Established in 2002 the Mulberry Practice provides specialist primary health care services for people living in Sheffield who are seeking asylum in the UK, victims of trafficking, homeless or living in temporary or unstable accommodation. The registered list is 1700 and has risen significantly in the last 18 months
What We Did
Established in 2002 the Mulberry Practice provides specialist primary health care services for people living in Sheffield who are seeking asylum in the UK, victims of trafficking, homeless or living in temporary or unstable accommodation. The registered list is 1700 and has risen significantly in the last 18 months with further increases expected this year. A GP specialist service for this client group is unique with only a handful across the country.
The Practice was established directly as a result of the UK Border Agency’s Dispersal Policy. The policy of dispersal spreads asylum seekers around the country on a ‘no choice’ basis, often moving individuals many times.
Sheffield was the first city in the UK to take some of the 90 refugees the British Government agrees to take each year through the Gateway (refugees who apply for relocation through the International Organisation for Migration from refugee camps to start a new life in participating countries). In 2007, with the support of the City Council, Sheffield became the UK’s first ‘City of Sanctuary’ for asylum seekers and refugees – a city that takes pride in the welcome it offers to people in need of safety.
The client group of the Practice have complex needs due to their status. All clients have mental health issues, in the main post traumatic stress disorder (PTSD)often arising from torture or rape. Added to this the continuing emotional uncertainty as to whether they will be granted leave to remain in the UK impacts on their psychological wellbeing. Many will also have physical health problems, including illnesses such as HIV, Hepatitis B or TB.
The Practice adopts a holistic approach to health and wellbeing, acknowledging that the client group presents with both health and social needs. The Practice has a specialist counselor and a specialist health visitor as part of the core team and is a nurse-led service, staffed by highly qualified and specialised nurse practitioners. They also receive support from a GP experienced in managing mental health in primary care as a member of the core health care team.
On first appointment, the Practice undertakes a full range of screening (Hepatitis B and C, HIV, TB, syphilis, chlamydia and gonorrhoea) as well as general physical health checks such as blood pressure monitoring. The Practice tries to offer as many services as possible in-house, acknowledging that the client group are more likely to attend one familiar city centre location than to travel to appointments with different services citywide.
At the first appointment reception staff assist the patient to complete the necessary forms to enable them to access dental services and receive free prescriptions. The team work closely with the City of Sanctuary volunteers to take patients to the pharmacy to ensure they are able to collect medication. City of Sanctuary also takes groups of patients who are waiting to be seen for a drink and snack while they are waiting. Volunteers are on hand to provide a welcome and signpost to various agencies such as the Victoria Hall drop in service, football club, lunch clubs, women only groups and dance groups.
If at any time a patient is identified as being at increased risk due to deteriorating mental health an alert is placed on the clinical system. Reception staff are trained to always check the home screen of the system when a patient presents at reception. If an alert is in place a clinician will always see and assess the patient that day. This ensures timely and appropriate access for the most vulnerable and prevents a deterioration in mental and physical health. This model of working has also significantly impacted on the use of secondary care services by this group, in that the majority of their care is provided by the core multi-disciplinary team at Mulberry and this proactive care reduces unnecessary hospital and unscheduled care attendance.
The city centre location of the service ensures that it is accessible to all and is a maximum of one bus ride away for the clients or not too far to walk. The client group has limited funds and reducing travel costs is an important factor which impacts on the likelihood of them attending appointments and reducing DNA rates. Similarly, the client group has, due to past experiences, trust issues, and seeing the same practitioners and administrative staff in a familiar building builds trust and confidence.
The reception staff are experienced in working with people suffering with mental illness and distress and are highly skilled at dealing with patients in an agitated state. They recognize that patients may suffer with anger management issues, anxiety and concentration problems due to mental illness. Patients are encouraged to bring any letters into clinic so they can be explained to them to reduce anxiety and also reduce DNA rates for appointments elsewhere. The service acknowledges that mental illness requires a holistic approach and is influenced by social issues such as isolation, housing and lack of purposeful activity.
A drop in service is provided every day staffed by a specialist nurse practitioner. The nurse practitioners have extensive experience working with this patient group. They see and treat 90% of drop in patients without needing a follow up GP appointment. They can refer to secondary care and regularly liaise with mental health services on behalf of patients who are already under these services but experiencing worsening mental health.
