Introduction

Inclusion health is an umbrella term used to describe people who are socially excluded, who typically experience multiple interacting risk factors for poor health, such as stigma, discrimination, poverty, violence, and complex trauma.

People in inclusion health groups tend to have poor experiences of healthcare services because of barriers created by service design. These negative experiences can lead to people in inclusion health groups avoiding future contact with NHS services and being least likely to receive healthcare despite have high needs. This can result in significantly poorer health outcomes and earlier death among people in inclusion health groups compared with the general population.

Extremely poor health status among inclusion health groups is driven by severe disadvantage and clusters of social risk experienced when people are socially excluded. For example, someone who is alcohol dependent may also be homeless resulting in vulnerability, limited opportunities, extremely poor health and a reduced life expectancy. Risks may also build up over the life course. For example, adverse experiences in childhood may be associated with social exclusion, vulnerabilities and health needs both in childhood and later in life.

Inclusion health groups therefore require an explicit, tangible focus in system efforts to reduce healthcare inequalities.

What is meant by inclusion health?

People in inclusion health groups include:

• People who experience homelessness
• People with drug and alcohol dependence
• Vulnerable migrants and refugees
• Gypsy, Roma, and Traveller communities
• People in contact with the justice system
• Victims of modern slavery
• Sex workers
• Other marginalised groups

People who are socially excluded are likely to have the following experiences in common:

• Discrimination and stigma
• Violence and the experience of trauma
• Poverty
• Invisibility in health datasets

Which result in:

• Insecure and inadequate housing
• Very poor access to healthcare services due to service design
• Poor experience of public services
• Poorer health than people in other socially disadvantaged groups.

Our vision for reducing healthcare inequalities is to provide exceptional quality healthcare for all, through equitable access, excellent experience, and optimal outcomes.

This framework focuses on the role that the NHS plays in improving healthcare, and how partnerships across sectors such as housing and the voluntary and community sector play a key role in addressing wider determinants of health.

The framework is based on five principles for action on inclusion health (Figure 1). It is focused on actions to address issues which are common across inclusion health groups. Useful resources are listed at the end to inform more detailed planning.

Figure 1: Principles for action on inclusion health

Inclusion health principles

1. Commit to action on inclusion health
2. Understand the characteristics and needs of people in inclusion health groups
3. Develop the workforce for inclusion health
4. Deliver integrated and accessible services for inclusion health
5. Demonstrate impact and improvement through action on inclusion health

This framework has been developed by NHS England in collaboration with a wide range of partners such as the Office for Health Improvement and Disparities (OHID), the UK Health Security Agency (UKHSA) and voluntary, community and social enterprise organisations. NHS England ran several workshops with people with lived experience of inclusion health to understand challenges that individuals face. Learnings from their experience highlighted the urgent need to improve inclusion health now and form an important part of this framework.

Policy context

Reducing health inequalities is an NHS England priority. Delivering effective services that address the issues faced by inclusion health groups is an important contribution to this ambition, seeking sustained action that responds to the needs that vary across inclusion health groups. This action is key to achieving the government ambition to improve healthy life expectancy by 2035 while narrowing the gap between areas where life expectancy is highest and lowest.

NHS England has set out five strategic priorities for reducing healthcare inequalities and the Core20PLUS5 approach for adults and for children and young people to give a practical focus for action. Core20PLUS5 sets out the population focus (the Core20PLUS), as well as clinical areas for action on healthcare inequalities. The ‘Core20’ population is the most deprived 20% of areas of England as defined by the Index of Multiple Deprivation, while PLUS groups are other groups who may experience poorer than average access to, experiences of, or outcomes from NHS services. Inclusion health groups are therefore a priority group, and we are calling for all parts of the system to drive efforts to improve healthcare provision for this group in our ambition to reduce health inequalities.

NHS England and integrated care boards (ICBs) have a legal duty to have regard to reducing inequalities associated with access to and outcomes from NHS services. ICBs have statutory duties to support partnership working, where this would help to tackle inequalities. A focus on responding to inclusion health groups will be crucial for fulfilling these duties.

This framework is intended to help every integrated care system to shape and take their next steps in improving access, experience, and outcomes for people in inclusion health groups, recognising that systems will be at different stages in this journey.

NHS leaders at all levels of the system will need to act on this agenda with their partners. The multiple interacting causes of social exclusion and ill health in inclusion health groups require cross-sector, interagency working within integrated care systems (ICSs), and responses will need to be shaped through coproduction with people with lived experience.

The Long-Term Plan and Long-Term Workforce Plan made commitments to increase the role of the NHS as an anchor organisation. There are many examples of how NHS anchor organisations are supporting inclusion health groups, and other communities that experience inequalities. The Health Anchors Learning Network provides resources and learning opportunities to support organisations to influence the health and wellbeing in communities.

