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Matching health needs of refugee children with services: how big is the gap?– A response


Correspondence to:
Dr John Scopel, The Clinic Footscray, 91 Paisley St, Footscray, Victoria 3011. Fax: (03) 9689 6008; e-mail johnscopel@hotmail.com

I have the following comments to make about an important area of need in relation to care for new arrivals.

I have worked in general practice for 15 years, mostly concurrently in both private practice and community health centres. Over the years there has developed a large cohort of new arrivals who attend me regularly. They are a group that do well given the right supports. The involvement with people soon after their arrival in this country I find is one of the most fruitful times. After a few years, this initial involvement has profound rewards in terms of trust and continuity.

Support for new arrivals in my area is provided by a settlement support agency under contract from the Department of Immigration and Citizenship (DIAC). Currently, DIAC is reviewing contracts. I have worked with several agencies over the years and witnessed the impact of government policy. The focus of this letter relates to that support.

After attempting to coordinate with the local support agency, I ceased accepting new referrals early in 2008, as the support provided had regularly been extremely poor. This is despite many unsuccessful attempts at working with the layers of the support agency to rectify repetitive problems.

The following are examples of the problems I have encountered. The regular, fundamental problems that involved dozens of workers from the support agency included:

  • people were regularly booked but not brought to appointments;
  • support workers had inadequate English skills, they also changed regularly (as did managers), and they often did not know how to access basic services (e.g. pharmacy) nor an understanding of routine matters;
  • support workers did not know basic details about new arrivals;
  • I was often not alerted to hospitalisations nor family reunifications;
  • fragmentation of medical care (an increasing problem, where different members of a family group are taken to different practices) triples my workload, as I have to piece together past care;
  • likewise, inadequate care may have already occurred elsewhere, and there is subsequent mistrust as to the need for a thorough assessment (there can also be duplication of services and pathology, often at much expense); and
  • the support workers themselves have often never had complete health assessments.

Ten years ago support was provided by a local agency called VFSTT (Victorian Foundation for the Survivors of Torture and Trauma). The one support worker generally had a mastery of English, had commonsense, was aware of boundaries and used their autonomy sensitively. VFSTT no longer has this role, and support has become fragmented and of a poorer quality. I now find that support roles I would never have performed in the past now occupy ∼30% of my time. In my experience, the likelihood of there being a private bulk billing general practice that will do this extra work, on top of using appropriate communication methods, as well as addressing all the relevant complex issues is extremely low. A very similar experience will occur in community health centres in Victoria, although the obligation in these centres is to persist no matter how difficult the predicament (until staff leave).

At times, I hear an argument that the health needs of new arrivals would be better provided by a centralised specialist service and, once screened, these people would then be placed with a family general practice. I think this misses opportunities for rapport and trust to be established during the critical initial assessment phase, and also the opportunity for new arrivals to become empowered using mainstream services. One of the main groups of doctors advocating for refugee care are doctors working solely in community health centres. I frequently hear a similar argument that only these centres can provide adequate new arrival healthcare. My experience is that there will always be a role for these organisations to support the most complex of new arrivals, however, I think these centres have adapted to the worsening poor support provided over the years for new arrivals. Many new arrivals could have accessed mainstream private general practice if appropriate supports had been in place. Instead, community health centre doctors (who often attempt to provide good care in difficult circumstances) burn out and turn over in the process of trying to provide care with poor support, or the community health centre closes its books to new appointments. Also, there is a small proportion of private general practices that end up seeing these people in a frequently unprofessional manner, where incomplete (if at all) health assessments occur and inappropriate Medicare billing occurs. I have seen this situation occur frequently. I have reached the unfortunate conclusion that it is the option of least resistance used by the settlement agency to avoid providing more-appropriate support and establishing relationships, and providing support to competent practices. Case worker support is so integral, and most GPs in private practice will not become involved unless there is better support.

I have the clear impression that my local support agency is struggling and presumably poorly funded due to the high turnover of staff, lack of communication, regular poor experiences with case managers and recurrent problems.

I now only accept referrals for new patients from a cohort of capable volunteers. Their work is invaluable and often unrecognised. I also work closely with the Victorian Government-funded refugee health nurses. Both these groups are compensating for the inadequate main support service. As a result of trust in my work and familiarity with my processes, my current patients also refer me new patients as a result of reunifications, sponsorships and friendships.

I fear that the situation will worsen as the number of sponsored arrivals increase and support agencies attempt to transfer responsibility onto sponsors who are often unavailable or incapable.

I am sure many new arrivals are missing out on any initial health screening altogether, with dramatic outcomes.

My hope is that capable support workers be part of any future strategy, working closely and in coordination with general practice.