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I will introduce her while she settles up on the stage. Doctor Longley is an NHS consultant in infectious diseases and travel medicine at the Hospital for Tropical Diseases at UCL H. She's associate professor in Travel Medicine at the London School of Hygiene and Tropical Medicine. She is a member of the Faculty of Travel Medicine at the Royal College of Physicians and Surgeons of Glasgow, the International Expert Committee for Travel Medicine and TA for NAC. She runs the short course in travel medicine and teaches travel medicine on the diploma in tropical medicine and hygiene at the L SHTM. She is also a medical co of respond, a free confidential health service hosted by UCL H for asylum seekers and refugees. Ok, good. Thanks everyone. Um It always makes you sound far more important than you really are these introductions anyway. Um Welcome. It's quite tropical in this room, isn't it? So do you um sort of jump up and down and wave and if anybody needs to go to the loo or anything before, let me know. I um and also let me know if you can hear me because I've decided not to hold hold a mic. But wave at the fact if I'm too quiet, I'm super happy to be interrupted because I think actually a lot of what comes out of this really is having a discussion around health systems and individuals and uh how we work. But I will get going and I have got some slides. So what I'm hoping to do is to just make everybody thinks to start with and to think about how when we're setting up health services and dealing with vulnerable individuals, everybody is an individual and just that and often when we're developing services, we try and think about the problems that we perceive rather than that, which individuals have gone through. Um I'm also trying to justify why I think, or we think dedicated services are needed. Cos actually a lot of the problems that we see are multifactorial and if you broke them down into isolated problems, you could say these could be delivered by anybody who has an understanding of health. Um I also then want to just use an example of what we set up UCL H and by no means, am I saying that there aren't other pockets of excellence? But it's just our findings and um how we have served this population with a few outcomes of what we've found. And then I'm gonna go through a case, but I've left quite a large chunk of time for questions and answers because I think that's really um where we're at and talk about our sort of barriers and what we found. So before I start, I just want to make sure that you take a look and take some time to reflect of who's around you because we often make assumptions. Well, this is sort of doing a scary thing on its own without letting me press the button. But we make assumptions about people all the time. We all have inherent bias and you um it's really important because you don't know what your colleagues and your patients have been through and this is outside of this setting. But in any setting at all, I think it's really important to um make sure and note that no two of refugees or asylum, asylum seekers, patients stories are the same and therefore their profile of health needs are not the same. So just hold that in the back of your mind all the time. Um This is a super old thing and I'm sure everybody here has heard of Maslow. Maslow's hierarchy of needs. But really just again, whenever you're seeing patients or when and whenever you're interacting with people, it's really important to understand. But until people can self actualize and enjoy life, they need to have first their physical needs and or their physiological needs, then their safety, then to feel loved and belonging. And it's only later on, they start to say actually this is going wrong, this is what I would like. And often when we see people right at the beginning, we're asking them to talk about things far higher up. So keep revisiting and keep thinking about these things. I'm not doing this to minimize your knowledge or to patronize anybody. But it's really important from a legal and political perspective to understand some of the terms and definitions. And I don't want to assume people's background knowledge. So human migration and I hate the term that gets banded about in the press all the time to save migrants. But it all it means is a movement of people from one place to settle in another place as an individual or family or larger groups and this can be voluntary as well as forced. Um We then get on to why people move and for a lot of those reasons are good reasons, but some of them are bad movement reasons and we, this is, you know, goes back to your G CSE geography but you know, you have those push factors. So environmental, social, economic, political and people are leaving because they are frightened because of poverty, because of natural disasters, because of destabilization, because of lack of opportunity. And they're moving because they want to find safety, they want to get jobs, maybe their family moved, maybe they want more freedom, maybe they want understanding and it's just really, you know, people aren't going unless there is a reason to go and displaced people. And this is where we really are. Talking are those that are forced to move and that's either a game because of civil unrest, natural disaster, political or religious reasons or dis or persecution. Um And where it becomes important legally, and this makes a very big difference to individuals um where they interact with you or the government or anything else is an asylum seeker, is someone who has already put in a formal application for refuge in another country. So that's a legal term and then