Inclusive Practice

inclusion health Inclusive Practice Vulnerable Migrants, Gypsies and Travellers, People Who Are Homeless, and Sex Workers: A Review and Synthesis of Interventions/Service Models that Improve Access to Primary Care & Reduce Risk of Avoidable Admission to Hospital Peter J Aspinall Reader in Population Health, University of Kent 2014 1 Contents Acknowledgements 5 Foreword 6 Executive Summary and Recommendations 7 1. Introduction 18 2. Methods 19 3. Findings 24 3.1 Vulnerable Migrants 24 Definition 24 Policies on asylum seekers/refugees 24 Access to primary care 26 Promising practice in primary care 30 Primary care service models 30 Gateway services 31 Core services 31 Ancillary services 31 Examples of good practice in primary care settings 32 Gateway services 32 Service models that seek to ensure comprehensive GP registration & initial health screening 33 Separate stand-alone services, whether specialist practices for asylum seekers/refugees or a generic vulnerable population 35 Locally enhanced services 37 Other components of good practice 38 Interpreting services 38 Patient-held records 39 Interventions which have been shown to reduce the risk of admission/readmission to hospital 41 Summary: elements of good practice across all service models 43 Implications for further research/evaluation 45 2 3.2 Gypsies and Irish Travellers 47 Definition 47 Policies on Gypsies/Travellers 47 Access to primary care 51 Interventions: Introduction 54 Interventions to improve generic health awareness & to improve access to primary care 55 Health Champions Pilot, Sheffield 55 Health Ambassadors Programme 56 Community Health Advocates 56 Cultural Awareness Raising Projects 57 Increasing GP Registration Projects 58 Health Trainer Projects 59 Mobile health and dental clinic projects 62 Improving the oral health of Gypsies and Travellers in Sussex 65 GP enhanced services for Gypsies/Travellers: The Market Harborough Practice 67 Specially commissioned GP services for Adult Gypsies/Travellers in unauthorised encampments 68 Components of interventions cited as good practice 68 Hand-held patient records 68 Scrutiny reviews: South Somerset and Southwark Councils 72 Access to and use of Secondary Care Services 73 Summary: Elements of good practice in service models 74 Implications for further research/evaluation 75 3.3 People who are homeless 78 Definition 78 Policies on people who are homeless 78 Access to primary care 81 Specialist primary care services 83 Examples of models 84 Mainstream services that provide some services for the homeless with/without outreach services 84 Dedicated GP services that provide full primary care specialist homelessness team 85 Fully co-ordinated primary and secondary care 87 Other models or elements in the provision of care 89 Mobile health and dental clinics 89 Hospital admission and discharge protocols and interventions 91 Intermediate care 93 Community sanctuaries and model ‘respite care’ approaches for the homeless with complex medical and psycho-social needs 96 Summary: elements of good practice in service models 98 3 Implications for further research/evaluation 99 3.4 Sex workers 101 Definition 101 Policies on sex workers 101 Accessing primary care 103 Service/organisational interventions: introduction 106 Interventions to increase GP registration 107 Dedicated specialist clinics and practices 107 Specialist outreach & sexual health services for sex workers 109 Drug and alcohol interventions 114 Holistic interventions including exit from sex work 114 Local Authority-wide multi-agency partnerships 116 Components of good practice 118 Summary: elements of good practice in service models 122 Implications for further research/evaluation 125 Appendix 1: A note on terminology and definitions 128 Appendix 2: Membership of the Data and Research Group 132 4 Acknowledgements Dr Bobbie Jacobson, chair, and members of the National Inclusion Health Board’s Data and Research Working Group (Appendix 2) provided valuable feedback on earlier drafts of this report at two meetings of the Group. I am grateful to Adrian Hegenbarth, Nigel Hewett, Mark RD Johnson, and Matthew Brindley for their informative peer review comments on the report and to Alison Powell for supplying documentation for NIHB sponsored scrutiny reviews. I am also grateful to a number of people involved in representing, providing advocacy to, and developing services for Gypsies andTravellers for the opportunity to meet and discuss interventions relating to Gypsies and Irish Travellers: Matthew Brindley, Policy Manager, Irish Traveller Movement in Britain (ITMB); Zoe Matthews, Strategic Health Improvement Manager, Friends Families and Travellers, Brighton; and Rose Palmer, Development Manager for Gypsies and Travellers, Housing Commissioning, Royal Borough of Kensington and Chelsea. Useful information was also provided by Helen Jones, Chief Executive Officer, Leeds Gypsy and Traveller Exchange, and Charlotte Smythe, Health Trainer Co-ordinator, Swale/Thanet. I also thank Dr Judith Eling, GP with the Refugee Service, Health Inclusion Team, for providing a set of very useful documents on the New Entrant Health Check scheme. 