Abstract
Executive summary
Unaccompanied asylum seeking children (UASC) are a specific group of looked after children in the UK who have increased and specific health needs. This project looks at four set health interventions: dental checks, eye checks, immunisations and tuberculosis (TB) screening. Data were collected in 2016 for a sample period covering six months between June and November. Further data were then sought from stakeholders that included GP practices, social workers and young people themselves. The same outcome measures were collected again a year later in 2017 over the same six-month period.
A number of changes were implemented in this time, including re-activation of a referral system to Northwick Park Hospital Paediatric TB services directly from the Children Looked After (CLA) team, visiting a GP surgery where the majority of UASC register, attending two Harrow UASC forums to educate and gain the views of the young people and attending the UASC social worker team meeting to ascertain their views. In addition, the importance of immunisations was promoted by contacting all local GPs, giving the young person a copy of the schedule during their appointment and highlighting the priority of immunisations to the independent reviewing officer (IRO) in order for the message to be reinforced to social workers.
The results showed an overall four-fold improvement in rates of TB screening and immunisations from 22% to 83% compliance. There was a slight decrease in rates of dental and eye checks. The health needs of the 2017 cohort were analysed to reveal a number of primary care complaints, mostly related to dermatology and musculoskeletal problems. In addition, 55% of these young people required dental treatment and/or glasses to correct vision. In addition, the health outcomes of the 2016 cohort were followed up a year later and showed that all outstanding needs were either in the process of being met or that the young person had turned 18 years old and was no longer under the care of children’s services.
Future service provision and education will encompass continued training and support to social workers, primary care staff and young people to ensure high levels of achievement are continued across these important health areas.
Background
UASC are young people who are under 18 years and have travelled to another country to seek asylum due to fear of persecution in their home country. They have become separated from their usual parent or carer, often due to death or imprisonment or circumstances that mean they must travel alone.
The literature suggests that UASC have significant physical and mental health needs. These are influenced by access to basic health care in their home country as well as their experience of hardship, including the witnessing and experiencing of traumatic events and the conditions they have survived on their journey to the UK. The most important physical health issues include infectious diseases (e.g. TB screening and vaccination), dental health, nutrition (e.g. anaemia) and sexual health (Griffiths, 2018).
In addition to physical needs, UASC are at higher risk of emotional problems and mental illness than the general population.
Nationally, compared to the previous year, the number of looked after UASC increased by 54% to 4210 children at 31 March 2016. This is in part due to the dismantling of the ‘Calais Jungle’ in October 2016.
In Harrow, the total number of such young people in 2016 (April 2016 to March 2017) was 30 on average, with a high of 32. In 2017 (April 2017 to March 2018), the total was 33 as of March 2018.
Aims and objectives
The aims of this local study were to identify the health needs and improve the health outcomes for the UASC population.
Methodology and measures
Data were collected for all UASC seen at their initial health assessments in the London Borough of Harrow during a six-month period between June and November 2016 (inclusive). The outcome measures included TB and blood-borne virus (BBV) screening, dental check and eye test within six months of becoming looked after and immunisations commenced (Table 1).
The same information was collected again a year later between June and November 2017 for comparison after a number of change cycles were instigated (Table 2). Data were retrieved from clinical systems, requests from social workers and carers where appropriate, clinic letters and GP summaries. Details were recorded and analysed using Microsoft Excel.
Baseline data June to November 2016
Data in actual figures and percentages for measured outcomes in 2016.
Implementing changes
TB services
In July 2017, Northwick Park Hospital began to accept referrals for UASC screening of TB and BBVs directly from the Harrow CLA team. This change followed a two-way communication with the Infectious Diseases team about the need for such a service with development of a new referral form. This replaced testing via the GP.
GP surgeries
The Northwick Surgery in Harrow was visited by the CLA doctor and specialist nurse with the Paediatric Infectious Diseases consultant from Northwick Park Hospital. The surgery registers the majority of UASC in Harrow and we discussed challenges with registrations and specific health needs for this group of young people.
