Ukraine refugee health screening service in Wales Ukraine/Powys case study 2022 by Powys Teaching Health Board and technology-enabled care Cymru

Abstract

The development of the new health screening service for Ukraine Refugees put in place by Powys Teaching Health Board in 2022 has seen extensive use from Ukrainian families in need of extra support from the National Health Service (NHS) and signposting to specific NHS departments. To discuss the experiences of the staff from Powys regarding their role in setting up the screening service and working within it, Research Assistants from Technology Enabled Care, Wales conducted interviews with two staff members. These clinical leads suggested improvements for the screening service, as captured through analysing the data collected via the interviews. This included recognition of benefits, challenges and future recommendations.

Introduction

Currently, millions of Ukrainian refugees are facing traumatic and uncertain times. ¹ Many find themselves struggling financially, due to the hardship in finding jobs, as well as facing problems with schooling and child care. ¹ Among these challenges, the majority face worries from uncertainties of how long the displacement from their loved ones will persist. ² Due to this many suffer from emotional and psychological implications, as well as an inability to integrate with host families due to changing living environments. ¹

Problems from a global perspective, especially in the UK show with the current cost of living crisis is creating pressures on the ability to host safe accommodation and provide a place for support through the ‘Ukraine Family Scheme’. ³ The current housing problems are reported to worsen in the coming months, where estimates from February 2023 suggest four million refugees will need neighbouring countries’ protection over the next few months. ⁴ Globally, the perspective to support Ukrainian refugees has been to bring together relevant partners from the United Nations and Non-Governmental Organisations, to present human rights values and protect those fleeing with a safe territory to remain in. ⁵ Furthermore, struggles are also evident whereby Ukrainian refugees face limited access to the availability of healthcare; such as prescriptions and appointments, even once settled with their hosting families. ⁶

A new innovative health screening process for Ukraine refugees that are placed in the Powys area of Wales was developed in 2022 by the Powys Teaching Health Board (PTHB). ⁷ The service was designed to:

Implement high-volume health screening in response to the 460 Ukrainian refugees who have been accepted to stay with host families in Powys.

The aim of this evaluative service offered and conducted by TEC Cymru researchers was to help support the continued care of Ukrainian refugees within PTHB, while also capturing and reporting the experience of the medical team at PTHB in assisting the Ukrainian refugees while using the screening service. This was done by independently gathering local data and presenting the findings from the new innovative health screening process, to share their experience as a pocket of ‘good practice’ on a national level.

Data was captured for this case study which is written in the style of a short report, from an informal semi-interview with two clinical leads from the Powys Health Screening team. Altogether, this team is made up of nine members of staff (see Appendix 1 the for topic guide used). They discussed with members of the research team from Tec Cymru at length their experiences of the screening service to date, highlighting what they perceived as strengths and weaknesses of working with the new health screening service in Powys, Wales. The interview took place online via Microsoft Teams, in the style of a focus group, in this, both interviewees gave verbal consent before the interview started. This took 40 minutes to complete.

Following the initial stages of screening, Ukrainian citizens are followed up by primary care for their next steps if they require it, including general practitioners (GPs), nurses, healthcare assistance and occupational therapies. It became clear from interviewing the two clinical leads that this is all dependent on the individual's personal needs. Since starting the health screening service in May 2022, PTHB has provided over 200 health screenings, which have helped to signpost care to over 460 Ukrainian refugees who have come to Wales. ⁸

This service was started with the intention to help screen for any serious conditions and to explain the functions of the Welsh healthcare system (National Health Service (NHS) Wales). The screening staff were able to identify any high-risk physical or mental health symptoms, for example, clinical diseases such as tuberculosis. In addition to screening for health issues, they also used the service to introduce and inform Ukrainian patients to the UK healthcare system (NHS Wales service in this case). For example, the 111 service to prevent avoidable Accident and Emergency (A&E) admissions. Alongside this, information and support were provided to the Ukrainian patients surrounding matters of health and social care services, if relevant.

Methodology of the screening service

The process for the screening service first began with the Ukrainian arrivals being inputted into the screening app on the PTHB intranet. From here, staff on the screening team could access the Ukrainian app and identify who needed to be contacted. Initial contact was made via email, which was sent out to the citizens or host families by the team. These emails included an introduction to the team and enquired about convenient times to meet for the screening. Replies would be received giving suitable dates and times. These also included whether translators would be required.

