Gateway Mental Health Project

1. Gateway Mental Health Project John O�Neil Refugee Health Team Lambeth, Southwark & Lewisham London, UK

2. National Health Service (NHS) Conception: Introduced on 7th July 1948 by the Minister for Health, Aneurin Bevan (Welsh Labour Politician & Socialist) To �slay� the �five giants�: want, disease, squalor, ignorance, idleness Not a new idea, developed fragmentally since 19thC, (e.g. London County Council Hospitals) Described as �an essential part of a civilized society� in Sir William Beveridge�s report on Social Security & National Insurance (BMJ, Dec 12th 1942) Not unique, similar models developed throughout the then Eastern Block

3. Principles Financed almost 100% from Central Taxation Everyone eligible for care, even those temporarily resident or visiting the country Entirely free at point of use, (though some charges introduced later, such as prescriptions, dentistry etc)

4. The NHS today The NHS Plan of 2000 saw the tumultuous formation, dissolution and rearrangement of the entire service resulting in: 10 Strategic Health Authorities controlling: 200 Primary Care Trusts (PCT�s) contracting: Public & private providers, NHS Trusts, NHS Foundation Trusts, Hospitals, Community Care, Ambulance Services, Mental Health Services, General Practices (GP�s) and Primary Care Services Other than financing, the principles remain the same

5. Mental Health Service provision in the UK National Health Service provides health care via local health authorities and trusts Local Authority Social Services provide and arrange social support Local and national voluntary organisations provide a wide range of services, e.g. advocacy, information Commercial agencies provide a range of services such as Counselling, Psychotherapy, Self-Help

6. Other services Residential facilities e.g. staffed care homes, hostels and supported housing schemes Day centres and drop-in centres (often run by social services or voluntary agencies) Welfare rights advice e.g. Law Centres and Citizen Advice Bureaus Miscellaneous services e.g. information services, helplines, advocacy, websites. Many of these are run by local and national voluntary agencies

7. Statutory Service Tiers Primary Secondary Tertiary Primary care services aim at disease prevention and health promotion, as well as managing the vast majority of ailments and illnesses. e.g. General health: early detection and treatment of illness Mental health: moderate depressive illness Secondary care services aim to manage more pervasive, chronic problems. e.g. General health: Type 1 Diabetes, Mental health: Schizophrenia, Manic Depressive Psychosis, Personality Disorders Tertiary care services provide specialist input e.g. General health: terminal cancers Mental health: Posttraumatic Stress Disorder, Neurological disordersPrimary care services aim at disease prevention and health promotion, as well as managing the vast majority of ailments and illnesses. e.g. General health: early detection and treatment of illness Mental health: moderate depressive illness Secondary care services aim to manage more pervasive, chronic problems. e.g. General health: Type 1 Diabetes, Mental health: Schizophrenia, Manic Depressive Psychosis, Personality Disorders Tertiary care services provide specialist input e.g. General health: terminal cancers Mental health: Posttraumatic Stress Disorder, Neurological disorders

8. Refugee Health Team LSL The RHT LSL works across the inner London Boroughs of Lambeth Southwark and Lewisham to improve access to and quality of primary health care services for refugees and asylum seekers. RHT is a Primary Health Care Team Lambeth, Southwark and Lewisham are inner boroughs of London. They are multicultural and the inhabitants represent a wide range of people from around the world. They are wracked by some of the highest levels of poverty, crime, poor education etc in the UK RHT is a Primary Health Care Team Lambeth, Southwark and Lewisham are inner boroughs of London. They are multicultural and the inhabitants represent a wide range of people from around the world. They are wracked by some of the highest levels of poverty, crime, poor education etc in the UK

