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Delivering healthservices in an era ofsuperdiversity: newchallenges or oldproblems?Dr Jenny PhillimoreInstitute for Research into SuperdiversityInstitute of Applied Social StudiesThe University of Birmingham

Introduction Superdiversity and welfare provision Superdiversity in the West Midlands Old problems and new challenges in healthprovision 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. Bostonhighest increase in AoW (11.4%) Complexity – gender, status, age, reason formigration, class, faith....... Fragmentation – from many migrants from afew countries to a few from many Super-mobility

Superdiversity and access to welfare Emergence of superdiversity and globalneighbourhoods Social scientific and policy challenges (Vertovec2006) Viability of MC approaches to welfare deliveryquestioned (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, 2 nd biggest urban area, highdeprivation and rural remoteness Birmingham to become majority/minority city Migrants from 187 countries – old and newmigrants, clustered and fragmented (table) High levels of deprivation, exclusion, poorhealth outcomes and highest infant mortalityrates in Europe Is there a crisis in welfare delivery? Are there new challenges for providers?

Methods No reliable/complete socio demographic data Need to generate findings with policy relevanceto improve services Four research projects focusing on differentaspects of health (MH, maternity, primary care) Move from ethnicity sampling to SD sampling Selection on the basis of difference Questionnaires and interviews by communityresearchers with new migrants Interviews with health professionals

Old problemsNew challengesMigrantsLanguage Initially Difficulty identifying translators/ interpreters forTransiencyPressure onservicesRights andentitlementsInability tounderstandinstitutionalcultureCultural needsnot metPopulations tended to be morefixedInitiallyFree access to NHS – assumed inthe UK legallyInitially“new” languages”Break in continuity of carePressure of numbers means limited GeneralPractitioner spacesOver-use of A&EEnd of free access - health problems neglecteduntil acuteOthers incorrectly denied free access“Misuse” of servicesInitially but later specialist For “old” migrants but not newservices developedDestitution No In hiding and no income so health seeking isIsolationNorestrictedFragmentation means lack of critical mass

LanguagesOld problemsProvidersInitially but eventuallyinterpretation and minority staffand development of expertiseNew challengesProblems accessing appropriatetranslation/ interpretation plus reducedbudgetsTransiency No Inability build relationships withpatients, new patients requiringintensive interventionLack of data Yes YesLack of knowledge Initially but over time knowledgeacquiredConstant newness and novelty mitigatesagainst development of knowledgeOutsourcing ofimmigration controlNoHealth providers have role inrestrictionalism and expected to denythose who can’t payDestitution No Charges for those with NRPFMultiple problems To some extent New levels of complexity as immigrationstatus interacts with ethnicity, language,culture etc

Discussion: newness and novelty Novelty– Novel language, culture and systems for migrants– Novel languages, cultures, immigration rules androles, 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 collectiveknowledge to support or guide migrants– Patients always new when high levels of transiency:require extra time and admin costs– No opportunity to develop knowledge orexpertise

Discussion Scale of arrivals exceeds all previous experience Superdiversity treated as a problem to becontrolled at borders rather than a condition No funds, time or training to adjust NHS restructuring and austerity cuts leading to lossof expertise around old problemsConsequences: Migrants: over-use, misuse or don’t use system Professionals: overwhelmed, confused andpowerless and sometimes resentful

What to do? Need to acknowledge new reality of SD Not practical/possible for professionals toacquire comprehensive cultural knowledge oridentify interpreters for all Move from multicultural mindset tointerculturalism – make no assumptions Train all new professionals in interculturalcommunication 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 associatedwith “super”- diversity, scale, speed andspread, complexity and fragmentation Much work is needed to :– Understand common and divergentchallenges– Identify innovative, sustainable and freesolutions