Upon agreeing to dates and times, translators were arranged if needed and confirmation of the appointments was agreed with both translator and citizen. It was informed to the individual that this was via the Attend Anywhere (AA) platform ⁹ and instructions to the app were accessible via email. At the appointment time, staff would enter the meeting on AA and allow entry of the citizen into the call. To support Ukrainian arrival, prompt host families were also present in some of the screening support calls. The screening would then take place, completing the forms online via the screening app. Once the screening was complete, this was the end of the screening services contact with the citizens, where staff would then send the completed forms through to the current GP surgery via the app.

It was noted in the interview by the Powys team that signposting was provided to the patients via the service, following the screening. Signposting informed patients on ‘where’ and ‘how’ to register, and access GPs and other local surgeries, health centres, and A&E departments in nearby hospitals.

Evaluation of the case

The screening service used the NHS Wales AA platform. This AA platform is one virtual consultation platform created by TEC Cymru ¹⁰ in collaboration with NHS Wales video consultation service, for safer healthcare access when face-to-face interactions were limited. This short report focuses on the staff perspective of using the platform with Ukrainian patients, to explore the benefits and challenges that have come to light, while also providing some service evaluation data. At Tec Cymru, we provide the use of this national platform for access to digital healthcare across Wales.

Benefits

The Powys team informed the Researchers of the benefits experienced since working with the Ukrainian patients, via virtual consultation through AA during the interviews.

Some of the themes that came out of the discussion included the following.

Medication viewing

Ukrainian families were able to visually show their medications and prescriptions on screen over the video consultation platform. This meant that healthcare professionals could easily identify the drug names and the brands. For example, where the Ukrainian families in many cases were using herbal medicines, this helped the service to identify them and then signpost to where they could obtain these medications.

One of the things that we mentioned was good when they're taking medications, that they can show us on the screen what the medication is so that we can read what it is, because there are lots of medications that are the same as what they'd get over here, but they're called different things under different brands.

Chat features and interpreters

While there were obvious instances of language barriers between Ukraine families and UK healthcare professionals, it was revealed, however, that a significant benefit of the screening platform (via the Welsh AA Video Consulting platform) was the chat feature, which enabled lines of communication while using the chat functionality, with support of interpreters.

It was stated in the interview, that:

The chat function worked, so we could see each other on the screen, albeit not moving, but the chat function was still working. So, we did the whole thing by chat.

The chat function was also successfully used for sending links to Ukraine families to signpost them to a wide range of different organisations in the UK, and for other purposes, such as to use if the signal of the call was too poor for audio.

In terms of having interpreters, it was noted in the interviews that it is easier and quicker to obtain an interpreter virtually than if requested face-to-face.

If we need a translator, it's much better to book a translator for a block period.

Concluding that it is much more convenient for everybody involved in the process.

Forming relationships

Furthermore, the healthcare professionals pointed out that the platform allowed them to create positive relationships with the families.

I think the relationships that we establish with them are lovely. We often speak to them quite a lot before we screen them.

Additionally, these interactions gave the healthcare professionals reassurance, as they could virtually see the family members compared to other digital methods, such as via the telephone.

It's just nice to see the families and the children, and to know that they're okay and that they're smiling. It's nice to be able to wave at them and smile and carry on that relationship.

During the interviews, the screening service staff spoke fondly of these virtual relationships as a result of the platform, providing them with personal interactions which limited their worry about safeguarding issues.

Typically, having the sessions via video, benefitted the healthcare professionals and the families as it saved time. This was convenient for all and meant that more patients could be seen compared to if they were face-to-face.

For example, it was stated that:

Plus, it's convenient for us timewise. There are days when we've had to do numerous screenings for particularly people in emergency accommodation, we wouldn't be able to fit in that many. Obviously, it's important for us to screen them as soon as possible, so we can get quite a few done in a day because we're in one place.

Further, this also meant that there was less stress on the families to attend a clinic.

I think it's less stress on the individuals. They don’t have to worry about running to different hospitals.

Thus, giving them better access to medical professionals.

Challenges

Despite many benefits outline above, there were challenges reported. Some of the themes that came out of the discussion included the following.

Language gap

It was relayed back to us that language was an obvious challenge where many of the Ukrainian families speak little or no English, which posed problems while using the screening service, as translators were required.

We use a service, the Welsh Interpretation Service (WIT), and we find there's often a delay with that, because of the lack of availability, really.

However, the Powys screening service developed innovative ways to overcome language barriers such as virtually linking in the translator service, which meant that their calls could run smoothly once set up.

Once we've got the translator it's pretty easy using it via Attend Anywhere, because everybody's in the same place at the same time.

In addition, and as mentioned above in the benefits section, it was quickly discovered that the chat function was also a way to overcome language barriers.