they become a refugee in the UK, if that application is successful, so then they have legal status to remain. And that alters what their um what uh recourse they have to funds and to services. But it also alters people's feeling of stability and uncertainty. And as we know in all areas of health, even if the answer of an outcome, if you're being investigated for a cancer, for example, even if you get told your disease is terminal and you're down a palliative pathway that is far more stabilizing than, than not knowing. So it's just really important to do to, to think about that and what I haven't put down, I think I for some reason, written internally displaced by mistake is um the people who are undocumented and this by far accounts for the majority of people who have not put in a legal application at all and therefore are often going under the radar and we don't see people in a planned way. Ok? These, this slide is really just to give a little bit of a, a background and to understand the UK system. And I know there are lots of people online that are listening to this abroad, but I'm talking to this from a UK perspective, but lots of it will be mirrored in other countries. So we always think, and the news makes us think that we're by far and away have the most, um, asylum seekers and refugees. But actually, we're sort of about halfway down in a European setting. Um What happens to people and this is where is it is, you know, there is this whole, how do you put in a claim for asylum? And it's very difficult in the UK, the government wants you to say you need to do this before you come. But there really isn't that pathway. So people will arrive, they're then placed in initial accommodation, which is often hotel accommodation. But increasingly it's things like army barracks. There's the very, you know, well known about this Stockholm Barge. There are other places, there's the mans camp and at that point, they have then have a screening interview by the home office where they will gather information and then they're meant to have a decision made and this process is meant to take three months. But what we've found is people are in this accommodation for sometimes up to three years. So that, that feeling of uncertainty is there for a long time, once the decision has been made, if you're granted status to, to, to remain, then you're given uh about 20 days to get out of that initial accommodation and find somewhere else and you don't have a national insurance card at that point. So you can't find money, you can't play cards or housing. So we're seeing increasing homelessness in people who are allowed to stay. If it's refused. Then ordinarily you were able to um put in an appeal and get a pro bono lawyer. But actually what is they're trying to do is to say that if you have not made your claim before arriving in the UK, you're you're not allowed to um go to appeal. So it's a very difficult sort of situation. I'm not coming up with an answer for this, but just so that we try and have an understanding the terms asylum seeker and refugee are those sort of legal terms. Actually, there's been a lot of um quantitative work with this population asking what people would like to be pulled. And the term sanctuary seeker is, is what it seems to be preferred, but it's all people seeking asylum and refuge. So, but it's difficult and please forgive me. Um where I've sort of interchanged these terms throughout. So this is again, just talking about London and what we have seen is there in the date. The numbers are, are similar but slightly old. It's 2021 date. So they are around about 50,000 applications in London alone. And in the northeast of the UK, there's far higher and in other places in Europe, it's far higher as well. And about 8000 people are placed in contingency accommodation in London and our service was set up and I'll talk about it in a minute because almost overnight during COVID, we had over 2000 asylum seekers placed in hotels that were cleared out because they were not being used by travelers or students or other people. Um This population has multiple medical and psychological problems. So you're placing them in crowded accommodation in a new city without services that have been set up and asking them to try and navigate the NHS. So these huge barriers are sitting there and it's very difficult for people to know what's going on. What are these barriers? So again, as I said, people with social environmental, economic, physical mental health problems often can't speak the language of the country they're in, there's a lack of awareness about the access and how to access and social care services. There's a fear of the cost because they don't know that it is free at the point of access. They've been told they're not, they don't have a legal right to remain. There's a fear of persecution and stigma and often what we've seen is people, for example, may have been fleeing their country for gender identity or um sort of sexual preference reasons are placed in male only hostels with people that they're fleeing from. So there's this issue as well. They're often moved frequently and at very short notice. So we've, you know, we've had people in our service who we said what phoned up or sent a message to say, why haven't you come to the appointment? And they've been moved at one in the morning to stop without knowing where they're going. Um, and there's digital poverty. So people often don't have wifi or a working um working sort of iphone, they often will have some sort of cell phone. But again, that changes. Um and then clashing appointments because if you have all these needs going on, you and you're given 10 different healthcare