5 December 2008

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fair for all

"Consultative mechanisms need to be developed to involve ethnic minority communities in the planning of services and to enable patients to articulate their needs and give feedback on the quality of services received."

Other Ethnic Minority Groups and Good Practice Models

Rural Communities and Ethnic Minority Health

Rurality and Access to Services

In her recent research 'Invisible Communities: Black and Ethnic Minority Communities in Rural Areas of Scotland', Ms de Lima interviewed a number of households across four rural areas of Scotland, focusing on their experiences of living in a rural community and their access to services.

Her findings included:

Service providers - main barriers

• There is a colour-blind approach to service provision and assessment not taking account of ethnicity and culture.
• A myth that black and ethnic minority communities are 'looking after their own'.
• Lack of information about services in community languages and variable interpretation and translation facilities.
• Racism -overt and inadvertent racial discrimination, individual and institutional. The greatest problem in many rural areas has been a perception that race equality was simply not a priority issue - the 'no problem here' culture persists.
• Services are not provided in a culturally sensitive manner and are at times alien to black and ethnic minority users.
• Little or no recognition and understanding of the complexities of ethnic minority communities, resulting in services that either fail to reach them or meet their needs.
• Little in the way of an effective strategy to identify, make contact, and consult with ethnic minority groups in planning services.
• The lack of up to date information on numbers, geographical and age distribution of these groups makes it impossible to assess the quality of services received by them.

Ways forward

• Language issues: in partnership with other agencies develop a strategy and action plan for ensuring access to a professional language and interpretation service.
• Advocacy service to empower patients especially those who feel disadvantaged because they are unable to communicate effectively with GPs and their primary health care teams.
• Baseline information - accurate information is a first step in addressing the 'knowledge gap' about black and ethnic minority communities in rural areas.
• Race equality policy and practice - There is a need for service providers to be
  pro-active and invest in policies and practices, which are sensitive to the needs of all members of the community. The services will need to take account of the cultural and religious requirements, for example, diet, meeting place for prayers and/or worship.
• Consultative mechanisms need to be developed to involve ethnic minority communities in the planning of services and to enable patients to articulate their needs and give feedback on quality of services received.
• The organisations need to take equal opportunities and complaints about discrimination seriously including:
• Recruiting more black and ethnic minority individuals into the public sector.
• Consulting with ethnic minority groups in the planning and delivery of services.
• Implementing equality of opportunities in employment.
• Establish procedures to address complaints relating to racial discrimination.
• Recognition of overseas qualification as well as experiences gained abroad.
• Removing 'cronyism' and the 'old boys' network' operating against those in employment.
• Establish a mechanism to address capacity building and assistance for Health Boards and Trusts with regard to race equality issues.
• Assist with the development of a community infrastructure/network of support for members of ethnic minority communities.
• Provide assistance with transportation, which may negatively affect immediate access services.
• RARARI provides a unique opportunity to ensure that race equality issues in rural areas are embedded within the mainstream and that the needs of the black and ethnic minority groups are addressed as part of the social exclusion agenda and that these issues are addressed as part of a partnership/inter-agency approach.

Asylum Seekers and Refugees: Health Strategy

The UK has a resident refugee population of about 230,000. Almost half of the Asylum Seekers and refugees entering the UK live in London. The current dispersal programme has designated Scotland as one of the 'cluster regions' for asylum seekers and refugees.

The Scottish Cross-Party Parliamentary Refugee Group, Scottish Refugee Council, the Parliament's Social Inclusion, Housing and Voluntary Sector Committee and the Equal Opportunities Committee have an interest in asylum seeker and refugee issues.

The Scottish Asylum Seekers Consortium administers the dispersal of refugees in Scotland. So far only one local authority has signed a contract to receive refugees but other regions are considering their own plans.

There are special challenges experienced by and asylum seekers and refugees. They are particularly vulnerable to mental health problems due to a combination of harrowing past experiences and problems on arrival to Britain. Many have physical injuries resulting from torture, which require specialist medical attention. Unaccompanied refugee children and minors may suffer from the unresolved effect of physical and emotional trauma.

