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5.3.1 JSNA development and the perpetuation of inequalities

Increased local responsibility for commissioning of services is believed to increase health care providers’

accountability to the populations they serve. In theory, conducting detailed local needs assessments and designing services accordingly should lead to the development of services that reflect community health priorities (Department of Health, 2010a; Department of Health 2010b; HM Government, 2010a). In practice, however, Health and Wellbeing Boards incorporate only limited public voice (in the form of one elected representative) and there is no clear and consistent framework for conducting consultations with members of local communities to discern their preferences for health service design. Critiques of service design under the HSCA have noted that ‘rather than universal provision, there will be different levels of provision within different CCGs depending upon what the CCG decides to prioritise in that locality. One CCG may not offer the same services as a neighbouring CCG’ (Speed & Gabe, 2013, p. 571).

Prior to passage of the HSCA, patient and public involvement forums and local involvement networks (LINks) afforded local communities the opportunity to evaluate health systems (Department of Health, 2007). Healthwatch (the closest equivalent to LINks under the HSCA), however, functions primarily in providing advice and information, while lacking the capacity to influence service improvement that was afforded to past public engagement bodies. While the HSCA required that a representative of Healthwatch sit on each Health and Wellbeing Board, there is no requirement that community involvement activities of CCGs must incorporate Healthwatch, nor is there any consistent mechanism for feeding back on commissioning decisions to the public (Tritter & Koivusalo, 2013). Local health system decision-makers are accountable only to NHS England and not to the communities impacted by their decisions, creating a situation in which actual public satisfaction with services is secondary to statutory requirements to meet community engagement targets (Tritter & Koivusalo, 2013).

Under the current commissioning system, JSNAs are the only consistent vehicles for promoting commissioners’ accountability to community needs (Tritter & Koivusalo, 2013). JSNAs are, in theory, intended to highlight key inequalities, yet lack of guidance on assessment of need can give rise to significant local discrepancies in commissioning for marginalised groups. In the case of GRT communities, these variations are particularly striking.

5.3.2 Inclusion of GRT in JSNAs

Building on FFT’s review of JSNA coverage in the South East and South West of England, I conducted an expanded review, which addressed the whole of England and looked specifically at inclusion of Roma migrants in JSNAs. This review occurred in two waves – first during the summer of 2016 and again in the autumn of 2018 – to capture the impacts of annual cycles of JSNA updates. The method for each review was the same: after obtaining a list of all local authority areas in England, I then identified the most recent JSNA documents for each area and conducted keyword searches using the words ‘Gypsy’, ‘Roma’

and ‘Traveller.’ I then entered this information into a database breaking down JSNA content by area, inclusion of GRT, extent of attention to GRT needs, inclusion of CEE Roma and key health issues and barriers to care identified. At the conclusion of the 2018 review, I compared JSNA data against school census data denoting the number of ‘Gypsy/Roma’ pupils for each local area, which aided in ascertaining whether the extent of JSNA coverage was commensurate with population size.

Each phase of the policy review utilised the most recent published JSNA data, though it is relevant to note that all local authorities had not made their most recent JSNAs publicly available (and others did not list the year of publication). In 2016, 49 out of 152 included references to GRT in their JSNAs, 14 of which specifically addressed Roma migrants. In 2018, 52 local authorities produced JSNAs that made reference to GRT health, with 10 mentioning Roma migrants. GRT coverage in JSNAs could range from a chapter dedicated to GRT health to a sentence mentioning that these groups are likely to experience poorer health outcomes. While omission of GRT populations from JSNAs may simply indicate a small local GRT population or Health and Wellbeing Board members’ lack of awareness of these groups, comparing JSNA data against school census data showing Gypsy/Roma populations reveals no apparent correlation between population size and JSNA inclusion. School census data for Bath and North East Somerset, for example, report two Gypsy/Roma pupils in school, yet the JSNA includes a full chapter on Gypsy and Traveller health needs (likely as a consequence of the 2012-2013 Gypsy, Traveller, Boater,

Showman and Roma Health Survey conducted by Greenfields & Lowe). Bradford, by contrast, lists 651 Gypsy/Roma school pupils, yet does not include GRT in its JSNA.