appointments often may happen at the same time. And as we all know, the NHS just doesn't talk to itself properly. And then there's the issue that most of this should be able to be dealt with in primary care. Primary care is on its means and this is by no means me criticizing um general practice at all. But when you're told you have 10 minute appointment for one problem and you have a person who's sitting there and is traumatized, it's just absolutely impossible to deal with. So what's our mission in response? So our mission was to try and set up a health screening and care planning service for um asylum seekers and refugees. And what we wanted to do was try and place uh have people seen as a family unit at the heart of the service and to try to acknowledge that their health needs sit at that intersection of physical mental health and social welfare. Um We wanted to try and look at what evidence is out there and there isn't any good, nice guidance for this particular population, but a lot of the needs will align with people experiencing homelessness. And so what we've tried to do is have a service that is person centered, that it's empathetic, that it's non judgmental. And we try to address the health needs and health inequalities across there. And I'm not gonna read all of this out. But one of the key things is thinking about using a trauma informed um care or trauma informed practice. And, and that is to just say that each individual and this is staff included because staff often suffer from vicarious trauma. Um need to have their thoughts placed at the beginning to give the space for them to let you know what is what they are able to, to talk about at that time, to give them the space to revisit but try not to be traumatized. So try not to go through what we often do if somebody comes into A&E and they have to tell the story 3456 times and it's very traumatizing and to sit and go have asked for permission to share that story if it's been given to you, give people space to come back to it later and make sure that those that are doing the follow on care can read the history from before rather than re traumatizing. But more importantly, giving people the space to speak. Um The other thing that a lot of you would probably have seen is this call 20 plus five, which is part of the whole government agenda of leveling up health care. And what we've really tried to do is to map the service onto that. And that's to say that it's not just dealing with infection as most of us are infectious diseases, um clinicians, but it's to sit and, and, and deal with all the other uh things of inequality. So looking at cancer screening, looking at um social welfare for the Children, looking at oral health, respiratory disease, severe mental health problems um and trying to map out in a way that this will work. Um And then what did we do? Um So what is our service? So actually when this started up um during COVID, we were really how it started with one of my colleagues who is the lead for safeguarding in North central London for Children um who deals a lot with the unaccompanied asylum seeking population and has been doing this since about 2016, 2017. The social workers for a long time are coming to us suddenly going, I don't know what's going on. We've had like 500 patients trying to register at one new GP practice. Can you help? And so we've been talking for a long time about setting something up because COVID had sort of decimated travel and tropical health. It meant I had time in my job plan when I wasn't on the wards and as did my pediatric colleagues, so we set this service up with the goodwill of our trust cos this is one thing people often say is where do you get the funding for this? And it was one of these serendipitous times that we are, we had space in our job plan. Um So what we were very much doing to start with was going out to GP practices that were asking for our help and doing holistic screening in the GP practices to give them a bit more space. And this was predominantly to start with, with the asylum. And this was lone adults which will um probably be about three quarters of the population, but then family units as well. Um And uh we were doing in infectious diseases screening and treatment and then these cholest health care plans, my colleagues have been looking after the unaccompanied asylum seeking Children for a long time and that continues and they um and I'm not going to spend a long time talking about that today, but um Children have the right to remain in the UK until they're 18. So what um so and they will get a social worker aside and they all get somewhere to stay. It's not often ideal but there is somewhere. And so they have a less holistic um service which is infectious diseases, screening and treatment at UCL H. But they have all the community things that are going on and have been for many years and there's just complex political funding reasons for that. And then the other population of the Afghan resettlement population. So these government schemes, there was a Syria scheme before there's homes for Ukraine. And this is when there are specific populations that the government has determined to have the right to remain and will place that they don't give us funding to look after this population. So we saw a stark problem because there were about 2000 of this population airlifted out of Afghanistan and placed in hotels, accommodation. And um they had a private company that were meant to be dealing with their needs and just did not have the training and were not dealing properly. So our was suddenly flooded with people coming in with trauma, with kids, with nappy rash, with adults with a, you know, minor