Tag Archives: asylum seekers

Time for a change: retired GP volunteering to treat asylum seekers

JN pictureJim Newmark is a GP who has progressed in his career from senior partnership to salaried to volunteer doctor status. He feels that his Christian faith and family make up for his abysmal memory and gross humiliation in pub quizzes.

In November 2015 I reached the first anniversary of my volunteer/honorary primary care contract that is specifically intended to help asylum seekers with complex needs. It has more than worked for me and as the months have gone by I have increasingly thought that it is an idea worth passing on.

It is clear that the NHS will never, ever fund this group of patients adequately. Yet these are human beings, just like us. The obvious differences relate to the effects of their experiences. This is the very stuff of primary care – to be an advocate, to try to make sense of an undifferentiated mass of needs, to come up with a plan, and to have the freedom to follow this up. Nowadays, who in mainstream really has the time to do this?

Hello and welcome to all those GPs who are approaching retirement, who used to love the job, who are financially secure, and who are looking round for things to do!

I loved my job – the team is fantastic, the workload was manageable, and the patients are intensely rewarding to treat. It has involved learning completely new skills as well as maintaining the old. My new expertise includes, among many others, such features as learning about the housing labyrinth, the appropriate voluntary sector to approach, and a thorough knowledge of the legal aspects of asylum claims.  Despite often feeling humbled and inadequate, I sometimes have the power to change things.  For those for whom I feel  I have contributed little, somehow my patients do not seem to think that this is the case.

What I did NOT like was the constant background turbulence of targets and finance that was increasingly stealing time from me that otherwise would have been used for this work. But I was being paid to do the job, and so I had a responsibility to conform to the will of my paymasters.

I approached my employer with a suggestion of an Honorary Contract. My idea was to leave formal employment but they would pay for my defence and reasonable CPD. In return I would maintain appropriate Clinical Governance provisions so that I could continue to use NHS resources for the treatment and care of NHS patients on a supernumerary basis. In simple terms, I was to become a volunteer doctor who adds value, but not capacity, to the service.  My manager was intrigued and happy to hear me out. As I would now be supernumerary, I suggested that my only role would be to see those patients for whom there was a shortfall in NHS provision and for which my acquired expertise would be appropriate.

After a couple of months of minor logistical juggling we have determined on long “complex consultation” appointments (30 minutes) that are booked by our experienced Nurse Practitioners at their discretion following the New Patient check , with the reviews booked by myself into the same slots.

Two distinct roles have developed – the first being to try to sort out the immediate physical and psychological needs that have been assessed as particularly complex, the other is for documentation of scarring or PTSD following torture for potential reports at the request of their solicitor.

With regard to the first, in practice, most of the complexity is psychological rather than physical and it is good to have the time available that these deserve.  It is not generally known that there is no NHS psychological provision for asylum seekers, as the basis of the treatments available is dependent on background stability.

With regard to the latter, the practice has pro-forma letters designed to invite the solicitor to request a formal report from us (with scale of charges) if we feel that this could be indicated and if the solicitor feels that such a report is appropriate. To assist them we give a very brief indication of our preliminary findings. We are careful to say that these cannot be expert witness reports but must be simple documentation of findings – such a simple, or at times complex, report falls well within any front line clinician competency.  This arrangement has been going on alongside the clinical work for some years, set up and continued by another doctor more experienced than I. However, as the “normal” workload increased it was becoming much more difficult to continue this “non NHS” work in the same way. The difference it made to me personally was that I could exclusively concentrate on this role and take some of the pressure from the rest of the team, especially as this service was felt to be part of the ethos of the practice.  The reports also bring in income to help offset my defence and CPD costs.

It seems to have worked. As it is a particularly “specialist” GP function the demand is not overwhelming. In addition, in my voluntary and supernumerary role I feel that I have control over my workload and this is good for my morale. True,  I sometimes have to suppress my conscience when I see how busy my colleagues are and occasionally, when a client does not attend or when I have time for any other reason, I am very happy to help out and take a few patients from them. In truth I need to see a reasonable number of such patients for my appraisal validation, and I supplement the numbers by occasional locums in the same practice.