Technology and coverage

As always when working with technology, it can sometimes be a challenging experience, with one stating that:

I had one, the reception was so bad that there was no video, it was just a frozen image of each other on each other's screens.

In some other cases, the result of poor mobile phone coverage resulted in telephone-only appointments which are often unreliable and not considered as beneficial.

Visas

During the interviews, it was reported that at times, concerns were raised by the Ukraine families, regarding their visas and their rights to use the screening service. For many, this resulted in some resistance from families during their sessions in what information they revealed.

They were worried about their visas, and what would impact on their visas. So, I think you get a lot of resistance initially.

The individuals from the health screening team revealed that this often had an impact on how the families in need acted around them, causing challenges to get them to open up and provide relevant and important information. In overcoming this, the screening team explained that the patients needed a lot of reassurance and appropriate signposting, often leading to additional time needed.

It took a little bit of extra time, sat down, talked to her, gave her the reassurance, and then I could signpost her appropriately to the correct services.

Incorrect information

Finally, additional challenges were identified, which were not specific to the screening service being delivered via videoconferencing (VC) per sue, but rather as a knock-on effect of how the families were provided with unhelpful healthcare information by other professionals, and at times, their hosts.

One interview disclosed an example, by stating:

She’d (their host) told them that 111 was the emergency number, and so trying to change that, when the person that they’re living with had told them one thing, was a bit difficult.

These inaccuracies often posed a challenge for the screening team, which caused frustration, and impacted building relationships and trust.

They got it in the end, but it was a bit frustrating that they’d been told something not right.

Proposed solution/future changes

In conclusion of the interviews, and based on their own experiences, the screening staff recommended a few possible amendments that they would like implemented into the service for the future. They highlighted their desire for pre-designed information packs, which could be easily provided to refugee families on arrival to the UK, which would explain how to use the health screening platform itself, but also how to access UK healthcare and other services, with one stating, ‘Yes, we’d like the pack’.

This model could easily be replicated and translated to suit needs and languages.

The screening staff discussed how a lot of unnecessary time went into explaining the process to families, and at times, caused worry for the families if they were unsure how to use it, or hadn't heard about it before.

I had back and forth emails, and the lady was like, ‘Where have we got to go to have the screen?’ I explained to her it was online, and when she came online and did screen, she was like, ‘I was so worried I wasn’t going to be able to find where we were going to go, if I had to go somewhere’.

Having information packs for the patients will help to aid them navigate their way around the platform.

The suggestion of these welcome packs from the Powys Health Board will be informative and helpful for the families, where they have previously been implemented via the Government for Ukrainian refugees. These information documents and packs provided information concerning banking, schooling information and how to contact host families. They have also included minor details concerning healthcare services, but not specifically Welsh health boards.

Personal experience (anecdotes)

In the personal experience of the staff, it was clear that they often felt they were overloading the patients with information, and in many cases that although the patients said they understood no notes were taken to remind them of the information.

I don’t see a lot of families that I’ve screened taking notes when I’m screening them. They say that they understand that they know what to do, and that they’re happy with the information, and all that sort of thing, but then they’ve got nothing then in writing to go back to afterwards. Obviously, it's a lot to take in.

The healthcare professionals reiterated that by having these welcome information packs with all the correct information it would be a useful tool for the families.

It would be really useful that if what we're saying to them is reiterated in those welcome packs in writing.

Access links are an alternative solution to ensuring that each patient gets the information they need available to them. The staff mentioned these in the interview and used them to describe how the patients could access the services they require to help decide which one is best suited to their needs.

I’d like links to all be available… Because we do send initial links out, but there are a lot more links that could go in, especially local links of what services are available.

Combining welcome packs and information links should provide the patients with enough information and resources to be able to access and navigate to where they need to be. It will also outline to them how to use the AA platform if they are a first-time user of the virtual screening services and other UK healthcare services.

Conclusion

The data captured in this case study presents the benefits, challenges and possible solutions of using a virtual platform (in this case, the Welsh AA platform) for the health screening of Ukrainian families. The pre-provision of refugee welcome information packs has been recommended by the screening staff and researchers to be made available on arrival to the UK. These will outline the functions of the UK healthcare service (in this case, NHS Wales), and services such as the Powys health screening service discussed in this case study.

As this research was only conducted with two clinical leads from the team, the opinions may not be generalisable across the whole staffing service. We note that this sample is small and therefore future research on the health screening service will extend its methodology and sample. With this in mind, this short report was written with the purpose of informing and extending research at a larger scale in the future. Furthermore, it was felt that this kind of provision would provide refugee families with reassurance and ultimately, reduce stress and worry about accessing services in a foreign country.