Table 4 Detailed Description of the five prioritised interventions agreed across GRT communities and their Service Providers

1: Cultural competence training for Health Professionals and Frontline Staff

(Links with interventions 2 and 3)

National policy intervention to include cultural competence training as a Key Performance Indicator to improve standards and best practice across all GP practices. Cultural competence training of Health Professionals and Frontline Staff on: Cultural norms of different GRT communities towards immunisation in general; these should include positive and negative norms, for example, prioritising children and their good health within the family; Cultural concerns regarding specific immunisations to enable staff to openly and confidently discuss these issues with GRTs; Awareness and understanding of the prejudice that GRTs can face in general; Removal of negative stereotypes towards GRTs and ensure trust and respect is shown towards GRTs; Culturally appropriate methods of collecting ethnicity data from different GRT communities; Cultural understanding of GRT lifestyle and values for interpreters who are often middle class and may not have previously worked with GRTs.

As a minimum standard, training to target GPs, Practice Nurses, Health Visitors, Midwives, Specialist Health Workers and Receptionists.

Widespread support warrants national policy and guidance to achieve universal implementation and standards of service.

Culturally informed concerns about pregnancy vaccines and HPV were particularly evident in the Bristol English Gypsy/Irish Traveller community.

Existing resources may be available via some local training schemes but long-term core funding needed to enable consistency of standards and practice.

2: Identify GRTs in health records to record immunisation uptake and tailor support

(Links with interventions 1 and 3)

Policy mandate (as for 2001 census) for electronic identification of GRTs based on 2011 census which included an English Gypsy/Irish Traveller ethnicity category, with additional categories for Roma and Occupational Travellers; NHS England to provide guidance on codes for GRT identification as part of broader guidance on codes for ethnicity; Central government targets for routine data collection so recording GRT ethnicity becomes part of the ‘data dictionary’; National standards and protocols to provide clarity regarding confidentiality and sharing of information; Improved joined up working and cross-referencing records held by NHS, schools, social services and education, for example the annual school census held by Local Authorities includes a GRT code, local health worker knowledge, postcode data, distinctive surnames; New registration forms for GP practices to include 2011 census classification of ethnicity; Local health professionals to check immunisation status opportunistically to update GRTs’ health records; Local health professionals to encourage effective use of patient held records (Red Book) as an up-to-date immunisation record.

As a minimum, public bodies including GP practices and immunisation datasets to adopt 2011 categories with additional categories for Roma and Occupational Travellers as indicated above. All childhood and adult vaccines should be recorded on the electronic record for each identified GRT. Widespread support and complexity of intervention warrants national policy and guidance to achieve universal implementation and minimum standards for data protection and confidentiality.

Although there is widespread support for this intervention to improve service provision and record keeping, a sensitive approach is needed to take this intervention forward, with particular attention to: Fears of prejudice if identified as GRTs; A general reluctance to self-identify by Romanian and Slovakian Roma; The Romanian and Slovakian Roma community in Glasgow were particularly interested in improving links with health services in Romania and Slovakia so that information on ‘immunisation’ status can be shared across countries. This intervention was not taken to the workshop for consideration by the Glasgow Scottish Showpeople and their Service Providers as it was not supported as a potentially useful intervention based on their interview data. This is consistent with the overarching view of this community as an integral part of the local community with good access to mainstream services.

A lack of national policy and guidance is likely to result in variation in practice between cities. Existing recording systems for data on Romanian and Slovakian Roma immigrants is considered to be poor in Bristol.

3: Named frontline person in GP practice to provide respectful and supportive service

(Links with interventions 1 and 2)

Existing high levels of trust for individual GPs, Practice Nurses and Health Visitors across all GRT communities provide a strong foundation on which to build this intervention. The named person(s) should be able to provide a consistently positive and culturally appropriate experience for the GRT on his/her arrival at the GP practice. In many cases, this simply refers to being spoken to with respect and politeness whereas in others, GRTs may require support with literacy or language issues to complete a form or identify the appropriate care pathway.

Receptionist(s) or Practice Administrators have been identified as potentially suitable to provide this basic standard of service

The frontline service should include a timely referral to a Health Professional who has the appropriate training, competency and local knowledge to provide a culturally appropriate immunisation service. Culturally appropriate frontline and health care services within the GP practice will provide continuity of care for any outreach services targeting the most socially excluded GRTs.

Widespread support warrants national policy and guidance to achieve universal implementation and standards of care.

Good practice should be identified and shared with other GP practices.

This intervention was not taken to the workshop for consideration by the Glasgow Scottish Showpeople and their Service Providers as it was not supported as a potentially useful intervention based on their interview data. This is consistent with the overarching view of this community as an integral part of the local community with good access to mainstream services.

Creation of a culturally appropriate and accessible primary care service will be of potential benefit to all childhood and adult health services for GRTs.

4: Flexible and diverse systems for booking appointments, recall and reminders

(Links with interventions 2 and 5)

The core component of this intervention is inclusion of a SMS text-based approach for immunisation recall systems, booking the appointment and regular reminders, in addition to existing letter systems. A combined system of both letter and SMS text communication is required due to differing literacy needs and fluctuating credit levels on phones. The core SMS text intervention should be demanded as standard through national policy and potentially as a quality indicator of ‘access and flexibility’ as per disability indicators. Appointments within 1–2 days of booking are more likely to be attended than appointments booked for a fortnight’s time due to some GRTs’ broad concepts of time and difficulty with the commitment of a fixed appointment. Existing annual reminder systems, e.g. for the flu vaccine, are considered to work well and should remain an integral part of any adapted system.

Widespread support warrants consideration for national policy and guidance to achieve universal implementation and standards of care.

This intervention was not discussed by SPs working with the Roma community in Glasgow. A more flexible system for conducting the immunisations e.g. out-of-hours appointments, was not supported. This intervention was not ranked within the top six priority interventions by GRT communities and SPs in York and London (ranked in top 8). SPs in York ranked this as a top priority. GRTs working in low paid employment, for example, Romanian and Slovakian Roma in Bristol, are often working long and antisocial hours, making it difficult to attend for immunisations within usual clinic times.

Health Visitors or other Health Professionals working with GRT communities could usefully provide additional, face-to-face reminders where possible.

Good practice should be identified and shared to other GP practices.

5: Protected funding for Health Visitor specialising in GRT health including immunisation

(Links with interventions 1 and 2)

The specialist service provides an important outreach component to target those families who do not access mainstream services.

The outreach service increases access to culturally appropriate and personalised information and service support, referral to immunisation services within the GP practice and improved linkages between GRT families and the GP practice. Practice based services delivered by a specialist Health Visitor identified as important to improve uptake of immunisation include drop-in clinics for specific population groups within GRT communities, e.g. adolescent girls and/or specific vaccines, e.g. HPV; out-of-hours appointments. A specialist Health Visitor has detailed local knowledge of existing and new families within the GRT community. This has typically resulted in a targeted and timely service and would inform identification of GRTs in their health records for improved monitoring of uptake (see Intervention 2).

Widespread support across all GRT communities warrants national policy and guidance to achieve universal implementation and minimum standards of care.

Continuity of high-quality care from a trusted service provider, typically a Health Visitor, has been identified as one of the most important and valued services by all GRT communities.

Loss of protected funding for this post in the past.

Additional resources are required with appropriate policy guidance to prioritise this service within the face of local budget constraints.