So, anybody else want to join me? It is a niche market and certain prerequisites are required –  a general practice that sees a lot of asylum seekers, an ongoing licence to practice, and clear boundaries spring to mind (I am treated and behave as any other locum when in that role) . Both in finance and time, it costs me, which causes some puzzlement around – but when I equate it to other voluntary roles outside medicine that most retired GPs take on then there is a degree of understanding.  There is a desperate need that is likely to increase dramatically over the next few years – with the current state of the world, how can it not?

Refugee medicine: time to get our act together

RFarringtonRebecca Farrington first worked overseas with refugees 20 years ago for MSF.  She is now a GPwSI in refugee mental health having worked in the UK as a GP with people seeking asylum for 10 years. She combines this with a clinical lecturer role at the University of Manchester and GP locums.

Last month I joined Turkish, Dutch, Swiss and Irish GPs to run workshops about refugee children at Wonca Europe in Istanbul. The topic is hot and was mentioned by many speakers. Wonca produced a valuable statement encouraging doctors across the continent to uphold a migrant’s rights to equitable care “unconditionally and based on a set of core values” fundamental to the practice of family medicine.

So how can we in the UK respond to the challenges? Delivery of primary care for asylum seekers in the UK is fragmented.  We have NGOs and foreign aid agencies in our cities struggling to find NHS care for the most vulnerable. There is undoubtedly goodwill amongst the GPs I meet, interest from trainees and First 5 doctors in knowing more, but there is little in the way of infrastructure and training. GPs are expected to ‘get on with it’, but asylum seekers are challenging patients. They don’t trust you and can’t navigate your system. They are often distressed, some having experienced trauma that is beyond your comprehension. Their priorities can be low on Maslow’s Hierarchy – safety, warmth and legal representation. Freedom from pain, often tied up in their expression of psychological distress, is a frequent demand. Most are socially and financially deprived, living in fear, and we know their health deteriorates in the asylum system.

It’s scary to ask the question ‘what happened to you?’ – even scarier when you only have 10 minutes and perhaps are under pressure to use inadequate or inappropriate interpretation. Disclosure can be traumatising for the practitioner and the patient. Who wants to end the consultation feeling worse? So to “screen and promptly identify cases of violence and abuse, prevent them and intervene in collaboration with the relevant authorities and community resources” can feel quite daunting. We are there to provide health care, not decide their asylum claim, but many have complex medicolegal needs that remain unaddressed without our advocacy as their doctors.

For 7 years in Salford we had a PCT-managed asylum seeker surgery. We developed expertise and, just as important, we looked after each other. We had good interpretation and excellent links with the voluntary sector. We knew how to write letters that actually made a difference for patients. In 2012 we were closed following a failed tendering process: there were no ‘willing providers’. No one ever said we weren’t doing a good job, but there was ‘no way’ to commission it directly in the new structure.

Salford CCG and GMW Mental Health Trust now support me to work as a GPwSI but we all recognise its limitations especially in overcoming the barriers to access. With an influx of new refugees – people with the same hopes, dreams and fears as you and me – what are we actually going to do to ensure “sustainable and uninterruptable provision of comprehensive and integrated health care”? Our response to this is the ‘canary in the mine’. If we can get this safety net right for our most vulnerable then other disempowered, communities will also benefit.

People seeking sanctuary arrive on their knees. If we can give them a hand up we will have a young, fit population keen and able to contribute to our economy. If we don’t, we risk social alienation and a chronic disease burden that can be prevented.

In the North West we propose a hub and spoke model: GPs and nurses with specialist knowledge and skills supported by local practices sharing care. Innovations in IT with remote access to notes and co-production by refugees themselves, many of whom bring professional skills, can make for safe, appropriate, culturally sensible and patient-centred care. Strong primary care is an economically sound investment for this group and at such a hub we could provide workplace training in social medicine for our new GPs.

There are people in the UK who know what needs to be done. Many of us were doing it prior to 2012, but we need an infrastructure to support us. John Yaphe at Wonca said “We need the head, the hands and the heart to make it happen”. I would add we need the political will, and that we should move now to turn talk into action.