RESPOND: an integrated asylum-seeker and refugee health service

RESPOND is an integrated, co-designed health system providing services for asylum seekers and refugees (ASR). Our Outreach Assessment Service has seen more than 1400 asylum-seekers in initial accommodation centres in North-Central London (NCL), exploring physical, mental, sexual, dental and social health needs (aligned to CORE20PLUS5), using a holistic care-planning framework to promote service access. A specialist multidisciplinary team (MDT) facilitates partnership-working, and a comprehensive patient-held health plan is created for service-users. RESPOND addresses health inequality in a vulnerable population, and has demonstrated improved access to health services, identification of health needs and patient / stakeholder experience.

The Challenge

RESPOND was established in response to large numbers of asylum-seeking children, families and lone adults placed in our sector during the COVID-19 pandemic. Existing healthcare systems neither had capacity nor could easily respond to the needs of the population, who are known to face significant barriers to accessing healthcare, and to have extensive and complex health needs, affecting physical, mental, sexual, dental and developmental health.

The Approach

RESPOND sought to develop, operationalise and evaluate a novel co-designed model to tackle health inequality and improve patient outcomes and experience. Using a fixed budget from sectoral funding and, later, per capita commissioned funds, RESPOND recruited and trained a team to deliver holistic community-based health assessments and care planning to asylum-seekers across the sector.

RESPOND aimed to provide a flexible service, responding to changes to accommodation sites, proactively identifying eligible people and achieving effective engagement, including GP registration. A framework was developed to cover all key CORE20-PLUS5 priorities for both adults and children and to identify and address unmet physical, mental, dental and social health needs. A network was established to facilitate onward referral through partnership working across primary, secondary and tertiary health care services as well as local authority, social care and third sector organisations.

By developing and validating a comprehensive electronic screening tool we developed live dashboards for continuous real-time review of relevant metrics. We established a programme of continuous improvement based on service-user /stakeholder feedback, health encounter data and longer term evaluation to assess impact on wider health systems and cost implications.

Impacts

Patient access

Through proactive liaison with accommodation sites by specialist nurses, community outreach clinics were established for 12 sites across 4 boroughs and more than 1400 patients have been seen to date. None had previously received health screening. Development of bespoke administrative processes in response to service-user and stakeholder feedback increased attendance rate. Service-users were supported to register with a GP.

Patient Outcomes

A bespoke electronic screening tool identified extensive unmet health needs across CORE20PLUS5 domains. Of those assessed, 94% underwent infection screening; 100% with infections completed treatment. 100% received an Integrated Healthcare Plan. Approximately 3-5 referrals/patient were made supporting service users to access appropriate healthcare at the right time in the right place for them. More than 150 patients have been supported by our Complex Case MDT. We are securing academic funding to evaluate long-term outcomes. Service-user feedback reflected perception of health outcome improvement.

Public health

RESPOND identifies those in need of immunisation and identifies significant asymptomatic infection (45% of patients had at least one infection, including latent tuberculosis infection, hepatitis B and sexually transmitted infections). RESPOND was able to detect outbreaks of infection early and liaise with UKHSA and Health Protection Teams.

Advocacy and research

RESPOND has consistently advocated for appropriate service provision for ASR populations in NCL and nationally, with publications and contributions to national guidance and policy. RESPOND has a large dataset regarding ASR health needs, including the voice of the population themselves.

Value for money

Systematic, continuous data collection and detailed evaluation has achieved significant efficiencies. By proactively identifying and addressing health needs, RESPOND impacts positively on wider services in terms of capacity and cost, helping prevent acute, unplanned, complex presentations. Direct referrals save approximately £3.60/min (approximately £72/patient, or £77k of GP time for the patients seen to date). Our data suggests significant cost-saving potential by RESPOND by identifying infections alone.

Sharing of learning:

Learning has been shared locally, regionally and nationally, with organisations such as UK Refugee Council and Helen Bamber Foundation and with people with lived experience. Our work has been presented in national and international academic fora and is in preparation for publication in peer reviewed journals. We have developed a freely available online training series. Our work has contributed to workstreams of UK-HSA and RCPCH.

