An Outreach Nurse for the Gypsy and Traveller Community in Leeds
8 February 2019 | Liz Keat, Queen's Nurse
I tell everyone I meet that I probably have one of the best jobs in the NHS. Thank you for the opportunity to tell you a bit about it.
This blog highlights some of the inequalities that Gypsies and Travellers experience in health, and some of the learning from the project I have been involved in. It may be interesting to consider the Gypsy and Traveller Community in the context of homelessness; however many marginalised communities experience the same inequalities.
Sadly, we live in a world where Gypsies and Travellers are often met with hostility and suspicion, particularly if they are living roadside. NHS Leeds Clinical Commissioning Group (CCG), Leeds Community Healthcare (LCH) and Leeds Gypsy and Traveller Exchange (GATE) began a project to consider whether employing an outreach nurse for the community would be accepted, not only to improve health but also to ‘in-reach’ to systems, improve relationships and remove barriers. This was independently evaluated by Leeds Beckett University.
This is a role where one of the expectations is to go out and build relationships with people. On the days when I deliver outreach to Gypsy and Traveller sites, these are the working days when I am the happiest and I genuinely cannot believe my luck, getting paid for a job that I love. As a stranger, to be given such a warm reception has always been humbling to me, from a community that itself rarely receives a welcome from anyone. What can be better than that?
I listen to people’s stories: there is such power and experience in those stories and it is such a privilege to be trusted with them. Together we work out what is important to these people, what they are strong at, and how can health systems complement what they are doing well already?
Then there are the hard bits.
The challenges to accessing health care if you are a Gypsy or a Traveller can be complex. Many people have had experiences where accessing a GP has been refused, due to not being able to produce proof of address, or health services have not made enough effort to make reasonable adjustments for those who may struggle with literacy. Rigid structures and referral processes hinder people who are unable to respond to written invitations. Those who do not understand how to choose and book appointments are usually discharged by services due to their not opting in.
Many of our Local Authority sites are not in areas close to any amenities, thus compounding the vulnerabilities. Gypsies and Travellers have shocking health statistics that are closer to the norm for street homeless people, with a life expectancy of around 50. They have poorer health outcomes than any other ethnic minority (Parry et al; Baker; 2005). Gypsies and Travellers are more likely to have experienced the death of a child, have high rates of suicide, have a long term condition and have anxiety or depression symptoms than the general population (Parry et al, 2004).
Gypsies and Travellers experience stigma similar to homeless people, sex workers and migrants. It can affect their care, health and wellbeing. The response to Gypsies and Travellers can sometimes be brilliant, but sadly can range from ambivalent, to unwelcoming, to rude. Gypsies and Travellers may have had prior experiences of discrimination and may legitimately fear that they will be discriminated against again.
Imagine just for a minute how that must feel, anticipating that everywhere you go, you will be judged negatively and your access to services, including health, will be affected, time after time after time.
There can also be a perception among healthcare staff that Gypsy and Traveller sites are unsafe and some may be reluctant to visit them, or only undertake visits in twos, which they may not do in other areas.
Leeds Gypsy and Traveller Exchange found that when they did Asset Based Community Development alongside the community, they are very caring towards each other and are very resourceful. They have had to be.
Don’t become professionally marginalised. Those that work with vulnerable groups run the risk of becoming marginalised themselves. The success of this project lies in the joint support and leadership from Leeds Gypsy and Traveller Exchange (Leeds GATE), Leeds Clinical Commissioning Group (CCG) and Leeds Community Healthcare. Find mentors, work closely with community groups: they may know more than you do.
Break the rules
Well, sort of! Question them! If your service says to discharge someone for not engaging, what does that mean? Change your language. If your service was unable to engage with people, ask why not. Is your patient vulnerable; is any reasonable adjustment needed? If your service has very rigid structures, question them! How well do they meet the needs of all patients?
Who don’t you see?
Most services are overwhelmed with people they do see, but do you notice who you don’t see? For example if you ran a COPD clinic and you do not see any Gypsies or Travellers, why not?
Just for a minute, reflect on the thoughts that come into your head when you think about Gypsies and Travellers, homeless people, sex workers, migrants. Notice your thoughts, words, associations. Then consider why you might think those things. How might these things affect the experience of care?
Be flexible and make every contact count
Whenever you have the opportunity, remind people of screening services. Screening invites can get missed for roadside Gypsies and Travellers, so any opportunistic visit is a great moment to talk about NHS screening offers, immunisations, health checks, rights to register with a GP and other services. Sometimes just asking how everyone in the family is can be really helpful.
I have learnt so much about compassion, care, resilience, resourcefulness and empathy from this community and I owe them so much for sharing their skills and assets with me.
Liz Keat, Queen’s Nurse
Parry G, Van Cleemput P, Peters J (2004) The Heath Status of Gypsies and Travellers in England. Report of Department of Health Initiative project 121/75
Baker M (2005) Gypsies and Travellers Baseline Census 2004-2005