The case for action

Inclusion health groups are relatively small but significant populations with high needs for healthcare, but who face a range of barriers in accessing healthcare services.

Whilst numbers may be small, the cost is high to individuals and systems. By taking a strategic systems approach to inclusion health systems think about how to better utilise resources and work with partners to develop approaches that reduce pressure on the system, save lives and improve health life expectancy.

Extremely poor health outcomes

People in inclusion health groups experience a range of poor health outcomes. In particular, people inclusion health groups tend to die earlier than the general population. Figure 2 illustrates that the relative mortality of people in inclusion health groups far exceeds that of people from the most deprived communities of England – the inequality of outcomes among inclusion groups is extreme.

Figure 2: Standardised all-cause mortality ratio for inclusion health groups, compared to the general population by deprivation decile.

Source: Office for Health Improvement and Disparities (2022).

People in inclusion health groups are also more likely to experience range of morbidities particularly mental health problems and substance dependence, and often have untreated long-term conditions. The children of parents in inclusion health groups are more likely to have poor health across their life-course because of their extremely disadvantaged start in life. There is a risk that disadvantages in socially excluded groups flow from generation to generation – from parent, to child, to grandchildren. Appendix A includes selected statistics on the health of inclusion health groups.

Barriers to accessing health services

Discrimination and stigmatisation

Many individuals report negative experiences when using services often relating to the attitudes of staff. They highlight that discrimination and stigmatisation discourage them from engaging with services. For example:

• Gypsy, Roma and Traveller communities report difficulties in registering with a GP because of a lack of cultural awareness and a perception that they will be ‘expensive patients’. GPs may also be reluctant to visit sites.
• People who have been in contact with the criminal justice system avoid contact with the NHS because of distrust linked to previous negative experiences of statutory services such as the care system.
• Sex workers do not attend cervical screening and antenatal appointments because of fear of discrimination, stigmatisation and criminalisation among other factors.

Logistical challenges and service design

In many cases there is evidence that inclusion health groups are excluded or discouraged from using health services due to unnecessary logistical challenges or badly designed services. For example:

• Gypsy, Roma and Traveller communities report issues when attempting to register with a GP due to low literacy levels. They also report difficulty completing GP registration forms and a lack of support from professionals to help.
• Vulnerable migrants report limited access to translation services, which greatly impacts their capacity and confidence to engage with care and support.
• Sex workers cite opening hours and the location of services as a barrier to accessing routine health checks, cervical screening and antenatal checks.

Invisibility in health datasets

Inclusion health groups are not consistently recorded in electronic health datasets when interacting with health services. This means they are effectively invisible in data used for service design and evaluation, and so services do not meet their needs.

Digital exclusion

Digital technologies present a key opportunity to overcome many communication and logistical barriers to accessing services. This may include presenting information in short films and pictures, using online tools to translate to different languages and providing remote access to services at times that suit. As there can be high rates of digital exclusion among inclusion health groups, digital technologies can present some challenges, and will need to be properly considered. For example, 90% of people experiencing homelessness own mobile phones rather than laptops or home computers, which means that they access the internet with technology that is less reliable. This is due to issues such as cost of mobile devices and data, theft, poorer network coverage and comparatively lower data access. The NHS Digital Inclusion Framework provides more information on how to take action in this area.

Lack of empowerment

The complex structural barriers created by social exclusion and negative experiences of using public services can make it difficult for people to look after their health and wellbeing. Personalised care and peer support are key to understanding what matters to the person and empowering them to have greater choice and control over their health and the way their care is delivered. For instance, a recent study highlighted that a lack of peer support in the self-management of long-term conditions.is an issue for people experiencing homelessness and rough sleeping. Strategic coproduction and asset-based approaches are important ways to empower people and communities and use their strengths to improve healthcare.

Benefits of improved pathways

Without good access to primary and community care, and early or preventative interventions, people in inclusion health groups are likely to turn to acute services. For example, A&E attendance is 6-8 times higher for people experiencing homelessness and 28 times higher for people who experience both homelessness and rough sleeping and alcohol dependency.

There is evidence that implementing solutions for inclusion health, such as improved health and social care pathways and providing accessible effective services, benefits patients and reduces the costs of health and social care services.

A study undertaken in 2022 investigating the cost-effectiveness of three different ‘in patient care coordination and discharge planning’ configurations for adults experiencing homelessness, highlighted that specialist Homeless Hospital Discharge (HHD) care is more cost-effective than standard care.

