New Scots: integrating refugees in Scotland's communities 2014-2017 final report

Health

Key Achievements:

• Scottish Government engagement in the Health thematic group has ensured national health strategies are informed by refugees' health needs where appropriate.
• Membership of the group widened to include health leads from local authorities resettling Syrian refugees, securing a Scottish wide input. This supported shared learning and an improved, joined up approach to health provision for refugees.
• A learning session was delivered to local authority lead officers working with newly arrived Syrian refugees. This session included sharing Glasgow's experience of working with asylum seekers and refugees from a health perspective, including both primary and secondary care as well as responses to mental health wellbeing.

Policy Context

The provision of health services is devolved to the Scottish Government which has directed NHS Scotland to provide health services to all refugees and asylum seekers, including people whose claim for asylum has been refused, on the same basis as anyone legally resident in Scotland.

The Scottish Government's '2020 Vision: Achieving Sustainable Quality in Scotland's Healthcare' ^[57] sets out the need for a healthcare system where we have integrated health and social care, a focus on prevention, anticipation, supported self-management and reduction in health inequalities.

Access to good quality health care is important for people who may arrive in Scotland with physical or mental health needs associated with the reasons they were forced to travel to the UK to claim asylum. This includes gender-based violence, sexual violence, torture and other degrading treatment. The experience of seeking asylum and the social isolation that can be an effect of the process, can exacerbate existing mental health problems or create new ones. ^[58]

A range of specialist health care services have developed in Glasgow over the last 15 years to meet the needs of refugees and asylum seekers, including: the Compass Mental Health Team - now the Glasgow Psychological Trauma Service ( ANCHOR); the Bridging Team within Greater Glasgow and Clyde Health Board; and also voluntary sector services such as Freedom from Torture.

The Syrian Resettlement Programme includes specific vulnerability criteria for refugees accepted for resettlement. People arriving under the programme may have health needs which cannot be treated in the region, be particularly vulnerable or at risk and may have been victims of torture. Refugees' experiences raise the likelihood of associated mental health support needs. The national distribution of refugees across Scotland increases the importance of sharing learning and good practice across Scotland.

NHS Scotland and other agencies such as the Mental Health Foundation and Rape Crisis are working closely with the Scottish Refugee Council to identify opportunities to meet the health care needs of refugees and asylum seekers.

The Scottish Government is funding the Mental Health Foundation, in partnership with Freedom From Torture, to undertake the Musawa refugee rights and participation project, aimed at raising the visibility of refugees and refugee issues across mental health services.

Strategy Outcomes

In 2014 the New Scots strategy set out three outcomes for Health:

1. The planning and delivery of health services in Scotland is informed by the needs of asylum seekers and local communities leading to an increase in integration.

2. An understanding of refugee integration pathways is embedded in all health-related strategies leading to more person-centred services.

3. Refugees and asylum seekers are fully supported to fully understand their rights and entitlements. Service providers are increasingly aware of how to meet their needs. As a result refugee and asylum seeker health needs are better met.

1. Planning and delivery of health services

Consistent engagement from the Scottish Government as part of the Health thematic group has improved opportunities for consideration of refugee issues as part of influencing wider health strategies in Scotland. For example, the Scottish Government's Mental Health Strategy involved consultation with a range of stakeholders. Scottish Refugee Council, Mental Health Foundation and NHS Greater Glasgow and Clyde ( NHSGGC) Trauma Services, who are all part of the thematic group, were among those providing responses which highlighted the specific needs of refugees.

Scottish Refugee Council in partnership with Mental Health Foundation and funded by See Me, ran a project combining policy and community development to tackle mental health stigma and discrimination among refugee communities. A briefing paper, Refugees, mental health and stigma in Scotland, ^[59] was published and disseminated in August 2016. It aimed to provide policy makers and service providers with an overview of what we know about refugees' experience of mental health stigma and discrimination, and set out recommendations for how best to respond to the mental health needs of new refugee communities. The community development aspect of the project provided training to community activists on becoming Community Champions. Champions were supported to take action to tackle mental health stigma and discrimination in their own communities and to raise their concerns with decision makers.

Case Study

Community Champion Training

Lubna has been living in Scotland for 14 years. Lubna became a refugee Community Champion after a friend gave her information about the project.

"It felt easy to express my experience though at first I was not sure if I could talk about what happened to me. But when I heard and saw the video clips it kind of motivated me to speak out without fear. I felt free."
Lubna

The Community Champion project aimed to train people from the asylum seeking and refugee community to play a lead role in challenging mental health stigma and discrimination in their local communities. The training was delivered in partnership by the Mental Health Foundation and the Scottish Refugee Council, with funding from See Me.

The Community Champion training took place over 8 weeks. One of the aims of the training was to give Community Champions the confidence to speak about mental health and to share their awareness of issues which can impact their community. Following the training Lubna volunteered to be part of a discussion panel which followed the screening of a film called 'Seeking Refuge'. 40 people, from a variety of backgrounds, attended the screening. Lubna contributed to discussions on the mental health impact of being a refugee.

"It was a real privilege to have Lubna present at the event."

Screening Event Organiser

Female Genital Mutilation ( FGM) is recognised internationally as a violation of the human rights of girls and women. Refugees living in Scotland may have left an FGM practising country to seek protection for them or their child from FGM, have particular health needs as a consequence of FGM, or remain at risk of FGM. ^[60] The Scottish Government is committed to working with partners to prevent and eradicate FGM and all other forms of violence against women under the guise of gender, culture or religion (so called Honour Based Violence).

