Empowering professionals: a multidisciplinary approach to supporting people seeking asylum and refugees

Abstract

People seeking asylum and refugees living in initial accommodation in the UK can experience significant barriers to accessing care. They often have complex health and social needs and may experience fragmentation in the delivery of services. The Respond Integrated Refugee Health Service, hosted by University College London Hospital and operating across North Central London, has been created to address some of these challenges. In addition to offering in-person holistic health and well-being assessments, infection screening and onward care planning, Respond has developed an online multidisciplinary team (MDT) forum to support professionals working with the most complex of cases. Key professional groups from across the network are invited to contribute to multidisciplinary care planning, providing an efficient and streamlined multiagency model of care, improved access to interdisciplinary pathways and opportunities for interprofessional learning. Here, we describe the creation of the Respond Complex Refugee Health Advice and Guidance MDT and discuss the perceived benefits and limitations of the MDT approach in improving the care of people seeking asylum and refugees.

Key messages.

• Effective and efficient care for vulnerable populations with complex needs requires adaptation of traditional models of healthcare delivery.

• Virtual multidisciplinary team (MDT) working can improve the care of people seeking asylum and refugees by optimising communication between teams across health, social care and third-sector organisations.

• MDT fora promote the delivery of trauma-informed care and consideration of the bio-psycho-social factors of health.

• Healthcare professionals feel supported through timely access to specialist expertise within a virtual MDT forum.

• By bringing multiple stakeholders together simultaneously, the interdisciplinary, proactive approach of the MDT may produce efficiencies in time and cost.

Introduction: challenges in delivering integrated care to PSAR

People seeking asylum and refugees (PSAR), including children and young people, often face significant challenges in accessing healthcare and may experience complex and multiple biopsychosocial needs,¹,⁴ which can be challenging to address effectively in time-limited medical encounters due to language and cultural barriers.² Significant systemic and structural challenges exist, including fragmented National Health Service (NHS) and social care services⁵ with multiple digital operating systems, lack of understanding of care eligibility by both service users and service providers,⁶,⁸ financial and digital poverty and frequent short-notice relocations by the Home Office.⁶

Despite the best efforts of healthcare workers, these intersecting factors can lead to disjointed care and long waiting times for patients,⁶ thus increasing uncertainty and suffering.⁹ Safeguarding and complex medical needs in vulnerable individuals may be left unmet,⁹ resulting in increased emergency and unscheduled healthcare attendances,¹ potentially high ‘lost to follow-up’ rates and poor health outcomes. Case coordination to address complexity and safeguarding issues is often lacking.¹⁰

In addition to the negative impact on service users, these challenges can lead to feelings of frustration and isolation among professionals.¹¹,¹⁵ Healthcare teams may suffer vicarious trauma and feelings of moral injury while working hard to support service users with limited resources, often in a politically hostile environment.¹⁶

A multidisciplinary, cross-sectoral team (MDT) approach with access to shared resources, pathways and decision-making tools may help to streamline care planning and address these challenges, in line with the vision of a truly integrated care system.¹⁷

We present a novel approach to supporting professionals working with PSAR with the aim of improving the care of those with the most complex health and well-being needs.

A novel way of working: the Respond Complex Refugee Health Advice and Guidance MDT

Between July 2021 and March 2023, the Respond Integrated Refugee Health Service at University College London Hospital (UCLH) delivered a pilot scheme to improve the care of PSAR placed in initial accommodation in North Central London (NCL).^{18 19} Trauma-informed and holistic healthcare assessments (with associated care planning) were delivered by a specialist nurse (figure 1) in community settings. A virtual MDT service was established as part of the six-step model from the outset to further support professionals by providing rapid access to expert advice on the management of the most complex health and social issues.

Figure 1. Steps in the Respond model of care, including step 5: ‘Consultation to support complex case management at the Respond MDT’. GP, general practitioner; MDT, multidisciplinary team.

The Respond Complex Refugee Health Advice and Guidance MDT meeting occurred virtually via MS Teams every 2–4 weeks (depending on demand) and constituted a quorate expert panel (table 1). Key professionals from across the local health and social care network, third-sector/charitable organisations and tertiary care specialists were invited to attend according to the needs of the individual cases being discussed.

Table 1. Composition of the Respond Complex Refugee Health Advice and Guidance MDT.