cough, things that could be dealt with in the community. So we've sort of we we've now managed to set up an infection treatment, infection screening halfway for them and try to do a more holistic screen when they're there. What we have done is set up a virtual complex refugee health advice and guidance, multidisciplinary team meeting that happens every two weeks and you can access this from around the country. And in that meeting, we have adult and pediatric infection, adult, pediatric, safeguarding, adult, pediatric, mental health, social care, school, nursing and any other specialist that we bring in for specific problems. Oh, so yeah, I'm not gonna cover the US today. I'll try and talk a bit about the others. So um the a a scheme I'm going to talk briefly about. Um and this, what we do here, as I've just said is we see the um this, so this population were air, it is very unique. So this particular population were airlifted out of Kabul and it was a very, as you will all remember from the press and I'll do a case example later on. Um it was very sudden collapse and withdrawal from the UK and US and this population were airlifted out. They had really disrupted water systems in the in the airport for a long period of time. And so what we have seen is through our service, about 471 individuals in 24 families units with a median of seven people per family and some of the families were huge and some of them, you know, you'd have a room with 100s of people. We tried to do it in a clinic in a very trauma informed way and the median age of the adults was 34 and the median age of Children were nine years and they've all been in the UK for less than a year because it was a very sudden removal for the strong outreach team, which we've been talking about before. And this was the set up during COVID. We've been um seeing people in eight sites of, of initial accommodation and GP practices. So either going into the GP practices, whether registered or a room put aside in the hotel. And again, we've seen about 1.5 1000 individuals. 100 of those are families, but most of those are lone adults with some Children and it's across four boroughs. So Barnett Islington, Camden Harring. Um and what did we, what do we do? So this is our service. So step one, we try to get people to, they all have to have an NHS number to access the service. Ok. So this is not undocumented people because we just do not have the funding or recourse for that. And people like doctors of the world will be dealing with that population and it's not to say we don't want to, we just can't register them. Um So, but we will try to get people to register with a GP and we will help with that um And find those that are hardest to reach. So going into the hotels, um we then have uh an infection inclusion health practitioner, largely specialist nurses, but we have had um advanced practitioners and paramedics working with us as well and they will complete the health screening appointment and this is the physical mental health and safeguarding assessment that max onto that co 20 plus five. At that point, the um in infection inclusion health practitioner will then um sort out the local referrals and sign posting. So they will help them register with a dentist find an optician deal with an antenatal appointment if need it if need be and help to break down those difficult barriers. Um And then we'll do a targeted care planning with either one of us or with the local GP to say, you know, what do you need? What can we do? How can we plan this? How can we triage the problems that, that are there? Um And streamline that health intervention to say, you know, for primary care, these are the most important things you need to deal with. This person is a newly diagnosed diabetic. They don't have any medication. Can you please urgently deal with that? But we will try to triage these other things later on. Um And then those that have uh particularly complex needs will slot into our MDT and then we will develop a integrated health care plan which is both electronic and our UC H Ethics system. It is sort of ethic but not quite as epic as the nature um says and um also handheld cos most importantly, it's giving the individuals some agency. So when they're moved. It's not that back to square one, it's giving them the results of what's been done and the outline of what's done needs done. Um So what do we do in terms of blood? So that's all done in the hotels and then the nurses will take it back and process it at UC H. So everybody gets a full blood count specifically looking for eosinophilia. They'll get an IGRA as a screening for TB and latent TB bloodborne viruses. So HIV HEP B HEP C syphilis, Strongyloides serology. Um and we, we do schist dose serology as well and, and there's stool um which is a mixture of OC P novo diag other PCR depending on what the lab are doing. Novo diag apparently, which is a um multicomplex. PCR has just told us last week that they're stopping. So we're moving to some new funky A I stool processing. But anyway, watch this space. We'll let you know how that goes. Um And then a urine for go um gonorrhea and chlamydia. Um what we put down as schistosis, not for Arab because that population is unique in that they were airlifted out. And there isn't currently any schistosis in Afghanistan. We made the pragmatic decision for all other groups because they've often had a very long and torturous journey across multiple countries not to go into a detailed travel history because it is so traumatizing and people can't remember and often don't know where they've been um, we, because I was being built at this time, we were lucky enough to get in there and get, um, bespoke