Adapting primary care for refugees and asylum seekers

Refugees and asylum seekers can register for and receive free primary care like any other patient, yet many find navigating primary care services a challenge. In a series of interviews, Madeleine Anderson explores the situation.

While some GP practices have undertaken training to help make them more accessible and remove some of the barriers to registration, it seems there is still work to be done to ensure a uniformed approach for all refugee and asylum seekers.

Nursing in Practice speaks to one advanced nurse practitioner (ANP), who has dedicated much of her career to supporting often marginalised and overlooked communities, about why the nursing profession and health and care systems must continue to adapt the way they work to best support vulnerable groups such as refugees.

We also hear about the experience of a refugee who was denied registration with a GP practice, at a time that she has worrying concerns about her health having only just arrived in a new country.

‘We should be adapting the way we work for people’

Kirit Sehmbi, an ANP who has worked in primary care nursing for more than a decade, speaks about some of the barriers and challenges she has seen that blocks access to healthcare for some refugees and asylum seekers.

She is championing the role of nurses in helping to improve the situation.

Ms Sehmbi has been working and volunteering with the international healthcare charity, Doctors of the World since the 2010s.

Doctors of the World supports medical care and advice for displaced people, including refugees and asylum seekers. Their services include a clinic in Stratford, east London, open twice a week for people who are struggling to register with a GP in the UK.

Over two-thirds of people supported by the organisation in the UK are either homeless or living in inadequate or insecure housing, with over 80% living under the destitution threshold.

Globally, the charity provides services for more than seven million people, across 70 countries around the world. Ms Sehmbi tells Nursing in Practice about ongoing challenges of organising regular appointments for patients who do not have an indoor, stable or fixed address in the UK, particularly for follow up care.

Misinformation about the cost of primary care services – people not understanding that services are free to access – is sometimes also preventing people from seeking the care and medication they need.

She believes that nurses should be leading the way in efforts for primary care ‘adapting the way they work for people’ and for teams to take more time to consider the needs of each patient as individuals.

She warns against services, including GP practices, from ‘gatekeeping’ access for vulnerable groups for the sake of targets or the paperwork required.

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‘[A receptionist] may well have been told by someone else, “no, you can only register people who have got A, B and C documents”,’ she said.

‘But I do think that both clinical and non-clinical staff all need to not sing from the same hymn sheet and look beyond “will this person ruin our QOF targets”, or whatever it is, and almost gatekeeping access.

‘When you’re seeing whole families or children being denied access to public to primary care, it’s really worrying,’ she explains.

Ms Sehmbi also challenges the concept of some groups of people being ‘hard to reach’.

She says: ‘Something I’ve learnt is that we always label particular populations as “hard to reach”, when actually the learning from this is that we are hard to reach, and we as services need to adapt to them.’

Ms Sehmbi believes that nurses are particularly well equipped to ‘go into community spaces’ to deliver preventative care for vulnerable communities and called for increased investment into community services which empower and deliver ‘real meaningful health promotion’.

‘We’re really well placed to give this opportunity, and I think we should make the most of that,’ she says.

Taking opportunities to reach out when they present is always helpful, she suggests.

‘Whether it’s in a church or school, in the morning once the parents have dropped their kids off – that’s your moment to grab them and have a chat with them. If it doesn’t happen there then you end up with people at the stage when there’s their emergencies.’

‘See us as human beings’

Ruth Jonathan* is a refugee from Nigeria, who volunteers with Doctors of the World.

She told Nursing in Practice about some of the challenges she faced after she came to the UK as an asylum seeker in 2010.

Despite not knowing where she was going to live and how she was going to make money, Ms Jonathan says her health was the ‘first thing’ she thought of when arriving to the UK.

But she was denied GP registration after trying to book an appointment to discuss a worsening of her health since moving to England. She has a range of complex mental health conditions.

Ms Jonathan was told she did not have the appropriate identification or proof of residence to register with a practice, even though immigration and residency status have no effect on a patient’s entitlement to register with a GP practice in England, Scotland and Wales.

In Northern Ireland, entitlement to primary care is typically based on ‘ordinary residence’, which requires individuals to ‘be lawfully residing’ in Northern Ireland and have an ‘identifiable and settled purpose’ there. However, a specific exemption is made for refugees who have made a claim for asylum, including refused asylum seekers.

Ms Jonathan describes how she felt that the reception staff who she first contacted, ‘didn’t see me as a person’.

‘I didn’t know what to do. They don’t see us as human beings,’ she says.

‘Being denied GP registration killed my confidence completely.’

Having been denied registration at the practice, Ms Jonathan’s condition continued to worsen and her need for medical support increased even more, she tells Nursing in Practice.

She believes additional training of non-clinical administrative and reception staff is key in improving the experiences refugees and asylum seekers trying to access primary care services, to ensure staff are up to date on the rights of these groups to receive healthcare support.

‘The first point of contact, which is the reception, is very important,’ she suggests.

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Ms Jonathan eventually sought help from Doctors of the World, who supported her through the process of registering with a nearby practice.

But she says her early experience of UK healthcare means she still often struggles to trust her local primary care services.

She now volunteers as a national health advisor for the Doctors of the World, encouraging other refugees and asylum seekers to register with primary care services in the UK, and supporting them through the process of finding their nearest practice and receiving the support they need.

‘Vital’ that refugees access the care they need

Director of the Institute for General Practice Managers (IGPM), Kay Keane, told Nursing in Practice that many marginalised communities have difficulties in accessing public services, ‘for a multitude of reasons’. 

‘We know that in some areas members of our communities do have issues accessing General Medical Services,’ she says.

The IGPM has arranged for the organisation’s members to access training from Doctors of the World – a scheme called Safe Surgeries – that ‘aims to remove some of the barriers to registration and make practices more accessible’.

‘Part of this training is the reiteration that you do not need ID, proof of address or immigration status to register with a UK GP,’ Ms Keane explains.

‘There are over 1,500 practices registered as Safe Surgeries and this is just one of the programmes that we promote to our members as part of good practice’.

The training is available for any practices who might find it useful.

She says: ‘While we would not mandate any training for practices as they are independent contractors, we know our members would advocate for robust induction for their front desk teams and regular refresher training sessions.’

There is also opportunity for more work to be done, she suggests.

‘As the representative body for practice management, we would be delighted to collaborate with relevant stakeholders, such as NHS England and other healthcare organisations, to develop and disseminate training materials and resources that address these specific needs and will continue to press for fair investment in our general practice community,’ says Ms Keane.

Responding to the issues discussed in this article, a Department of Health and Social Care spokesperson commented it is ‘vital’ that refugees and asylum seekers have access to the ‘healthcare they need’ in the UK.

‘For specific schemes such as Ukraine and Afghanistan, information on how to register with GPs and use different health services is available on gov.uk as well as tailored advice provided in welcome packs that are provided to all arrivals and translated,’ they said.

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*Ruth’s name has been partly changed to maintain anonymity.