Expert core panel members
Chair: Respond Clinical Lead
Chair also represented: Consultant Community Paediatrician (child development)
Chair also represented: Named Doctor for Safeguarding Children
Consultant Paediatrician with expertise in Infectious Diseases and General Paediatrics
Adult infectious diseases physician
Adult refugee mental health specialist (charitable/third sector—Helen Bamber Foundation)
CAMHS with expertise in refugee and asylum seeker mental health
Respond general practitioner
Respond specialist inclusion health nurse
Core network stakeholders	Ad hocspecialist attendees invited as needed
Named general practitioner	Local CAMHS team
Children and young person’s NHS safeguarding team	Special educational needs and educational psychology
Adult safeguarding NHS team	Sexual health team
Adult mental health services NHS team	Chronic pain team
School nursing	Female genital mutilation specialist team (paediatric)
Health visiting	Red thread (trauma-informed youth intervention programme)
Local authority early help and social care team	Children looked after health team (NHS)

CAMHSChild and Adolescent Mental Health ServicesNHSNational Health Service

The MDT service was promoted via local, regional and national teaching sessions. While most referrals originated from within the NCL region, referrals were accepted from anywhere within the UK and were made by a range of professionals from hospitals, community-based health and social care, as well as third-sector and local authority settings. Cases did not need to have already accessed the Respond service to be discussed at the MDT. Consent to discuss the cases was sought from individual service users (or their parents/carers where appropriate). The case mix comprised lone adults, family groups and children. A wide range of mental, physical, safeguarding and social reasons for referral were accepted. The MDT did not replace referral to local urgent health and/or safeguarding services but offered support with accessing specialist services and advice.

Between December 2021 and March 2023, 24 MDT meetings included 20 different professional teams. 152 cases were discussed, including 19 lone adults, 6 unaccompanied children and age-disputed young people seeking asylum and 24 family groups (76 were children discussed as part of a family case and 14 children were discussed as single cases).

Each MDT was scheduled for 90 minutes, with the aim of discussing between one and four index cases and reviewing additional linked family members as relevant. The terms of reference regarding patient confidentiality and information governance were shared at the start of every meeting. Cases were presented by the referrer using a modified Situation, Background, Assessment, Recommendation (SBAR) format²⁰ with the addition of a subsequent specific question(s) component for the quorate expert panel and network. The case discussion, led by the MDT chair, was structured using the Respond integrated healthcare planning framework (based on the Respond outreach clinical assessment tool and integrated healthcare plan). Clearly defined action points were agreed upon by MDT consensus and allocated to specific professionals within the network. A focused summary of the discussion and a list of agreed actions were shared securely with those allocated tasks.

Reasons for referral to the MDT were diverse, including but not limited to physical health needs, mental health difficulties (including trauma and post-traumatic stress), safeguarding risk, neurodevelopment and learning difficulties, female genital mutilation, sexual violence, reunification with family members, infectious diseases and concerns about access to education and social support services. Most cases included more than one reason for referral. An example case study is presented in figure 2.

Figure 2. An anonymised case study representative of the experiences of several families discussed at The Respond Complex Refugee Health Advice and Guidance MDT. GP, general practitioner; MDT. multidisciplinary team.

Actions arising from the MDT meeting included the provision of expert clinical advice, streamlining direct referrals to appropriate secondary care services, advice on and/or initiation of child protection pathways (including the national referral mechanism for human trafficking), liaison with the local authority (education and social care services) and referral to third sector support organisations and legal services.

Multiprofessional feedback about the Respond Complex Refugee Health Advice and Guidance MDT

All health and social care professionals who had previously attended the Respond MDT (n=87) were asked for feedback about their experience of using the service via an online survey in March 2023. The survey was completed by 20 professionals (23%). Of those who responded, 100% felt that the MDT was ‘very or extremely valuable’ for improving communication between teams, agencies and local resources to promote more effective care, patient safety and appropriate utilisation of resources, as well as for consensus decision-making in particularly complex cases within a governance framework. Attendance by primary care and social services was highlighted as most valuable. Examples of free text feedback are shown in figure 3.

Figure 3. Free text feedback from MDT attendees. MDT, multidisciplinary team.

The benefits of MDT working for complex refugee healthcare

The importance of integrating care across primary and secondary level services is well recognised²¹ and may be associated with improved communication and coordination between service providers, increased client satisfaction and increased preventative health service utilisation. MDTs can be valuable in the care of vulnerable inclusion health populations and may improve outcomes.²²,²⁴

MDT working has been shown to be somewhat beneficial in other healthcare settings, for example, increased survival rates in cancer care²⁵ and a possible reduction in unplanned admissions when used in national integrated care pilots over time.²⁶ The value of involving multidisciplinary healthcare professionals in healthcare delivery for PSAR has been acknowledged,^{27 28} but to our knowledge, there are no published reports on the development and delivery of an MDT meeting designed specifically to support professionals with the management of PSAR with complex needs.

The WHO recognises that addressing the health needs of refugees and migrants early via preventive and primary care reduces long‐term costs for the healthcare system,³ thus supporting our MDT approach. The Respond MDT also aligns with the Social Care Institute for Excellence guidelines surrounding the expectations of MDT working for integrated care.²⁹ It meets the five interdependent strategies of the WHO Framework on integrated people-centred health services,²¹ including coordinating services across sectors; engaging and empowering people and communities; creating an enabling environment; strengthening governance and accountability; and reorienting the model of care.

The Respond MDT aims to improve access to and delivery of care to the vulnerable refugee and asylum-seeking population. According to an Equality and Human Rights Commission Report, healthcare staff often show considerable uncertainty with regard to the entitlements of refugees to healthcare services,^{6 9} exemplified by instances where refugees are incorrectly denied registration at general practitioner (GP) practices due to the absence of paperwork pertaining to a permanent address. Access to the Respond MDT provided prompt and inclusive advice and support regarding eligibility and access to services.

