What do primary care staff know and do about blood borne virus testing and care for migrant patients? A national survey

Migrants in the UK from intermediate or high prevalence areas for HIV, hepatitis B (HBV) and hepatitis C (HCV) are at increased risk of these infections compared to the UK-born population, and experience a disproportionate burden of disease [1‐3]. In 2017 almost half (49%) of newly diagnosed cases of HIV among heterosexuals were among black Africans or heterosexuals born in a high prevalence country [2] and an estimated 95% of new chronic HBV infections in the UK are among individuals who probably acquired their infection overseas in endemic countries, often perinatally or in childhood [4]. For all three blood borne viruses (BBV) the undiagnosed fraction remains high, with a high proportion of infections diagnosed late, potentially contributing to avoidable morbidity and mortality and increased risk of onward transmission [5‐8].

In 2016, the UK government signed up to the World Health Organisation (WHO) goal of eliminating viral hepatitis as a public health threat by 2030 [9]. HBV and HCV testing in primary care for migrants from countries with intermediate or high prevalence (> 2%) has been recommended by National Institute for Health and Care Excellence (NICE) guidance since 2012 [10], and since 2018 European Centre for Disease Prevention and Control (ECDC) recommends screening newly arrived migrants for BBV [11]. Although surveillance data indicates that an increasing proportion of BBV diagnoses take place in primary care, evidence suggests a low proportion of eligible migrants receive the recommended BBV testing in this setting [12, 13].

Language, stigma and poor knowledge and understanding of disease create barriers for migrants to accessing testing and treatment for viral hepatitis [14, 15] and migrants often experience discrimination and bureaucratic obstacles when trying to access healthcare [16, 17]. In August 2017 UK healthcare entitlements for migrants changed and the list of chargeable services was expanded [18, 19]. While many services, including primary care, are still free to all migrants, for others a patient should now be deemed ordinarily resident in the UK to access services for free. Sexual health, family planning, GP and nurse consultations in primary care, emergency department (ED) and walk-in centres, and treatment of mental and physical conditions caused by torture, female genital mutilation (FGM), domestic or sexual violence are free to all migrants, while communicable disease diagnosis and treatment is free to all for a list of specified diseases, including HIV, viral hepatitis, TB and Middle East respiratory syndrome [18‐20]. For surgery or outpatient services in secondary care, a patient should be deemed ordinarily resident in the UK to access the service free of charge. This additional complexity may lead to uncertainty among both migrants and professionals about entitlements, and could create additional barriers to accessing services.

We, therefore, conducted a national survey to understand primary care staff’s knowledge, attitudes, policies and practice regarding BBVs in migrant patients, influences on these, and their perceptions of the barriers for migrants in accessing healthcare.

Primary care staff knowledge, attitudes, policy and practice regarding migrants’ healthcare entitlements and their BBV testing and care was very variable in this sample of English practices. One in four were unaware that GP and nurse consultations are free for all. Universal opt-out BBV testing for migrants was not common practice, and only one in three clinical staff would routinely consider BBV risk assessments for newly registering migrant patients. Where testing was requested, most respondents requested the recommended tests, and over 90% indicated they would refer diagnosed cases to secondary care. Respondents identified access barriers relating to a range of factors including language; patient knowledge, stigma and fear; time pressures of appointments, practices not having a BBV testing policy and lack of knowledge and awareness among staff.

Knowledge of entitlements to health services varied. Of particular concern is that a quarter of clinical staff were unaware that GP and nurse consultations are free to all. Vulnerable patients, including migrants could be wrongly refused GP registration, despite national guidance that lack of documentation should not be a barrier to registering with a GP [24]. Three UK studies estimate that refusal ranges from 20 to 39% [25‐27]. As primary care is the first point of access, ‘gatekeeper’ to other services, and a trusted source of health information, GP staff’s poor knowledge of entitlements is likely to create a further access barrier in addition to the system, cultural and language barriers migrants face, especially when it comes to communicable disease control [28, 29]. There were no substantial differences in knowledge of healthcare entitlements of migrants between GPs and nurses; GPs were more likely to know that operations and outpatient appointments are not free, and nurses were more likely to know that care for FGM, torture etc. is free, which likely reflects their roles in general practice.

BBV testing was more often conducted on an ad-hoc than opt-out basis, and BBV risk assessments for newly registering migrant patients were routinely considered by only a third of respondents, and more often considered on a situation specific basis. Most respondents stated existing migrant patients were identified for testing opportunistically during consultation, and only 14% systematically flagged migrant patients for BBV testing. These findings suggest that migrant patients eligible for BBV testing are not often routinely identified as such, which is likely to hinder adherence to BHIVA, ECDC and NICE guidelines which recommend BBV testing for migrant patients from higher HBV and HCV prevalence (> = 2%) areas and HIV testing for all patients in high (> 2 per 1000) prevalence areas in the UK [10, 11, 30], and is consistent with other studies which report low adherence to testing guidelines for BBVs outside of the sexual and antenatal health setting [12, 31]. Opt-out rapid testing in general practice has been shown to increase diagnosis rates for HIV, and universal opt-out testing initiatives for migrants which offer opportunities to normalise testing are subject to ongoing evaluations and have been well received by staff and patients [32‐34].

Improved practice staff knowledge is needed to help reduce barriers and variations in service provision. Resources are available, such as the PHE Migrant Health Guide which outlines NHS entitlements and gives guidance on assessing new patients from overseas [35], RCGP e-learning courses [36], but also PHE and charities co-branded promotional videos, posters and leaflets on BBV in multiple languages for patient waiting areas can be downloaded or ordered from gov.uk [37]. Further work is needed to understand current awareness and to increase uptake of these resources.

