Supporting access to Covid-19 vaccination for Gypsy, Traveller and Liveaboard Boater communities: Guidance for professionals

Watch our video: How to support access to the COVID-19 vaccine in Gypsy and Traveller communities

Everyone in society should have fair access to a COVID-19 vaccination when they’re entitled to one, and everyone should have the opportunity to remain up to date and informed on relevant information about the vaccine.

We know that for some groups who are facing longstanding inequalities in healthcare access and outcomes however, there will be barriers that may impact uptake to the vaccine, and that some people may not be receiving key, relevant health messages.

Evidence from studies on uptake of immunisations broadly suggests that for Gypsy and Traveller communities, access, rather than vaccine refusal, is the most significant barrier to vaccine uptake. There are a few practical adjustments healthcare professionals can make to support access to the COVID-19 vaccine for Gypsy and Traveller communities, and a number of things that healthcare professionals can be aware of to help to ensure that people from Gypsy and Traveller communities can make an informed choice around vaccination.

In this guidance, we’ll cover some of the key issues for access to vaccination for Gypsy and Traveller communities, and some simple, practical recommendations that can help to support access to vaccination. This includes ensuring that no one is wrongfully refused registration in primary care, that no one is refused access to vaccination as a result of no NHS number or GP registration, tips for linking in with trusted local charities and networks to support culturally competent community engagement, and ensuring that your communication approach is accessible and inclusive.

 Gypsy and Traveller communities

  • There are estimated to be around 300,000 Gypsy and Traveller people in the UK – that is around 1 in 200 people. Within Gypsy and Traveller communities, around three quarters of people live in bricks and mortar housing, whilst around 10,000 people live on roadside camps and around 70,000 people live on Gypsy or Traveller sites.
  • There are a huge diversity of communities who fit under the “Gypsy and Traveller” umbrella term – this includes Romany Gypsies, Irish Travellers, Scottish Gypsy/Travellers, Welsh Gypsy/Travellers, New Travellers, Boaters and many more. Each community has its own distinct history and many of the communities have their own distinct cultures and languages. Romany Gypsy and Irish Traveller communities are recognised in English law as ethnic groups, but the same would also apply to Scottish Gypsy Travellers and Welsh Gypsy Travellers.
  • Of course, people from Gypsy and Traveller communities don’t all hold the same views on everything or have the same experiences in everything, so it’s important not to assume Gypsies and Travellers are one homogenous group.
  • Gypsy and Traveller communities are known to face some of the most severe health inequalities and poorest life outcomes amongst the UK population, with higher rates of long‐term illness, higher overall prevalence of reported chest pain and cardiovascular conditions, and higher levels of respiratory problems, which means that within Gypsy and Traveller communities, there is a disproportionately high number of people at increased risk of severe illness from coronavirus (link). A recent study from the University of Manchester shows that the average health of a 60 year old in a Gypsy or Irish Traveller community in England is similar to the average health of an 80 year old from the White British population (link).
  • Disaggregated data on the health of Gypsies and Travellers tends not to be routinely monitored within NHS services. Your service may therefore not be aware of Gypsy and Traveller communities in your local population, their needs, or the inequalities they face. However, this does not mean they are not important or there is not much you can do.
  • If you would like to access data to help you understand the population size of Gypsy and Traveller people in your area, please view page 35 of our guide on tackling health inequalities in Gypsy, Roma and Traveller communities

Vaccination for those with no NHS number or GP

“Patients and NHS staff do not require an NHS number or GP registration to receive a vaccination and should never be denied one on this basis, either in person when presenting for a vaccine, or through the design of booking systems.

If a patient has not been issued with an NHS number, then providers should vaccinate now, record locally via a paper system and ensure that the vaccination event is recorded on Outcomes4Health/Pinnacle at a later date. NHS England and NHS Improvement are looking into a longer-term solution, but providers should not wait for this before vaccinating. Providers will be advised once a solution is in place so they can transfer the vaccination record on to Outcomes4Health/Pinnacle and be paid for these vaccinations in the next payment period.”