Cost effective analysis shows that patients accessing HHD care use fewer bed days per year (including both planned and unplanned readmissions) and presented better quality-adjusted life year (QALY) outcomes. In addition, patients using specialist care have more planned readmissions to hospital and, overall, use more NHS resources than those who use standard care.

Furthermore, a recent cost-benefit analysis based on current experiences of Gypsy, Roma and Traveller families showed that an improved Dementia and Carer stress or depression pathway was estimated at less than half the cost of the current pathway, from £20,298 down to £8,884. The analysis also highlighted that up-front investment, for example in appropriate social work engagement, or in GP outreach work, can pay for itself many times over in the longer term.

Some areas have introduced High Intensity Use (HIU) Services to proactively meet the needs of the most frequent attenders of the local A&E, a significant portion of whom belong to inclusion health groups helping to address health inequalities faced by this cohort while alleviating pressure on urgent and emergency care pathway.

Research has shown a clear link between high intensity use of emergency services and wider inequalities. There is a correlation between the poorest parts of the country and those with the highest concentration of individuals attending A&E frequently. High intensity users are thought to equate to almost a third (29%) of all ambulance arrivals at A&E, and one in four (26%) emergency admissions. HIU services help to free up frontline resources and reduce costs, while improving care for cohorts that face challenges with accessing healthcare and wider support from public services in the community.

The cost of doing nothing

Failing to address inclusion health costs the NHS and society at large. For example,

• Meeting the needs of people in severe and multiple disadvantaged groups costs society an estimated £10.1 billion per year.
• Prior to COVID-19, health inequalities were estimated to cost the NHS an extra £4.8 billion a year
• The frequency of unplanned emergency care has a significant impact on the health system, putting greater strain on the service and costing the NHS £2.5 billion a year.

Further costs are also associated with delays in discharge due to the complications in securing out of hospital care, particularly for those who have no home to return to. Inclusion health groups make up a large part of delayed discharge costs.

• In 2022/2023, delayed discharge cost the NHS £1.89bn.
• In December 2022, more than 13,000, out of a total of 100,000 hospital beds in England were occupied by patients who were medically fit for discharge.

Once discharged, people in inclusion health groups are more likely to be readmitted due to difficulties in maintaining their health while recovering.

Roles and responsibilities

Everyone needs to take practical action to improve outcomes for inclusion health groups to address systemic health inequalities they face. To do this, we need an understanding of the issues people face, and to develop knowledge, skills and confidence alongside partners to help and deliver change.

Figure 3 illustrates the roles of different partners who can work together to develop personalised integrated support for people in inclusion health groups. It is not exhaustive and, depending on local circumstances, different stakeholders may be involved. Appendix B has further information on roles of different partners.

Figure 3: An overview of roles and responsibilities in relation to inclusion health.

Principles for action

This section sets out principles for practical action and high impact changes that can be made now to improve access and outcomes for inclusion health groups, recognising that long-term cross sector changes to policy and services are needed to tackle the extreme burden of disease and poor quality of life experienced by people in inclusion health groups.

The principles were developed following a review of available best-evidence on inclusion health and listening to people with lived experience and key stakeholders. Stakeholders included people with lived experience, VCSE organisations, ICSs, OHID, the UKHSA. national and regional teams and the Inclusion Health Network for seven ICSs, supported by Pathway, Groundswell and the Kings Fund

The principles are intended to guide the design and delivery of inclusion health strategy and services nationally, regionally and locally, providing guidance for NHS organisation and other partners working collaboratively as part of integrated care systems. Within each principle, we have identified useful actions, explained what good looks like, highlighted practical action, and provided a case study to illustrate effective working.

Figure 4: Principles for action on inclusion

Principle 1: Commit to action on inclusion health

The voices of socially excluded members of our communities are often left unheard, and their needs invisible. To serve their communities inclusively, senior leaders need to advocate for inclusion health at every level and enable all voices to be heard.  This requires commitment and action from the very top with leaders spending time in their community, and seeing first-hand the challenges people are experiencing.  Senior leaders will need to balance operational pressures with a focus on providing equitable services for all members of their community. 

Good looks like

There is a named clinical lead on the ICB with clear responsibility for inclusion health who provides direction and advocates to ensure that meaningful actions are set out in key strategies and plans. This will ensure that:

• Senior leaders commit to hearing and responding to the voices of people with lived experience and spend time within their communities to understand their needs.
• Strong cross sector strategic partnerships are established between NHS bodies, local authorities, VCSE organisations and wider partners with commitment to developing and implementing integrated approaches and services for people in inclusion health groups. For example, West Yorkshire ICB are in the process of setting up an Inclusion Health Unit to lead and drive forward progress. The unit will include members from across the system to progress collective priorities, share best practice, learning, resources, and deliver effective change on inclusion health across the ICB footprint.