Each phase of my JSNA review revealed very low levels of attention to Roma migrant communities. This may be attributable to limited local awareness of Roma communities, though it is worth noting that neither JSNA for my research sites (London Borough of Newham and Luton) made reference to European Roma as of 2018. This omission occurs despite engagement with both of my partner organisations with local authority and CCG officials. On a national level, the lack of data on Roma migrant populations makes it difficult to ascertain the extent to which JSNAs reflect actual population size, as school census data disaggregates only by Gypsy/Roma, yet does not allow for distinction between Gypsy and Roma identity. It can only be posited that the current state of Roma inclusion in JSNAs underrepresents population size and that the extent of attention to Roma migrant health needs far underestimates the reality of community demand for improved attention within services.

5.3.3 Comparisons of 2016 review and 2018 update

Comparing the results of the 2016 and 2018 JSNA reviews reveals minor variations in GRT inclusion in JSNAs, with Gypsy and Traveller groups receiving marginally greater coverage and European Roma receiving marginally less. A set of 41 local authorities represented areas of change (either omitting references to GRT where they had previously been included or including GRT where they had previously been omitted) with regard to inclusion of GRT in their JSNAs. Of these, 22 local areas did not mention GRT in 2016 but included them in 2018. A total of 13 local authorities represented areas of change with regard to CEE Roma, with only four including Roma where they previously had been omitted.

It is difficult to ascertain the precise reasons for these variations. Omissions of GRT from JSNAs in which they were previously included could be attributable to changes in the makeup of Health and Wellbeing Boards, through which new members may not be adequately briefed on previous target areas. This could be a particular issue for ensuring inclusion of Roma migrant communities, as the lack of reliable data on Roma populations could lead them to be routinely overlooked. In the 2018 review, JSNAs additionally appeared to increasingly follow a standard format in which they track population health across life stages, rather than focusing on particular disadvantaged groups. When the focus is shifted to

broader population health, it becomes less likely that any given ethnic minority group will be identified as a target for health promotion activities or adjustment of service provision.

5.3.4 Characterisations of GRT health and recommendations for services improvement

Nearly every JSNA addressing GRT groups highlights their poorer levels of self-reported health compared with other disadvantaged and marginalised groups. Other commonly reported problems include low life expectancy, high infant mortality rates, low immunisation uptake and higher rates of anxiety and depression. These issues are frequently attributed to the generally disadvantaged socioeconomic profile of GRT populations, which is reported to impact other key areas such as access to adequate housing and levels of educational attainment. Problematically, many JSNAs present GRT health issues in the context of travelling behaviour, focusing on high levels of mobility and limited experience of living in settled accommodation as key health determinants. Misconceptions about travelling behaviours, communication methods and cultural taboos could lead to the development of services that disregard segments of GRT populations whose behaviours do not reflect official conceptions of GRT lifestyles. In this sense, an emphasis on the needs of highly mobile Gypsies and Travellers could cause the needs of European Roma living in permanent accommodation (as well as housed Gypsies and Travellers) to go unnoticed in the development of commissioning priorities.

Many JSNAs make no concrete recommendations for improvement of service in light of GRT-specific needs. Of those that do, there is often a focus on methods for enhancing communication between health service staff and GRT patients. Cultural awareness training for frontline staff and development of resources through consultation with GRT communities are common recommendations for promoting better mutual understanding between GRT community members and service providers. Some JSNAs additionally seek to increase engagement of GRT communities with health services by outlining health champion programmes, in which trained GRT health advocates provide heath advice to their communities. Finally, there have also been vague calls for ‘awareness raising’ as an area for action, yet these do not specify whether awareness raising activities will be directed at service providers, service users or both.