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NEWS FOCUS...Primary care for vulnerable adults

Specialist community services can improve the health of the vulnerable and reduce pressure on A&E departments. Seeta Bhardwa investigates.

At the very end of last year health ministers announced that migrants and overseas visitors are to face new charges for some NHS services in England.

While GP and nurse consultations will remain free, other primary care services for which charges are being considered include minor surgery carried out by a GP and physiotherapy that has been referred by a GP. 1

The specific details of how these changes will be implemented are unclear but the plan outlining the charges is due to be released in March 2014.

Health Minister, Lord Howe, said: 'Having a universal health service free at the point of use rightly makes us the envy of the world, but we must make sure the system is fair to the hardworking British taxpayers who fund it.

'We know that we need to make changes across the NHS to better identify and charge visitors and migrants. Introducing charging at primary care[level] is the first step to achieving this.'

A number of services across the country based in community health projects and social enterprises do cater specifically to the complex needs that this patient group can present with and can help to divert them from using A&E and hospital facilities.

Nurse-led clinics

The Haven is a specialist primary care service which meets the initial needs of asylum seekers and refugees arriving in the Bristol and South Gloucestershire area. The service was established in 2003, a time when an increased number of asylum seekers were coming to Bristol. It was set up as a specialist service to meet the complex needs of this patient group and to facilitate access into general practice and other relevant services. More recently, the service has also provided for family members coming to join refugees in the UK.

The service is commissioned by Bristol CCG and is managed by Bristol Community Health, a community interest company.

The nurse-led clinics are held at Montpelier Health Centre, three mornings a week. Patients are offered: a comprehensive health assessment, investigation, treatment and follow-up of current and complex medical needs with referral as necessary, screening for communicable diseases, updating of immunisations, signposting of other services, information in their own language about the health service, help with registration with a local GP surgery, summaries of current health issues sent in writing to the newly allocated GP and access to help with healthcare costs.

The aim of the service is to reduce health inequalities by providing care that understands and responds to the particular needs of asylum seekers and refugees. It also relieves pressure on other services, and is able to identify the unmet needs of this population group and the service improvements that are required.

The patients that Anne Gachango, a specialist nurse for asylum and refugee health, based at The Haven, sees most often include those with mental health problems and the victims of rape and torture, and FGM. Patients commonly present with diseases such as TB, hepatitis B and HIV/AIDS, uncontrolled long-term conditions such as diabetes and hypertension, vitamin deficiencies and a lack of or incomplete immunisations. She is often required to administer specialist medicine for tropical diseases.

Unique patient profile

The Whitehouse Centre in Huddersfield is part of the Locala Community Partnership, an independent community interest company providing NHS services for people in the surrounding areas.

The practice caters for the vulnerable: asylum seekers, refugees, the homeless, those living in temporary accommodation and those who have problems with alcohol or other substances. Due to the specific client groups that The Whitehouse Centre works with, there is a relatively low incidence of long-term conditions but a high incidence of substance misuse and mental health problems, including depression, anxiety, post-traumatic stress disorder (PTSD) and psychosis.

The majority of the patients are under 40 and there is only one patient over the age of 70. This highlights a patient population that is essentially the opposite to that of a standard GP surgery, which means there is very little management of long-term conditions needed.

The majority of patients are treated for issues related to alcohol and other substance misuse, often with shared care from specialists. A substance misuse specialist nurse runs a clinic in the surgery each week to provide targeted care for those who need it. Many of the patients also present with some form of mental health problem with depression and anxiety being the most common problems.

Mathew Sidebottom, an advanced nurse practitioner from The Whitehouse Centre, says that a number of the nurses have in-depth experience in the diagnosis and management of PTSD in primary care. PTSD often goes undiagnosed in primary care and is difficult to treat. The lead doctor from Freedom from Torture (a medical charity looking after victims of torture) also works at the Whitehouse Centre to provide specific care for such patients. Once the patient is diagnosed the necessary treatment is prescribed and the patients are provided with specialist knowledge and advice and they are mostly managed within the surgery.

Mr Sidebottom describes many of the patients as 'revolving door patients' as they attend A&E and other acute services regularly. 'By [The Whitehouse Centre] having an open access model they are able to turn up and be seen on any given day. As they have better access to GP services and the healthcare professionals at The Whitehouse Centre manage their medical, psychological and social problems in one place, they use acute services less.'

Health of the homeless

Another vulnerable adult group that often requires specific care are the homeless. Salford Health Matters, a community interest company founded in 2007, operates the Homeless Health Project in the Windsor Centre, Salford.

At the project a GP and nurse practitioner provide healthcare services for the homeless people in the area. These include routine checks and blood tests, hepatitis C vaccinations and full healthcare advice. It also offers referral to counsellors for any drug and alcohol-related issues, as well as advice on housing and work-related issues.

As with The Haven and The Whitehouse Centre, mental health problems are the predominant issues that clinicians at the project see: generally depression and anxiety disorders. These can in turn be complicated by additional drug and/or alcohol misuse.