Suggested practical actions

• Identify a named senior responsible officer at ICB level who has responsibility for championing, challenging and driving action on health inequalities and inclusion health.
• Identify a named senior responsible officer for health inequalities and inclusion health in each partner organisation within the ICS.
• Report on progress delivering inclusion health activity at board level and provide opportunities for board members to spend time with people in inclusion health groups and understand their needs.
• Use the VCSE Inclusion Health Audit Tool to understand how effectively your organisation is engaging with service users and trusted community partners.
• Document how engagement with people with lived experience has informed service delivery and ensure this information is made publicly available. 
• Build leadership for inclusion health into leadership programmes.
• Use communication strategies to raise awareness of the needs of people in inclusion health groups and what good looks like.

Principle 2: Understand the characteristics and needs of people in inclusion health groups

Information about people in inclusion health groups is often not recorded in traditional data sources. This means that their needs are often overlooked, and their voices are seldom heard. Assessing the needs of our entire communities requires us to look beyond routinely available data and work creatively with all residents and groups to seek wider sources of information. NHS organisations doing this well will balance the use of information held in traditional data sources with the qualitative insights from trusted community partners.  They will work with people experiencing social exclusion to understand and prioritise problems from their perspective.

Good looks like

There is a robust health needs assessment for inclusion health which informs the actions of the ICS. This requires:

• Taking a co-ordinated and consistent approach to understanding the needs of inclusion health groups.
• Using current data on deprivation, inclusion health, learning disabilities, severe mental illness, substance misuse and proxy measures for social exclusion
• Working with trusted community partners who hold a wealth of information about your population, as well as Local Authority public health teams and analysts.
• Listening to the voices of people with lived experience.

Suggested practical actions

• Ensure that place based plans and joint strategic needs assessments reflect the needs of the people in your communities living in inclusion health groups. This should inform the actions of the ICS.
• Work collaboratively with wider system partners to use Public Health Outcomes Framework (PHOF) indicators, such as homelessness indicators, school readiness and drug misuse indicators, to build an understanding of local needs.
• Improve methods of collecting routine data by using the Fingertips tool, SPOTLIGHT tool and health inequalities dashboard to build the inclusion health data profile in your area.
• Work with your data and Populations Health Management (PHM) experts to draw on all available information to inform service provision. The Population Health Management Academy available via Future NHS provides a forum for information, discussion, news and the sharing of best practice for health, social care, public health and voluntary sector colleagues who want to collaborate and innovate to drive personalised approaches to care interventions.
• Develop a research approach with trusted community and academic partners to draw on rich qualitative measures.
• Use participative research approaches to support people with lived experience contribute to research and evidence.

Principle 3: Develop the workforce for inclusion health

The workforce is a key enabler in improving healthcare access, experience, and outcomes. It is important that all staff understand how to support people well. This includes delivering personalised care, allowing for extra time and support, and treating people with dignity and empathy. People from inclusion health groups are entitled to use NHS services but too often they are turned away when seeking care.

Having plans in place to ensure staff are up to date with training around entitlement to care, inclusion health and trauma-informed approaches will help address this. Using levers such as ICB workforce strategies and the NHS’s position as an anchor organisation can ensure we have an inclusive workforce fit to support people in inclusion health groups.  

Good looks like

Ensuring that training on inclusion health is mandatory for every worker. This will lead to:

• Everyone (policy makers, commissioners, providers, and front-line staff) understanding what inclusion health is, and the impact on access, outcomes and experience.
• Frontline staff having the skills needed to work with inclusion health groups, such as compassionate care which is culturally competent and responsive to relational injury and trauma.
• Ensuring inclusion health is included in workforce development strategies and plans.

Suggested practical actions

• Ensure training on inclusion health is accessible to all staff (see Figure 6 for more details).
• Provide opportunities for leaders and specialist staff to develop expertise in meeting the needs of inclusion health groups.
• Share best practice and learning across the system at national, regional, and local levels.
• Offer paid and voluntary employment opportunities to people from inclusion health groups.

Figure 6: Training on inclusion health

Principle 4: Deliver integrated and accessible services for inclusion health 

Poor access to health and care services and negative experiences are commonplace for people in inclusion health, often related to the way healthcare services are commissioned and delivered. Although there are pockets of excellence, sustainable and widespread best practice requires NHS services reduce unwarranted variation across systems and partnering with the voluntary and community sector and other agencies to address issues. This means finding the right balance between making mainstream services accessible to all as well as providing specialist provision for excluded groups. These principles are key for all NHS services – not just specialist services – to ensure that people are not turned away from seeking care.

