When the nhs was founded in 1946 it was upon on the principle that "everybody, irrespective of means, age, sex or occupation shall have equal opportunity to benefit from the best and most up-to-date medical and allied services available". However a circular uncovered by the Guardian this June has revealed that at least one NHS Trust does not seem to be applying this principle to refugees after it emerged that mental health services were being denied to asylum seekers in North London.

The Barnet, Enfield and Haringey Mental Health NHS Trust wrote to GPs in North London in May to state that it could not accept the referral of a Turkish man for cognitive behavioural therapy as the patient's status "was still uncertain". The authority was not "currently accepting referrals of asylum seekers" because, it said: "The stress of their uncertain status in this country confounds the multiple psychosocial problems that they undoubtedly already have and which we are not equipped to deal with in addition to the heavy volume of more standard referrals."

In answer to a written question from the Conservative MP for Westbury, Andrew Murrison, last November, the Health Minister John Hutton replied: "Under NHS legislation, any asylum seeker given leave to remain in the UK or awaiting a decision on their application is regarded as ordinarily resident and is eligible for free treatment from a GP and eligible to receive NHS hospital treatment."

However the Turkish patient in Edmonton, who suffers from Post Traumatic Stress Disorder (PTSD) after experiencing brutal treatment at the hands of the police in his homeland, has still yet to receive any treatment.

Dr Angela Burnett, of the Medical Foundation of the Victims of Torture - one of the specialist voluntary agencies which the Trust suggested GPs forward their refugee patients to - said that this was probably not an isolated incident but it was usually difficult to prove that care was being denied as "in other cases it happens more covertly".

Burnett said one of the more frequently cited excuses used to deny asylum seekers medical assistance was services saying that they couldn't work with interpreters. "But in fact, with training, it is very possible to do mental health work with interpreters," she said.

Dr James Barrett, a Consultant Psychiatrist at Charing Cross Hospital, says that he has heard of many anecdotal reports of refugees who have gone to GPs to register only to be told that the list was full. "And then if somebody who is white and speaks English turns-up five minutes later the list is magically not full," he says. Whether this is because of mis-communication and/or the cost factor of registering a refugee, Barrett says he can't be sure - but it was his "suspicion" that economic issues were at least in part responsible.

However another factor, Angela Burnett says, is time: "Obviously these are people with complex issues and using an interpreter can take double the time. I appreciate health workers are overwhelmed with targets at the moment. I know of GPs who go without their lunch in order to see people and try and make a proper assessment."

But possibly the biggest single factor affecting the care of asylum seekers, she says, is mobility. "People get moved around so much it is actually very hard to access secondary care services because even if it is still quite a short waiting list, people have often moved on by the time their appointment comes up - or else they can go once and then can't go for the follow-up," Burnett says. "And some asylum seekers are moved so many times it is actually very disorientating for the person themselves and it makes planning care a nightmare."

Burnett cites cases of women being moved not long after having premature babies: "A baby who is born prematurely at 26-27 weeks needs follow-up care and monitoring. Now we are certainly not saying that this care is not available throughout the UK, but ideal care actually requires continuity in an instance like that."

James Barrett agrees that the dispersal policy often causes great problems in providing treatment: "And of course they have got no money because they are not actually paid any expenses. I remember there was one guy, I was meant to see him at 10 o'clock in the morning in London. He looked a bit knackered when I saw him and he was wearing a heavy coat, despite it being a hot day. It turned out that he had walked from Essex starting out at 9 o'clock the previous night."

Dr Barrett says that although he sees a whole range of psychiatric conditions amongst the refugee community they tend to be the "same things you see in everybody else really. Depression, anxiety, more than your fair share of post-traumatic stress disorder, but also substance misuse, learning difficulties and schizophrenia". And whilst some of the problems are the result of being an asylum seeker, this "tends to be a more of a maintaining factor than a precipitating one" as a result of the anxiety of "not knowing what's going to happen to you".

Angela Burnett agrees: "People have the whole gamut of medical issues that anyone else would have plus having to cope with the whole issue of dislocation. Their health actually deteriorates after they arrive [in the UK] both physically and mentally. And I think that is very much to do with the poverty the people are living in and the isolation."

Tuberculosis is a very good example of how environmental factors are clearly at work: "It is quite interesting that the highest incidence of TB [among refugees] is actually during the year following their arrival. They don't often arrive with open TB. Now that is unfortunately being exacerbated and sometimes created by the conditions in which people are living."

Mobility also presents problems to people who have been subject to sexual violence: "Certainly a large number of women, and some men, have been raped and have experienced sexual torture. That has always been a common experience in war and conflict, particularly for women, but it is now getting greater acknowledgement."

And whilst people react in different ways, she says, generally survivors experience feelings of stigma and shame. "And this is where the whole issue of building-up trust is very important and again where this lack of continuity and moving people around all the time makes it very hard," she says. "It is not the sort of thing that you are likely to be able to talk easily about to someone you have just met."

One measure which would make an immediate impact on the health of a small number of asylum seekers would be to provide milk tokens for women who are pregnant and HIV positive: "The point needs to be made that it is completely contrary to medical advice [to breast feed if HIV positive] and it means that we are actually intentionally creating an illness which simply could have been preventable. Milk tokens are peanuts compared to the cost of anti-retrovirals for a baby who might subsequently become HIV positive. It does not make good economic sense."

Dr Barrett treats many refugees in immigration removal centres for psychological problems but he has "never ever had a request for any kind of medical attendance for somebody in a centre by the centre itself. And I have never met any doctor or any psychiatrist who has". He has received all his requests through lawyers visiting clients in the centres, despite the fact that all such residents of immigration removal centres must have access to a nurse.

This may be partly because some of the staff of the centres might be under the suspicion that the claim is being made to support the application for asylum. But this attitude is inevitable, says Liz Peretz of Barbed Wire Britain: "Clearly in an institution where there is a criminalising aspect to it - because these are people that haven't done anything wrong - the guards are locking them in and they are being told to lock them in, so they get into a situation where they think that they must have done something wrong."

Additional problems are caused by the contracting of companies such as Group 4 to run Immigration Removal Centres who, unlike government-run centres, have to privately hire-in medical services: "The relationship between those medics and the medics in the local hospitals, for instance, and local community teams, is a bit tortuous, because they are not in the same organisation. And because Group 4 are worried about people escaping there is a whole set of complications that can end-up in people not getting what common sense and medical ethics would dictate people should get."

So, for instance, people are not allowed out of Campsfield House unless there are two guards to go with them: "If there are two guards to go with them they have to go in handcuffs. If there are three guards to go with them they don't have to have handcuffs. This means that, firstly people often can't keep hospital appointments because there aren't two guards available. And secondly, when they do go, because they aren't usually more than two guards, they always go in handcuffs. It is a very rare occasion indeed when people turn-up in hospital without handcuffs on - people who are really ill, having operations and so on."

Dr James Barrett describes the level of psychiatric care which he has seen in immigration removal centres as "pretty poor really"I haven't seen people being given what you might call exemplary treatment".

Barrett says that all asylum seekers detained in an immigration removal centre should get the same mental health care as provided to those in prison through the joint Home Office and Department of Health "Mental Health Prison In-reach Project". "The health care provided to detainees should be of a standard similar to those who are detained in prison. That would be a good first move."

Once somebody has made the decision that an asylum seeker should be detained "then I think that you are duty bound to provide the same care you would to somebody who is on remand, because both parties are people who have committed no offence, and are presumed innocent until proven guilty. A very similar situation so, one would assume, should have similar sets of rights to healthcare".