electronic um, questionnaires that were built for us, which has meant extracting the data has been easier. I wouldn't say easy, but easier than if it was all paper based. Um And then we built a live RBI dashboard, which is really great for the staff actually as well as for us because you can see where people have come from, what um you have found. And then most importantly, when they've been moved around the country where they have been reregistered. So it's a really good sort of morale booster for the nurses who are often at the front line, having to deal with this again and again, to go look, you've seen this number of people and it is worth it. And it's also great for sort of commissioning purposes to actually be able to show some data. Um We have the full questionnaire and we tried to get it um to translated into the top five languages and we use language line um to for the translation with each appointment, there are because there's so many different languages that are represented. It's impossible to do face to face translation basically. Um But we are looking at trying to bring in peer support workers and train up people um that can, that may be able to help us with this. Um So we've also done a whole load of onward planning and an evaluation cycle. So, what we've done is we've spoke to service users and said, what is it that you want? What are the barriers, what will help and often cost is a big thing. So we've applied for charity for oyster cards. And actually, we've just started the refugee week to get people within the trust of donate old oyster cards and they don't use. Most people have got them lying around the house and then put a bit of money on. That means that appointment can be transport to and from appointments can be paid for. We did a whole load of questionnaires and interviews to say what, what is it, what's good and the same with service providers. And one of the key things was he heard for the first time and having been given the time. So the appointments are long. Um What did we find? So we found about 50% of people had a mental health need with almost 20% having thought about self harm or suicide, which is huge and about 28% had physical or sexual abuse at some 0.8% felt unsafe at the time of appointment and 31% had experienced torture with 9% of the women having experienced FGM and these numbers are really large. So when you're then starting to ask, wanted to go for a smear test, you realize why people find that very traumatizing or can't do that. 90% of people had some form of unmet physical health need, which again is stuff and not all, most of those are not things you necessarily need to be dealt with in secondary care. But that's a huge burden for our primary care colleagues. Um And 44% of people have some form of treatable infection. Um uh And dental needs was very high. Visual concerns was high, but most of that can be dealt with with a high street optician. It's just knowing how to access and knowing who gets free. Um Optician parents sort of, I'm short sighted. I don't have any glasses as opposed to sort of complex visual concern, but the dental pain is a big problem. And what we managed to do for the pediatric population is there's a, a brilliant charity called the Dental Wellness Trust and they set up, they brought, they set up some uh Saturday pre dental clinics for the kids and that was brilliant, but we can't find people to do the same for adults. Um So infection prevalence because I'm an ID consultant. So I've got to put in a bit of this. Um So we've seen a lot of latent TB and what's interesting is, is higher than expected in the A population. Again, lots of Giardia in Children in the ar population and that's disrupted water system in Kabul Airport. So it's a, it was a very unique setting for that. Um and then lots of other things along the line, slightly lower, well, lot much lower rates of bloodborne viruses than one would expect to be led to believe. But across the board, around about 2% of people have HEP B at surfers Antigen positive. And that's really important because what we're not getting right is immunization. And so you will have adult in a family that is a carrier and what we're not doing in this country is then going and, and immunizing all the Children. So it's what can we do to prevent these problems becoming uh difficult later, some sexually transmitted infections and those are super easy to treat. But if you don't look for them, you're not treating them and then it becomes a problem later. Um and then quite a lot of the eosinophilia and I'm not gonna go into the granular detail of what the cause is or what with that. Um The other things that are big problems. So these are things of poverty. So when you keep people in crowded accommodation where they don't have much space missing, lots of scabies, lots of staph staph infections and quite a lot of PVL staff. Um and then a lot of COVID and flu and we had a big chicken pox outbreak from people and often uh these, this population will come from countries where there is much less chicken pox and you come to the UK and nobody's chicken pox immune and nobody really knows what's going on. So we are seeing a lot of that coming into our A&E that wouldn't normally come to an A&E um and then we start talking uh talking about what um at the sort of cost effectiveness of this because actually doing all these tests is really expensive. But actually if you reduce the transmission of one case of HIV or hepatitis B or stop an outbreak of TB in a hotel accommodation very soon it becomes AAA obviously cost effective um process. The, the harder it is to justify the latent TB actually, and nobody in the TB world can quite work out