5 Foreword “It is more important to focus on the systems which trigger and cause vulnerability and aim to correct those rather than the people who were adversely affected. Vulnerability isn’t a characteristic of disadvantaged people but of the “social spaces” they have to occupy in unequal societies.” Source: Understanding vulnerability. Workshop of the Data and Research Working Group, Inclusion Health Programme, May 2012 Our report “Inclusive Practice” is founded on this definition of vulnerability. Instead of seeking to focus on the characteristics of individuals, we have attempted to provide a foundation for understanding the changes that might need to be brought about in the health and related systems to meet the needs of individuals living in an unequal society. Inclusive practice was commissioned and overseen by the Data and Research Working Group of the Inclusion Health Programme and approved for publication by the National Inclusion Health Board. It is one of a series of reports from the Inclusion Health programme. Inclusive Practice provides a detailed synthesis of the scientific literature within the UK and elsewhere, of the impact of efforts to provide good access to primary care and to prevent avoidable hospitalisation for the four vulnerable groups identified in the Department of Health Inclusion Health programme: vulnerable migrants, Gypsies and Irish Travellers, people who are homeless, and sex workers. The challenges of providing accessible primary care are manifold at a time of economic constraint, especially as this report shows that improving registration rates for vulnerable groups is only the first step in providing a truly accessible service. The paucity of independent evaluation of models of primary care speaks volumes about the value we attach to some of the most disadvantaged groups in society, as does the myriad of start/stop projects we reviewed whose future funding was uncertain. Despite this, there are many examples of promising practice that are waiting to be more widely adopted. We hope this report will provide a stimulus to reducing the widespread variation in access we have identified and to further research into the unanswered questions we have identified. Dr Bobbie Jacobson OBE, Chair, Data and Research Working Group, Inclusion Health Programme. February 2014 6 Inclusive Practice Executive Summary and recommendations A review and synthesis of the evidence on improving access to primary care and preventing avoidable admission to hospital among vulnerable migrants, Gypsies and Travellers, people who are homeless, and sex workers. 1. Introduction and Background This report forms part of the work led by the Department of Health’s National Inclusion Health Board. It is the second in a series of reviews commissioned by the Data and Research Working Group of the Board. The membership of the working group is attached at Appendix 2. The Board’s focus so far has been on four vulnerable groups whose health experience has been particularly poor: • Vulnerable migrants, notably, refugees and asylum seekers • Gypsies and Travellers • Homeless people • Sex workers Its first report “Hidden needs” reviewed the availability and gaps in routine data and surveys covering the needs and health outcomes of these four groups. It identified significant gaps in the definition, collection, reporting and analyses of these groups. It made a number of recommendations including working with research organisations to develop and commission specialist surveys to bridge the gap in good use/outcomes data in vulnerable groups. This report follows on from this work with the aim of: reviewing the literature on improving access to primary care and prevention of avoidable admissions to hospital for the four groups. 2. Definitions 2.1 Vulnerable Migrants Asylum seekers (including failed asylum seekers), refugees, and undocumented or irregular migrants (including those who have entered the country illegally and migrants with irregular documentation, such as visa overstayers) are included in the definition of vulnerable migrants. Other groups may be vulnerable with respect to health care access (e.g. students from overseas). 7 2.2 Gypsies and Travellers This report uses the term ‘Gypsy or Irish Traveller’, as defined in the 2011 England and Wales Census. However, the term as used in this report also encompasses Roma people. 2.3 People who are homeless The

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