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Section 8: Broader Needs of the Traveller Community
I - Health

Previous Committee Involvement in Health Issues

8.1 During its final two years the Committee has looked specifically at two aspects of the broader needs of the Traveller community: health and education. Health is examined in this section of the report and education in section 9.

8.2 Only in recent years has an appreciation of the varied health needs of discrete groups of the general population been widely recognised. Nevertheless the health of the Traveller community has already been identified by previous Committees as an area of concern. Reference was made to the health of the Traveller community in the original Scottish Office study of Travellers (Gentleman and Swift, 1971) but little factual evidence was available at the time. It remained as one of the wider Traveller welfare needs within the remits of a number of successive Advisory Committees whose membership and advisers at various times have included medical and environmental health professionals. Specific recommendations on this issue were made in two earlier Committee reports (Appendix C - Recommendations 83-84). However, in practice little further work appears to have been done in light of these.

8.3 While there has been some research in England and Wales into Traveller lifestyle and culture including health issues, no similar work had been undertaken to any extent in Scotland, until the review of health issues by the present Advisory Committee.

Health Working Group

8.4 Reference to the health needs of Scotland's Travelling People was highlighted in our predecessor's report (Eighth Term Report: Paras. 6.15-17) and two specific recom-mendations were made (Appendix C - Recom-mendations 85-86).

8.5 In light of these, the ninth Committee set up a working group specifically to examine health issues among Travellers. The group's remit was to:

• investigate the health needs of Travellers and their families affected by their particular culture and lifestyle;
• undertake small-scale research into the take up of NHS services by the Traveller population;
• investigate the knowledge of health professionals, other agencies and the voluntary sector across Scotland of those health needs;
• collate the information gathered in order to establish best practice guidelines for those health professionals and agencies with an interest in Travellers' welfare.

8.6 The group consulted with GPs, health boards, NHS Trusts, voluntary agencies and, in particular, with health visitors with an interest in Travellers' health throughout Scotland. The breadth of the group's consultation drew on a wide geographical spread of experience and practice among those working in the field of Traveller health. As with the settled population, and perhaps even more so, the variety of physical and climatic environments within which Travellers live, whether urban or rural, have implications for their health. At the same time the investigation indicated that healthcare for Travellers and their families throughout Scotland clearly is not uniform even though the availability of NHS services to this community should be the same as for the settled community, including the specific needs of minority groups.

8.7 The discussions with health visitors generated valuable information and gave a snapshot of healthcare provision for the Traveller community and highlighted our concern that healthcare for Travellers and their families was not uniform across Scotland. In light of this the group was able to consider guidelines for health authorities, health professionals and other agencies with an interest in Traveller welfare. We feel that these should ensure that Travellers become aware of all aspects of healthcare and of the delivery of service at all levels. At the same time Travellers need to become aware of their own responsibility for their health and the preventative measures available to them to ensure good health.

Assessment of Need

8.8 Looking towards the future, the theme running through sections 7 to 9 of this report is that of assessment of need. The developments and approaches outlined above are positive but the Committee feels that if Travellers are to achieve equality with the rest of the population in the field of health there are still areas where improvements are necessary.

8.9 While the position may be simpler for Travellers who are settled on a long-term basis on a local authority or privately owned site, there is evidence that frequent change of address associated with a more mobile way of life has led to a lack of easy access to GP and other health services. Consequently Travellers can miss out on the full range of positive health services. There is also anecdotal evidence that some GPs are reluctant, or even refuse, to make home visits to Traveller sites and, in particular, to roadside families. As a result Travellers have traditionally relied on accident and emergency departments for their more pressing needs and therefore lack any continuity in their medical and health care.

8.10 Traveller children miss out on the regular school health screenings, dental checks and immunisation programmes. This can lead to increased risk of common infections, unidentified cases of deafness (including 'glue ear'), or visual impairment, which can affect the child's ability to benefit from school learning.

8.11 Positive steps taken to address some women's health issues have had tangible results across authority boundaries however, equivalence for men's health issues has proved more difficult to implement. Some positive discrimination action still requires to be developed.

8.12 There is a need for appropriate publications on health issues specifically geared towards Traveller ways of life and cultural values in order to support ready access to health care, including health improvement programmes.

8.13 Information relayed directly to Travellers by regular practitioners has proved effective in increasing access and demand for services.

Aims for Improving Traveller Access to Health Services

8.14 Social inclusion for all groups, especially marginalised and deprived communities, is a major feature on the agenda of the new Scottish Parliament. The nature of Travellers' lifestyle, their relationship with the settled community and the difficulties which they have faced for centuries makes them clear candidates for such a grouping. Though the settled community has traditionally tended to have negative perceptions, the Traveller community's lifestyle and culture, evolved over centuries, should command as much respect as any other sector of the Scottish population. Better understanding of their particular needs is critical to improving their health and general well-being.