Dr Oliver Totty, the GP based at the project, emphasised the importance of taking an individual approach to each patient. 'The treatment offered has no restrictions compared to normal general practice, from counselling and psychology services to secondary mental health services and assertive outreach teams,' said Dr Totty.

The nurse practitioner at the service is responsible for taking bloods, blood pressure checks, CVD risk scoring, smears, spirometry and vaccinations. She also reviews the long-term conditions such as diabetes and asthma.

Access to NHS care: refugees and asylum seekers

Like other UK residents, people with application for refugee status in the UK are entitled to use NHS services without charge.

Asylum seekers are entitled to free healthcare from all NHS services while they are waiting for the outcome of their asylum application and appeals. They can receive without charge:

  • GP and nurse treatment,
  • non-emergency treatment at a hospital including maternity services,
  • emergency hospital treatment at an A&E department,
  • prescriptions,
  • NHS dental treatments, sight tests, and travel costs to and from hospital,
  • treatment for infectious diseases (including TB) and STIs,
  • HIV/AIDs test treatment.
  • If an asylum claim has been refused and the appeal has been unsuccessful but the patient has been unable to leave the country they are able to access:
  • GP treatment,
  • hospital treatment that began before asylum refusal,
  • emergency treatment at A&E.


Vulnerable patients, rewarding practice

Mathew Sidebottom, advanced nurse practitioner at The Whitehouse Centre, recalls treating an asylum seeker with multiple health issues:

'A middle-aged Zimbabwean women came to the UK seeking asylum as she had been persecuted in her own country for her sexual orientation. Because she was a lesbian she had been beaten, verbally abused and even raped to be "cured" of her sexuality. She had suffered female genital mutilation (FGM) and had caught HIV from a man who had raped her in Zimbabwe. It was when she came to the UK, she found out she had HIV and also discovered she had inoperable breast cancer. This lady was still going through the legal process of seeking political asylum due to her persecution at this time. Her main concern was wanting to die with dignity in the UK. We were able to work with her legal team by providing medical evidence to support her need for special care for leave to remain in the UK. She was able to access primary care, palliative care and HIV treatment, and was able to fulfil her wish of dying with dignity.'

The extra mile

However, working with such complex patient groups is not without its challenges. Mr Sidebottom, explains that patients often have different opinions and stigmas attached to various health problems. 'Their view of mental health, HIV and other problems is often different from the professional view in the UK and requires a large amount of input to understand their view and alleviate anxieties about health, infections, sexuality and psychological issues.'

Ms Gachango agrees that language barriers and culturally different viewpoints on health problems are one of the most difficult things about the job. 'The job requires an ability to communicate across language barriers and to work with interpreters. Consultations often take longer because of interpretation requirements and extra time is needed to explore and accommodate different cultural health beliefs and to build up trust.

'Practitioners also need to be aware of the rapidly changing asylum process and anticipate how the process may impact on a patient's care.'

Dr Totty also highlighted a lack of continuity as a challenge when working with vulnerable adults.

'As the patients have no fixed address, providing continuity of care can be difficult. An abnormal result or report can pose a challenge if the patient does not return and referrals that are not followed through can be frustrating.

'You are often dealing with patients with a limited background knowledge of their medical history and they may have moved from your books by the time their notes arrive,' he said.

External agencies

Partnerships with other agencies are vital to ensuring that these healthcare services provide a rounded service, Ms Gachango says. The Haven works in association with Refugee Action, Bristol Refugee Rights, British Red Cross, Refugee Women of Bristol, Trauma Foundation of South West, Womankind, BFriend, Unseen and the Brigstowe project. These services help the clients to access health services.

For services such as the Homeless Health Project to continue running in the future, partner agency working is essential, and in austere times these services become more necessary. 'In these financially restricted times, it looks certain that more and more people will potentially face the reality of what it is to become homeless at some point in their life,'said Dr Totty.


Mr Sidebottom believes that the most rewarding part of working in a specialist GP practice is working with patients who have often come from troubled backgrounds with a complex mix of physical, psychological and social problems. 'By having the time to case manage these patients and prioritising their care needs, we see their health slowly improve in the majority of cases. In any other GP surgery, the GP and nursing team does not have the same liberty of time that we have at the Whitehouse Centre.'

He also highlights the importance of keeping these services running for the NHS. 'We effectively keep hospital admissions and A&E attendances down for our patient groups, bridge the gap between mental health, primary and secondary care services for our patients and ensure that these complex patients have access to specialist nursing and medical care.

'I fear that we will be seen simply as an "expensive GP surgery" and we are currently looking to produce evidence about what we do and the influence we have, including the benefits to the wider health economy.'

While the changes to the way migrants and overseas visitors access the NHS are being proposed to save money, services with staff trained specifically to deal with the vulnerable and displaced could be one way to ease some of the pressures on A&E and hospitals.


1. Department of Health. Sustaining services, ensuring fairness. 2013. Accessed January 2014.