'That's how we got around it': a qualitative exploration of healthcare professionals' experiences of care provision for asylum applicants' with limited English proficiency in UK contingency accommodation.

OBJECTIVES: The inadequate provision of language interpretation for people with limited English proficiency (LEP) is a determinant of poor health, yet interpreters are underused. This research explores the experiences of National Health Service (NHS) staff providing primary care for people seeking asylum, housed in contingency accommodation during COVID-19. This group often have LEP and face multiple additional barriers to healthcare access. Language discrimination is used as a theoretical framework. The potential utility of this concept is explored as a way of understanding and addressing inequities in care. DESIGN: Qualitative research using semistructured interviews and inductive thematic analysis. SETTING: An NHS primary care service for people seeking asylum based in contingency accommodation during COVID-19 housing superdiverse residents speaking a wide spectrum of languages. PARTICIPANTS: Ten staff including doctors, nurses, mental health practitioners, healthcare assistants and students participated in semistructured online interviews. Some staff were redeployed to this work due to the pandemic. RESULTS: All interviewees described patients' LEP as significant. Inadequate provision of interpretation services impacted the staff's ability to provide care and compromised patient safety. Discrimination, such as that based on migration status, was recognised and challenged by staff. However, inequity based on language was not articulated as discrimination. Instead, insufficient and substandard interpretation was accepted as the status quo and workarounds used, such as gesticulating or translation phone apps. The theoretical lens of language discrimination shows how this propagates existing social hierarchies and further disadvantages those with LEP. CONCLUSIONS: This research provides empirical evidence of how the inadequate provision of interpreters forces the hand of healthcare staff to use shortcuts. Although this innovative 'tinkering' allows staff to get the job done, it risks normalising structural gaps in care provision for people with LEP. Policy-makers must rethink their approach to interpretation provision which prioritises costs over quality. We assert that the concept of language discrimination is a valuable framework for clinicians to better identify and articulate unfair treatment on the grounds of LEP.

General Practitioner Educators on Clinical Debrief: A Qualitative Investigation into the Experience of Teaching Third-Year Medical Students to Care.

Phenomenon: There is a paucity of research reporting the experiences of general practitioner clinical educators. Providing education for students could lead to better clinical skills and greater job satisfaction for the educator. However, it could also result in increased stress and mental fatigue, adding to what is an already pressured situation in the current primary care climate. Clinical Debrief is a model of case-based learning with integrated supervision developed to prepare medical students for clinical practice. This study aimed to explore the experiences of general practitioners who facilitate Clinical Debrief. Approach: Eight general practitioner educators with experience of facilitating Clinical Debrief participated in semi-structured qualitative interviews. Results were analyzed using Reflexive Thematic Analysis, and four main themes were developed. Findings: Themes included: Personal enrichment: psychological "respite" and wellbeing; Professional enrichment: Clinical Debrief as a "two-way" door; Becoming a facilitator: a journey; and, Relationships in teaching: blurred boundaries and multiple roles. Insights: Being a Clinical Debrief facilitator had a transformative impact on the personal and professional lives of the GPs who participated in this study. The implications of these findings for individual GPs, their patients, and the wider healthcare system, are discussed.

In critique of moral resilience: UK healthcare professionals' experiences working with asylum applicants housed in contingency accommodation during the COVID-19 pandemic.

This research explores the experiences of UK NHS healthcare professionals working with asylum applicants housed in contingency accommodation during the COVID-19 pandemic. Using a critical understanding of the concept of moral resilience as a theoretical framework, we explore how the difficult circumstances in which they worked were navigated, and the extent to which moral suffering led to moral transformation. Ten staff from a general practice participated in semistructured interviews. Encountering the harms endured by people seeking asylum prior to arrival in the UK and through the UK's 'Hostile Environment' caused healthcare staff moral suffering. They responded to this in several ways, including: (1) feeling grateful for their own fortunes; (2) defining the limitations of their professional obligations; (3) focusing on the rewards of work and (4) going above and beyond usual care. Although moral resilience is reflected in much of the data, some participants described how the work caused ideological transformations and motivated challenges to systems of oppression. We show how current moral resilience theory fails to capture these transformative political and social responses, warning of how, instead, it might encourage healthcare staff to maintain the status quo. We caution against the widespread endorsement of current formulations of moral resilience in contemporary social and political climates, where the hostile and austere systems causing suffering are the result of ideological political decisions. Future work should instead focus on enabling working conditions to support, and developing theory to capture, collective resistance.

