed to :

– Understand common and divergent challenges – Identify innovative, sustainable and free solutions