what to do there because it's quite cost um intensive to treat people for latent TB. And we know it's only a 10% lifetime risk of converting from latent TB to active TB. Um And so having that whole debate about whether people, you know, from a government population health perspective is really hard. Um immunizations I said before, big problem, I think they're not being, you know, we have a very much a reactive healthcare system and reactive public health care system and these aren't being done. And often again and again, the story that you will hear in healthcare is people don't want the vaccinations. Actually, they're not really being offered it in a proper way of anybody. Understanding. Certainly what we've seen is the minute you talk about it, everyone rolls up their arm and I'm like, I'm really sorry, in secondary care, we just can't do that because we don't have the end even though we can all provide it. And when you looked at, um there was a big thing in the, the area that so of, of COVID vaccinations in the hotels, about 70% of this population took up the COVID vaccinations in the hotels, which is huge compared to a lot of the rest of the population, which to me indicates that actually it's all failing in health rather than individuals not wanting to take up these in. Um So what are our, what's the impact it reduces, unplanned emergency health care encounters? So that is for sure. Um And we've got data to show that and hopefully it will be published quite soon. Um It definitely we've managed to reduce the DNA rate of people by with quite intensive um sort of background work from our nurses and admin team of making people understand what, where, how to get to probably say it's about 3 to 5 GP appointments per patient and then reduce is that long term social risk and the case escalation. So if you can get people, especially the families in with early health teams and early social social worker linkage, it stops it escalating to crisis point. And certainly from a perspective where I run a family clinic with my pediatric colleagues, and we'll see sort of some people between four and 10 people in one room is hugely more efficient, but also it allows you to identify those safeguarding needs that you wouldn't or developmental needs that you wouldn't otherwise identify because you can see the interactions between the family members. Um So before we kind of talk about it, I'm just gonna give an example of a family. Um and this is a sort of i rather than a family, this is actually an amalgamation of families, but very typical because it needs to be unidentified because often people are very unsafe. So this and I'm trying to do this in a sort of person place time because I think that is the best logical way of thinking about anybody that comes into a healthcare setting. So this, there was a family that came to see us. So the mother who's 25 and she came with her four Children aged 1310, 3 and five, they've been airlifted out of Afghanistan for operation pitting and they've been placed in hotel accommodation and this was around August. They were airlifted so far too many zeros were like projecting into the future. Um So August 2021 and we saw them a few months after they had arrived in the UK. So um what do we know? So from screening the mother, um she had latent tuberculosis. So she was a positive um and had mental health concerns and was not really able to focus fully on her Children. Um that wasn't around, wasn't able to talk about it at the time that she was waking up at night and having recurring dreams and flashbacks of everything that was going on. A 13 year old, her stool was positive for Hymen nana, which is a long fancy word for us to take one and was not in school because she was having to do the childcare because mum was unable to interact well with the little kids. So that automatically brings in a safeguarding concern for your 13 year old. The 10 year old had some form of developmental delay. So behavioral problems wetting the bed at night um has been epileptic the whole whole life but only had three days of medication remaining. And this was taking up a lot of causing a lot of disruption for the family. And then three year old and five year old had had abdominal pain and bloating and also were positive for S Nana and Giardia. Um and I'm not gonna go into the whole massive treatment. But what I am able to say is that in this appointment, what we're then able to do is to engage with mental health services and talk to mum about that to engage with the community to say like, you know, right, let's assign you a social worker. What additional support do you need? How can we get your daughter into school to get the health visitor to engage in social care and make an urgent safeguarding referral for the family. Um we, my pediatric infection, he probably was able to do a, a beginning of a developmental assessment and refer to the, the community ped services and we could super easily treat these infections. Right. I mean, it's like latent TB. You can say that can wait a bit until your mental health is more stable and the others, it's a one off treatment with a, with a pill and then go, come back, Don't give us another stool in a couple of months and we will retreat if it's, if it's an issue and that automatically will take away some of the problems for the three and five year old. Definitely, if you're treating everybody in one go and giving public health information about hand washing and bed, bed clothes washing, you're not going to have that cycle of so reinfection within a family where if you treat one person and then it takes about a year to get a stool back, you get this cycle. Um And uh then it sort of