A wide breadth of expertise was represented at the Respond MDT, which is likely to have contributed to better holistic, patient/family-centred care, recognition of social and health inequalities and enabling a proactive approach to improved care planning. The discussion of family groups together meant complex issues could be addressed in the context of the wider family, enabling better quality and continuity of care. This approach is likely to have improved opportunities for particularly vulnerable people to be seen in the right place, by the right team and at the right time.

Trauma-informed care and cultural competency were prioritised by experienced professionals among the quorate panel members and attendees. This is likely to have led to a reduction in the number of healthcare encounters at which PSARs may need to recount their background histories, thus avoiding retraumatisation.³⁰ In addition, routine consideration of safeguarding factors in each case discussion is likely to have improved patient safety. Advice and education on challenging subjects, such as female genital mutilation, gender reassignment, modern slavery and human trafficking, were provided. Children not attending school could be identified promptly, supporting parents to navigate the education system and reducing safeguarding risk.

MDT case discussion is likely to have enabled time and cost efficiencies for service users, healthcare staff and the wider health system. Streamlining referral pathways, allowing direct referral from the MDT to a range of specialist teams (including mental health services), may help promote earlier diagnosis and management of complex health issues. This may reduce duplication or omission of investigations, the total number of healthcare appointments, the administrative burden on primary care and the time and cost burden of engaging with healthcare.

In addition to immediate benefits such as system-wide care planning and streamlined case management, the MDT also optimised opportunities for interdisciplinary and intersectoral communication, trust and collaboration, allowing knowledge and expertise to be shared. The educational value of the MDT was highlighted by attendees, enabling training and ‘upskilling’ of colleagues. This finding is supported by other studies showing the importance of similar educational interventions for healthcare workers²⁷ to improve their knowledge of caring for PSAR. Attendees could take learning back to their own teams and implement best practices more widely. Professionals may have felt more supported to advocate locally for service entitlements and empowered to promote professional development in improving the care for PSAR.

Challenges and limitations of the Respond Complex Refugee Health Advice and Guidance MDT approach

The principal limitation of the MDT was the relatively low levels of attendance and involvement of service user GPs. This highlights the significant pressures experienced by primary care services, whereby GPs have minimal flexibility to attend clinical meetings at short notice. Giving GPs a longer notice period and options for a different time to attend may increase attendance at the meeting. It is also likely that input from GPs themselves in developing and refining the model would be of benefit to ensure the model appropriately meets the unique needs and priorities of primary care practitioners.

Uncertain immigration status can contribute negatively to the physical and mental well-being of PSAR. Currently, the MDT lacks permanent legal representation in the core attendee group. Through prior experience, many specialist members of the MDT have some existing knowledge of the legal issues facing service users; however, regular attendance from an expert in this area would be extremely valuable.

Further evaluation of the impact of the Respond MDT model is essential. Data regarding the completion rates of MDT recommendations are currently lacking, largely as a result of the cross-sectoral and diverse composition of the MDT limiting the ability to routinely and centrally record completed actions. Evaluating outcomes and impacts of MDT care is also challenging due to the absence of validated outcome measures and the complexity and scope of the care provided. Relevant outcome measures may include self-assessed health status, overall service costs, health outcomes, utilisation of primary and non-specialist care, secondary care use and patient satisfaction.²² Prioritising the perspectives of service users is crucial for the effective co-design of care models and must be a central focus in any evaluation process.

It is also important to acknowledge that this model of care has worked effectively in a well-resourced central London location, as part of a bespoke wider model of care. Many referrals were received from inclusion health outreach nurses working within the service itself and may not be easily generalisable to other settings without a similar outreach service. To ensure effective implementation, MDTs not only need to be well led from a clinical perspective but also supported by an enabling administrative infrastructure.²⁹ This requires significant and sustainable funding, which is often challenging to obtain, particularly for a cross-sector service addressing the needs of a highly mobile population such as this. Creative and flexible budgeting from several different sources (including integrated care boards, local grant schemes and charitable donations) may be required, out with conventional commissioning mechanisms.

Conclusion and future developments

The Respond Integrated Refugee Health Service is a novel model of care incorporating a virtual MDT for complex case management, with the aim of delivering joined-up, person-centred and trauma-informed care that is both efficient and effective.

As a case study, we have demonstrated the potential value and acceptability of a virtual MDT approach in working with PSAR. The Respond service has now secured sustainable funding and continues to deliver a monthly Complex Refugee Health Advice and Guidance MDT meeting virtually at national level, accepting referrals for case discussion from across the UK. Respond is also working on an enhanced package of training for healthcare workers to improve the care of PSAR. Perhaps most importantly, the Respond team is currently working with people with lived experience of seeking asylum to contribute to ongoing service development, and is exploring opportunities for this role within the core MDT panel. For more information or enquiries, please visit the Respond website.¹⁹