How we can improve healthcare for Gypsy, Roma, Traveller, Boater, and Showmen communities living outside the system

In London, over 44 000 people from the Gypsy, Roma, Traveller, Boater, and Showmen (GRTBS) communities live in precarious conditions. They live in a cycle of distrust and disengagement with healthcare services that local authorities consistently struggle to break.1 People from these communities face many barriers to accessing healthcare services, leading to many going unseen by the NHS and leaving their healthcare needs unmet.

Communities commonly categorised under the GRTBS umbrella are not homogenous and have different healthcare and access needs. These communities vary in terms of language, immigration status, accommodation habits, histories, education levels, and beliefs. In the 2021 Census, 62% of this population presented in “fair,” “bad,” or "very bad” health, versus 18% of the average population in England and Wales.2 These figures likely do not account for the many people that have been missed by the system entirely. Many do not access healthcare until they reach a critical point.3 Barriers to care include poor health literacy, limited understanding of their healthcare rights, language barriers, distrust of statutory bodies, stigma, and discrimination. For people in these communities, barriers are posed by frequent relocation, often enforced by local authorities.

Anecdotal observations from within the Bulgarian Roma community highlight wider issues, for example, poor awareness of healthcare rights has left people vulnerable to exploitation.4 People and families are sometimes scammed into paying hundreds of pounds for GP registration, despite primary care in the UK being free. Immigration status is also a barrier as there is a prevalent belief that access to primary NHS care is dependent upon the legal right to reside in the UK. In our work we have seen poor nutrition, high smoking rates, high demand for pregnancy and contraception advice, and numerous long term, chronic health conditions that also affect the communities’ wellbeing.

Access to GRTBS groups to deliver healthcare services depends heavily on providers having strong relationships with people embedded within each community. Despite the barriers, there are opportunities to deliver better healthcare. In a year long project aimed at tackling low rates of GP registration in GRTBS communities, Doctors of the World worked with almost 200 adults and children to assist with GP registration and provided health assessments from their own accommodation and in community spaces. This enabled flexible, accessible service provision and trust building.5 This project had the strongest links and access to the Bulgarian Roma community, but the findings can in many cases be applied to other communities in the GRTBS category.

Health promotion and education sessions were particularly successful in this community because of poor health literacy and awareness of health services. With the help of an in-person translator, we held sessions for parents in schools about the NHS and how to access healthcare, mental health, contraception, and abortion services. The appetite for sexual health education and workshops appeared to be particularly strong as they tend to be disengaged with or unable to access healthcare and health information. Our team were informed by community members that family planning and reproductive health are rarely discussed within the Bulgarian Roma community, and therefore information about contraception is little known or unavailable. Some community members described self-induced termination attempts without any medical professional supervision.

Based on our experience with this diverse community, we provide the following recommendations. People from GRTBS communities must be able to access primary care—including being supported to register with a GP. This should be combined with outreach services that support health education and rights, provide services, and build trust. Registration should not conflict with nomadic lifestyles. This can be overcome by not requiring a proof of address upon registration, providing ongoing support to patients even outside catchment areas, and finding ways to ensure the swift transfer of healthcare records.

Distrust within GRTBS communities of the medical and statutory systems make it even more essential for health services to build long lasting trust and relationships, working with respected peers embedded within the community. Healthcare services for these communities should be built around consistent, accessible services, and should account for frequent transience. Health promotion activities around topics such as sexual and reproductive health, mental health and rights to access to primary and secondary care, should be delivered on a regular basis and dialogue encouraged through group sessions. Registration with a GP must be as accessible as possible, with multiple routes to registration, translation, and literacy support provided at the point of access. Proof of identity and address documents must not be a barrier to registration, and initial health assessments should provide information to patients about how the NHS works and accessing various NHS services.

Some communities under the GRTBS umbrella continue to be excluded from the digital transformation of healthcare. They generally have poor written and reading literacy in English and sometimes also in their native languages and when using digital systems. This barrier is compounded by limited internet access. Interviews with members of GRTBS communities showed that 38% had a household internet connection, compared with 86% of the general population.6 Translation services and pictorial materials help to improve health literacy and bridge language barriers.

People from GRTBS communities are less likely to engage with vital services and are less visible to healthcare providers and statutory services. The complex and overlapping vulnerabilities that affect people from these communities mean that a holistic approach to health and wellbeing should be adopted when designing services—considering that needs and stressors may affect their health. Referral processes between services including healthcare, immigration, legal, housing, welfare, modern slavery, and safeguarding must be strong. Without such interconnected systems, tackling the social determinants of ill health and wellbeing in these communities will remain difficult, and the burden of complex and overlapping needs risks falling to a singular service to support.

Services must be tailored to respond to the specific needs of people from GRTBS communities. Commissioners and health professionals working to improve healthcare in these communities must remove access barriers and break a perpetual cycle of distrust and disengagement.