everybody feels heard and, and mum is feeling like we're taking the whole thing seriously. So it's just to sort of say you can imagine this is that although it takes a long time, you can see how much overall health care intervention it reduces. So for our whole service, what have our barriers and challenges been? So, funding is a nightmare. Ok. So I'm not going to sort of pretend it isn't and it's taken a, actually a huge amount. It's cross disciplinary, it's cross ICB. And when you talk to anybody, it's trying to find these different pots for different, you know, from different sort of bits is in, is impossible. And however much everybody knows that wanting to do cross ICB work and cross disciplinary work is what's needed for the patients. Still, there's that whole square peg round hole because you can't get everybody to talk to each other. Our service is pretty proactive and the NHS is set up in a very reactive way and that's been really difficult for us, but it takes years to get people to sort of, you know, think outside the box, it also has to be really flexible because you get hotels that will open and close at very short notice and the government are not particularly transparent about what's gonna happen. So we've got to have staff that are willing to, to sort of set up in all these different areas and work with hotel managers and try and find a room and get in and each time it's a hugely labor intensive cost staff wellbeing. And we've learned a lot about this is really difficult because if you're going out into the community, they don't feel as much part the team and having a and it takes almost as much time if not more to do the onward referrals, the t chasing of results, the holding those cases and hearing about all that mental health turmoil and torture as it does to do the clinic. And so it's making sure people are job planned with a, a day of each and a day of sort of reflective practice something where they feel like a team and everybody's coming back in and that again feels very expensive. Um And then accessibility. So if you're saying we wanna h hold this service in a, in a center, then um it's trying to get the individuals to come to that center when actually they feel too frightened to leave their hotel. Um trying to get funding for research is difficult because there are no defined outcomes for this population, the population is unstable and it's multidisciplinary. And also what's really needed is to look at those long term outcomes. Because if you're wanting to do what's a quite a cost, heavy intervention early on what you want to know is what happens in 5, 10 years time to these Children that you've held and tried to care for at the beginning and we don't know whether they'll even be in the UK. Um What have we done? So this is my last two slides when you've got questions. Um So I guess how have we sort of spread this? What have we tried to do? So we've developed an e learning package that will be live soon on the NHS website. Um We're trying to set up some bespoke training courses and we did run a migrant health series that was free and open access to anybody. And we should probably look at redoing that at some point in time. From a service delivery perspective. This was, we've got the National Advice and Guidance MDT. We actually paused the outreach service for a while trying to sort out funding and we just started up again. So we're now seeing people in UC H but we're just about to start going back out into the community soon. Um And uh from an uh a policy perspective, we fed into the Migrant Health Guide, the Royal College of Pediatrics guide and um various other bits and pieces and I'm not going sort of drone on about how many peer reviewed articles we've published and sort of massage my ego. Um So in summary, um it's in a really complex cohort with multiple physical mental health and social care needs. I think being trauma informed is super key and being holistic and having a person centered approach is really important to just understand those determinants of health. And it's really important to be reflexive and flexible and to try where possible to have a peer led approach. So listen to those service users and find out what they mean. And that is the end, this is just a part of our team that we have a much larger team. We're not very diverse is my first is very female heavy. Um This and this is not out of choice it, it just sort of there. Yeah. Anyway, um, so questions bye. Thank you, Doctor Long. Um And what a brilliant service you're running at UCL. Um We've got lots of questions and for that came in before the conference. As always, if you want to post any questions online, please do and we'll be taking questions from the room. Um I'll keep off with all the questions that came in before. Um And that question was specifically how can people who are interested in a career in healthcare for space? People get involved. Yeah, that's really, I guess it depends slightly what you're wanting to do. What we can't do is have lots of people observing because it's really, really difficult. I think. Um, I think we have, we run a AAA sort of a, a question and answer session monthly where people want, who sort of want to, uh, you want to help with the service in some way can dial in and speak. And it's about sort of opportunities and funding in various bits and pieces, I guess places like dots in the world and MS who really do have that sort of grounding. It's thinking about whether you're wanting to do it from a research perspective or a clinical perspective. And then it's sort of looking at what training you can do and how so I'm being very like, opaque about this because it's really hard because