Since january, the Dutch association for paediatric medicine has had a notification centre where paediatricians can report problems they encounter when caring for the children of refugees. Children get lost in the shuffle of the many relocations and doctors do not know how and where to find them.
Since last year, the number of children fleeing to the Netherlands has increased sharply. In 2015, twelve thousand children were in the asylum system, three thousand of which were on their own. That is more than twice as many as in 2014. It is expected that at least as many refugee children will arrive this year as in 2015. Most are coming from Syria and Eritrea. These children are entitled to medical care. Are they receiving it? “We are not under the impression that it is going terribly wrong, but each child that does not receive proper medical care is one too many,” says retired paediatrician Louis Kollée of the Dutch Association for Paediatric Medicine (DAPM). He coordinates the ‘Notification centre for care problems involving the children of refugees’ that the DAPM began in January. Last year, the association was notified by paediatricians that children were being lost. The children were being referred to a hospital from emergency assistance locations. After seeing the paediatrician the first time, they were not showing up for the follow-up appointment. This prevented treatment from being started. The notification centre was set up to gain more insight into the gaps in medical treatment for refugee children. At the end of April, 35 notifications were made by paediatricians, primarily for children who did not appear for their appointment at the hospital or who disappeared after their first visit.
Paediatrician Michel Van Vliet of Refaja Hospital in Stadskanaal has already made several reports. Every week, three to six children are referred to Refaja from the registration centre in Ter Apel. “Children who are acutely ill, because they have malaria or are extremely short of breath, always show up for the appointment,” says Van Vliet. “It goes wrong more often with children who have less acute issues.” Each week, Stadskanaal loses track of a child. A girl with liver problems, who does not show up to her follow- up appointment. A boy with epilepsy, whom Van Vliet has never even met. A baby who was referred due to nutritional issues and disappears without a trace. At Refaja Hospital, children from the Ter Apel registration centre take precedence. “We guarantee that they can be seen within a week of referral, so that we can lessen the chance that they be relocated in the meantime,” says Van Vliet. “That helps, but it does not entirely solve the problem,” he says. He reports every child that is lost to the DAPM notification centre. Sometimes, the child will appear again at a different hospital. Van Vliet: “Due to privacy concerns, we are not permitted to provide the names or birth information of the children to the notification centre. That makes it difficult to find the children again.”
All asylum seekers can be found in the physician information system of the CRA (Central Agency for the Reception of Asylum Seekers), even after six or seven relocations.
For instance, on the CRA healthcare pass, there may be another date of birth than the one provided by parents or guardians. “This means that a child may be registered at our hospital under a different date of birth than at the hospital where they were registered after a relocation. So we are unable to find them in our system.” Ella Bool of the Asylum Seekers Health Centre (AHC) recognises the problem. The AHC provides care from physicians at asylum centres and the emergency assistance locations of the CRA. Bool: “We have trouble with that, too. A refugee should register using their alien registration number or CRA healthcare number, because that is a unique insurance number. The name and date of birth are prone to being changed every now and then and that makes it difficult to search for patients.” Bool feels that primarily children from municipal emergency locations could have fallen off the radar in the past few months.
That problem may have been largely resolved since then. “The explosive influx throughout the country has spurred the opening of temporary municipal emergency locations and we were unable to provide medical care there. Now, the municipal emergency locations have been taken over by the CRA and there are also medical teams present at all of them. We have a medical profile for all asylum seekers in CRA locations in our national physician information system. Every asylum seeker in the Netherlands can be found in it, even after six or seven relocations. The profiles are managed by the AHC, which is available 24 hours a day via the hotline.
Van Vliet requests that paediatricians hold weekly hours in external outpatient clinics at registration centres for refugees and at large emergency assistance locations. “It would be very patient friendly if we approached sick children instead of the other way around.” There is already informal talk of this, but Louis Kollée finds it unrealistic. “That would mean that the children of refugees would be receiving better treatment than other children in the Netherlands. I don’t think that is up for discussion from a political standpoint.” Another solution is that refugees be settled into one location during their entire asylum procedure. Karin Kloosterboer of UNICEF Netherlands and “The Work Group for Children in Asylum Centres” advocate for this. This allows children to always see the same doctors and providers and to not have to re-tell their story each time. Kloosterboer: This makes monitoring health problems much simpler. At the moment, asylum seekers relocate six or seven times. If you stay in one place for four weeks and another six weeks somewhere else, no one can get a good idea of your background.
MHS Examination
All refugee children who arrive in the Netherlands undergo a medical examination by the Municipal Health Service (MHS). It is observed whether they have infectious diseases or other acute medical issues, both physical and psychological. According to MHS protocol, these intake examinations must occur within six weeks. In a recent report by the Ombudsman for Children, it appears that this has long since been impossible within the established time frame. In December 2015 and January-February 2016, the ombudsman performed a study of the situation of children in emergency assistance locations.
According to the healthcare professionals that the ombudsman spoke to, this is primarily because a number of practical problems stand in the way of rapid intake. At many emergency assistance locations, there is insufficient room to perform an intake or the MHS post is set up at a difficult-to-find location, which results in the parents not showing up and the children missing the appointment. According to the Ombudsman for Children, access to care from physicians is in good shape at CRA locations. The AHC posts are usually open for several days or parts of the day per week. Outside of these times, the hotline is available 24 hours a day.
