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The effectiveness and cost-effectiveness of various models for promoting improved access to primary care services for vulnerable populations, including asylum seekers, refugees, Gypsies and Travellers, and homeless individuals. It provides examples of good practice, such as specialist centres, dedicated GPs, and annual notifications to PCTs and local authorities. The document also covers interventions to increase GP registration and partnership working with communities.
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Dr Bobbie Jacobson, chair, and members of the National Inclusion Health Board’s Data and Research Working Group (Appendix 2) provided valuable feedback on earlier drafts of this report at two meetings of the Group. I am grateful to Adrian Hegenbarth, Nigel Hewett, Mark RD Johnson, and Matthew Brindley for their informative peer review comments on the report and to Alison Powell for supplying documentation for NIHB sponsored scrutiny reviews.
I am also grateful to a number of people involved in representing, providing advocacy to, and developing services for Gypsies andTravellers for the opportunity to meet and discuss interventions relating to Gypsies and Irish Travellers: Matthew Brindley, Policy Manager, Irish Traveller Movement in Britain (ITMB); Zoe Matthews, Strategic Health Improvement Manager, Friends Families and Travellers, Brighton; and Rose Palmer, Development Manager for Gypsies and Travellers, Housing Commissioning, Royal Borough of Kensington and Chelsea. Useful information was also provided by Helen Jones, Chief Executive Officer, Leeds Gypsy and Traveller Exchange, and Charlotte Smythe, Health Trainer Co-ordinator, Swale/Thanet.
I also thank Dr Judith Eling, GP with the Refugee Service, Health Inclusion Team, for providing a set of very useful documents on the New Entrant Health Check scheme.
2.1 Vulnerable Migrants
Asylum seekers (including failed asylum seekers), refugees, and undocumented or irregular migrants (including those who have entered the country illegally and migrants with irregular documentation, such as visa overstayers) are included in the definition of vulnerable migrants. Other groups may be vulnerable with respect to health care access (e.g. students from overseas).
2.2 Gypsies and Travellers
This report uses the term ‘Gypsy or Irish Traveller’, as defined in the 2011 England and Wales Census. However, the term as used in this report also encompasses Roma people.
2.3 People who are homeless
The vulnerable segment of this population is defined by the Department of Health and in this report as people who are rough sleepers or those sleeping in a hostel, a squat or on friends’ floors (insecure or short-term accommodation). These groups frequently cycle in and out of street homelessness. The definition does not include people such as families (with children) living in temporary accommodation provided by a local authority under homelessness legislation. The definition also excludes people living in overcrowded or unsuitable accommodation. However, it is acknowledged that persons who fall into these other categories of homelessness may also experience vulnerability. They are excluded by the Department of Health because ‘… although their housing may be unsettled (potentially leading to increased health problems as a consequence), they are not considered to have substantially different health needs to the mainstream population, and will not generally have significant problems in accessing primary health care’.
2.4 Sex workers
the term ‘sex worker’ has been used in contradistinction to ‘prostitute’ which has derogatory connotations. The choice of terms in the policy literature varies. While bodies such as the Department of Health and National Inclusion Health Board use ‘sex worker’, the salient term in Home Office publications is ‘prostitute’.
3.1 Search Strategies
An initial scoping study was undertaken in December 2012 which showed the literature to be limited and heterogeneous, often located in the segment that is non-peer-reviewed. This was followed for the health and social care peer-reviewed journal literature by highly structured Boolean search algorithms built around a PICO (Population-Intervention-Comparison-Outcome) framework and of hand
3.3 Quality grading of evaluations and impact
An attempt has been made to prioritise well-described and documented interventions that have been formally evaluated.