Many asylum seekers and refugees face difficulties finding their way around an unfamiliar healthcare system. They come from a variety of nations, bringing with them a great diversity of culture, language, religious beliefs, experiences and skills. The health and social problems of refugees in Scotland reflect this heterogeneous make up of the refugee population.

The emerging health issues for asylum seekers and refugees include the following:

Difficulties in accessing health care services
Mental health and physical trauma
Incomplete immunisation of minors
Poor diet and nutrition
Lack of social support and community development
Social - economic factors

Key areas for action includes:

Employment - Many asylum seekers and refugees require a 'fast track' programme to accelerate and boost their chances of employment.

Capacity Building and Community Involvement - Asylum seekers and refugees should be encouraged to be joint participants in the planning, design and delivery of services which impacts on them and their community. Bilingual (health advocates) from these communities can be trained to ensure that a holistic approach is developed and cultural sensitivity and respect is upheld.

Outreach programmes or One-Stop Centres - Asylum Seekers and refugees are a vulnerable community and outreach services would have the advantage of promoting access to services. 'One Stop Centres' would ensure that complex health problems are dealt with quickly and within a safe environment.

Training and Development - In-service learning and training programmes for frontline staff should be developed jointly by local authorities and health boards in partnership with refugee groups, to promote general awareness and reduce stereotyping.

Access to Primary Health care - Ensuring access to full range of services provided by general practitioners is essential to improve health. The LHCC's should have a pivotal role in planning, developing and supporting activities and programmes, which promote integrated health care for Asylum seekers and refugees.

Information and Communication - Dissemination of health information in specific languages should be developed according to the needs of Asylum seekers and refugees. Resources for interpreting and advocacy should be strengthened; teaching of English language courses should also be provided to encourage links with the wider community.

Monitoring - There needs to be an effective system for monitoring the uptake of health services and recording outcomes. Public and Patient Involvement should be reviewed to encourage confidence in our health care systems.

Support Services - There is a fundamental need to develop and strengthen existing advocacy support to asylum seekers and refugees.

The Health of Gypsy Travellers

'The context of Travellers' lives includes the stress generated by living in a hostile society where discrimination is a constant reality, and this is compounded by frequently enforced change in their way of life. This context impacts adversely on Travellers' health.'

Demography

The Gypsy Travellers population is relatively small in Scotland, and most do not appear on electoral registers or in the phone book. Therefore, it is very difficult to compile statistics on the group, other than broad estimates.

The Scottish Executive, Central Statistics Unit carries out a half yearly count of Gypsy Travellers and estimate that there are about 500 Gypsy Travellers living in caravans. The Scottish Gypsy Travellers Association hotly disputes this figure, because it does not include Gypsy Travellers who live in the house for part of the year, or many of those who live on the side of the road. The organisation believes that there are around 15,000 Gypsy Travellers living in Scotland.

The 2001 Census was an opportunity to gather more workable statistics on the numbers of Gypsy Travellers in Scotland, but unfortunately Gypsy Travellers were not listed as a separate group under ethnic origin.

Geographically, Gypsy Travellers can be found in every region of the country, from the islands in the north to the Borders in the south. Many live in official sites, often not by choice, but because traditional stopping places have been blocked off and built on. Many official sites have been built on land, which has many environmental hazards (pylons, dumps, railway lines, etc.).

Background

There is a dearth of published information about the health status of this ethnic minority group in Scotland. In England there have been a number of small localised studies but we must look to Ireland for any large-scale epidemiological study. This paper is therefore based on the experience of Save the Children and the views of some of the few health professionals working with Gypsy Traveller families in Scotland.

At the time of writing the Scottish Parliament Equal Opportunities Committee is conducting an inquiry into Gypsy Travellers which will address issues of health and access to healthcare. Their report is due at the end of June 2001.

Health Challenges

The health of Gypsy Travellers is intrinsically linked to the choice of accommodation and the location and condition of sites. The former is determined by various push factors; lack of facilities, insecurity on roadside camps, forced eviction and harsh treatment. Other pull factors in operation include, access to water, electricity, and chance to enrol children at school, and access to medical facilities.

