Development of a refugee health assessment toolkit for specific populations to support primary care

In autumn 2021, approximately 4000 refugees arrived from Afghanistan into London. GPs identified a need for readily accessible and comprehensive guidance to support them in conducting health assessments for the new arrivals with a complex range of needs.[1] The rapid pace of the influx meant that additional infrastructure was required to enrol and support the health of this cohort, many of whom were in temporary accommodation. Primary care provision was also recovering from COVID-19-related pressures, and routine expertise in migrant health was not widespread. This led to concerns about the access to, and quality of, initial health assessments for newly arrived refugees.[2]

A London Health community of practice (CoP) had been established in September 2021 to respond to the arrival of the Afghan refugees. The CoP provided a structure in which the NHS, the Association of Directors of Public Health, local public health teams, the Office for Health Improvement and Disparities, the United Kingdom Health Security Agency London Region and Greater London Authority could facilitate multiagency conversations, identify issues and pragmatic solutions, escalate operational challenges, share practices and advocate for the health of refugees. The CoP connected into other national governmental structures (including the Home Office) coordinating support for Afghan arrivals. NGOs, such as Doctors of the World, were also closely involved.

The CoP outlined a need to develop a bespoke initial assessment toolkit for Afghan migrants, to support capacity-building in primary care and a standardized London-wide approach. The CoP facilitated the development of the toolkit and the compilation of a pan-London perspective on local challenges and initiatives. The CoP enabled both problem identification – insufficient infrastructure, capacity and guidance to meet the needs of refugees at this pace and scale – and suggested a solution (the toolkit), and brought together the partners necessary to realize this work.

The toolkit consolidated guidance and expertise across several sources:

- CoP expertise and advice;

- United Kingdom Afghan migrant health guide; and

- Clinicians with humanitarian experience, front-line practitioners, NGOs and those leading the health and public health response.

Interviews with stakeholders across the patient pathway from GP registration to specialist and routine care were interviewed, with a focus on mental health screening/presentation, health protection, immunization and safeguarding. This advice was complemented by suggestions from real-world experience to facilitate triaging of needs, for example on wound management, dental triage and malnutrition, while applying public health approaches to long-term condition prevention and management.

The final toolkit ensured greater consistency in assessments, considered primary needs alongside broader well-being and was responsive to both anticipated and known health priorities.

The initial health assessment toolkit for Afghan migrants demonstrated partnership working towards holistic initial health assessments for new migrants in the context of primary care. The toolkit and associated supporting information were made available nationally for the wider system and have formed a template that can be rapidly adapted to suit emerging needs, for example for further waves of migrants. This work is applicable to asylum seeker health, and these partnership structures and outputs have implications internationally for other countries experiencing similar trends in migration and providing health care to an increasing number of refugees. In London, the CoP has evolved into a new regional workstream to produce a core London offer of best practice in support for primary care capacity and access.

The central role of public health within the CoP allowed for the successful championing of broader well-being needs and patient voice – an asset when supporting new arrivals to rebuild their lives. Capturing the voices of migrants to drive and inform the content of the toolkit was anticipated. Unfortunately, this was delayed, highlighting a need for appropriate structures through which to engage with vulnerable communities around their health and care needs in a timely manner. Based on this learning, a targeted, co-produced piece of work is now underway to collect and incorporate their lived experience.

Organizational bureaucracy led to delays in publishing the toolkit. To overcome this, it was circulated in draft among health partners to ensure that the critical window of opportunity for assessments was not missed. This enabled the toolkit to be refined based on feedback prior to publication. Feedback from frontline staff using the draft toolkit suggest that it was well received; however, usage was not formally monitored because of its online format. Additional capacity is needed to evaluate its overall impact.

References:

[1] Office for Health Improvements and Disparities (2022). Afghan refugees and newly displaced populations: individual health assessment. London: Office for Health Improvements and Disparities (https://www.gov.uk/government/publications/individual-health-assessments-for-afghan-refugees/afghan-refugees-and-newly-displaced-populations-individual-health-assessment, accessed 10 December 2022).

[2] Boshari T, Hassan S, Hussain K, Billett J, Garry S, Weil L. (2022). Development of a refugee health assessment toolkit for specific populations to support primary care. Eur J Public Health. 32(suppl 3):ckac131.243. doi: 10.1093/eurpub/ckac131.243