We often hear from people with lived experience that our services are inaccessible and fragmented, for example first hand insights through a programme of work on Core20PLUS5 for people in contact in people with the criminal justice system. Best practice requires joined up, personalised care with a focus on what matters to the individual and their needs. This may require access to a dedicated individual who can advocate for and support the user on their journey throughout the system.

As people from inclusion health groups can be vulnerable, healthcare staff will need to be familiar with referral routes and safeguarding services.

Good looks like

Developing clear and achievable goals and monitoring the ICS performance against these. This means:

• Understanding the gap between inclusion health needs across the system and what is currently spent (this could include health inequalities, specialist services and generic primary, community acute and specialist services)
• Commissioning specialist services (such as outreach provision for excluded groups) that reflect best practice
• Making generic services more accessible.
• Co-designing and delivering services with people in inclusion health groups in response to local needs.
• Working across organisations with both VCSE and wider partners to fund and sustain provision for inclusion health.
• Ensuring that safeguarding is an inherent part of all service design and delivery.

Suggested practical actions

• Work with system partners to implement the NICE Guidelines on Integrated health and care for people experiencing homelessness. General principles from this guidance could be applied to all inclusion groups.
• Use tools such as the Health Equity Assessment Tool (HEAT) and the Safe Surgeries Toolkit to consider health inequalities when designing and reviewing services. Further tools can be found in the reference section.
• Set up mechanisms for co-designing services with people and communities, such as strategic co-production
• Develop integrated multidisciplinary teams which deliver proactive coordinated care which meet the needs of people in inclusion health groups as outlined in the Fuller Stocktake Report.
• Ensure that roles such as healthcare navigators, care coordinators and social prescribing link workers are available to support people through the system.
• Recognise that general health service provision may not meet the needs of inclusion health groups and that specialist outreach services will need to be commissioned to address this.
• Identify a named lead for inclusion health on Safeguarding Adults Boards.
• Where a person in contact with NHS services is homeless or at risk of homelessness, ensure public sector duty to refer guidance is followed.

Principle 5: Demonstrate impact and improvement through action on inclusion health

Effectively evaluating inclusion health services is critical for ensuring that everyone in our communities receives the support and care they need. This can be a complex task requiring more creative methods due to significant limitations in access to quantitative data because inclusion health groups are not consistently recorded in electronic health databases. People in inclusion groups are also less likely to use formal complaints routes due to their experiences of relational injury, and far less likely to have family members advocating for them so their voices remain unheard.  

Organisations making progress in this area use a mix of both established and new data collection and qualitative sources to give them the best understanding of how effective (or not) their services are. Co-designing evaluation approaches with relevant stakeholders including trusted community and VCSE partners, clinicians, and people with lived experience is central to supporting this approach.

Good looks like

Identifying clear and achievable targets on inclusion health and monitoring the ICS’s performance against these. This includes:

• Embedding evaluation into your everyday work.
• Including people with lived experience in your evaluation.
• Giving words and stories equal weight to numbers.
• Using inclusive language – finding out what language and terminology makes sense to the people involved and using it.
• Communicating your learnings to others – enabling stakeholders to act themselves.

Suggested practical actions

• Refer to ESS principles for good evaluation.
• Set clear achievable outcomes (differences or changes you hope to make) and indicators (what you need to measure to see if you are achieving your outcomes).
• Develop a logic model to set out the steps to reach your outcome. The VCSE Inclusion Health Audit Toolis a useful benchmarking resource.​
• Seek to collaborate with academic institutions such as universities to develop research and evaluate services. It is an NHS duty for all ICSs to include research strategy in their Joint Forward Plan.
• Work with your Patient Advice and Liaison Service (PALS) and complaints teams, who will have the skills needed to work with inclusion health groups and encourage feedback. Ensure that this information is fed into service improvement plans.
• Listen to VCSE organisations working with people in inclusion health groups. People in these groups often do not use formal routes to complain so it is important to listen to VCSE partners.
• Audit services through mystery shopping, providing feedback on quality of care.

Next steps

Integrated care systems

Integrated care systems should use this framework as a practical resource to develop and deliver integrated plans to improve inclusion health. Applying this framework will help ICSs deliver on healthcare inequalities priorities set out in operational planning implementation guidance to restore services inclusively and accelerate preventative programmes, particularly through the Core20PLUS5 approach. This will also support ICBs to fulfil their statutory duty on reducing health inequalities

Good plans will:

• be integrated with other activity, not siloed
• be based on engagement across the ICP and coproduction with people with lived experience
• consider delivery services in all parts of the NHS, particularly in primary care, urgent and emergency care, community care and acute services
• consider the balance of specialist and mainstream services as well as workforce plans
• include action at each level of an integrated care system (system, place and neighbourhood)

Changes to funding approaches may be needed to deliver change on inclusion health and shift resource where it is needed most. There is a range of potential funding sources for work on health inequalities.  This will require senior leadership discussion and commitment to understanding the true costs of supporting inclusion health through different services so that the resource can be used more effectively.