The service continues to respond to clients’ needs. Previously this was a morning only service however feedback from the client group was that this could be very difficult to get to if you were taking anti-depressant medication or sleeping aids which made you drowsy. Also many patients suffering with PTSD will stay awake overnight which is when they feel more hypervigilant. These patients will often go to sleep as the dawn breaks and sleep until late morning. In response to this feedback the service has added an afternoon drop. Some of the patients also find it difficult to sit and wait in a busy reception area due to anxiety or PTSD. To allow for this the team also offer pre-bookable appointments with a nurse practitioner. The aim is to make the service as accessible as possible, removing barriers that may exist in mainstream services.
The Practice has established close links with the Infectious Diseases Clinic at the Royal Hallamshire Hospital and a Consultant from the Clinic attends the Practice on a fortnightly basis to manage latent TB and other similar cases.
Clients are often new to the UK and all are new to Sheffield. The Practice has assisted new registrations whereby a bus collects all new arrivals and brings them to the Practice to be screened and registered weekly. The free bus ensures that all asylum seekers new to Sheffield receive appropriate physical and mental health input while also ensuring that clients know where to go for future appointments. The assisted new registrations service via the free bus is a nationally identified example of good practice and is detailed in ‘Promising Practice’ a project commissioned and overseen by the Data Research Working Group of the Inclusion Health programme and approved for publication by the National Inclusion Health Board.
Evidence recognises that this client group can face multiple problems in accessing mainstream services due to lack of knowledge of the NHS, language barriers, cultural barriers and the fact that mainstream services often do not know how to deal with the complex issues these clients present with. The Practice has strong links with partner organisations and the voluntary sector who can offer additional support to the client group and facilitates access where appropriate.
The level of specialist support offered by the Practice is greatly appreciated by the client group and quotes from clients are detailed below: “I was not in a good mentally and physically situation but you helped me with my mental illness to cope with my problems and make myself stronger”; “I was thinking I was going mad. I was using lots of depression pills as well as sleeping pills and felt myself unable to face issues related to my immigration matter as well as my relationship with my husband and kids. But by the help of sessions of counselling I felt much better. Although my basic issues are still there but my way to deal my issues is changed now”.
“Everyone that works here is so nice and helpful” “It’s the first time in my life I came across such good medical care it is true, true, true”; “You have been my inspiration, motivation, support, friend. You have change my life for good and I thank you for that”; “It’s made me feel like I am somebody in society”.
The Practice is so well regarded by its client group that many who have been granted leave to remain in the UK chose to remain registered rather than registering with a local GP.
Wider Active Support
As outlined above, the Practice works closely with the Infectious Disease Clinic at the Royal Hallamshire Hospital. They also work closely with a drop-in service for asylum seekers which is held at the Victoria Hall, a building very close to the Mulberry Practice. The drop-in offers a range of services and stalls include the Refugee Council, Northern Refugee Centre, ASSIST (Asylum Seeker Support Initiative Short Term) Sheffield and other organisations which offer support around education, training, form filling and legal advice etc.
The Practice also works with SOLACE a Leeds’-based charity which provides psychotherapy, complementary therapies and advocacy support to the survivors of persecution and exile living in the Yorkshire and Humber region, many of whom have been traumatised by torture, rape, the death or disappearance of loved ones and often combinations of all of these and other atrocities.
The service is built around the needs of its client group. The focus is on ‘what would I need if I was new to the UK? What would help me?’ and this actively drives how the service operates.
Current pressures on primary care and the complexities of the client presentations means that a specialist service can offer a more holistic approach to care for this client group. The cultural aspects of a client’s experience and background are many and varied and the team at the Practice are experienced and knowledgeable and can provide a tailored, personalized approach to care that would not be possible in a mainstream primary care setting.
Looking Back/Challenges Faced
On reflection, the size of the building in which the Practice is based is less than ideal. When the service was established in 2002 the primacy of a city centre location was acknowledged and a suitable space for the Practice was found. However, it was not fully understood or realized at the time that the Practice’s success would impact on the numbers of clients seen by the Practice and also that successful asylum seekers would choose to remain with the Practice, impacting on stretched services and making the building size less than ideal for a changing and growing service.
One of the main challenges faced has been the language difficulty and the increasing volume of asylum seekers and victims of trafficking into the city without additional resources being available. The broad range of languages spoken by the client group was acknowledged to be a major challenge when the service was established in 2002. Therefore, Sheffield Community Access and Interpreting Service (SCAIS) was established at the same time to try to address these issues. SCAIS offer interpreters in a wide range of languages and work closely with the Practice to plan recruitment in advance of new communities relocating to Sheffield. This has worked well on the whole, with many asylum seekers who have been granted leave to remain, going on to gain employment as interpreters via SCAIS.