Other health issues include:

• Inability to follow up treatment when being forced to move on, which often results in the treatment of symptoms rather than cause, and the late detection of abnormalities and sometimes misdiagnosis.
• Lack of continuity of care and the disruption of any planned treatment and education. Interruptions or delays to treatments will occur when Gypsy Travellers are suddenly forced to move out of a site. One pregnant woman stated:

'the midwife was due to come back and see me. She was going to bring me milk tokens and some baby clothes ... but the police wouldn't let me wait'.

• Poor uptake of preventative healthcare (especially well-women care and immunisation).
• Anxiety and distress for Gypsy Travellers families, in particular, possible long-term mental health difficulties for women ... a result of feeling trapped in a site where no one would want to live.
• Difficulties in registering with a General Practitioner or family doctor. Often GPs will only register families as temporary residents, resulting in exclusion from screening services and inappropriate use of A&E department.
• Lack of a postal address can mean that dates/times for appointments are never received.
• Lack of medical records resulting in delays in diagnosis and treatment.
• There is little advocacy support for Gypsy Travellers who may have difficulties in accessing the service.
• Racist/intolerant attitudes of health staff and receptionists. The latter have been known to refuse Gypsy Travellers contact with GPs.

Examples of practices already underway:

• Development of patient-held records in some localities.
• The employment of specialist health visitors. In the past, this had consisted of small numbers of staff with specialist knowledge of working with Gypsy Travellers, who have taken the individual commitment or interest rather than Trust or Health Board planning.
• Assessment of the health needs of Gypsy Travellers community in a few localities.
• Culturally specific health education work with young Gypsy Travellers.

However, the current provision across Scotland is patchy and initiatives are often short-term.

What can be done?

• An independent working party to oversee a national health strategy, with associated resources, to address the educational and health needs of Gypsy Travellers and to monitor progress towards an agreed strategy/programme of work.
• There is a requirement for further research, particularly on specific health matters to Gypsy Travellers. The study would include a look at other contributory influence on ill health such as economic, social and environmental factors.
• There is a growing need to change society attitudes to Gypsy Travellers' and their way of life through awareness raising and education.
• Health promotion initiatives need to be delivered in a culturally appropriate manner with respect and sensitivity to Gypsy Travellers' culture. This has been shown to have significant results, especially when they have been designed, planned and delivered with them.
• The introduction of a patient/family-held health records for Gypsy Travellers families across the country. It would be simple and easy to understand and would provide a continuity of care, wherever the patient/family move throughout Scotland. It will also encourage the families to take charge and responsibility for their health and lifestyle.
• The provision of personnel to co-ordinate and support developments, nationally, to improve the health status of Gypsy Travellers. This would ensure monitoring and evaluation of local initiatives which can be shared and extended.

Good Practice Models

Good Practice

'... constitutes those activities that are designed to 'promote' and 'encourage' developments in the chosen area of interest. These are to do with relationships between organisation, structures (both internal and external) and policies. More than often, good practices are a common sense approach to solving a given problem or challenge and not necessarily a demonstrated or proven way of doing things'.

Good Practice Model

'... is everything that 'good practice' entails plus a demonstrated 'model' of doing things which has been shown to work. A 'good practice model' in Ethnicity and Health will include some or all of the following:

Lead to demonstrable improvement in health (measurable Health Gain)
Innovative
Transferable
Workable
Exciting
Participatory and involving the target group
Been up-and-running for a defined length of time
Provide a template for that area of work
Monitored and Evaluated*

*... the purpose of which is to demonstrate whether an activity has been successful or to what degree it has failed to achieve some stated aims.

In Scotland the majority of work done with regards to Ethnicity and Health can be described as 'good practice'. The Scottish Executive Health Department has undertaken a Scotland-wide 'stocktake' to gain a 'snapshot' view of where Health Boards and provider units are in the provision of healthcare to ethnic minority groups. The ultimate aim would be to encourage the development of Scotland wide standard in healthcare delivery to the ethnic minority communities and to further encourage and strengthen existing good practice models.