Regional teams across the health system

Regional teams across NHSE, OHID and UKHSA play an important role in championing inclusion health and supporting systems to deliver good practice. And have played a key role in developing this framework. Regional teams can build on this work by:

• Raising awareness of this framework through established routes.
• Supporting systems to understand the needs of their local populations, benchmarking activity, sharing good practice and helping to solve barriers to improvement.
• Signposting people to references in and beyond the framework.
• Sharing best practice with national teams and highlighting barriers which require national attention.
• Working with NHS England to establish effective programmes such as the HIU service.

NHS England

We will continue to highlight the need for practical action to improve inclusion health as part of our wider Healthcare Inequalities and Improvement programme and work across NHS England to ensure the needs of people at risk of health inequalities and in inclusion health groups are reflected in relevant policies and plans, for both adults and children and young people.

We will work across NHS England and with key partners such as OHID and UKHSA, other government departments and national partners to develop joined up approaches to inclusion health and better enable action in integrated care systems and at a local level, including through improvements to data and evidence. For example, we have heard that lack of funding for outreach homelessness services and short-term funding brings challenges for this group of patients. We need a collaborative and a long-term funding approach to deliver sustainable healthcare support for people in inclusion health groups.

We will continue to work to develop initiatives and resources to ensure the NHS workforce has the knowledge, skills and confidence to address health inequalities, including those experienced by people in inclusion health groups.

We will also share learning and best practice across the nation and will:

• Share examples of best practice gathered through our call for evidence through the inclusion health space on the NHS Futures Collaborative Platform. The platform will provide an interactive space for people to share good practice in relation to the framework and support each other to solve problems.
• Share best practice from our Core20PLUS5 community connectors which include people from inclusion health communities working with systems to deliver improvement in each of the five clinical areas identified in Core20PLUS5.
• Build on the work of Inclusion health network supported by Pathway, Groundswell and the Kings Fund and explore how we can spread good practice and support other ICSs who want to go further faster.

Appendix A: Selected statistics on the health of inclusion health groups

Mortality of inclusion health group

• A systematic review and meta-analysis found that mortality in high-income countries was approximately 12 times higher in women in inclusion health groups compared with the general population, and 8 times higher in men.  
• The average age of death for patients experiencing homelessness and rough sleeping is 43 years for women and 45 years for men.
• Gypsy and Traveller communities are estimated to have life expectancies of between 10 and 25 years shorter than the general population.
• Female sex workers in London have a mortality rate that is 12 times the national average. 

Mental health and physical health

• More than two thirds (68%) of female sex workers in London meet the criteria for post-traumatic stress disorder (PTSD).
• Asylum seekers are 10-20 times more likely to suffer from PSTD compared with the general population due to war, violence and living in fear.
• People in the criminal justice system experience rates of mental ill health three times higher compared to the general population.
• The rate of suicides in boys aged 15-17 who have been sentenced and remanded in custody are 18 times higher than the rate of suicides in boys in the general population.
• The suicide rate among Irish Travellers is as high as 6 times that of the non-traveller population.
• The homeless population has a greater number of missing and decayed teeth and fewer filled teeth with almost a third (32%) reporting dental pain.
• Over half (58%) of trafficked female sex workers reported having dental problems.
• Many trafficked sex workers experienced physical violence, with 8% having experienced direct assault to the face.

Child health

• Over a quarter of children with parents who experience homelessness and rough sleeping feel depressed (26%) or socially isolated (28%) because of living in temporary accommodation.
• Roma, Gypsy, and Traveller communities experience high infant mortality rates with 18% of women having experienced the death of a child.

Appendix B: Roles and responsibilities of different organisations

NHS England

While the fundamental social drivers of health inequalities lie outside the healthcare system, the NHS can make a central contribution to narrowing inequalities in healthcare outcomes by tackling disparities in healthcare provision – in access to services and patient experience.  NHS England has therefore set out a programme to reduce inequalities in health service delivery in line with the strategic intent set out in the NHS Long Term Plan.  

The NHS focus on tackling inequalities is underpinned by new legal duties. NHS England and ICBs have duties to have due regard to reducing inequalities between persons with respect to their ability to access health services, and the outcomes achieved by the provision of health services.