Another challenge faced is the cultural differences between the different individuals who use the service. The client group come from many different countries and embrace many different cultures. The team need to ensure that they are respectful and understanding of the cultural backgrounds of each individual and work hard to provide a holistic approach to each and every individual. The team are very experienced practitioners, however, they also ensure that they undertake appropriate research and speak with relevant professionals (in all sectors) when a new community are relocated to Sheffield.
Another challenge is that posed by the UK Border Agency and the asylum process. The system is constantly changing and asylum seekers can be moved around the country at very short notice which makes ensuring continuity of care very difficult. Deportations can also occur at very short notice. The Practice works very hard to ensure that new referrals are quickly processed and that all relevant health checks are carried out. The Practice also ensures that all prescribed medications are appropriately recorded so that this information can go with the individual if they are relocated or deported at short notice, and, where appropriate, that medications prescribed are accessible in case of relocation (eg would this medication be available if this individual is deported back to their home country?).
Further challenges are the perceptions of asylum seekers from both the general public and other professionals. This lack of understanding of migration in general causes stigmatization and isolation for this group. The negative press and the reactive responses from government on asylum issues lead to inaccurate assumptions in relation to entitlements and provision. The Practice promotes a positive image of the client group and the team is happy to dispel myths and perceptions by providing information sessions on asylum seekers.
The team at the Practice have a strong team spirit and work closely together. All those working in the team are fully committed to working with asylum seekers, victims of trafficking and refugees and are extremely client focused. It is a small team that offers great support to each other. The team works closely with G4S and both the Trust (Sheffield Health & Social Care NHS Foundation Trust) and Sheffield City Council are fully committed to ensuring that the service continues. There is regular liaison between the Practice, the Trust, G4S, Sheffield City Council and Education. The Manager who established the service in 2002 left four years ago and the Practice has continued to provide a quality service with dedicated staff. The current Manager is also a clinician
Due to the nature of the client group, it has proved difficult for the service to use traditional evaluation tools to gain client feedback. It has proved difficult to accurately measure patient experience due to language barriers, cultural barriers and differing expectations.
The Practice tried to establish a patient focus group to gain feedback and to work with the clients on service improvements. The focus group was widely advertised and staff also recommended it to clients. Only one lady attended the focus group. She thought the group was about her asylum claim and only wanted to discuss this. For the majority of clients, their main issue of concern is their asylum status and the Practice accepts this. Acknowledging this is important as it allows us to build a relationship of trust and respect with the client group. Many patients are unable to focus on physical or mental health needs if they do not feel they are being listened to with regards to the struggles with asylum.
The Practice welcomes feedback and actively addresses all issues raised with them by clients and fellow professionals. The practice has agreed for amendments to be made to the Friends and Family test as many of the client group are in the country in isolation and asking such a question could cause distress. The question asked if they would recommend the service to anyone else.
The Practice routinely monitors safety issues via the Trust’s incident reporting system. They follow all Trust policies and procedures and any incidents are scrupulously reviewed and investigated.
The Practice employs a specialist health visitor who ensure that safeguarding procedures are strictly followed and that alerts are raised where necessary works closely with a specialist health visiting team who understand the asylum process and have expertise working with survivors of human trafficking. Regular safeguarding meetings are held with midwifery and health visitor to discuss any concerns. All staff have regular 1:1s and there are regular team meetings to ensure good communication. The Practice has a flatter structure than most NHS teams and is actively unhierarchical. Protected learning initiatives are in place (a half day on a regular basis) when staff can update their skills and training and also share best practice on how to deal with the many distressing and tragic stories they hear as part of their work. In the past, external counsellors have been brought in to help debrief and counsel staff, however, due to the specialised nature of the work of the Practice, these counsellors found themselves out of their depth. Peer support is now offered.
The Practice is fully committed to sharing good practice. They are involved with the SHARE project – an European Union initiative which encourages EU cities to take resettlement refugees. In 2014 representatives from the Practice attended a SHARE project conference in Belgium to share their experiences. The Practice is considered by SHARE to be an example of excellent practice. Delegations from all over the EU visit the Practice to see what they are doing and to learn from them. The Practice is always pleased to share their expertise with other services and would be more than willing to host a learning event.