Advice for GP surgeries: Providing an inclusive service to Gypsies, Travellers and Boaters

The first principle of the NHS constitution sets out that the “NHS provides a comprehensive service, available to all”. In particular, the principle highlights that the NHS “has a wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population.”

Despite this, in a recent mystery shop of 100 GP surgeries in England, we found that 74 GP surgeries broke NHS England guidance and refused to register our mystery shopper because they were unable to provide proof of identity, proof of fixed address, register online or another reason. This has significant impacts on access to healthcare, and invitations to preventative interventions such as immunisations and screening, which are based on GP records.

We work with many Gypsies, Travellers and Boaters who have been refused registration at a GP, often with devastating consequences. We know that you will share our belief that everyone should have access to primary care. In this guidance, we’ll cover the legal responsibilities of GP practices towards Gypsy, Traveller and Boater patients, as well as guidance on providing an inclusive service.

GP registration: key responsibilities

The NHS England Patient Registration Standard Operating Principles for Primary Medical Care (General Practice), state that:

"As there is no requirement under the regulations to produce identity or residence information, the patient MUST be registered on application unless the practice has reasonable grounds to decline. Registration and appointments should not be withheld because a patient does not have the necessary proof of residence or personal identification. Inability by a patient to provide identification or proof of address would not be considered reasonable grounds to refuse to register a patient."

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.”

It is important to note that health and care services have clear legal, as well as moral, reasons to tackle health inequalities in their everyday work. Staff within your GP surgery should be aware of their legal duties to provide access to services and to reduce inequalities.

Romany Gypsies and Irish Travellers are recognised by law as ethnic groups and therefore have protection against both direct and indirect discrimination under the Equality Act 2010. Discrimination means receiving unfair treatment because of who you are. Indirect discrimination is when there’s a practice, policy or rule which applies to everyone in the same way, but it has a worse effect on some people than others. Refusing to register a Romany Gypsy or Irish Traveller patient because they travel and are unable to to provide proof of address, would be considered indirect discrimination.

How to provide an inclusive service

Temporary vs permanent registrations

Being registered as a temporary patient can restrict access for patients to non-urgent care, invites to routine screenings or referrals to specialist care, which has important implications for health. When processing registrations for patients from Gypsy, Traveller and Boater communities, don’t assume that the patient always wishes to be registered as a temporary patient.

Gypsy, Traveller and Boater patients may travel in and out of your area. Indeed, some patients may never be in any area of the country for any significant amount of time. Because a patient isn't going to be in your area for a significant amount of time doesn't mean they must be register as a temporary patient. Since 2015, all GP practices in England have been free to register patients outside of practice boundaries in order to support patient choice.

In order to determine what is best, listen to the patient on whether they would prefer to be registered as a permanent or temporary patient and ensure they are aware of the repercussions of any decision they may choose to make. You should also inform the patient on their entitlement to home visits depending on where they are located at any given time. Where a patient becomes unwell outside of your geographic catchment area and requires a home visit, you can and should contact GP practices in that area to register the patient and arrange a home visit.

Contact details and methods of contact

For those living nomadically, make sure you're using the most relevant contact details and methods. 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 correspondence 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.

Taking account of communication needs

According to the National Literacy Trust, 16.4% of adults in England, or 7.1 million people, can be described as having 'very poor literacy skills.' Due to inequalities in the education system, disproportionate numbers of Gypsy and Traveller people 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.

It is important that all staff members in your GP practice know not to assume that everyone they meet has a high level of literacy. Ensure that when asking a patient to undertake any activity which involves reading or writing, this is accompanied by a verbal offer to support with this if needed.

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. Offer videos and audio recordings of information wherever possible, offer telephone communication as opposed to written correspondence where needed, and consider the use of audio tools such as Browsealoud, which adds speech, reading and translation to websites. Don't make assumptions about peoples' ability to read and write - one way or another.

Taking account of digital exclusion

Ensure that your service is accessible to people experiencing digital exclusion. Our research and casework has shown that there are disproportionately high levels of digital exclusion in Gypsy and Traveller communities. It's important that no practices within your GP surgery are digital by default and that there is clear information provided to patients about their rights to access the service in a way that is accessible to them.

Patients experiencing digital exclusion should experience the same quality of service as patients who are not experiencing digital exclusion. If you are offering your service using a digital first approach, consider how long it takes for patients to access appointments and advice through digital vs. not digital routes. For example, if you're offering the majority of appointments online, make sure you are holding over enough appointments for people who phone in to book to see their GP.

Respect patient choice

Remember that all patients, including Gypsies, Travellers and Boaters, can register at a GP of their choice, not only at homeless GPs or walk in centres. We often work with people who have been signposted from one GP to another, and while the intention might be good, it can leave individuals feeling like nobody wants to register them. Respect patient choice about where they would like to be registered and make sure they feel welcomed in your practice.

Take into account distance within total triage models

In our recent research study into the health of 356 Liveaboard Boaters, we found that respondents reported that on average they were 47 kilometres away from their GP.

During the pandemic, many GP surgeries have put in place effective total triage models to manage the large amount of patients seeking support. It's important to take into account that some flexibility may be required within the total triage model to account for patients who may be some distance away.

Capitalise on emerging opportunities within general practice

Emerging trends within general practice, such as the increase in electronic prescribing may be particularly beneficial for patients living nomadically, so make sure your patients are aware of the opportunities this could offer them and proactively look out for other opportunities which might make health and care easier to access for people who travel.

Further resources and training

While the information laid out on this page may give you some food for thought about how you can make your GP surgery more inclusive, you can find information below on where you can go to for more training:

• With over 25 years’ experience of working with individuals from Gypsy, Traveller and nomadic communities, our Gypsy and Traveller cultural awareness training can support your GP surgery to improve your work with Gypsy and Traveller people. Find out more here.
• Together with partners, we've developed an online tool to help your Primary Care Network to assess it’s engagement with Inclusion Health groups. These are the groups identified as experiencing the worst health inequalities in the UK. The tool consists of five sections and takes around 10 minutes to complete. Once you have completed the self assessment, you will be provided with a unique and tailored guide which will help your Primary Care Network to embed action on tackling health inequalities into its everyday activities. Find out more here.
• To accompany the Inclusion Health Self Assessment Tool for Primary Care Networks, with our partners at Homeless Link, National Ugly Mugs, Doctors of the World and Stonewall Housing, we have recently launched an invitation for Primary Care Networks to receive guidance and training to improve their work with Inclusion Health groups. Find out more here.

Thank you for reading this advice, information and guidance.