Hard to Reach or Easy to Exclude

1. Graham Culyer: Expert by ExperienceDonald Lane: Expert by ExperienceKevin Hanner: Service ManagerSeptember 2015

4. “We can foresee a better NHS that eliminates discrimination and reduces inequality in care.” Liberating the NHS Department of Health 2012

5. Hard to Reach or Easy to Exclude

7. What are we? The aim of the service is to provide primary care health services for people who frequently find it difficult to appropriate health care: those that are homeless, at risk of homelessness, asylum seekers, refugees, sex workers, Gypsies and Travellers or who are not accessing mainstream GP services for any other reason. The team consists of GP’s, Nurse Practitioners, Practice Nurses, Health Visitors and Clinical Support Workers. Provided by Norfolk Community Health & Care NHS Trust • Established in 2001. • At current location since 2010. • Integration and co-location of the Matrix in October 2013

8. Where are we?

9. Outreach What are we?

10. In Reach

11. The Jigsaw Primary Care Local Authority/ Social Services Secondary Care Individual Social Support Third Sector Criminal Justice

12. The Final Piece Primary Care Local Authority/ Social Services Secondary Care Communication & Integration Social Support Third Sector Criminal Justice

13. The Completed Puzzle Primary Care Local Authority/ Social Services Secondary Care Individual Care Pathways Social Support Third Sector Criminal Justice

14. Who do we see? • 500+ patients accessing the service at any time. Approximately 50 new patients each month and approximately 50 patients leaving the service each month. 90% of deregistering patients are linked in with appropriate healthcare at point of deregistration. We provide approximately 250 nursing and 250 GP consultations each month. • 55% of patients have been registered with service under 6 months and 85% under 12 months • Sex: 68% Male and 32% female • Age: 5% 0-4, 5% 5-14, 16% 15-24, 30% 25-34, 23% 35-44, 13% 45-54, 5% 55-64, 1% 65+ • Approx Referrals: 65% homeless, 20% Asylum Seekers/Refugees, 5% Gypsy & Traveller, 5% Women’s Refuge, 5% Sex Workers

21. Health & Homelessness * The average age of death of a homeless person is estimated to be 43-47 (Crisis 2011) * Rough sleepers experience TB at 200 times that of the known rate among the general population. * 40% of homeless people will have used A&E in the past six months, and nearly a third will have been admitted to hospital as an inpatient. Homeless Link 2012

22. HOMELESSNESS, MENTAL HEALTH AND WELLBEING GUIDE UNDERSTANDING HOMELESSNESS, MENTAL HEALTH AND WELLBEING http://homeless.org.uk/sites/default/files/SECTION_2_Understanding_mental_health_wellbeing_and_homelessness%20pdf.pdf

23. Levels of need •72% of clients said they had one or more mental health need •45% said they had one or more long-term mental health need (61% of all those with a mental health need) •35% of those with a mental health need said that they would like more support with their mental health •Other research also found that 60% of people in homelessness services have been found to be affected by complex trauma or personality disorder. Currently •44% of those with a mental health problem said they self-medicate with drugs or alcohol •14% of clients stated that they self-harm, compared with 4% of the population •One fifth of clients who had recently attended A&E had done so because of either mental health or self harm •Only 10% of clients have additional support from mental health services HEALTH NEEDS AUDIT: Homelesslink 2011 • 900 people from hostels, day services and those in contact with outreach teams. • http://homeless.org.uk/health-needs-audit

25. Homeless/Health Inclusion Link’s policy pages To find out more about mental health policy and how affects the needs of homeless people: http://homeless.org.uk/mental-health-policy-context Also see Homeless Links consultation responses: http://www.homeless.org.uk/closedconsultations Health Inclusion: Hospital Discharge Paper: http://www.londonpathway.org.uk/uploads/BMJ_2012345-e5999.pdf Standards for Commissioners & Providers: http://www.pathway.org.uk/publications/faculty-for-homeless-and-inclusion-health-publications/#the-faculty-for-homeless-and-inclusion-health-service-standards-for-commissioners-and-service-providers-version-2 Link Aidan Halligan: http://www.londonpathway.org.uk/

26. Mental Health Service Interventions for Rough Sleepers: Tools and Guidance Background: Targeted approach in London 2009. 205 entrenched rough sleepers identified who had been on the streets for over 5 years. Action: Intensive support, over 50 offers of help each. Outcome: 45 remain on the street. High percentage of significant mental health condition, isolated, not claiming benefits, and reluctant to engage. SCR: Lambeth September 2012 http://www.pathway.org.uk/wp-content/uploads/2013/09/RSG-ONLINE-FINAL-lo-res.pdf