In order to help readers assess the quality of evaluations, a quality grading system has been devised that seeks to take account of the robustness and comprehensiveness of the evaluation, and whether it was independently undertaken or not. The review has identified evaluations of quality which have been undertaken by teams delivering the intervention so independence is not a necessary requirement of robustness or quality. 4 grades are identified:
[G1]: Incorporates some assessment of process (intermediate outcomes), user-assessed final outcomes, and cost evaluation (cost effectiveness or return on investment [ROI] type calculations at best, otherwise costs of providing the service)
[G2]: Incorporates some assessment of process and user-assessed final outcomes but no cost data
[G3]: Incorporates some assessment of process and / or final outcomes (not user-assessed)
[G4]: General descriptive accounts of the intervention or expert opinions, but without an explicit focus on evaluation (process or final outcomes). Although descriptive, a significant proportion of grade 4 interventions have been cited as good practice examples and in some cases have been the recipients of awards for innovative practice et al.
IE = independently evaluated; NIE = not independently evaluated (this attribution is not relevant to interventions graded 4)
4. Findings for Vulnerable Migrants
4.1 Policy on access to primary and secondary care
There is no required minimum period of stay in the UK before a person - including asylum seekers, refugees, and failed asylum seekers - can be registered with a GP. GPs can only decline such people if their list is closed or on non-discriminatory grounds. GPs have a duty to provide emergency treatment free of charge regardless of migrants’ residential or registration status. Charging regulations in secondary care have frequently changed. Since May 2012 a person granted asylum, temporary or humanitarian protection under immigration rules is exempt from NHS charges and should be recognised as a refugee. Those seeking asylum, where the outcome is not known, are also exempt from secondary care charges. Failed asylum seekers are generally liable for NHS hospital treatment charges, although there are exemptions for those continuing to be supported by the Border Agency.
Since October 2012 diagnosis and treatment for HIV/AIDS is now free to all overseas visitors. On 3 July 2013 a further open consultation was launched on migrant access to the NHS, which includes plans to end free access to primary care for all visitors and tourists.
4.2 Access to Primary Care
Studies of registration levels for refugees and asylum seekers are variable in quality and often specific to particular parts of the country only. The most robust estimates suggest that only about a third of all generic new entrants to the UK. Within this group asylum seekers were least likely to become registered (around 19%) compared with other migrants. It should be noted this evidence is based on those entering the UK from countries with a high risk of TB who underwent port health tuberculosis screening. Surveys focused on major urban centres such as London show much higher registration rates have been achieved, including rates in excess of 90%. Significant and continuing barriers to registration continue to be reported including: the unwillingness of practices to register asylum seekers; a shortfall in translation services; lack of knowledge of eligibility by practice staff; and burden of documentation required to show proof of residence.
4.3 Elements of Promising Practice in Primary care
A number of promising, but largely unevaluated models of service have developed, mostly based within urban centres with large concentrations of refugees/asylum seekers, including London, Sheffield, Nottingham, Sandwell and Glasgow. Elements of good practice that have been identified include: o The incorporation of health advocates to help navigate barriers to registration can significantly increase registrations o The development of specialist GP practices for refugees and asylum seekers o In the absence of specialist practices, using contractual arrangements such as Locally Enhanced Schemes to incentivise general practice. o New entrant schemes to facilitate registration and assessment, including bussing of new arrivals from Induction Centres to specialist and other practices
4.4 Prevention of Avoidable Hospital Admission
Few interventions have been identified; it is likely that avoidable attendance at A&E can be prevented by effective registration in primary care, but there are no robust evaluations to demonstrate this. For asylum seekers, one of the main issues for concern is whether practitioners can be trusted to interpret eligibility rules for free care correctly. Maternity care is a major health issue; some parts of the country have developed maternity care pathways for non-English speaking migrants but barriers to GP registration inhibit cost effective maternity care.
5.4 Elements of Good Practice in Secondary Care There were few studies identifiable for this group. The lack of adoption of the 2011 Census ethnic category for Gypsies and Travellers in hospital episode statistics (HES) makes this task harder.
6. Findings: People who are Homeless
6.1 Policy
The Cross-government Ministerial group on Preventing and Tackling Homelessness has focused on reducing the risks of homelessness in groups such as single men and women who are outside the legislation on homelessness. It has also focused on reducing street homelessness by supporting efforts to prevent people from being discharged from hospital on to the street and to ensure that housing benefit changes do not have an adverse impact. A number of coordinated, resourced voluntary sector initiatives have reduced rough sleeping. The Localism Act has allowed local authorities more flexibility in offering rented private sector accommodation if it meets a “suitability” threshold.