Problems in Access

8.15 Many Travellers and their families enjoy comfortable living accommodation but, as in the settled community, there are wide variations. Some Travellers live in poor accommodation which is likely to have an adverse effect on general health, with children and elderly people being especially vulnerable. Clean water supply, proper sanitary and washing facilities are important factors preventing infectious illnesses and are standard amenities on all authorised sites. Families living on permanent sites, whether local authority or privately owned, enjoy a better standard of living and should be able to pursue their lifestyle and culture within a secure environment. Ability to link up to utilities for warmth is an essential component in Scotland's uncertain climate and the regular collection of refuse by the local authority promotes a quality of life for the Traveller families, which must benefit their general health. It is the unauthorised roadside sites lacking any of these facilities which give greater grounds for concern over potential health problems.

Developments in Meeting the Particular Needs of Travellers

8.16 The Committee is aware of a variety of health education projects affecting Travellers being piloted by GPs and health visitors, funded by their local health boards on a fixed term basis. These projects have highlighted a number of good practice guidelines throughout Scotland. One practice, while providing healthcare for travelling families, has also researched patterns of illness within families, highlighting major diseases which have persisted through successive generations.

8.17 Within a relatively closed community there is a likelihood of close intermarriage. Within any such community there is potential for genetically related illnesses to emerge. It is the view of health professionals that genetic counselling should be freely available to all 'at risk' groups, which also includes Travellers. It is seen as particularly important if there are carriers of potentially life threatening genes. Particularly in more remote areas some problems of this nature have been identified within some families in the Traveller community.

8.18 The nature of Traveller culture, where women do not discuss health matters in the presence of male relatives, and the existence of family matriarchs, who are still regarded as an authority on their families' health needs, possibly have made it difficult to raise issues of this kind in the past. However, it seems that the younger generation are now questioning such traditions, seeking more information and forming their own opinions on health matters.

Health Records

8.19 Another continuing project based within a primary care practice aims to establish a service for travelling families within their Health Board area and could provide a benchmark for other practices throughout Scotland. This seeks to achieve health gain and maximise the development of a structured primary care led service, leading to improved access to mainstream services such as immunisation and screening.

8.20 One important component of the project is the introduction of a patient-held health record for Traveller families. Designed to be simple and easily understood by the family, it charts the health records of all the family members, providing the potential for continuity of care for families wherever they go throughout Scotland. In this way it eliminates the need to forward patient records between primary care practitioners with obvious benefits to the patients themselves.

8.21 Experience of hand-held family health records is that they have made a positive contribution to confident engagement with
the health service, with Travellers taking responsibility for their own contribution to a healthy life-style. Use of such records has already led to increased use of GP and other services as families travel and there has also been a significant increase in the uptake of preventative health programmes. Records of this kind should be provided and their use encouraged among Travellers throughout Scotland.

8.22 Good practice has been developing in a number of areas in the UK, but the example of the Stirling project, developed over a number of years, offers a range of approaches which can readily be adopted within the Scottish health provision system.

8.23 Evidence of other projects in different parts of Scotland focus on general health education, the needs and care of elderly and disabled Travellers, dental health care, access to primary care services, well women projects and male health problems. The last of these is only in the very early stages of development. Alcohol and drug abuse are also being addressed.

8.24 All these projects appear to have established good relationships with the Traveller families. Liaison between the families and primary care centres is generally through health visitors. Although Travellers tend to regard people from 'authority' with suspicion, the health visitors have established trust within this community and are an important component in addressing Traveller health needs. In a number of fields these are now the accepted link between health professionals, local authorities, the voluntary sector and the Traveller population. We also note that they were the preferred, and successful agents in undertaking the 1992 national count of Travellers on behalf of the Scottish Office.

Links with Policies on Education

8.25 The result of the working group's investigations indicate that much is already being accomplished in terms of addressing health issues among Travellers. Traditionally, many of the Traveller cultural mores have focused on issues of 'cleanliness' and 'chastity' with much continuing effort to maintain long-held traditions in this respect. While younger generations of Travellers have greater expectations for their future, they still wish to retain their culture and lifestyle. Changing the established practices and cultural codes of Travellers will only happen as they gain sufficient information to make informed choices. It must be emphasised that any progress is closely linked with education and both should be addressed together. Better access and knowledge of health issues has enabled the Traveller community to be aware of different aspects of healthcare, its delivery at all levels and to each section of their community. In this way there is a better prospect of ensuring that Travellers are able to take responsibility for their own health and the preventative measures available to pursue good health practices within their own community.

8.26 Some issues were touched on in a project undertaken by Save The Children (SCF, 1999) in which teenage girls in one area were encouraged to meet together to talk about their health. The following direct quote from one of the teenagers who participated in this project sums up some of the difficulties...

'Our mums and dads are very protective and we're not allowed to just go off on our own. Young Travellers don't make a big deal about health, the way you find out is through your Mum or the telly. Sometimes it's hard and it can be embarrassing at the Doctors - you have to wait for someone to take you and that can be embarrassing too'.

8.27 However, the project also highlighted barriers which still have to be tackled. It focused on general health and included healthy eating, addictions, body image, exercise, hair care, skin care and first aid and was pronounced a big success by the participants. Similar projects with other young Travellers might dispel some myths regarding health matters which have been distilled orally though the generations.

Cultural Sensitivities

8.28 Sensitivity to and respect for Traveller cultural values and mores is of supreme importance. Where this approach has been adopted in handling health issues affecting Travellers it has led to significant progress. Without it many of the barriers will remain.

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