In broad terms, NHS England’s role is to support local systems to produce Joint Forward Plans, setting the direction, ensuring accountability, mobilising expert networks, enabling improvement, setting goals and supporting monitoring, and driving transformation – the Framework is a core part of that work, but other actions will be needed.

Office for Health Improvement and Disparities (OHID)

OHID, part of the Department of Health and Social Care (DHSC), focusses on improving the nation’s health, preventing ill health, and reducing health disparities. OHID is responsible for building the evidence base, leading, and developing policy, and supporting the effective delivery of services around inclusion health. With a focus on health improvement, OHID works with the NHS and local government to improve access to services, a priority for inclusion health groups.

UK Health Security Agency (UKHSA)

UKHSA is an executive agency sponsored by DHSC and is responsible for protecting communities, including those in inclusion health groups, from infectious diseases and other health threats. UKHSA also has a responsibility to reduce health inequalities caused by infectious diseases and environmental hazards and works with partners and stakeholders such as NHS England and OHID to do so.

This responsibility includes developing the evidence base for excess burden of disease related to infections and environmental hazards, developing surveillance systems to monitor progress, and sharing this information with other partners.  UKHSA also has a lead role in responding to incidents and outbreaks in Inclusion Health settings and populations.

Regional teams in the health systems (NHSE, OHID, UKHSA)

NHS England, OHID and UKHSA have regional teams which bridge the gap between the national bodies, and the local integrated care systems (ICSs) and other partners. They work in a collaborative way across organisations and may be ‘blended teams’ though the teams of each organisation have a specific remit.

NHS teams are responsible for the quality, financial, commissioning, and operational performance of NHS organisations in their regions, including access and outcomes for patients from inclusion health groups. OHID regional teams support the delivery of both national and local priorities for improving people’s health, preventing ill health, and reducing health disparities.  UKHSA regional teams lead on health protection, with a focus on infectious diseases and other environmental health threats as well as supporting response to incidents and outbreaks in their regions.

Integrated care systems (including integrated care boards and integrated care partnerships)

Integrated care systems (ICSs) are made up of integrated care boards (ICBs) and integrated care partnerships (ICPs). ICSs as a whole are responsible for agreeing local inclusion health strategies with the regions, and then working with providers to implement these locally. They are also responsible for understanding the needs of inclusion health groups locally, and working to improve access and outcomes for these groups, for example through joint strategic needs assessments (JSNAs).

ICBs have developed and published delivery plans with partners for the integrated care strategy and the joint health and wellbeing strategy as set out in the five-year joint forward plans (JFPs).

Each ICB must also ensure that patients and communities (including those from inclusion health groups) are involved in the planning and commissioning of services. ICBs are responsible for commissioning primary care (including primary care practices that focus on the needs of inclusion health groups) and a range of public health functions.

ICPs are a statutory committee jointly formed of ICBs and local authorities within an ICS area, are responsible for ensuring partnership and collaboration between NHS bodies, local authorities, voluntary, community and social enterprise (VCSE) organisations and wider partners. This includes ensuring collaboration over commissioning of services to meet the needs of their population. 

General Practice and Primary Care Networks

General Practice has an essential role to play in addressing inclusion health, working in partnership with other system partners to prevent ill health and manage long-term conditions amongst socially excluded groups.

Primary care networks (PCNs) are the building blocks of integrated neighbourhood teams, and one of the main delivery partners of local place-based partnerships. As part of the Tackling Neighbourhood Health Inequalities Designated Enhanced Service (DES) specification (part of the GP contract), many PCNs have a nominated health inequalities lead, facilitating the join-up and sharing of learning and practice with provider trust and ICB SROs for health inequalities.

The Fuller Stocktake highlighted the critical role of primary care in both prevention and tackling health inequalities. Integrated neighbourhood teams can support this work by providing capacity to identify and reach out to communities who find it difficult to engage with health services, building on the learning from community outreach models of care that helped to increase uptake of the Covid-19 vaccination. 

Local authorities

Local authorities are core members of ICPs, represented by the Local Government Association (LGA) and play a key role in inclusion health. Local authorities have public health teams which are an integral part of health prevention and population health improvement in local areas. They also have teams such as housing which have a responsibility to work with agencies such as the NHS to improve access and outcomes for inclusion health populations at a community level.

Councils are uniquely placed to positively influence many of these wider determinants, such as housing, education, the environment, economic growth and skills. They work hand in hand with communities, people with lived experience, the NHS, businesses and many others to create the conditions necessary for good health. Prevention is a key focus of local authorities, and inclusion health populations are a key group to support in the prevention of ill-health, and promotion of good health.