Dumfries & Galloway HB

The Board has been pro-active in leading the NHSiD&G to look critically at access and health provision to ethnic minority groups in the area. A significant section on the Health Improvement Programme indicates the Board's commitment to work with this group.

A sessional worker has been appointed to work with the Gypsy Travelling/New Age community. Additionally, a designated member of staff has a remit to work with the Chinese community. There is also an ongoing Ethnic & Minorities Groups Health and Social Care Needs Assessment in collaboration with Social Services-Community Care.

Greater Glasgow HB

The Board has adopted a Race Equality Policy to complement the Equal Opportunity Policy. There is an Ethnic Minority Health Advisory Committee which has put together a collective response to how the Board intends to take forward its programme on ethnic minority health. The committee has representatives from the main ethnic minority groups in Glasgow and also designated senior managers from the NHSiGG. The committee also serves as a consultative forum and has been successful in getting a detailed section on ethnicity inserted into the Health Improvement Programme. A series of Action Agenda and Commissioning paper is the result of consultation dialogue with members of the ethnic minority groups, which it is hoped will inform policy developments and shape resource allocation.

Fife HB

The organisation is part of a multi-agency Ethnic Minority Community Safety Group that has developed a monitoring form for racial incident/harassment. All partner agencies are signed up to it and all reporting forms are collated by the Local Council.

The multi-agency Fairness Racial Awareness and Equality (FRAE), on which the Board has a representative, looks at capacity building work with ethnic minority communities. It acts to ensure that the ethnic minority groups know their entitlements and have access to all services.

The Board has its own Working Group on Ethnicity which has been established to take forward the recommendation from a study by Centre for Human and Social Research. The report looked at people's experiences and problems they encountered in accessing services.
The Board is also funding the Fife Interpreting and Translation Service as a result of another recommendation from the aforementioned study.

The Board is also reviewing staff training and development and will be revisiting issues of ethnicity as part of 'Learning Together'.

Scottish Ambulance Service

The Board is involved in a UK-Wide Working Group, which is presently reviewing recruitment strategy to encourage more black and ethnic minority staff into the Ambulance Service.

The organisation has an excellent training programme in equal opportunity, which is soon to receive accreditation (SVQ). The programme is in the process of being evaluated. Although not specifically for racial equality the programme has extensive coverage of race and is an example of good practice, nonetheless.

The organisation has been using black instructors as role models during recruitment drive at schools and colleges. They have also began a series of shadowing opportunities to encourage more black staff into the senior positions.

Grampian HB

The Board has convened the NHSiG Steering Group on Ethnic Minorities. The group has recently commissioned the local Racial Equality Council (GREC) to undertake a two-year phased programme of work which aims to look legitimately at issues of access and service delivery to the ethnic minority communities. The group also has representatives from the Local Council and other appropriate agencies in Grampian. The group has been transparent in its work whilst enabling the local ethnic minority groups to know how the Board intends to take forward the issues raised as part of the ongoing consultation with themselves. The Local Health Council has been pro-active in promoting this work, which appears in the front cover of their Newsletter, Check-Up.

Lothian Primary Care Trust

The Minority Ethnic Health Inclusion Project (MEHIP) was set up in 1999 as part of Lothian Primary Care NHS Trust commitment to 'improve the quality of and access to primary healthcare services by the black/minority ethnic and refugee communities across the Lothians'.

The project is staffed by a team leader, four linkworkers and an administrator and offers free, confidential and direct services in community languages to patients. Other services include: advice and support to health professionals, advocacy, health promotion, needs assessment and the development of culturally-sensitive service through training and support to health professionals.

Staff at MEHIP also provides links to the community and ensures that community views are effectively represented on Trusts issues through ongoing consultation and community development.

As part of the review of recruitment strategy, the Trust is proposing to:

• Advertise employment opportunities in the local ethnic minority library.
• Create opportunities for volunteer experience through placement developed in conjunction with Skillnet.