Immunisations
From the start of 2017, a print-out of the recommended immunisation schedule was given to every young person at their initial health assessment to take to their practice nurse, in addition to a copy sent to their GP. There is now also an increased awareness of the need for up-to-date immunisations via the IRO and therefore greater emphasis placed on social workers to complete this task. In addition, the CLA nurse and administrator have been regularly chasing outstanding immunisations.
UASC forum
A talk and quiz was held by the CLA specialist nurse and doctor about TB in order to promote awareness for the need to screen for it.
Re-audit data June to November 2017 following implementation
Comparison of results data for 2016 and 2017 samples.
Discussion
In the 2016 sample, only 14% of young people (those placed in Harrow and OOB) were tested for TB; two were directly referred by the CLA team as per a historical system and one child was found to be symptomatic and subsequently treated for TB. There was an almost four-fold improvement in TB screening from 22% to 83% for young people placed in Harrow a year later, likely to be due to the reinstatement of direct referrals from CLA to the local infectious diseases clinic. The reason for any missed TB screening in 2017 was due to non-attendance of a pre-planned appointment. The previous system required the young people to attend the GP for a blood test, which created more barriers to having the test done. It also did not always include screening for BBVs as this was felt to be outside the remit of a GP. Of note, there was also an increase of TB screening across young people placed OOB in 2017.
In the 2016 sample, 22% of young people placed in Harrow had started their immunisation schedule. A total of three courses are required over three months. This increased to 83% in 2017 and is likely to be attributed to more stringent monitoring and increased awareness across health professionals. As above, there was also increased uptake noted across those placed OOB in 2017.
In the 2016 sample, 89% of young people placed in Harrow were up to date with dental and eye checks compared to 83% and 66% respectively in 2017. The reason for not attending in 2017 was cancellation of a pre-booked appointment rather than a lack of attempt altogether. In addition, changes were made to the key worker availability to support young people to attend for these checks, which may have contributed to a slight decrease in 2017. One dental check was excluded for being just outside the six-month outcome measure period.
In the 2016 sample, 35% of the young people had emotional health needs that required further support from primary or secondary care in the form of therapy or medication. In 2017, this proportion remained similar at 40%. Of note, it also included a letter from the Home Office outlining their concerns about the mental well-being of one young person.
The physical health needs of UASC in the 2017 sample demonstrated a range of problems. The largest groups were dental caries and the need for glasses which comprised 55% of the total. Other health issues included general conditions across nutrition, dermatology, gastrointestinal and musculoskeletal systems that would be appropriate for primary care. There was one referral to cardiology for a background heart condition.
Results from a small sample size of social workers in the UASC team in Harrow revealed that they were generally confident in understanding the need for TB screening and found it relatively easy to support the young people’s attendance for immunisations and dental and eye checks. Interpreters are booked for these interactions. Difficulties related to registration delays with the Home Office and enrolling in education in order to access free health services. In addition, removal of ‘clinic-in-a-box’ sexual health outreach services in the care home has reduced access to sexual health services for these young people.
The UASC themselves rated dental health, eye care, depression and immunisations as highly important with more than half scoring 9 or 10 out of 10. Areas such as TB/blood tests and sexual health were rated slightly less important with more scores of 6 and 8 out of 10. Alcohol and smoking scored in the majority as zero as it was felt that they were not good for health.
Conclusion
Between the two time periods there was an overall improvement in TB screening and immunisations. Attendance for dental and eye checks was slightly lower but remained at a high standard, with reasons including cancellation of a pre-booked appointment.
Social workers feel confident managing the health requirements for UASC and the young people themselves have a good understanding of their own health needs.
Further service provision needs to be put in place for key workers to take young people to appointments, including the STI clinics where appropriate. Social workers will be supported and reminded about the importance of health outcomes as part of a young person’s general well-being. Ongoing support to access primary care is needed to ensure good immunisation rates and continuation of secondary care referral to the TB clinic.