27. The project was set up after a serious case review, published in September 2012, undertaken by the Lambeth Safeguarding Adult Partnership Board. The review concerned a mentally ill person who was sleeping rough and died on the street in the winter of 2010. He had previously been under the care of mental health services and had contact with street outreach teams, ambulance crews and police at his rough sleeping site. He refused all the help that was offered and subsequently died on the street. The Serious Case Review panel decided that it would be helpful to develop a common set of protocols and tools for services working directly with people sleeping rough on the streets. • Risk Assessment • Mental Capacity Act • Mental Health Act • Hospital Admission Plan • Safeguarding Adults

28. Gypsy & Traveller’s Overview It is estimated that there are between 200- and 300,000 Gypsies and Travellers in the UK, two-thirds of which are settled in brick and mortar. 1000+ in Norfolk The Traveller identity is often used as an umbrella definition for all populations coming from a nomadic cultural background, including Romany, Welsh, Irish, English and Scottish Gypsies, Roma, as well as fairground and boating communities. The availability of culturally appropriate accommodation in the form of authorised, appropriately equipped site plots is extremely limited, hence many recur to illegal or non-fit for purpose arrangements, or reluctantly move into stable housing. The Health of Gypsy Travellers in England CD: Richard O’Neill and Mally Dow

29. Health & social exclusion issues There are a range of contributing factors to the poor health outcomes and the difficulties in accessing services for members of this community. Low levels of literacy, together with stigma, poor access to health information and some widespread health-beliefs increase the likeliness that they will not seek treatment, or will underestimate the seriousness of the condition (Van Cleemphut, 2009). 42 per cent of English Gypsies are affected by a long-term condition, as opposed to 18 per cent of the general population (Parry et al., 2007). Life expectancy 10-12 years less 38% long term illness (26% general) Infant mortality 25 out 142 women compared to 1 in 110. Under 50% immunisation uptake Suicide rates 8.5% higher than general population (Harris & Barraclough, 1997) 79% reported depression or ‘nerves’

30. Access issues The main reported health-related difficulties for this group are lack of suitable accommodation and GP registration, as many are turned down as problematic users (Cemlyn et al., 2009). Lack of cultural awareness, including racism, perceived judgemental behaviours, or inability to ‘explain things properly’ often contributes to the poor patient experience (FFT, 2010). The nomadic lifestyle complicates access to appropriate care: registration can be difficult, information is not being shared, and patients can often not articulate their needs. Hence, they often travel long distances to see a professional they trust (Cemlyn, 2002).

31. Considerations Information sharing: Key factor in improving access for Gypsies and Travellers, especially given their high mobility and complex needs. Community engagement : is important for professionals to establish a relationship with the wider network of people, and makes sure that a trusted relationship is gradually set up. This will also contribute to the design of a service that meets the community’s perceived need and develop a sense of ownership. Mainstream services: Even though one of the most widely implemented strategies has been the ‘dedicated health visitor’, this should not necessarily be seen as an example of best practice. In fact, Travellers do not want dedicated services, but would much rather be able to access the same high quality services as everyone else, which will also reduce ‘singling out’ (PCC Framework, 2009). Poor living conditions and environmental factors: The single most influential contributing factor to the poor health status of Gypsies and Travellers, including stress. This makes partnership working between the different agencies, including the NHS, Local Authorities Social Services, Housing and Environmental Health, and voluntary sector organisations, even more important to provide a coordinated response to these inter-related issues.

32. Sex Workers Overview It is estimated that there are about 80,000 sex workers in the UK, up to 20,000 of which could be migrants (TAMPEP, 2009). Whilst the common representation of the phenomenon involves street-based sex-work, this only accounts for about a third of the total volume, whilst the other two-thirds consist of ‘parlour-based’ activity and takes place indoors (Hough & Rice, 2008). The motivations drawing these two very different groups into the sex industry tend to vary, as substance addiction and chaotic lifestyles are influential drivers among street-based workers, whilst financial difficulties are often the key motivation for indoor-based prostitution (Home Office, 2004). k

33. http://www.uknswp.org/ www.matrixproject.org

34. Detached Outreach: Street/ public place, cruising, dogging, cold calling Peripatetic Outreach: Off-the street, massage parlours, saunas, clubs, flats, lap dancing bars; and public sex venues (saunas, private clubs, fetish parties). Satellite Outreach: Satellite outreach is when one organisation is located within another. Prisons, day centres or GUM clinics. Domiciliary Outreach: Domiciliary outreach is specific outreach with individuals outside their working environment. Own homes, hospital and prison visits; and attending appointments with service users. ‘ Netreach’’: outreach where projects make contact with sex workers using the internet/ social media. k