Forth Valley HB

The organisation is part of RAHMAS (Racial Attacks and Harassment Steering Multi-Agency Strategy), which has produced a hand book 'Staff Cultural Awareness Handbook' to help staff become more culturally aware and religiously sensitive in service delivery to members of ethnic minority groups living in Central Scotland. The Nursing and Midwifery unit of University of Stirling is currently reviewing the handbook.

The RAHMAS group has also produced 'Racism - How to get help' and 'Racism - Raising the profile'. The latter aims to raise staff awareness and responsibility in the proper receiving and recording of incidents of a racial nature.

The Board is embarking on a process of personal development planning as part of 'Learning Together' and training in equality will be enhanced utilising the RAHMAS pack.

Greater Glasgow Primary Care NHS Trust

The Trust is the first in Scotland to adopt a Race Equality policy to complement the Equal Opportunities policy.

It has established the Multicultural Health Development Programme (MHDP) to help operationalise the Race Equality policy. The work is directed by a Consultant in Public Health, assisted by Multicultural Health Support Team, part of whose role is to provide holistic models of care for complex problems within one-stop clinic in pilot community agencies. Staff also work closely with managers and clinical colleagues in developing standards to improve the access to and experience of primary care services by black and ethnic minority communities.

The Trust has resourced, and will be rolling out a training and learning programme in multicultural healthcare to all managers and staff in line with the agreement in the National Health Plan to 'ensure that NHS staff are professionally and culturally equipped to meet the distinctive needs of people and family groups from ethnic minority communities'. Training will commence in mid 2001, and will initially be rolled out to staff working in areas of high-density ethnic minority population. Also all managers working in such areas have ethnic minority health as one of their key result areas.

The Trust has also been working in collaboration with the Health Board's Ethnic Minority Health Advisory Committee to set out specific actions to look at the local NHS response to health and healthcare services to ethnic minority groups. These key areas for implementation are being developed and are reflected in the Board's health Improvement programme and the Trust Implementation Plans.

Rural Health 'There is no available good practice'

In one of the rural Health Boards, a rural health inequalities manager working within the health promotion department has responsibility in this area. However, ethnic minority health has not, as yet, been a feature of the work.

Greater Glasgow Primary Care NHS Trust: Refugees and Asylum Seekers:

Greater Glasgow Health Board has allocated £600,000 through the Health Improvement Programme to Greater Glasgow Primary Care NHS Trust, Asylum Health Co-ordinating Group to promote access to primary healthcare services for asylum seekers and refugees in the city.

The group works closely in partnership with the local authority and other NHS Trusts to ensure a co-ordinated response in terms of service delivery and quality of care. In particular the group is keen to share knowledge and information as to develop good practice models within the city of Glasgow.

The activities of the group have included the

• delivery of a multi-professional learning and training programme to help raise awareness of staff on the complex health issues facing asylum seekers and refugees. Over 500 staff from NHS Glasgow have so far been given training and the number is set to increase with involvement of other NHS trusts;
• provision of salaried and locum General Practitioners to ease the extra demand on primary care services;
• creation of specific Mental health and sexual abuse clinics to cope with the specific needs of asylum seekers.

Highland Primary Care NHS Trust: Gypsy Travellers:

In January 2001, Highland Primary Care NHS Trust set up the 'Primary Care Outreach Service for Gypsy Travellers in Inverness' in response to the knowledge that Gypsy Travellers often experience poor health and in particular have poor access to primary health care facilities. Funded for an initial 12 months, the project employed a health visitor who worked eight hours a week and a local GP practice providing the equivalent of two sessions per month. It aims to identify the health needs of people staying on the local site, to develop knowledge of Gypsy Travellers' culture, to identify how to enable better access to health care and to provide appropriate services.

Much of the work of the health visitor involves making contact with people when they arrive in the area and assisting them to access appropriate services. This may involve for example, contacting a GP on their behalf, liaison with the GP they are registered with to obtain background information, or expediting hospital appointments so they can attend before moving on. It may involve advocacy and liaison in relation to other agencies such as housing or education department.

