132 Integrating refugees into national health systems: clinician advocacy as boundary work in mental health services in England

Abstract PTH 3: Mental Health and Refugees 1, B307 (FCSH), September 3, 2025, 17:00 - 17:54 Aims: The global policy turn to integrating refugees into national health systems aims to enhance equity, efficiency and sustainability of care. However, it also risks refugees being adversely incorporated into health systems beset by inadequate funding, unequal access and discrimination. This study of integration of fragmented refugee mental health services into the English NHS asks how and why progressive or regressive refugee integration occurs. Methods: Fieldwork took place during 2015-2016 and 2019-2021. It included six months of participant observation and interviews with 21 clinicians across 16 different NHS and NGO service providers specialised in prevention and treatment of PTSD and psychosis respectively, as well as four mental health commissioners and national policymakers. Transcripts and fieldnotes were inductively analysed. Data from fieldnotes, interviews, and policy document analysis were triangulated. Results: Integration was hindered by a bifurcation in clinician advocacy, which inadvertently reproduced a simplified dichotomy of patient groups, services and pathologies. Refugees with PTSD were constructed as passive, secure and unracialised, in opposition to “ethnic minorities” with psychosis constructed as active, risky and racialised. This bifurcation promoted the inclusion of some marginalized groups, but excluded others, such as refugees with psychosis, or people experiencing complex racial trauma. Theories of boundary work across three axes (epistemic, community and organisational) help explain the persistence of this bifurcation. Epistemic boundaries relating to clinical diagnoses were questioned by clinicians and were relatively amenable to integration. Community boundaries were less porous; clinicians’ intrinsic motivation often derived from their identities, or personal values. However, the main driver of bifurcation was the need for health services to be legible to funders, who favoured the reproduction of organisational boundaries. Conclusions: Intersectional approaches to clinician advocacy and health system financing are needed to support refugee integration into national health systems which struggle to serve domestic marginalised population groups.