35. Resources: Good Practice Guide/ Working with Sex Workers Outreach: http://www.uknswp.org/wp-content/uploads/GPG2.pdf Good Practice Guide/ Working with Migrant Sex Workers: http://www.uknswp.org/wp-content/uploads/GPG3.pdf Good Practice Guide/ Working with Male & Transgender Sex Workers: http://www.uknswp.org/wp-content/uploads/GPG4.pdf Good Practice Guide/ Working with Sex Workers, exiting: http://www.uknswp.org/wp-content/uploads/GPG5.pdf UEA research 2015: http://www.uea.ac.uk/documents/3437903/4264977/Matrix+FINAL+12+March+2015.pdf/e78fef51-952d-437d-8df3-e7acc141f9c7 k

36. Asylum seeker: a person who enters a country to claim asylum (under the 1951 UN Convention and its 1967 Protocol). Individuals undergo the asylum process to have their claim assessed. Refugee: "… a person who "owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country...". Refugee status, or temporary 'leave to remain' (sometimes granted on humanitarian grounds) is awarded by the Home Secretary and affords the same welfare rights as other UK citizens. Refused (also known as 'failed') asylum seeker: a person whose claim has been rejected by the Home Office. Individuals have no right to remain in the UK but can appeal. If all rights of appeal have been exhausted, all Home Office support is taken away, and they are asked to return to their country of origin.

37. 44 Million individuals dispersed internationally • Half women and children • Main areas 2012: • Palestine • Afghanistan • Iraq • Columbia • Sudan • Somalia

38. City Reach Health Services Asylum Health Team In summary the Asylum Health Team made direct contact with 72 newly dispersed Asylum Seekers between the 1st November 2011 and the 31st January 2012, all of whom had arrived in Norwich since the 1st August 2011. Of the 72 new referrals, 38 were female and 34 male. Only 13 (18%) had previously been registered with a GP and had an allocated NHS number, although after the intervention of the team 69 (96%) have an allocated NHS number and have successfully been registered at an appropriate local surgery. Using a model developed from the NHS Choose Well campaign, 96% of the population have also received individual support, physical orientation and education in explaining how the NHS works, how to use services appropriately, including pharmacies, primary care and emergency services. The BMA (1) and Faculty of Public Health (2) state that unfamiliarity with NHS primary care provision is a major barrier to Asylum Seekers and we anticipate that this timely intervention will improve individual health outcomes and reduce inappropriate use of NHS acute services which will therefore produce savings to the health economy. 1: BMA Ethics (January 2012) Access to health care for Asylum Seekers- Guidance for Doctors. 2: Faculty of Public Health (2008) The Health needs of Asylum Seekers.

39. Norwich: A City of Refuge Gateway Resettlement Project http://www.youtube.com/watch?v=VpqGwaULj9M&hl=en-GB&gl=GB 450+ individuals resettled in Norwich http://www.youtube.com/watch?v=A1nvPbB1n0Y

40. Factors impacting on Health Pre-flight Famine Loss of shelter Limited Medical War Torture Imprisonment Death & loss Upheaval & change Disrupted education and health care Exploitation Abuse

41. Flight Secrecy No goodbye or closure Unknown No belongings/ID Fear Survivors guilt Loss Illness Death

42. Post-flight Second class citizens New language and culture Rejection Loss Survivors guilt Conform but discrinination Lack of control Western service models/delivery Alienation Isolation Financial, social and cultural deprivation Abuse Racism Blame

43. Mental Health • Every year thousands of people arrive in the UK seeking sanctuary, often fleeing conflict and persecution having experienced torture, violence or imprisonment. It's not surprising that many will have developed mental health problems as a result of their traumatic experiences but what is surprising is that many more will develop mental health problems once on UK soil. A popular assumption is that once refugees arrive in this country that their problems are over but research has clearly shown that it can be just the beginning

46. NRPF and Migrant Health: http://www.healthwatchnorfolk.co.uk/sites/default/files/hwn_report_on_migrant_workers_accessing_healthcare_in_norfolk.pdf

47. Patient Experience: “I previously had experienced doctors looking to blame me rather than help. This has left me disillusioned and resulted in me walking out.”- “I couldn’t ask for anything better. I’ve found a doctor who will listen, not judge, and who takes the time to explain my symptoms and options,” “I wasn’t bothered about accessing healthcare when I came out of prison as I had other priorities. However, in hindsight I needed medical advice and the outreach nurses found me.”- “The best thing about City Reach was the support worker. They supported me attending hospital appointments and gave me the confidence to access a normal surgery,”

48. Where are we? City Reach Health Services Norfolk Community Health & Care NHS Trust Under 1 Roof Westwick Street Norwich Norfolk NR2 4SZ T: 01603 612481 F: 01603 883429 Freephone: 08000287174 E: city.reach@nhs.net