From principles to practice: embedding clinical reasoning as a longitudinal curriculum theme in a medical school programme.

There is consensus that clinical reasoning (CR) is crucial for increasing the value of diagnosis, medical decision-making and error reduction. These skills should be developed throughout medical education, starting with undergraduate study. International guidance provides principles for CR curricula but interventions to date, are short term in nature. In this report, we describe the creation of a longitudinal, spiral CR curriculum within a large UK medical school programme (2500 students). A working group drove systematic evidence-based reform of existing structures. We utilised recognised models for curriculum development and mapping, relating learning outcomes to competency frameworks. Application of multiple teaching methodologies, rooted in enquiry-based learning and reported in CR literature, encourage metacognition for information-processing and illness script development. Development of CR is emphasised with recurrent, progressive learning opportunities, each stage purposefully building upon previous experiences. Formative and summative assessment approaches to drive learning, encouraging students' ability to apply and articulate CR, is constructed via Miller's Prism of Clinical Competence. Implementation of pedagogy is contingent on faculty development. Whilst many clinicians practice sound CR, the ability to articulate it to students is often a novel skill. Engagement in faculty development was strengthened through cross-institutional recognition of teaching workload and flexibility of delivery. We report lessons learned from the implementation phase and plans for measuring impact.

Consternation and complexity: learning from people who seek asylum.

People seeking asylum experience health inequalities, and it is challenging to meet their needs in primary care. Consultations can feel overwhelming; however, there are excellent opportunities for Transformational Learning, transferable to other vulnerable people. A critical approach to evidence-based medicine, emphasising values, can be used to mitigate the consternation generated by these encounters and expand learners' perceptions about their roles and responsibilities. Global health, diversity, discrimination, intersectionality and power differentials can be explored. Realisation of the part practitioners play in leadership and advocacy is key. Helping the most marginalised is crucial to understanding patient-safety and quality improvement. Community-orientated approaches are performed well by Voluntary and Community Organisations. There is much to learn about co-production and their 'No Wrong Door' philosophy. Recognition of health literacy and promoting cultural sensibility for a growing population with Limited English Proficiency, also requires learning advanced communication skills. Developing therapeutic trust with forced migrants subjected to ill-treatment brings skills and behaviour relevant to other challenging encounters in primary care. Vicarious traumatisation is well-recognised when dealing with the sequelae of violence and, aided by their educators, primary care learners must understand ways to protect themselves and reflect on vicarious resilience, through recognising meaning in their work.

Healthcare access for asylum seekers and refugees in England: a mixed methods study exploring service users' and health care professionals' awareness.

BACKGROUND: With the aim of decreasing immigration, the British government extended charging for healthcare in England for certain migrants in 2017. There is concern these policies amplify the barriers to healthcare already faced by asylum seekers and refugees (ASRs). Awareness has been shown to be fundamental to access. This article jointly explores (i) health care professionals' (HCPs) awareness of migrants' eligibility for healthcare, and (ii) ASRs' awareness of health services. METHODS: Mixed methods were used. Quantitative survey data explored HCPs' awareness of migrants' eligibility to healthcare after the extension of charging regulations. Qualitative data from semi-structured interviews with ASRs were analyzed thematically using Saurman's domains of awareness as a framework. RESULTS: In total 514 HCPs responded to the survey. Significant gaps in HCPs' awareness of definitions, entitlements and charging regulations were identified. 80% of HCP respondents were not confident defining the immigration categories upon which eligibility for care rests. Only a small minority (6%) reported both awareness and understanding of the charging regulations. In parallel, the 18 ASRs interviewed had poor awareness of their eligibility for free National Health Service care and suitability for particular services. This was compounded by language difficulties, social isolation, frequent asylum dispersal accommodation moves, and poverty. CONCLUSION: This study identifies significant confusion amongst both HCP and ASR concerning eligibility and healthcare access. The consequent negative impact on health is concerning given the contemporary political climate, where eligibility for healthcare depends on immigration status.