6.2 Access to Primary Care and Prevention of Avoidable Hospital Admissions
As there is still no common agreed definition of homelessness across government, studies of GP registration rates may not be comparable. The most reliable audits by Homeless Link have found a registration rate of 82-85%, most with permanent registration. Registration rates with dentists are much lower at around 40%.
For most single homeless people barriers to registration and receipt of effective primary care relate to their chaotic lifestyles, often worsened by drug and alcohol misuse. In addition the mobility of homeless people makes it difficult to engage with the rigid opening hours of core services. This often results in a pattern of deferring consultation until health issues become acute and can lead to frequent attendance in hospital, the so-called “revolving door” phenomenon.
6.3 Elements of Good Practice: Primary and Secondary Care
Numerous models of care have been developed, ranging from: no specialist/mainstream provision through to nurse-led outreach to a fully dedicated, specialist homeless service integrating both primary and secondary care. The fully integrated model includes an intermediate “step-down” facility that is currently being piloted in London and will be evaluated. There are also a number of mobile clinics that provide services to homeless people and others such as sex workers. Surveys indicate that about one third of former Primary Care Trusts do not provide any specialist homeless services, a quarter provide outreach, and 10% provide temporary registration. This finding does not in itself define good practice as cost-effective practice models will be related to the size of population served.
Most of the models across the range have not been evaluated. Notable exceptions are the city- wide Integrated Services for Homeless People in Boston, USA and the London Healthcare Pathway for Homeless People in London. The Boston service is a mix of primary, outreach, intermediate and hospital care: its notable achievements include medical respite care that bridges the widening gap between hospitals and shelters, an electronic medical record system that coordinates care and
monitors quality measures across two hospitals and 80-plus shelter and street clinics, multidisciplinary teams that integrate medical and behavioural care and ensure continuity of care, the inclusion of the homeless in the programme's governance and design of services, and consistent provision of preventive services. The London Healthcare Pathway involves a fully funded discharge planning team with primary care leadership, hostel involvement, and a health care navigator with experience of homelessness. This is one of the very few evaluations identified in the review that has demonstrated both a reduction in use of in-patient care and an increase in cost-effectiveness. It is now being adopted by several other trusts serving urban populations.
There are a number of intermediate care services based within or separately from homeless hostels. The need is based on the assumption that many homeless people have chronic conditions that require continuing care and rehabilitation that does not require the full services of an acute hospital. The largest, led by St Mungo’s in London, has shown promising results in relation to improved health of its clients, better engagement with services, and significantly reduced use of hospital care.
Key emerging elements of good practice include:
o Multidisciplinary care across sectors o Person-centred care o Service user engagement and influence o Inclusion of linked primary, hospital and respite services o Coordinated care and effective discharge planning in hospital o Specialist services/facilities in areas serving high concentrations of homeless people
7. Findings: Sex workers
7.1 National Policy
The Department of Health’s sexual health framework acknowledges the need to provide specialist services to meet the significantly poorer health experience of sex workers and to address the sensitivities of sex workers to disclosure in statutory services. Both the Department of Health and the Home Office have supported initiatives to protect sex workers from violence, to prevent and arrest sex traffickers, and to facilitate the better reporting of violence to the police. Some of these initiatives have had a positive effect although a recent policy change before the Olympics that resulted in the closure of a number of brothels in the Olympic boroughs resulted in a serious fall-off in attendance of sex workers at well-established specialist sexual health clinics.