Use of software programmes to identify and automatically flag patients for testing based on risk factors or risk proxies recorded on practice registers has been shown to be effective for groups including migrants in primary care and other settings [38‐40]. This requires migrant status to be recorded on GP systems for migrants to be flagged as at risk. Although 59% of respondents stated that their practice routinely recorded country of birth, data from the Clinical Practice Research Datalink suggests recording is a lot lower at 1.6% [41]. This discrepancy could in part be due to biases in our sample or respondents giving socially desirable answers, however it may be that practices are recording this data on other systems where the data is not extractable. This highlights a need to increase awareness of the importance of recording patient country of birth amongst practitioners and information service providers, and for practitioners to assess risks associated with country of birth as a part of the first registration consultation.

Flagging and opt-out testing for newly registering migrant patients was more frequently reported where respondents said they see migrant patients frequently, in smaller practices and highest in Yorkshire and Humber and London, but lowest in the South East. A similar pattern was observed for services such as specially designated clinics, longer appointments at registration and projects to register migrants – these were more frequently reported where respondents saw migrants frequently. Outreach services and projects to register migrants were higher in small practices. These variations may reflect GP surgeries adopting policies and practices that reflect the needs and diversity of their local populations, and the ability of smaller practices to be more responsive and adaptive in implementing migrant focused services.

Performance payment structure may be the most influential way to incentivise BBV testing [42‐44], and PHE and CCG recommendations were also more often stated to provide motivation to test than alternative sources. Only half of respondents indicated that NHSE and CMO recommendations would provide motivation for testing, which may reflect a relative lack of confidence in these bodies versus the perceived scientific credibility and independence of PHE and the more direct relationship and understanding of local PHE teams with CCGs. Interestingly, nurses were more likely than GPs to be motivated by local targets, national goals, CCG recommendations and NICE guidance.

Over 90% of GPs reported referring diagnosed cases of HBV and HCV to secondary care, and over half followed patients up if they did not attend secondary care appointments. Three quarters would offer close contacts of HBV infected cases testing, and three quarters would offer close contacts hepatitis B vaccination. These proportions seem high, as many patients diagnosed with HBV and HCV are known not to be accessing secondary care – in a 2012 UK study only a third of HBV diagnosed patients were on treatment [45] and an analysis of England sentinel surveillance data showed that between 2004 and 2017 only 21% of viraemic HCV diagnosed patients had evidence of treatment [46], and baseline HBV testing of close contacts was only 34% in a 2018 UK study [47]. Our results may be due to sampling and responder bias, due to initially contacting networks who were interested in migrant health, and those who were interested being more likely to respond, as well as wishing to give socially acceptable or desirable responses.

Differences in knowledge of BBV diagnosis and management were noted between nurses and GPs, with nurses being less likely to know whether all diagnosed HBV/HCV patients are referred and whether referrals are followed up, and less likely to know the diagnostic tests to request for HCV and HIV but there was no significant difference for HBV. Generally, there is a need for improved understanding of diagnostic testing for BBV in practices. Regardless of service, respondents cited language as the main barrier to accessing healthcare, which is consistent with the literature [14, 15, 48]. For patients who require linguistic support, interpreting services are recommended in General Medical Council guidance and were provided by 88% of respondents’ practices [49‐51]. Nevertheless, there is evidence that interpreting services are underused, despite incurring no direct cost for practices [52]. This may be partly due to time pressures within appointments and the indirect costs of longer appointment times, as well as the need for forward planning and a lack of professional confidence in working with interpreters [53]. Brief education may help improve professional confidence in when and how to use interpreters [54]. Improved provision of translated materials is also likely to be beneficial in improving patient access to health information; efforts to ensure materials about BBV are translated are ongoing [55].

Patient knowledge and understanding of disease, and the location of secondary care services were cited as barriers to accessing secondary care. Community based treatment pathways, as have been demonstrated to be effective for HCV [56, 57], could help to overcome geographic barriers, although one recent study found that (first and second generation) migrant patients were no more likely to complete treatment on a community pathway [40]. Assessing patient attitudes towards BBV, and increasing patient knowledge would also be valuable and could be considered by practices to improve their services.

Systematic or universal opt-out testing for migrant patients are uncommon and testing is more often done on an ad hoc basis, despite BASHH, PHE and NICE guidelines. Achieving the WHO goal of eliminating viral hepatitis as a public health threat by 2030 requires coordinated efforts to increase case-finding of patients with HBV and HCV; our results suggest that current testing practices for high-risk migrants in primary care are likely to be inadequate to meet the elimination goal among this population. Improved systematic risk-based flagging of migrant patients for BBV screening and checks or prompts for referral and attendance to specialist services is needed to reduce the burden of undiagnosed infection and improve uptake of treatment, noting this is curative for hepatitis C. Local and national commissioning specifications for primary care testing and management of BBV infected patients may be required to achieve this goal. General practice professionals’ knowledge of migrants’ entitlements to healthcare was variable and could affect migrants’ access to care. Perceived barriers to accessing healthcare consistently included language and lack of patient and staff information and awareness. These are not insurmountable but require sustained commitment, professional awareness as well as resource. The ultimate goal is to reduce morbidity, mortality and inequalities associated with BBV infections in migrant populations, mindful of the fact that this population is already vulnerable to disparities in healthcare access and health outcomes.