9. The motley crew The teamThe team

10. The team�s objectives are to: Identify and address difficulties preventing access to health services by refugees and asylum seekers Reduce the inequalities facing our clients and prevent social exclusion Influence the quality and appropriateness of primary health care services in LSL Ensure that refugees and asylum seekers exercise their rights to NHS services and are shown respect for their privacy, dignity and religious and cultural beliefs Work with other relevant organisations to raise awareness of the NHS and health issues Main objective of the team is to ensure refugees and asylum seekers have equal access to the services they need and to assist services to provide that support, regardless of the additional problems faced in working with this client groupMain objective of the team is to ensure refugees and asylum seekers have equal access to the services they need and to assist services to provide that support, regardless of the additional problems faced in working with this client group

11. RHT LSL operation 3 Senior Refugee Health Workers develop and maintain relationships with the plethora of non-government and refugee community organisations in the three boroughs 3 Refugee Health Workers and 3 Specialist Physical Health Nurses accessible to all through continuous presence at community organisations and provide holistic health screening and facilitate all aspects of access to care Health & Well-Being Specialist provides health promotion and self-help techniques to client group Specialist GP provides all aspects of primary health care and support to the team

12. Refugees & mental health Problems faced by refugees above and beyond that of the settled population: Adjustment to a new language, culture and country Uncertainty about their future Confusion around how the systems work Discrimination and racism Poverty and homelessness Lack of recognition of prior skills, qualifications and values Isolation Stigma By far the greatest health challenge amongst migrant populations is mental health, most especially amongst refugeesBy far the greatest health challenge amongst migrant populations is mental health, most especially amongst refugees

13. Refugees & mental health Feeling guilty for abandoning their relatives, friends and country Change of traditional roles in adults (increase or decrease in social status) Change of traditional roles of children (translators, carers, etc), gender issues Relationship reconstruction following periods of long separation Loss of extended family, community support Perceived loss of culture and values, especially in offspring Powerlessness to protect against racism, bullying and poverty Inability to prioritise essential needs Existing mental health services are not designed to encompass the needs of migrants, though significant improvements have been madeExisting mental health services are not designed to encompass the needs of migrants, though significant improvements have been made

14. In a nut-shell (Maslow)

15. Gateway Mental Health Project Recruitment of a Community Psychiatric Nurse (CPN) in 2004 following a service review and an analysis of the mental health needs of asylum seekers and refugees in 2002 (Rojas-Jaimes & Webster; Psychiatric Bulletin, 2002) Supervised by South London & Maudsley Mental Health Trust�s Refugee Lead and informally within the Trust�s Traumatic Stress Service Monitored closely by commissioner via quarterly reports and updates Recently gained permanent funding through Lambeth PCT

16. GMHP objectives Create access pathways to mental health care through: Capacity building within Refugee Health Team Capacity building of NGO�s & RCO�s Development of culturally sensitive assessment tool Development of partnerships with relevant organisations Provision of a specialist triage service Peer group training and supervision Creation of access pathways to mainstream services Ongoing support of a small caseload of clients

17. Some opportunities Culturally sensitive assessment and treatment Consistent use of professional interpreters Up-to-date information on asylum policies and issues Specialist knowledge of refugee issues Bio-psycho-social interventions in partnership One-stop-shop style approach Room to be tenacious

18. Some dangers Further marginalisation of client group Danger of becoming too focussed Balance of referral base versus capacity Seen as additional service (e.g. asked to �hold� clients) De-skilling of NGO�s & RCO�s Tenacity can attract automatic negative responses

19. Access to the project Client�s discovered by RHT LSL with direct referral and co-working practice Direct referral by British Refugee Council Specialist Team based in central Lambeth �Clinic� provision within the community Partially based within South London�s Homelessness Mental Health Team (START) Advice and liaison for all support providers

20. GMHP interventions offered All interventions are culturally appropriated as far as is possible Full mental health assessment Education (psycho and other) Brief psychological interventions Brief solution focussed therapy Trauma focussed therapy Sign-posting to helpful agencies Inter-service liaison and support

21. Continued... Direct referral to secondary services Direct referral to social services Referral to Medical Foundation / Helen Bamber Foundation PTSD screening and �proxy� diagnosis (through supervision) Homelessness preventative measures (e.g. Sec 4, �Dispersal� management and/or prevention, sign-posting)