7.2 Access to primary Care
GP registration rates, mainly in major urban areas, have been reported at about 80% with GPs being the most common source of healthcare. However, there is evidence that sex workers do not often disclose their occupation to their GP and also have low uptake rates of key preventive services such as cervical screening and hepatitis B vaccination. About 80% report difficulties attending an appointment, especially those sex workers who work at night. Street sex workers, whose health is often poorest and who may have drug misuse problems, find it particularly difficult to keep appointments.
https://www.gov.uk/government/publications/effective-health-care-for-vulnerable- groups-prevented-by-data-gaps
An initial scoping study was undertaken in December 2012 which showed the literature to be limited and heterogenous. Further structured searches have indicated that the majority of studies of interventions are small-scale, descriptive and observational, with very few examples of use of robust evaluative methodologies (RCTs, case-control studies, et al .). Nevertheless, for each of the four vulnerable groups, interventions have been found that had been evaluated, albeit frequently by the team responsible for implementing the intervention. Some of these studies, notably those relating to interventions for people who are homeless, include cost effectiveness data. The reported lack of studies on service users and of the costs of services has limited this approach with regard to interventions for sex workers.
Search strategies
Search strategies used for the health and social care peer-reviewed journal literature have been highly structured and built around a PICO (Population-Intervention-Comparison-Outcome) framework, enabling search terms to be grouped into thematic sets. All keywords and synonyms have been identified for each element in the PICO framework and searches undertaken for all possible combinations of search terms to maximise retrieval (the search terms have been linked together using logical Boolean operators). Use has been made of specific groups of search terms that locate specific types of literature, including the widely used Cochrane Highly Sensitive Search Strategies for identifying randomized trials in MEDLINE. Other groups of hedges encompass qualitative studies, reviews et al. Hand-searching of some key journals has also been undertaken.
Use has also been made in the search strategy of tools such as the Cochrane Guidelines for PH reviews: http://ph.cochrane.org/resources-and-guidance.
The following literature databases have been searched:
Literature databases searched
Type of source Databases Medical and nursing literature databases EMBASE (Excerpta Medica); Highwire Press; MEDLINE (PubMed Central); CINAHL, British Nursing Index
Citation Indexes Web of Science (Arts & Humanities Index; Social Sciences Index; Sciences Index); SCOPUS (Elsevier) Conference proceedings, symposia, seminars ISI Proceedings; ZETOC (British Library) Consolidators of journal literature Academic Search Complete; Directory of Open Access Journals; EBSCO host; ScienceDirect (Elsevier); InformaWorld; IngentaConnect; Journals@Ovid/OVID SP databases; JSTOR; Literature Online (Proquest); FindArticles (LookSmart); Open J-Gate (4000 open access journals) Economics literature EconPapers (research papers in economics); Evidence-based medicine sources Cochrane Library (systematic reviews and controlled trials); DARE (University of York Centre for Reviews & Dissemination); NHS Economic Evaluation Database (NHS EED) (CRD)/Health Economic Evaluation Database; HTA Database (CRD); TRIP; and the National Institute for Health and Care Excellence collections. Grey literature (not elsewhere cited) DH Data; Kings Fund Database; Health Management Information Consortium (HMIC) Psychology literature PsycARTICLES; PsycINFO Social Science/Sociology/Social care literature
ASSIA (applied social science journals); IBSS (International Bibliography of the Social Sciences); REGARD (UK social science research); Social Care Online; Sociological Abstracts; SocINDEX
Grey literature :
A wide range of grey literature sources has been used to locate relevant interventions, including: statutory sources [PCT Public Health Annual Reports; Joint Strategic Needs Assessments; Local Area Agreements / Local Strategic Partnerships; webpages on the four vulnerable groups on NHS organisation^1 / local authority^2 websites; Overview & Scrutiny documents; NHS and local authority single equality statements and impact assessments^3 ], national programme documentation (e.g. Pacesetters Programme; NHS Health Trainers Programme; NIHME Mental Health Programme, etc.); (^1) E.g.: http://www.cumbria.nhs.uk/equality-and-diversity/gypsytravellerhealth.aspx (^2) E.g.: http://www.cornwall.gov.uk/default.aspx?page= (^3) E.g.: http://www.fenland.gov.uk/article/1843/Traveller-and-Diversity-Section---Equality-Impact-Assessment-- -Report; http://www.kingston.gov.uk/information/your_council/equalities/equality_impact_assessments/eqia_community _services/traveller_community_support.htm;
