The Welsh Assembly’s Inequality in Health’s influence on the design
The need for a health initiative designed to improve the health of Gypsies and Travellers in North Wales was identified following a health needs assessment carried out by the Project Lead and a Health Visitor co-worker prior to the initial bid for funding from the Welsh Assembly’s Inequality in Health Fund (see Chapter 2, section 2.1.2 for an account of the development of the bid for funding). This fund was designed to reduce inequalities in health by funding
initiatives that sought to produce a positive impact on the high levels of coronary heart disease (CHD) found. Therefore, the community health initiative (CHI) was designed to have a focus on CHD and its risk factors. An emphasis was placed on the importance of health promotion as a major area of focus for the Project Health Worker (see aims and objectives Chapter 2, section 2.1.3).
The original award from the Inequality in Health Fund was for a period of three years. However, there was suggestion in the Project Agreement Terms and Conditions, that subsequent funding would be considered by the Welsh Assembly subject to approval. In practice, the Welsh Assembly has extended the project twice since the initial funding, resulting in the present funding now due to end in April 2008. Although the project has been extended, the Welsh Assembly has asked projects to consider an exit strategy. This was expressed in the first bid for extended funds towards the end of the first phase of the project. The exit strategy planned was for the local LHBs in both Wrexham and Flintshire to take on responsibility for the health initiative, spreading the service and expense over the two areas. This was believed to be a more realistic and palatable proposition to present to the LHBs by the Project Lead than the expectation that one LHB would support the service alone.
Evaluation of the project was also an expectation of the Welsh Assembly. In the Project Agreement Terms and Conditions, it was stated that evaluation should be developed and implemented to demonstrate progress and achievement against the stated aims and objectives of the project. In particular, it states that the evaluation should demonstrate the specific contribution that the project makes towards the implementation of the National Service Framework for Coronary Heart Disease. This certainly had an impact on the design of the evaluation and influenced the decision to include the CHD health status study in the design.
5.3.1.2 Multi-agency Travellers Forum's influence on the design
In the design and early implementation phase of the project, input was sought from MAF concerning operational issues with the design and roll-out of the community health initiative. MAF discussed the inclusion criteria for the health initiative and research and decided that all Gypsies and Travellers who came in
and out of the area and Gypsy/Travellers who were born at the Wrexham Maelor Hospital would be included, but ‘New Age’ Travellers would not be included as this group did not share the same cultural background.
Questions were raised in MAF meetings concerning how they (MAF) could contribute to the project. It was agreed that MAF members could raise
awareness of the community health initiative with the Gypsies and Travellers they came across in their work. Decisions were made concerning operational issues such as safety on site. Involvement with the community initiative from MAF agencies in terms of visits in the health bus was also discussed. It was agreed that only those agencies that would be viewed by Gypsies and
Travellers as being of use to them, i.e. ‘givers’ should attend. These agencies were identified as Health, Education and Homecare (see section 5.3.6. for a description of partnership working between MAF and the project).
Following this initial input from MAF, the involvement became more one-way with regular reporting of project progress being given to MAF by the project workers, but with little in the way of decision making by that group, this fell instead to the Project Steering Group. There are several reasons for this, one is that the leadership of MAF had several interruptions due to the long-term
sickness and eventual death of the MAF Chairperson. Also, the project came to be viewed by the group as a ‘health project’, and so was distanced from it as they had no functional role in the project. Figure 5.2 below illustrates the
professional group relationships with the project.
Professional Group Relationships with Project
5.3.1.3 Gypsies' and Travellers' influence on design
There was no formal involvement in the design of the CHI by Gypsies and Travellers in the area, however, their opinions were sought in an informal way by the Project Lead prior to the start of the community health initiative. User involvement has been encouraged throughout the project and is one of the objectives of the project. There is, however, reluctance on the part of Gypsies and Travellers in Wrexham to get involved with organised groups, due mainly to scepticism of their voice being heard and also due to suspicion of outsiders and authority figures. This however, is now beginning to change and several
Gypsies and Travellers have attended the Multi-agency Traveller Forum Meetings in the life of this project, although limited to single attendees with infrequent attendance to represent an issue of importance to that individual at the time. There is reluctance in the local Gypsy/Traveller groups to speak for, or
represent the views of these communities as there is no formal structure to allow for this. As discussed in the previous chapter, Gypsy/Travellers are believed to have a ‘collective culture’ (Lehti 2001, Burger 1996, Sutherland 1992, Thomas 1985, Wetzel 1983, Mandell 1974), however, this appears to function more at the extended family level rather than community level in Wrexham.
5.3.1.4 Roll-out o f Community Health Initiative
There was a push by the Project Lead in the early phase of the project to be seen to provide a service quickly, this was in part, due to the delay in appointing the project workers by five months after the project funding had been obtained (see section 5.3.2). This resulted in writing protocols whilst ‘doing the work’ of providing the community health initiative. Project workers expressed difficulty in trying to set the project up whilst delivering a service and felt that it would have run more smoothly in the beginning had roles been more defined and protocols and policies had been in place before service began.
As this was a new service, the design of the initiative had to be adapted as the project team came across difficulties. Problems were identified and solutions and new approaches were developed to meet those challenges. One example of this is the unforeseen mental health need of the Gypsies and Travellers in Wrexham. Both service and research was altered to accommodate this need (see section 5.3.3 for a full description).
5.3.1.5 Service users' perspective of design
Although many of the Gypsy and Travellers interviewed said that they did not know about the CHI before it started, the general feeling was that the project was well designed and that they were happy with the design. When asked if there was anything that could be improved, the majority could not think of any improvements. However, one person suggested extending the hours that the
‘health bus’ visited the site to include evenings to reach those male Gypsy/Travellers who were not around during the working day. Another
expressed a desire for other mobile services such as a play bus for the children on site.