Voluntary, Community and Social Enterprise (VCSE) organisations

VCSEs are an important partner in the design and delivery of inclusion health services, and usually form part of ICPs. they have a responsibility to advocate for, represent and amplify the voices of people in inclusion health groups. They should also be involved in co-designing and co-delivering policy related to inclusion health, by working with national, regional, and local NHS bodies and other system partners.

Hospitals and trusts

Hospitals and trusts provide various NHS services to a local area and have a responsibility to ensure their care is accessible to all. They are responsible for ensuring that frontline staff and team leaders have the skills and confidence needed to support socially excluded groups and provide adaptations for patients when needed.

Hospitals and trusts have a duty to that ensure services are provided in an integrated way where this might reduce health inequalities including those experienced by inclusion health groups.

Hospitals and trusts also have a duty to refer where a person in contact with NHS services is homeless or threatened with homelessness.

People with lived experience

Evidence tells us that people with lived experience should be engaged by all these agencies to ensure that people and communities are involved at every stage of decision making, and that partnership working is embedded throughout all structures and policies. Working with people with lived experience is essential for improving access, experience, and outcomes of health services. There is a legal and moral duty to involve people with lived experience that exists because the evidence shows that it works.

Other key players

There are many key players in relation to inclusion health, and this is by no means an exhaustive list. Working collaboratively between agencies is essential to improve the healthcare access, experience, and outcomes for socially excluded people, and this goes beyond the NHS.

For instance, the Care Quality Commission are central to ensuring there are good quality services available for people from inclusion health groups. Safeguarding Adults Boards also are vital to ensure that vulnerable people are protected, and where there are failings, that they are learnt from.

Other government agencies also play a significant role for specific inclusion health groups, such as the Home Office and Department for Levelling Up, Housing and Communities, and HM Prison and Probation Service. At a more local level, agencies such as the police also work together with other key players to support people from inclusion health groups.

Glossary

Useful tools and resources

Guidance and policy

• Inclusion Health: applying All Our Health – GOV.UK (www.gov.uk)
• Homelessness: applying All Our Health – GOV.UK (www.gov.uk)
• NICE Guideline 214 – Integrated health and social care for people experiencing homelessness
• Homeless and Inclusion Health standards for commissioners and service providers
• Guidance for considering the needs of asylum seekers and refugees in commissioning health services
• Migrant health guide – GOV.UK (www.gov.uk)
• Guidance on the duty to refer
• Guidance on addressing health inequalities in the criminal justice system
• Statutory guidance on working in partnership with people and communities
• Health and justice framework for integration 2022-2025
• NHS Guidance: Action on digital inclusion

Data resources

• Spotlight – Improving Inclusion Health Outcomes
• Fingertips – Public Health Data
• Statistical profile of severe multiple disadvantage
• Public Health Outcomes Framework – Data on Health Inequalities
• Health-related quality of life and prevalence of six chronic diseases in homeless and housed people – BMJ Open
• Healthcare Inequalities Improvement Dashboard

Training resources

• Royal College of General Practice training
• Online inclusion health course – Pathway
• New Inclusion Health session added to All Our Health programme – eLearning for healthcare (e-lfh.org.uk)
• A brief introduction to inclusion health (fairhealth.org.uk)
• Inclusion Health Education Mapping and Review – Full Report.pdf (hee.nhs.uk)
• Pathway’s Inclusion Health Mapping and Review

 Self-assessment tools

• VCSE Inclusion Health Audit Tool
• Inclusion Health Self-Assessment Tool for Primary Care Networks
• Health Equity Assessment Tool (HEAT) – GOV.UK (www.gov.uk)

Other information and resources

• Beyond Pockets of Excellence: Integrated Care Systems for Inclusion Health
• What works in inclusion health: overview of effective interventions for marginalised and excluded populations – The Lancet
• From health for all to leaving no-one behind: public health agencies, inclusion health, and health inequalities – The Lancet Public Health
• Inclusion health: addressing the causes of the causes – The Lancet
• Homeless and Inclusion Health Programme – The Queen’s Nursing Institute (qni.org.uk)
• Toolkit for ICBs and PC Commissioners access to healthcare for asylum accommodation – DOTW
• Health inequalities and Gypsy, Roma, Traveller communities
• Supporting people experiencing homelessness in an accident and emergency setting

Acknowledgements

This National framework for NHS action on inclusion health has been developed in partnership with South Central and West Commissioning Support Unit. A range of partners and stakeholders contributed to development of the framework, including people with lived experience, the Office for Health Improvement and Disparities, the UK Health Security Agency, VCSE organisations, regional teams across NHSE, OHID and UKHSA regional teams and ICSs.

For further information or questions relating to this document, contact NHS England’s Health Inequalities Improvement Team: england.healthinequalities@nhs.net.

Publication reference: PRN00807