 GP registration

  • One of the key things that healthcare professionals can do to support access to vaccination, is to ensure that no one is wrongfully refused registration at a doctors surgery as a result of no fixed address or no ID.
  • Although there is no regulatory requirement to provide a fixed address or ID in order to register with a GP practice, and this is not reasonable grounds to refuse registration, many nomadic Gypsies, Travellers and Boaters are regularly refused registration on this basis. Difficulty accessing primary care services is a key barrier to accessing the COVID-19 vaccination for Gypsy, Traveller and Boater communities.
  • In 2018 we mystery shopped 50 GP practices in England, and found that nearly half of the practices we contacted refused registration on this basis. This has significant impacts on access to healthcare, and invitations to preventative interventions such as immunisations and screening, which are based on GP records. If people are not able to register with a GP, they will not be invited to vaccination when they should be.
  • It is really important that all members of staff within GP practices, including Practice Managers and Reception staff are aware of and up to date around patient rights around registration, and are fully informed of their responsibilities to register people with no fixed address and no identification. No one should be turned away from primary care services on this basis.
  • We have also heard of many reports during the pandemic of practices only allowing new registrations through online forms. The NHS England Guidance and standard operating procedures for General practice in the context of coronavirus is clear that:

“Practices should continue to register new patients where capacity allows, prioritising those with no fixed address, asylum seekers, refugees and people leaving custody. Practices may only refuse registration if they have reasonable grounds to refuse services to patients. Delivery of applications for patient registration may be by any means, including post and digital (eg scanned copy). Where a practice has online registration options, a supporting signed letter from the patient, posted or emailed to the practice, is acceptable to complete the registration.”

  • When processing registrations for patients from Gypsy, Traveller and Boater communities, it’s also important not to assume that a patient always wishes to be registered as a temporary patient, as this can restrict access for patients to non-urgent care, invites to routine screenings or referrals to specialist care, which has important implications for health.
  • Since 2015, all GP practices in England have been free to register patients outside of practice boundaries in order to support patient choice. For nomadic patients, travel outside of a practice boundary is often important for work and social reasons. When it comes to temporary or permanent registration, patient choice is key.

Linking in with trusted organisations and networks

  • Across the whole of the UK population, there have been high levels of fake news, and misleading information shared around the vaccine, which can contribute to concerns around vaccination. We are aware of specific concerns within Gypsy and Traveller communities that Gypsy and Traveller people may be targeted with the vaccination with negative intentions, including concerns that Gypsies and Travellers will be targeted in order to test the safety of the vaccine.
  • A poll commissioned in December 2020 by the Royal Society for Public Health showed that only 57% of respondents from Black, Asian and minority ethnic backgrounds were likely to accept a COVID-19 vaccine, compared to 79% of White respondents. While no official polling results have been launched for Gypsy and Traveller communities, we expect the results to be similar to people to people from other minority ethnic backgrounds or perhaps worse.
  • This reflects a lower level of trust in Government within Gypsy and Traveller communities due to historic and present day experiences of direct or indirect discrimination from public services. With this in mind, you may find people from Gypsy and Traveller communities in your local population to have lower levels of trust in the COVID-19 vaccine.
  • It’s really important that healthcare services consider how they can ensure everyone has all of the information they need to make an informed decision about taking the vaccine and that healthcare professionals are equipped to address misinformation about the vaccine. Linking in with local, trusted organisations and networks can support this, and trusted local services and organisations will be best placed to determine the best approaches to disseminate information on the vaccination locally.
  • We are aware of proposals in some areas to carry out assertive outreach onto Traveller sites with the vaccine. Broadly, in our organisation’s work over the past 20 years we’ve heard that most Gypsy and Traveller people want to access healthcare through the same means as other people in the population. Therefore, unless you have local evidence and longstanding, trusting and positive relationships with people living on Traveller sites in your area, we would not encourage you to visit Traveller sites to assertively outreach with the vaccine. There is a very real risk that this will either scare people or stigmatise people within their local communities.
  • You can refer to our service directory at Friends, Families and Travellers for more information on local trusted organisations and services and how to get in touch, or email us for advice.