The Scottish Government funded a collaborative research project between the Scottish Refugee Council and the London School of Hygiene and Tropical Medicine to inform work to address the issue of female genital mutilation ( FGM) in a Scottish context. The project report, Tackling FGM in Scotland: a Scottish model for intervention ^[61] was published in December 2014. It analysed existing data on communities potentially affected by FGM in Scotland and drew on examples of good practice from other EU countries to make recommendations for work with communities, the provision of services, prevention and protection. Following this work, the Scottish Government established a multi-agency FGM Short Life Working Group ( SLWG), which supported the development of Scotland's National Action Plan to Prevent and Eradicate FGM ^[62] published in February 2016. The plan sets out an agreed range of actions and associated activities to be taken forward by the Scottish Government and partners to prevent and ultimately eradicate FGM. A National Implementation Group is overseeing the implementation and monitoring of this plan.

A number of research projects explored the health needs of refugees and aimed to increase refugees' capacity to engage with health policy and forums in order to reduce barriers to access. For example, What do you mean, I have a right to health? ^[63] was a participatory action research project, funded by NHS Health Scotland and carried out in partnership by the Centre for Health Policy, University of Strathclyde, the Health and Social Care Alliance Scotland, the Mental Health Foundation and Glasgow Homelessness Network. The health and human rights project examined what the right to health means to people who face inequalities and may struggle to access support. The research used a participatory approach, involving peer researchers from the communities which were a focus of the research, this included female asylum seekers and refugees.

These research projects have all provided a platform for the potential development of future projects that have refugees at their core.

2. Refugee integration pathways embedded in health-related strategies

NHSGGC have embedded asylum seeker and refugee services into core functions as part of mainstreaming equality actions and outcomes for 2016-20. ^[64] This includes a specific outcome that: "People who have migrated to our area, asylum seekers and refugees, know how to access acute services." Work to achieve and measure this outcome includes improving the number of translated patient publications disseminated via services and voluntary sector organisations.

This progressive development has been shared with other health boards across Scotland as a best practice example. Health entitlement information produced by NHSGGC has also been shared with health boards across Scotland - making clear refugee and asylum seekers' entitlement to access healthcare services. This has benefitted local authorities resettling refugees through the Syrian Resettlement Programme who have indicated that health boards' work to ensure access to essential treatment has been an important part of the success of the programme.

3. Refugees and asylum seekers understand their rights and entitlements, and service providers are aware of how to meet their needs.

The research project referred to previously (What do you mean, I have a right to health? ^[65] ) provided an opportunity to gauge asylum seeking and refugee women's understanding of their rights and entitlements in relation to healthcare. The research indicated great variation in the experience of participants. However, it also revealed positive accounts of accessing health services in Glasgow - particularly that initial information provided on arrival in the UK is good and that they were able to access a GP service quickly and without difficulties.

The Health Peer Education project funded by the NHSGGC Health Improvement Team and run by the Scottish Refugee Council has proven to be an innovative model of health promotion. It equips, mobilises and supports refugees as 'Peers', enabling them to share knowledge and understanding, and plan collective action to maintain healthy lifestyles. Refugees who volunteered to participate in the project received training and support to enable them to build capacity within peer groups to create collective action plans and implement them. Initiatives undertaken by groups included investigating how to access sports facilities, organising trips and encouraging wider participation in health activities.

This model has been valued across New Scots thematic groups as a best practice model for an asset-based delivery approach which increases social connections. The model has been piloted in four local authority areas in Scotland to support resettled refugees with practical English and to build social connections to their new community.

Case Study

General Practice and Primary Care Seminar

General Practice and Primary Care at the University of Glasgow leads a programme of research focused on migrant health. They became aware that many GP practices in areas new to receiving refugees were not confident in caring for this population. A teaching event was organised in 2016, supported by the Scottish Government, to provide a broad overview of the care needs of asylum seekers and refugees.

80 people attended the event including 36 GPs, 3 Practice Nurses, 4 GP trainees and 7 Practice Managers. Attendees reported an increase in confidence caring for refugees from an average of 2.5 out of 5 at the beginning to 3.5 out of 5 by the end. A number of changes of practice which could be made were identified. Including, finding ways to increase the time available for refugee appointments and scheduling return appointments.

"What struck me was that all speakers were compassionate and they inspired me to look beyond the usual pressures I face in an ordinary session."

GP

The importance of being aware of the likely experiences of patients on their journey to the UK, the impact of the asylum process once here and the different support agencies involved was highlighted by participants.

"Better understanding of what a patient will have experienced in terms of agencies involved."

Locum GP

A number of participants said that they would take an altered approach to consultations for refugee patients, including taking more interest, feeling more confident in approach and exploring their attitudes toward these patients.

The training has already achieved tangible impacts, from increased use of community support services to the inclusion of a session on caring for asylum seekers and refugees in the compulsory Health Inequalities teaching provided by NHS Education for Scotland. Importantly, it has also prompted discussion regarding future training needs and how these might be best met.

Continuing Challenges

Refugees arriving in Scotland as part of the Syrian Resettlement Programme have had their health needs assessed prior to arrival, and matching to accommodation is influenced by access to necessary healthcare. This allows good planning of response including local health and social care.

This approach is welcomed, but highlights the lack of a systematic approach to providing health checks to other refugees, including those who enter the UK seeking asylum.