22. Some statistical outcomes Of the 512 people referred, 476 were seen (only 7% not seen). Without the project: 79% would have been referred to secondary care 21% would have been referred to A&E With the project: approx. 32% have been referred to secondary care approx. 1% (5 people) have been referred to A&E approx. 67% have been assisted in primary care

23. Khaled Ahmedi, a case study Born in 1990 near Kabul in Taliban controlled Afghanistan Youngest of three sons to a shop-keeper and his housekeeping wife Attended elementary school then began working in the shop from 9 years old 7th October 2001, US and UK troops invade, beginning a fresh period of war (almost continuous since 1839 and unbroken since 1978)

24. Refugee experience � part 1 In July 2004, (aged 14), �Taliban officials� raided the shop, killed his father and two brothers and seriously injured Khaled He was abducted by them and held captive for almost 3 years He was regularly abused physically, psychologically and sexually He was often subjected to mock executions, usually preparing to decapitate him going as far as cutting his neck with a knife

25. Refugee experience � part 2 Rescued by an �uncle� in April 2007 (aged 16) Smuggled overland via Turkey in �the back of a lorry� with strangers Physically abused by trafficker Understandably poor recollection of timings and events Arrived and claimed asylum at the sea-port of Dover in the UK on 2nd July 2007

26. Refugee experience � part 3 Subjected to the usual interrogation, accusations of lying and general unhelpful attitude Deemed �age disputed� therefore accommodated in a hostel with adult males, none of whom spoke Pashto, or his mother tongue Dari Financial support (just over � of National Welfare rate) provided through �vouchers� Found a peer group at the British Refugee Council in Lambeth and accessed health screening, English language classes, legal advice and other forms of support British Red Cross unable to locate his mother, or confirm her welfare

27. Initial presentation Khaled showed great difficulty adjusting to life in the UK Kept other hostel residents awake at night by screaming out and crying in his sleep They complained to him and about him Began cutting himself randomly and seriously, often going missing for long periods of time (usually after signing in at the Home office, a weekly affair) He found himself lost and bleeding in parks and strange places with no recollection of what had happened Hostel manager took him to A&E and left him there following a severe cutting episode

28. Experience at A&E Seen by medical doctor and referred to Psychiatric Liaison Nurse Described in notes as an �illegal immigrant� No interpreter used No psychiatrist consulted Asked by the nurse, �Why didn�t you kill yourself if you wanted to die?� Discharged to care of GP with a benzodiazepine prescription and the advice, �this is behavioural, not illness, as he only cuts himself in places he can reach�

29. Patient journey Deterioration and recent scarring noticed by a Volunteer at the British Refugee Council Referred to the council�s Health Worker that day Referred to the council�s Bi-Cultural Specialist Team on the same day Counsellor referred to GMHP for full mental health assessment and seen two days later

30. GMHP assessment Hopeless, despondent and distrustful Anxiety over periods of memory loss and difficulty in concentrating Gaunt looking with recent marked weight loss Recent loss of peer group as they felt he was �not right in the head� Extreme hypersensitivity around uniformed men No knowledge of anatomy or physiology, cutting severe, random and increasing in frequency (very high risk of accidental suicide) Poor sleep due to nightmares and flashbacks Intrusive thoughts of �ending it�

31. GMHP Initial intervention Understanding and reassurance conveyed and basis of trust established Liaison with GP, Benzodiazepine stopped. Commenced on Mirtazapine (antidepressant) and a small dose of Risperidone (antipsychotic) Directly referred to a Community Mental Health Team and a psychiatrist Directly referred to Traumatic Stress Service Weekly meetings to monitor, review and support with daily attendance at Refugee Council drop-in service Multi-disciplinary Medico-legal report prepared for solicitor

32. Khaled today Leave to Remain granted by the Home Office Living near the Afghan community in London English language skills improving by the hour Works in a local market place and is training in Butchery Attends therapy once per week at the Traumatic Stress Service Support provided by a local Community Mental Health Team Mood has improved greatly but is still plagued by nightmares Periods of dissociation have decreased in frequency, as have episodes of self harm