What did people say?

Stakeholders, service-users and people with lived experience (PLE) have been crucial to design, development, implementation and evaluation. A formal panel of PLE will imminently be convened to inform development of both clinical and research agenda.

Response to feedback has improved administrative, clinical, referral and communication processes.

Stakeholders:

I was very impressed by how (RESPOND) brings expertise together for coordinated care planning - Health Visitor

Great for improving communications between different agencies, formulating bespoke individual care pathways for children and families - Safeguarding Lead

Immensely efficient – rapid decision making between large number of key people. Brings together expertise and experience. ble – GP

There is a real gap in...provision and knowledge in healthcare professionals - it's what the NHS needs...that structure and training... and an evidence-based approach to deal with a whole lot of complex needs - 3rd Sector GP

There's a real opportunity to work with RESPOND to get a richer picture of the asylum seeker experience and how all different agencies can come together to meet those needs – Commissioner

RESPOND will take huge pressures off local services - 3rd Sector GP

RESPOND is absolutely how I would want to see every asylum seeker who arrives in this country receiving healthcare – GP

Their innovative and proactive approach to providing outreach support to this vulnerable and socially excluded group has resulted in increased access, streamlining of service use and a significant improvement in partnership working across the health, social care and charitable sectors – Chair of ICB

RESPOND has played a pivotal role in addressing the health needs of one of our most underserved and vulnerable communities. Commissioner

RESPOND prioritises early detection and effective system working so that people receive the appropriate intervention in a timely way, and this in turn helps to protection wider population health and reduce the burden on both primary and secondary healthcare services - UKHSA

I have been struck by the passion and motivation of the UCLH team to drive research to improve patient care and health outcomes in these marginalised communities – Academic collaborator

RESPOND is one of the leading innovation and multiagency services in the refugee sector in reducing healthcare inequalities and promoting wellbeing – Refugee Council

Service Users:

Information about services was very useful

It can be difficult as we don’t understand the language. In (RESPOND) they get interpreters – that's good

(Registering with a GP) is very important, I needed that support

Because we are refugees... (people) don't respond...in a good way. But they treated us like normal people and I think that's the most important thing for me

You are doing everything you can. You are doing the best job to help us. I want to thank you for everything you are doing

It is designed well and it covered everything. Today’s appointment with the RESPOND team was wonderful

For the first time, I talk about all the things (to) the same person, like healthcare...about problems, about background, all the issues I have. Sharing even part of the story... you just (feel) lighter

I like having an appointment with my family. We are completely satisfied with the service and I hope it continues. I am grateful

Has the appointment today addressed all the health needs of my family? 100%

Tips for Success

• proactive engagement (eg outreach into accommodation to identify individuals and bespoke administrative processes by trained staff) overcome barriers to healthcare access, addressing health inequalities
• novel approach (eg holistic one stop assessment) addresses complex needs efficiently and effectively and delivers cross-sectoral care
• there is a significant saving of time and money in wider NHS services as a result of a proactive approach
• staff trained in trauma informed care delivery ensures compassionate inclusive healthcare
• a holistic approach is essential to optimise efficiency, and identify health issues which, if not addressed, are likely to lead to unplanned presentations
• A family multidisciplinary approach ensures equity of access to screening and treatment for family groups
• provision of a written integrated health plan prevents omission and duplication and allows empowerment of service user to advocate for themselves if relocated
• cross sector work is key; partnerships with eg social care, health visiting, primary and secondary care are cost effective and efficient
• there is a significant impact on staff due to vicarious trauma; peer review and reflective practice are vital
• innovative approaches to funding is necessary for these services which need to work across traditional sector boundaries to deliver appropriate care. Equity of access for all asylum-seeker and refugee populations is essential.

Next steps

RESPOND is currently working to secure sustainable commissioning for our outreach holistic assessment service. Our other services continue, with high numbers of service users. We are developing a programme of patient and public involvement to inform next steps of our service development and evaluation, and to inform our research priorities. We are analysing our initial evaluation for publication and look forward to sharing data which will inform future service development.

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Host Organisation: University College London Hospitals NHS Foundation Trust.