Primary health care for refugees and asylum seekers: A review of the literature and a framework for services

Summary

Objectives

This paper aims to provide a framework for primary health care services to meet the recognized health needs of refugees and asylum seekers that can be used in planning and evaluating services for this group.

Review

Primary care services for refugees and asylum seekers are reviewed and presented in terms of a tripartite framework of gateway, core and ancillary services. Gateway services facilitate entry into primary care by identifying unregistered patients and carrying out health assessments. They are typically undertaken by nurse-led outreach services and specialist health visitors. Core services provide full registration and may be provided by dedicated practices or by mainstream practices, with or without additional support. Ancillary services are those that supplement and support core services’ ability to meet the additional health needs of this group. They include language and information services, close links with community-based organizations, specialist mental health services and services for survivors of torture and organized violence, as well as targeted health promotion and training of health workers.

Conclusions

The framework can be used for education and training, planning and commissioning, and to provide criteria for comparison and evaluation. The paper suggests that a lack of published evaluations and reports about interventions for refugees and asylum seekers constrains further policy development that could build on the strengths of such interventions. It also stresses the importance of ancillary services to successful mainstream provision.

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).