Primary health care for refugees and asylum seekers: A review of the literature and a framework for services
Introduction
Over the last two decades, the health needs of refugees and asylum seekers have been well documented. Reports indicate difficulties in accessing health services, including registration with general practitioners (GPs) or lack of language support, and of particular needs, especially mental health and chronic illnesses, being inadequately met.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 From the viewpoint of healthcare providers, GPs report increased pressure of work resulting from patients who cannot speak English and who may manifest multiple problems, with health only representing part of the broader social problems. GPs and other health workers are often unsure about asylum seekers’ entitlements to health, how to deal with asylum seekers’ mental health problems and where to make appropriate referrals.11, 13, 14, 15, 16
At the same time, there is now a wide range of experience and expertise in providing health care for refugees and asylum seekers. New types of primary care services have been developed in dispersal areas and in other areas (primarily in London) where large numbers of asylum seekers and refugees are to be found. Several resource packs and other general and regional reports on service availability include descriptions of primary care interventions for refugees, drawing on local reports and self-description of services that give good accounts of service need and show very clearly how services are organized.1, 3, 12, 17, 18 Good clinical practice has been identified in a number of papers,19, 20 as well as the crucial services that need to be available to meet the needs of refugees and asylum seekers,4, 5, 21 and there are also numerous guidelines and standards against which services can be judged.1, 2, 3, 17, 18, 22, 23
However, there has been little systematic analysis and evaluation of the effectiveness of the interventions that have been developed to meet refugee and asylum seekers’ needs. There is thus little evidence to guide primary care trusts (PCTs) and others in the development of new services.
This paper suggests a simple framework that classifies the objectives of a range of service models, based on recognized health care needs of refugees and asylum seekers. It is hoped that setting out clear objectives for services will facilitate comparison between different service models, and could assist PCTs to plan services for this group on the basis of clearer evidence. The framework distinguishes three different but complementary objectives of primary care services for refugees and asylum seekers: enabling access, comprehensive provision, and essential support services (Table 1).
Section snippets
Methods
The paper draws on a review of information on primary health provision for this group from published and ‘grey’ literature on the health needs and primary care services for refugees and asylum seekers. The full review of which can be found in the author's report for the Hounslow Primary Care Trust.62 Material was accessed through online and library literature searches, and by a request for information to chief executives of National Health Service (NHS) trusts in England and to directors of
Results and discussion
All the studies cited above agree that in order to benefit fully from the UK health care system, refugees and asylum seekers need:
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access to primary care with full permanent registration;
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information about health services;
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appropriate and comprehensive health assessments including mental and physical health;
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adequate access to translation, interpreting and advocacy services in appropriate languages;
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adequate and appropriate responses to mental health problems;
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access to specialist services for
Mainstream or specialist services
A recognized goal of health policy for asylum seekers is to integrate them into existing mainstream services with the same rights to high-quality treatment and care as others.2, 17, 18 Given the special service needs of asylum seekers, this may require, for a time, special models of service delivery or specialist personnel or services. This does not, however, imply a stark dichotomy between specialist and mainstream services, but rather criteria for identifying what model or combination of
A framework for primary care services for refugees and asylum seekers
Different service models and types of services can be incorporated into a tripartite framework of gateway services facilitating access, core services offering full registration with comprehensive health checks and standard primary care, and ancillary or support services.
Conclusion
The framework for service provision set out in this paper could be used for education and training, planning and commissioning services, and to provide criteria for comparison and evaluation. It has been developed in response to a reading of the literature and discussions with service providers which reveal ad hoc and reactive responses to the demands placed on primary care by the needs of refugees and asylum seekers. The concept of ancillary services, in particular, shows how provision needs
Acknowledgement
Research for this paper was carried out on behalf of Hounslow Primary Care Trust. The author is not aware of any competing interests. The author thanks all the health professionals who contributed either verbal or written information which informed this study. Particular thanks are due to Dylan Tomlinson of Hounslow PCT for his support throughout the study and to Dr. Davis Chappel of the North East Public Health Observatory for his helpful comments and advice.
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