New migrants and primary healthcare in the UK: A formative study of adaptation Elizabeth Such, Elizabeth Walton, Brigitte Delaney, Janet Harris and Sarah Salway University of Sheffield Project funded by Sheffield Clinical Commissioning Group and supported by NIHR Collaboration in Applied Health Research and Care Yorkshire and Humber EUPHA, Vienna, 12 November 2016

Introduction – why this study now? Migration Large global flows UK: highest ever rate of net migration in 2015 Politically and socially pertinent Policy International; National; Local Effective, efficient, equitable primary care Practice Guidelines and ‘best practice’ from the top-down Activity and innovation from the ‘bottom-up’ Slow response from institutions regarding guidance and best practice; focus on questions of eligibility. Requires exploration of what is happening ‘on the ground’ to formatively build a picture of how services are adapted, why and to what effect.

Aims and objectives AIM: To formatively scope and map out primary care service adaptation for new migrant populations OBJECTIVES: To identify a diverse range of examples of adaptation; To identify the characteristics of adaptation; To describe the key drivers of adaptation; To examine the form, nature and logic of service response; To identify the areas of primary care that are impacted (including GPs, other health professions and wider practice staff); To understand the barriers and limitations to service adaptation; Broader aim: identify promising service adaptations that could be evaluated rigorously in a subsequent NIHR-funded research project

Methods On-line survey and contact form (n=70) Case studies (n=8) 5 ‘mainstream’ GP services and 3 ‘specialist’ services for vulnerable migrants in four UK cities

Survey 86%: rapid/steady increase in migration FOCUS: Working with communities Adapting processes of, for example, screening, vaccination and health checks 1 in 5 offered no adaptations Some adaptations common e.g. signposting (73%); others rare e.g. outreach (36%) Lack of funding – barrier to service development (n=51; 73%). Provided a basic picture of the nature of migration in local areas and responses in primary healthcare Diverse population served in terms of country of origin and legal status 86% of respondents reported rapid/steady increase in migration in their practice area in the past 5 years Practitioners focussed on working with communities and external agencies and adapting processes of, for example, screening, vaccination and health checks Some adaptations common e.g. signposting (73%); others rare e.g. outreach (36%) 20% offered no adaptations Lack of funding was cited most frequently as a barrier to service development (n=51; 73%).

Case study findings Variety of and multiple modifications Drivers : Practitioner factors Organisational factors Wider contextual factors. Critical - organisational and practitioner commitment to equity. Addressed several dimensions of patient need: wider social determinants, trauma and violence, additional individual needs; delivering culturally-competent care. Variety of and multiple modifications e.g. coordinating primary care services with other agencies e.g. housing associations, providing cultural competency training for staff and providing ‘one stop shop’ clinics for new migrant patients. Drivers for adapting services in the case studies included practitioner, organisational and wider contextual factors. Critical drivers for adaptation included organisational and practitioner commitment to equity. Also need for efficiency. Factors that limited adaptation included funding limitations, staff skills and training and staff ‘burn-out’. Adaptations centred on addressing several dimensions of patient need: i) wider social determinants, ii) trauma and violence, and iii) additional individual needs; and on iv) delivering culturally-competent care.

Examples of practice adaptation   Delivering culturally-competent care Staffing Volunteer community health advocates Face-to-face interpreters at drop-in clinics Support staff with community languages Face-to-face interpreters wherever possible (S) Cultural competency training for staff (S) Patient-provider interaction Adapted written prescription guidelines to aide medication adherence Translated health education materials Development of patient involvement groups with new migrant representation (S) Addressing additional, specific individual needs Specialist health practitioners experienced in working with marginalised/migrant patients (S) Drop-in clinics for specific populations Local Vitamin D and Hepatitis B protocols Outreach services for those not attending clinics (S) Follow-up consultations with health professional after first contact (S) Tailored protocols for assessment of new arrivals (S) Engagement in tailored projects e.g. Roma Health Projects Pre-arrival preparation systems for people arriving under managed migration schemes (S) Longer appointment times to allow for interpreter use and assessment of complex cases (20 mins or up to 30 mins(S))  

Concluding remarks Findings cannot be generalised, however: Evidence of creativity Concern about resource – funding and personnel Partnership working central Findings consistent with those of studies of PHC access for marginalised groups Specialised services: further exploration needed to establish transferability to mainstream general practice. Findings cannot be generalised, however: Evidence of creative adaptations to the delivery of care Concern that resource – funding and personnel – not available to develop and deliver adaptations to meet need Partnership working in evidence: recognition of the social determinants of broader health and wellbeing of new arrivals Findings consistent with those of studies of PHC access for marginalised groups – especially culturally competent care and partnership working Some of the practices of specialised services warrant further exploration to establish transferability to mainstream general practice.

Contact and further resources Elizabeth Such, Research Fellow, Migrant and Minority Ethnic Health e.such@sheffield.ac.uk Health Equity and Inclusion Group @HEandIG scharr.dept.shef.ac.uk/healthequity Summary and Mini Case Study book: on-line scharr.dept.shef.ac.uk/healthequity Such, E., Walton, E. Delaney, B, Harris, J. and Salway, S. (2017, in press) Adapting primary care for new migrants: A formative assessment, BJGP Open