All refugees have the right to a free interpreter, even if they are only in the Netherlands for a few days.
“However, we are hearing from many refugee children that they feel as if they are not being seen or heard by doctors or healthcare professionals,” says Kloosterboer. “They also have the feeling that they are being dismissed when they make health complaints: sent away with just some paracetamol and a glass of water.” “That may also have something to do with the difference between healthcare in the Netherlands and that from the country of origin,” suggests Kollée. For instance, Syrians are not familiar with a system that employs general practitioners and birthing experts; they almost always go immediately to a hospital or specialist. Additionally, in countries like Syria and Eritrea, antibiotics are prescribed more quickly.
Bool also made another point: “In a country like Turkey for example, paracetamol is distributed under ten different names. The patient thinks that they are receiving something new each time, but it is always the paracetamol. In the Netherlands, we do not have all the different names.” Kollée: “Refugees have to be shown the ropes of the Dutch healthcare system.”
- A child* is referred to an asylum centre by a doctor from the Asylum Seeker Healthcare Centre (AHC). This referral occurs via a healthcare portal or paper referral letter. The employees of the AHC are not permitted to send letters by fax, because faxing is unsafe for sensitive, private information.
- The letter can be sent to the hospital via a Zorgmail address. If an outpatient clinic is not associated with Zorgmail, the AHC physician sends a password-secured email to the clinic. At the outpatient clinic, this often goes awry because the one-time password is often forgotten or the procedure is considered too convoluted. This is an important point of concern for hospitals.
- Feedback from the paediatrician to the AHC should take place via EDIFACT. It is important to include the correct address and the correct GDM code (general data management code). Physicians have a contract with the AHC and typically have their own practice as well. Specialists often send their messages to the personal practice of the physician. This can cause it to take a significant amount of time before the message reaches the AHC and added to the proper profile. For work at the AHC, the physician has a second GDM code. This must be completed by the specialist.
- Patients who have just arrived in the Netherlands and still cannot speak Dutch always have the right to a free interpreter, even if they are still not officially in the asylum process. The interpreter can be accessed 24 hours a day via the Concorde Interpreting Centre, telephone no.: 020-8202890. The patient must provide their CRA healthcare pass. The interpreter can participate in a three-way conversation with the specialist and the patient. For a significant examination such as a bronchoscopy, during which it is important that the patient understand all instructions, it is possible to reserve an interpreter. Therefore, it is unnecessary for the patient to bring a family member along to interpret.
- For instance, if a patient does not arrive for the appointment and no longer appears to be at the asylum centre, the Asylum Seekers Healthcare Centre hotline can be contacted 24 hours a day at 0881-122112. In the case of serious medical problems like cancer, the AHC requests that the CRA not relocate the patients, but this does not always work. The AHC can always look at the profile of the patient, see where they are located, and which appointments the patient has.
- First aid: the physicians from the AHC can accommodate patients at the National Exchange Point, because the patients do not have citizen service numbers. For supplementary information, the hotline can always be called: 0881-122112. The hotline has the profiles of all asylum seekers in the Netherlands and is available 24 hours a day.
- If a patient is relocated, it can happen that the specialist returns a letter to the wrong AHC. In that case, the letter arrives in a digital inbox. Triage nurses from the hotline will ensure that the message is placed in the proper profile.
- At small asylum centres, there are not always physicians. The operating hours and telephone numbers of all AHC locations can be found at www.gcasielzoekers.nl.
Individual effort
Refugees are not the only ones to get lost in the process, many physicians and paediatricians are unaware of how care for refugee children is organised and which path they should take. That is how Albertine Baauw experiences it, who, just like Kollée is a member of the ‘Notification centre for care problems involving the children of refugees’ and analyses what goes wrong with all reporting. Baauw: “It is true that some children do not appear at appointments for unclear reasons. However, a big part of the problem is that doctors do not know that they can send their letters to the AHC central address in Wageningen and that they can call the AHC hotline 24 hours a day.
It is also striking that the individual effort of paediatricians is often responsible for whether things go well. Paediatricians impress the importance of coming to the appointments upon the children, give them letters, call after appointments are missed, arrange interpreters from the Concorde Centre, and ensure that the family feels safe. That is important for this group: be sure that you make a connection with them.
Ditty Eimers
Information
www.gcasielzoekers.nl
www.coa.nl/nl/over-coa/keten-en- samenwerkingspartners
Click here for a Dutch language version of this article.
Volunteers
The DAPM has a national volunteer network of paediatricians that can be called upon on a case by case basis by general practitioners (including their assistants and healthcare professionals) who are involved in the medical care of refugee children at the shelters. Upon request, a paediatrician from this network can be called upon as a source of advice or a consultant for primary care providers. This is not about referrals. Many paediatricians who volunteer for this network have experience in the tropics or in the Middle East.
Information
DAPM, Anneke Van Wijngaarden
vanwijngaarden@nvk.nl
030-2823306 of 06-37477824