References

1. General Register Office for Scotland: The 1991 Census
2. Scottish Executive. The Stephen Lawrence Inquiry: An Action Plan for Scotland. July 1999
3. Scottish Executive. Equality Strategy: Working Together for Equality. November 2000
4. Scottish Executive. Our National Health: A Plan for Action, a plan for change. December 2000
5. NHS in Scotland Partnership Information Network (PIN) Board Guideline Development Group. Equal Opportunities Policies. June 2000
6. The Health of the Nation: A strategy for health in England. Presented to Parliament by the Secretary of State for Health. London: HMSO, 1992.
7. Balarajan R and Soni Raleigh V. Ethnicity and Health: A guide for the NHS. Department of Health, 1993
8. The National Health Service in Scotland. Access to Healthcare by Ethnic Minority Communities: A Guide to Good Practice. HMSO Scotland, 1994.

Rural Communities and Ethnic Minority Health

1. Ayrshire District Council (1993). Survey of the Health and Social Needs of the Chinese Community Living in Ayrshire. Report to the Joint Planning Team, Sept. 1993.
2. Bailey N, Bowes A and Sim D (1994). The Chinese Community in Scotland. Scottish Geographic Magazine Vol. 110, No 2, pp. 66-75.
3. Bailey N, Bowes A, Sim D (1995). Pakistanis in Scotland: Census Data and Research Issues. Scottish Geographic Magazine Vol. 111, N0. 1, pp. 36-45.
4. Dalton M and Hampton K (1994). Scotland's Ethnic Minority Community 1991: A Census Summary; Fact Sheet No. 1.
5. Dhalech M (1999). Challenging Racism in the Rural Idyll London NACB.
6. Francis D et al (1992). Working with Rural Communities. London: The Macmillan Press.
7. Henderson and Kaur (1999). Rural Racism in the UK. London CDF.
8. National Alliance of Women's Organisations (1994). Staring at Invisible Women: Black and Minority Ethnic Women in Rural Areas. Summary of Research Report from the NAWO. Rural Development Commission, London.
9. De Lima P (2001). 'Needs not Numbers': an exploration of minority ethnic communities in Scotland, Commission for Racial Equality, Scotland.
10. Rural Forum (Scotland) (1994). Disadvantage in Rural Scotland, Summary Report
11. Shucksmith M et al (1996). Rural Scotland Today. Haunts Avebury Press.

Asylum Seekers and Refugees: Health Strategy

1. Berlin A, Gill P, Eversley J. Refugee doctors in Britain: a wasted resource. BMJ 1997; 315:264-5
2. Control of Immigration: Statistics United Kingdom 1997. Home Office, London: HMSO, August 1998
3. Convection relating to the status of refugees. Geneva: UNHCR, 1951
4. Credit to the nation. A study of refugees in the United Kingdom. The Refugee Council. London, 1997
5. Health Service Circular: Overseas visitors' eligibility to receive primary care. HSC 1999/018; February 1999, paragraph 27
6. Jones D, Gill PS. Refugees and primary care: Tackling the inequalities. BMJ 1998, 317: 1444-6
7. Leather C, Wirz S. The training and development needs of Bi-lingual support workers in the NHS in Community settings. Centre for International Child Health, Institute of Child Health. NHS Executive: London, 1996
8. Rebuilding Lives. Scottish Refugee Council 'Annual Report 2000'

The Health of Travellers and Gypsies

1. Bancroft A, Lloyd M and Moran R. The Right to Roam - Travellers in Scotland. (1995/96), Chapter 5, pp 24-33. Published by Save the Children in Scotland.
2. Carrick K, Moran R, Barker C and Lloyd M. Moving Targets ... a publication by Save the Children Fund in Scotland (2000).
3. Lloyd M and Moran R. Failing the Test ... a publication by Save the Children in Scotland (1998).Neff-Smith M, Erickson G and Campbell J. Gypsies: Health Problems and Nursing Needs. The Journal of Multicultural Nursing & Health (1996), pp 36-42.

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