Community Practitioners: Championing health inclusion for forgotten populations
29 August 2019 | Dr Margaret Greenfields
Health services face multiple challenges, including staff shortages, a complex patient load, and limited time to develop service improvements for those who could benefit the most. Reading a blog about co-production of health interventions might feel like yet another ‘ask’ on top of an already growing workload.
However, it’s worth taking the time to reflect on how effective engagement between clinicians, communities and academics can transform services for the better. Partnership working helps us to fully understand patient need, and to develop innovative and cost-effective solutions. It re-engages individuals and communities who are often at risk of being ‘forgotten people’, unknown to commissioners, or dismissed as ‘hard to reach’.
Case Study: Gypsy, Traveller and Boater Communities
In my role as a Professor of Social Policy and Community Engagement, I am frequently involved in co-produced health studies. One such study took place in Bath and North East Somerset, a research project which worked with Gypsy, Traveller and Boater communities. This study was commissioned by a consortium of public health and local authority stakeholders, and is believed to be the first study in the UK that identified the health exclusion faced by people living in narrowboats.
The project found that this population faced poor access to healthcare, typically exacerbated by the lack of a regular mooring place and frequent evictions. For this ‘forgotten’ population it was found that frequent, legally enforced movement creates the same complexities in accessing regular healthcare as faced by people who become street homeless, or Gypsy or Travelling communities without access to sites.
Many of the Boaters we interviewed were older, single males who had long term untreated conditions, including mental health issues, and were often using harmful substances. They were frequently reluctant to engage with health services and often had problems registering for services. This distrust of health services and reluctance to access services was common among men from all the community groups we interviewed – as they tended to share an attitude of stoicism and unhelpful views on how men ‘should’ behave when facing pain or ill-health – which prevented them from seeking healthcare when it was needed. Poor experiences with health professionals (often because of lack of cultural awareness or professionals’ limited understanding of the challenges they faced in their living situation) could exacerbate the lack of confidence and trust.
The same study asked health professionals to explore the difficulties they faced in supporting these diverse ‘hard to reach’ populations. They reported lack of knowledge, fear of ‘unknown’ populations, lack of cultural competence, and practical concerns such as keeping in contact with patients when they are being evicted or living in places with poor mobile phone coverage.
Specific challenges we identified included the problem of ensuring continuity of care for roadside Travellers, and medication compliance problems when patients have poor functional literacy (and health literacy) skills. Other reported concerns included worries about having to physically transverse gangplanks to bring equipment onto a narrowboat, or concern over accessing poor quality unauthorised Traveller sites hidden away in rural areas with dogs roaming free. As such the report was able to identify concerns and misunderstandings from both ‘sides’, enabling partners to develop mutual understanding and solutions to the specific health needs of these groups.
As the above demonstrates, the circumstances of people living on narrowboats and Gypsy and Traveller communities are different from those of other communities. However, the principles of devising tailored healthcare solutions, aimed at providing earlier diagnosis and treatment, remain broadly similar to other successful interventions with patients who don’t fit into a ‘one size fits all’ service.
Working with the Community
Collaborating with local voluntary and community sector (VCS) organisations that have specialist community knowledge has been emphasised within the NHS Long Term Plan. Such organisations are well placed to facilitate innovation, build dialogue, develop trust and help to design in-reach opportunities that take account of cultural needs.
The Gypsy, Traveller and Boater report was successful partly due to the fact that the research team involved community members as advisors and trained interviewers. This was true particularly in relation to ‘stigmatising’ conditions such as mental health and substance use. They spoke to their own communities and brought back the evidence for collaborative analysis.
Working together, practitioners, community members and the academic team produced a balanced report that triangulated the evidence and enabled commissioners to create a specialist outreach support service in Bath and North East Somerset. This service aims to widen access to culturally competent health care and works holistically with communities impacted by the wider determinants of health.
Communities of Practice
Such interdisciplinary approaches might sound daunting for health professionals not familiar with this way of working. However, this project shows that by working across boundaries and engaging all parties, access to healthcare can be improved for a group of people with specific needs.
Where trust is developed between health professionals and service users – typically through long-term engagement and close collaboration – health improvements among populations are consistently demonstrated. Importantly, when communities see that their needs are taken seriously and they are listened to, we can begin to open the door to opportunistic health promotion, screening and preventative interventions, rather than ‘crisis care’.
Given a financial climate where short-term commissioning pertains, services need to demonstrate rapid change if they are to be recommissioned. Accordingly, we need to work collaboratively as ‘communities of practice’. Identifying and championing good practice should not just be seen as a ‘personal preference’ or a marginal activity undertaken by clinical specialists focused on ‘hard to reach’ and ‘marginalised’ populations, but something that is intrinsic to all health and social care professionals’ jobs, regardless of their role or grade.
The first way to do this is to join the free networks available, such as the QNI Homeless Health Network and the Faculty of Homeless and Inclusion Health, where films, blogs and specialist literature are shared. Another approach is to offer opportunities for both commissioners and other clinical practitioners to experience care delivered in off-site and ‘unusual’ settings with communities such as people living on narrowboats and Traveller sites.
By flagging up the effectiveness of good practice examples in meetings, through Twitter and blog discussions, in feedback to consultations and in professional conversations with colleagues, we can all collaborate in creating a cycle where commissioning for equality becomes the norm.
Dr Margaret Greenfields
Professor of Social Policy and Community Engagement
Buckinghamshire New University