Integrating Personalised Care for Refugees and Asylum Seekers: A Trauma-Informed Model Across Surrey & Sussex

Background: Refugees and asylum seekers in temporary accommodation across Surrey and Sussex face multiple barriers to healthcare, including trauma, digital exclusion, language barriers and social isolation. These challenges often result in unmanaged long-term conditions, avoidable emergency attendance and declining mental health. In response, Alliance for Better Care (ABC) established the Refugee and Asylum Seeker Personalised Care Team (RASS PCT) to improve access to trauma-informed, person-centred healthcare for people in Home Office accommodation. The model was Highly Commended at the 2025 HSJ Awards for its innovation and impact in improving equity and access to care.

 

 Approach: The RASS PCT delivers integrated personalised care through a multidisciplinary team of care coordinators and social prescribers, one of whom brings lived experience as a refugee. Personalised care combines practical care coordination with social, emotional and wellbeing support, empowering people to take an active role in their health and connect with community resources. Working collaboratively with GP practices, health commissioners, councils and the voluntary sector, the team bridges health and community services. They support people to register with GPs, navigate healthcare pathways, manage long-term conditions and access mental-health and wellbeing support.

 

The team co-produces community initiatives such as community kitchens, art classes and gardening clubs, which promote integration and peer support while helping to reduce isolation and community tensions. Personal Health Budgets enable people to make choices that improve wellbeing. For example, training courses to support employment, swimming sessions for a child with autism or gym memberships to support physical and mental health. The team draws on trauma-informed training with specialist organisations and reflective practice to ensure safe, compassionate support and workforce resilience.

 

 Results: Since launching in July 2023, the service has received over 650 referrals from primary care, NHS partners and voluntary organisations. Using an NHS-accredited wellbeing tool, 94% of participants reported improved wellbeing after personalised support. One GP practice recorded a 50% reduction in repeat-prescription appointments after the team delivered digital-literacy sessions on the NHS App, freeing up clinical time. These outcomes demonstrate both individual wellbeing gains and more efficient use of primary care resources. Qualitative feedback shows increased confidence and trust in healthcare. As one participant shared, “I am so thankful for this lifeline. It has brought us moments of joy in such a difficult time.” The service has strengthened local partnerships and improved system collaboration, contributing to reduced avoidable urgent-care use and greater understanding of trauma-informed and co-produced approaches within primary care.

 

Implications: This low-cost, high-impact model shows how a personalised, trauma-informed approach within primary care can improve access and outcomes for displaced populations. It offers a replicable blueprint for health systems seeking to reach communities excluded from traditional healthcare pathways. Key success factors include co-production, lived-experience leadership, cross-sector collaboration and community integration. The model now informs wider neighbourhood and Integrated Care Team (ICT) development within ABC, supporting inclusive, person-centred approaches across Surrey and Sussex. These insights can support integrated care systems internationally to design inclusion-focused models that meet the needs of refugees and asylum seekers through compassion, empowerment and partnership.