Inclusive communications

  • To ensure that health messages and information reach everyone, it is really important that these are delivered in accessible formats. Around 40% of our service users at FFT have low or no literacy. However, this is not an issue specific to Gypsy and Traveller people, in fact, around 16% of adults in England have low or no literacy. Without support, many patients with low or no literacy will find it difficult to read medical letters, access services, and access key information.
  • In addition to this, people from Gypsy and Traveller communities are more likely to be digitally excluded. We previously interviewed 50 Gypsy and Traveller people and found that one in five participants had never used the internet, compared to one in ten people from the general population, and only 38% of Gypsies and Travellers we interviewed (33% if housed) had a household internet connection, compared to 86% of the general population.
  • At doctors surgeries, vaccination hubs and other services, routinely offering discreet support with form filling can support those who may otherwise be unable to access services, or may be deterred from accessing a service if information isn’t provided in an accessible format. It can feel difficult or stigmatising to ask questions about this. Instead of saying, “Can you read or write?”, ask “Can I help you with this form/letter?”. You can also use Voice Notes instead of text messages to communicate with patients with low or no literacy.
  • In addition, to support access to services, ensure that no processes become “digital by default”. Digital processes can unwittingly exclude people facing digital exclusion as a result of literacy levels, levels of English language skills, or financial difficulty accessing data and devices. Ensure that you offer different ways of accessing support – flexibility is key!
  • In general, when providing information around the vaccination and other important health messages, consider how you can make your communications more accessible; offer videos and audio recordings of information wherever possible, offer telephone communication as opposed to written correspondence, and consider the use of audio tools such as Browsealoud, which adds speech, reading and translation to websites.

Nomadism

  • For people who are on the move, it’s really important that communication preferences and contact details are kept up to date, so that patients are able to receive invitations to vaccination. Many nomadic patients may be registered at a “care of address”, or with an address where they no longer live, so being flexible with your invitation approach, contacting people by text or telephone, and asking patients about the best ways to keep in touch will help to ensure that you are reaching people with important invitations and information about their health, rather than using a “one size fits all” approach and sending letters to people who might not have addresses.
  • Finally, for those living nomadically, consideration should be given to how best to administer the second round of the vaccine. There are both push and pull factors for travelling nomadically. In terms of push factors, evictions of roadside camps have continued throughout the pandemic and are likely to increase as lockdown measures lift. Failure to comply with evictions can result in being imprisoned, fined or having your home removed. Similarly, many people living on boats are subject to strict ‘continuous cruising’ rules requiring them to move from place to place every 14 days in a continuous direction along the canal. If Boaters fail to meet the requirements, they can have their boat license removed and potentially have their home seized. In terms of pull factors, people living nomadically often travel for work.
  • There are very practical implications for this in regards to people waiting for either their first or second round of the COVID-19 vaccine. It’s really important to have open discussions with your patients about where they are likely to be when the second round of the vaccine should be administered. If your patient is worried that they might be evicted or subjected to continuous cruising rules within this time, it may be really helpful for you to write a short letter highlighting the importance of the person being able to stay in the area for this period of time. Many waterways organisations have suspended continuous cruising rules during key periods of the pandemic, whilst many local authorities have implemented negotiated stopping during the pandemic.
Access to both doses of the vaccine while travelling
  • The COVID-19 vaccination is given in 2 doses, up to 12 weeks apart. If a patient is travelling, services will need to offer additional support to ensure that individuals can access both doses of the vaccine.
  • We have created a guidance piece for healthcare professionals and template letter to support patients to access the second dose of the vaccine

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