everybody emotionally wants to do something to help but what's not great for the population is to have 100s of different people each week stepping in. I guess one of the things we're trying to do is from a primary care perspective, we've linked in with the North CHS GP trainee scheme and from October, we're going to have one trainee come and do a couple of sessions a week, we can look at things like spin fellows later on when we've upscaled again. Um from a kind of more clinician hospital secondary care phase is trying to work out something in your job plan on looking up for, looking out for sort of opportunities in terms of research funding to work with us. Um And then coming to AQ and A and just ask and knowing what the specific skills are, I guess. Thank you. Um I've got a question online. Um It's, could you share a bit how, how you made need an idea to women in the? NH. Yeah. Um I think it is all around. I think it depends what you need is some time and you need buy in from wherever your trust is and you need to think and plan it out and say, what is it you're actually hoping to achieve? Um And it's really difficult because we're completely the NHS is in a very tricky financial place. I think one of the things that massively helped us during COVID is there were all these sort of little small pots of money. So if you need to come up with an idea and then look at what's out there, but you need buy in from your trust and your managers. And basically, I've spent about sort of four years applying for small grants, which you have to, like, have a very short deadline and then give you 50,000 lbs to use up before the end of the next financial year. So if you look around sort of, you know, with all those things that kind of go leveling out health care inequalities and the er f funding and all of this stuff, they all have money that's left in sort of February March and they ask you to do a quick turnaround and then put something, you know, so you need buying and you need your managers on side is the answer to that. But you've got to kind of think what do I wanna do and you can't do it all. And I think to start with, we were very idealistic about how much we wanted to achieve, but actually, it's sort of is that cost planning, it's really, it's really hard and I think we were, it was serendipitous the sort of increase amount of time we had during COVID. Basically, thank you. We have two more questions in the room with you first. I forgot to say earlier if you introduce yourself and tell us where in the UK. And um, but um obviously the population faces a lot of, and do you have in your organization and also to health service that in great question. And thank you very much. So, we have what we, we help with the letters of support. Um and we um will make recommendations about where people can find lawyers. Um It's really hard and no, we don't, you know, each to see that number of people and to help each individual is really impossible. And what we've had to do is to get our staff to slightly let go because they were becoming very traumatized by trying to really hold each case. And it's not, it isn't feasible. We, we do work with a lot of partner organizations, but again, everybody is very, very stretched. So, you know, freedom from torture and the Helen Bamba who are great and very on board, there's about a two year waiting list. So there's not a perfect answer for this at all. We'll try to do what we can. But within reason. And I guess a lot of the work that we have to do is sort of around advocacy and getting the voices heard. And there is a great um sort of advocacy leader, MSF who helps with some of this and it's really going, how can we help to disseminate some of this? But we just, you know, we, it's just impossible, basically. Um Good. Did I answer your full question? Integration? Oh, yes. So the other thing that we've got people doing at the moment, the integration into community is trying to work and look at social prescribing um and do some of that work with primary care. And what I've got an N NIH R in practice fellow who's looking at that sort of integration into care. But it's a, it, again, it's really hard getting good funding to do that. And unless you have sort of have it done as a study, you're doing something that you've got sort of money for, for six months and then you've got not much to show for it at the end. So it is, it is difficult. Um, but yeah, we're trying, um, this, uh, Dermatologist College. Um, I really enjoyed that there was a lot of, um, important messages here. And one of the things that's become increasingly concerning is that volunteers working with refugees also have a significant amount of mental health trauma as well. That's not what we were doing to that and also to manage it starts to happen. Yeah. Yeah, that's a really good question. It's something we found a lot. So, um, as I said before, one of the things that we've done is to make sure people have time as a team. So there's a day a week as a team where they're all in the office and then we set up with our hospital Psychological Support unit. I can't remember the name of the Reflective Practice. Um, that will happen as a group and offer them out psychological will support one on one if they would like to have that. Um, and it's really just trying to make sure that they have some time when they're not doing the direct clinical care as well. We've looked at whether people can have jobs that are doing a little bit of this and a little bit of something less intensive. Um, it's really hard and we've sort of spoken about partnering with MSF. But it, again, they're really stretched for funding at the moment as well. Um, but, yeah, that's ok.