Clinical Debrief: learning and well-being together.

BACKGROUND: Clinical environments can be so stressful to medical students as to be detrimental to their learning and well-being. Our intervention, Clinical Debrief, integrates learning through clinical experience with the development of positive coping strategies. Students shared cases and experiences during weekly small group classroom discussions, facilitated by general practitioners (from outside their current hospital placement), throughout two consecutive 12-week blocks of their first clinical year. Alongside enquiry-based and clinical reasoning learning, we gave students a safe space to reflect on their affect. Our aim was to critically examine students' views in Clinical Debrief. METHOD: Anonymised quantitative and qualitative evaluation data were collected over 3 years using online questionnaires on completion of each 12-week block. The data relating to psychological supervision were analysed independently and in parallel, using thematic analysis for qualitative data. We aim to help students develop positive coping mechanisms, promoting empathy,self-awarenessand wellbeing RESULTS: A total of 1857 evaluations were extracted (response rate 67%). The median (interquartile range) overall rating for Clinical Debrief sessions was 9 (8-10), where 10 indicates 'excellent' and 1 indicates 'significant improvement needed'. The rating for the supervisory aspects of the sessions and free-text comments were positive. Students appreciated safe environments, the session structure, facilitator role modelling, transitional support and processing of emotional experiences. DISCUSSION: Mandatory integrated longitudinal supervision, using trained clinician facilitators, was positively received by students in transition to clinical placements. Normalising the emotional impact of medical work destigmatises distress. Linking clinical reasoning with affective state awareness to contextualise case management, following Mezirow's transformative learning theory, brings added benefit to learning and well-being. Student demand for the expansion of Clinical Debrief is evidence of success.

Access to primary health care for asylum seekers and refugees: a qualitative study of service user experiences in the UK.

BACKGROUND: Asylum seekers and refugees (ASR) face difficulty accessing health care in host countries. In 2017, NHS charges for overseas visitors were extended to include some community care for refused asylum seekers. There is growing concern that this will increase access difficulties, but no recent research has documented the lived experiences of ASR accessing UK primary health care. AIM: To examine ASR experiences accessing primary health care in the UK in 2018. DESIGN AND SETTING: This was a qualitative community-based study. ASR were recruited by criterion-based sampling through voluntary community organisations. METHOD: A total of 18 ASR completed face-to-face semi-structured recorded interviews discussing primary care access. Transcripts underwent thematic analysis by three researchers using Penchansky and Thomas's modified theory of access. RESULTS: The qualitative data show that participants found primary care services difficult to navigate and negotiate. Dominant themes included language barriers and inadequate interpretation services; lack of awareness of the structure and function of the NHS; difficulty meeting the costs of dental care, prescription fees, and transport to appointments; and the perception of discrimination relating to race, religion, and immigration status. CONCLUSION: By centralising the voices of ASR and illustrating the negative consequences of poor healthcare access, this article urges consideration of how access to primary care in the UK can be enhanced for often marginalised individuals with complex needs.

Educating about female genital mutilation.

Female genital mutilation (FGM) is illegal in the UK but nevertheless practised in some immigrant communities. Effective educational approaches are required to inform policy and to direct resources, often in the voluntary sector. The opinions in this article arise from discussions with professionals and members of FGM-practising communities. We highlight the importance of sharing experiences and expertise across health and social care professionals as well as working in partnership with culturally sensitive Non-Governmental Organisations. Enlisting the support of men and religious leaders is crucial to breaking down barriers in male-dominated communities and dispelling myths about FGM being a 'requirement' of faith.