Guidance

Inclusion Health: applying All Our Health

Updated 10 May 2021

Introduction

This guide is part of ‘All Our Health’, a resource that helps health and care professionals prevent ill health and promote wellbeing as part of their everyday practice. The information below will help front-line health and care staff use their trusted relationships with individuals, families and communities to take action on inclusion health.

We also recommend important actions that managers and staff holding strategic roles can take. View the full range of ‘All Our Health’ topics, including the Homelessness: applying All Our Health resource.

Why take action on inclusion health in your professional practice

Health and care professionals should ensure that socially excluded people can access and benefit from the services they need. The basis to this is an understanding of inclusion health and social exclusion, how they influence people’s health and access to care, and what professionals can do to include and support people.

Inclusion health is a ‘catch-all’ term used to describe people who are socially excluded, typically experience multiple overlapping risk factors for poor health (such as poverty, violence and complex trauma), experience stigma and discrimination, and are not consistently accounted for in electronic records (such as healthcare databases). These experiences frequently lead to barriers in access to healthcare and extremely poor health outcomes. People belonging to inclusion health groups frequently suffer from multiple health issues, which can include mental and physical ill health and substance dependence issues. This leads to extremely poor health outcomes, often much worse than the general population, lower average age of death, and it contributes considerably to increasing health inequalities.

Inclusion health includes any population group that is socially excluded. This can include people who experience homelessness, drug and alcohol dependence, vulnerable migrants, Gypsy, Roma and Traveller communities, sex workers, people in contact with the justice system and victims of modern slavery, but can also include other socially excluded groups. There will be differences in needs within socially excluded groups (for example between men and women) and these differences must be understood and responded to appropriately.

The NHS provides a comprehensive service that in principle should be available to all. However, people who belong to inclusion health groups often face difficulties and barriers in accessing and engaging with NHS and other care services. Evidence shows that people who are socially excluded underuse some services, such as primary and preventative care, and often rely on emergency services such as A&E when their health needs become acute. This results in missed opportunities for preventive interventions, serious illness and inefficiencies, and further exacerbates existing health inequalities.

Poor access to health and care services is a result of multiple barriers, related both to the individual and to the services. People may:

• have difficulty understanding and navigating the system
• have had past experiences of being turned away from services or being badly treated
• not speak the language or be able to read or write
• be afraid of punitive action after accessing services

At the same time, services may not be prepared to deal with the complexity of problems socially excluded people face, they may consider they don’t have the resources to appropriately support them, and their staff may not be comfortable in dealing with people with socially complex problems. Furthermore, some services have policies and practices that explicitly exclude people from some of these groups.

Front line NHS and care professionals, including the wider public health workforce and allied health professionals, can do a lot to improve access and appropriate use of services by people who are socially excluded. Small actions can lead to considerable improvements in health outcomes, reduced inequalities, and reductions in cost for services.

Core principles for health and care professionals

This ‘All Our Health’ inclusion health information has been created to help all health and care professionals:

• understand how the concepts of inclusion health and social exclusion can be useful for your professional practice
• know about the health issues that socially excluded people living in your area are more likely to encounter
• understand specific activities and interventions that all health and care professionals can do to support the health and wellbeing of inclusion health groups
• consider the resources and services available in your area that can help people from inclusion health groups

Taking action

If you’re a front-line health and care professional

You can have an impact on health by ensuring that your relationship with individuals from inclusion health groups is appropriate to allow you to provide the necessary support

You can do this by:

• building trusting relationships, showing kindness, empathy and a non-judgemental attitude to the individual’s circumstances
• ensuring you communicate with individuals in a manner that allows them to understand and use information to make decisions about their health (see resources section for training and other resources on health literacy)

You can have an impact on health by ensuring individuals can access the service you are providing

You can do this by:

• offering access to a translator or interpreter instead of waiting for the individual to ask, to ensure they are fully able to communicate and understand
• making sure you are familiar with people’s entitlements to services and that you don’t refuse access to someone who is entitled to your service
• supporting individuals to attend appointments and engage with treatment and wider support
• taking part in outreach activities to bring the services you provide as a health and care professional to the community

You can have an impact on health by ensuring the individual’s health and social needs are met

You can do this by:

• providing holistic screening and health assessment to understand the social and health needs of the person beyond their immediate complaints
• ensuring that individuals with deteriorating health and increasing needs are identified and receive adequate support including, where appropriate, social care
• regularly asking about relevant social issues (such as housing status, access to benefits and welfare support)
• regularly recording relevant information (such as health and social care needs) in individuals’ records
• providing extended and personalised interventions for those who do not respond to brief interventions

You can have an impact on health by ensuring the individuals are connected to and can access health and other services they need

You can do this by:

• checking individuals are registered with a GP and helping them to register when they are not
• checking that once individuals are registered with a GP, they receive primary health care, vaccinations and screening
• checking individuals have a dentist and helping them find and access one when they have not
• acting rapidly when a window of opportunity arises (for example, moments of crisis may trigger a willingness to act), to ensure that opportunity is capitalised on
• if necessary, challenging system and professional barriers within health services to ensure people access the services they need

You can have an impact on health by ensuring you are aware of existing community assets that allow you to support inclusion health groups

You can do this by:

• making yourself aware of the available community programmes and activities that support people’s health, including those run by local voluntary and community groups, and promoting access to these programmes as appropriate
• making yourself aware of community outreach services that serve the needs of inclusion health groups and exploring collaborations with these
• supporting access to other care and support as appropriate, such as specialist and general health services (oral health, eye health, maternity), domestic and sexual violence and abuse services, harm reduction and exiting services for people involved in sex work

You can have an impact on health by ensuring your professional development and training is appropriate to allow you to provide the necessary support to inclusion health groups

You can do this by:

• ensuring you are aware of the health and social needs of the inclusion health groups in your area
• undergoing training in trauma-informed approaches to ensure you are aware of the importance of trauma in health outcomes and that you feel able to support and refer individuals appropriately
• ensuring you are aware that everyone can access primary care for free and of who is entitled to free NHS services, including dental services
• ensuring you are trained and confident in cultural competence and sensitivity
• learning how to identify people with immediate safeguarding needs, such as victims of domestic violence, modern slavery and human trafficking, and how to respond and refer
• ensuring you are aware of the best principles of health literacy and that you communicate with individuals in a way they understand and can act on
• ensuring you are up to date with the Making Every Contact Count training
• learning how to identify and refer people who need support from the local housing and health, energy advice or warm homes referral service
• ensuring you are aware and fulfil the requirements of the new public sector duty to refer where a person or household is homeless, or threatened with homelessness

If you’re a team leader or manager

You can have an impact by collaborating with local services to mutually support each other in taking action on inclusion health

You can do this by:

• working with local services to identify and target populations at risk of social exclusion
• familiarising yourself with the local information, advice, prevention and support services available in your area, including social prescribing schemes and outreach activities
• working with local services to put in place protocols for timely referrals to services and to enable smooth transitions from institutions (such as prisons or accommodation centres for asylum seekers) to the community
• working with local services to develop pathways and integrated approaches that ensure socially excluded people are appropriately supported to improve their health and wellbeing
• ensuring there is integrated health service provision in place for people who are socially excluded across mental health, substance misuse and primary care, with joint commissioning arrangements in place between the local authority and clinical commissioning groups (CCGs)

You can have an impact by ensuring your service is delivered in the highest quality standards and that it’s accessible to people who are socially excluded

You can do this by:

• ensuring your service follows the highest standards available – for example, from the Care Quality Commission or from the Faculty of Inclusion Health (see the measuring impact section for a list of helpful quality criteria)
• auditing access to your service by people in inclusion health groups, in partnership with people with lived experience, organisations that work closely with them and the local Healthwatch
• working with local partners, academia and people with lived experience to evaluate and improve how your service supports people in inclusion health groups
• commissioning health and care provision, including mental health care and support, that engages people who are socially excluded, by use of, for example, outreach services
• providing volunteer opportunities or employing people with lived experience of social exclusion
• promoting the involvement of people with lived experience of social exclusion being heard in the design, commissioning and improvement of local services

You can have an impact by ensuring your team has the right training, professional development opportunities and resources to support individuals from inclusion health groups

You can do this by:

• ensuring your team is aware and up to date on appropriate training, such as in cultural competence and sensitivity, homelessness health, identifying victims of modern slavery and human trafficking, trauma informed approaches, among others
• ensuring your team is aware and up to date on your service policies and protocols, particularly those regarding access to the service and referral options to other services, community programmes and activities
• ensuring your team is aware and fulfil the requirements of the new public sector duty to refer where a person or household is homeless, or threatened with homelessness

If you’re a senior or strategic leader

You can have an impact by providing leadership and supporting services in the area of inclusion health

You can do this by:

• being aware of the characteristics and needs of inclusion health groups in your area
• raising the profile of inclusion health and social exclusion as an important determinant of health and health inequalities among key partners
• ensuring that the characteristics and needs of inclusion health groups are clearly defined in your local Joint Strategic Needs Assessments (JSNAs)
• promoting a coherent local approach to inclusion health, ensuring all partners are aware of the issue and working towards the same goals; this should include partners from outside the social and health care sectors, such as police forces, the prison workforce, probation, job centre, schools, voluntary sector organisations, and others
• challenging current ways of working and advocating for the consideration of inclusion health groups in service design and commissioning, for example by ensuring integrated commissioning boards have a clear direction on inclusion health
• commissioning a single point of contact housing and health referral service, as recommended in NICE guidance NG6, or strengthening an existing service to better serve people who experience social exclusion
• ensuring frontline staff and team leaders have the appropriate tools, skills and knowledge to support socially excluded people in their work

Understanding local needs

Inclusion health groups are often not recorded in electronic health records and may be reluctant to engage with services and research, which can make understanding their health and social needs very challenging.

Local Authorities and CCGs produce JSNAs, which describe the characteristics and needs of the local population and highlight inequities of health outcomes and in access to services. The needs and outcomes of inclusion health groups should be considered in these assessments.

Public Health Outcomes Framework (PHOF) indicators, such as homelessness indicators, school readiness and drug misuse indicators, can be used to build this understanding of local needs.

Speaking with frontline staff and local people with lived experience of social exclusion should complement the data obtained via other sources.

Measuring impact

There is a range of reasons why it makes sense to measure your impact and demonstrate the value of your contribution. This could be about evaluating, auditing, reflecting on and sharing your work to benefit your colleagues and local people, or help you with your professional development.

The VCSE (voluntary, community and social enterprise) Inclusion Health Audit Tool is an online tool designed to help organisations audit their engagement with inclusion health groups. Once completed, the tool provides a ‘unique and tailored guide’ to help organisations embed action on tackling health inequalities into their everyday activities.

The Faculty for Homeless and Inclusion Health produces Homeless and Inclusion Health Standards for Commissioners and Service Providers, which sets out clear minimum standards for planning, commissioning and providing health care for homeless people and other multiply excluded groups.

The Care Quality Commission produces information and guidance for health and social care services.

Further reading, resources and good practice

Advice for individuals from inclusion health groups and the public

For people who are having problems accessing health and social care, free and confidential support is sometimes provided by local voluntary and community sector organisations. Organisations such as Doctors of the World UK, Healthwatch and Citizens Advice may also be able to provide support.

Professional resources and tools

General

Friends, Families and Travellers has worked with other organisations to develop a Primary Care Networks inclusion health tool. It supports Primary Care Networks to assess and improve their work with inclusion health groups. The tool takes approximately 10 minutes to complete. Primary Care Networks are asked to assess their performance across 22 metrics. The are then provided with a tailored guide to support them to embed action on tackling health inequalities into their everyday activities. Primary Care Networks who score highly across the 22 inclusion health metrics can download an Inclusion Health Quality Mark and use this across communications materials.

PHE published the Health Equity Assessment Tool, which includes resources and e-learning to support systematic action on health inequalities and equalities.

Revolving Doors Lived Experience Team has co-designed a Liaison and Diversion (L&D) Peer Support Model service specification with NHS England. This model has been successfully piloted in Birmingham and Wiltshire. The purpose of the guide is to enable commissioners and providers to plan for, implement and embed peer support within their L&D service.

A systematic review by Luchenski et al reviews and describes what interventions in health and social care are effective for inclusion health populations.

PHE has produced guidance on community-centred approaches for health and wellbeing, particularly relevant when engaging and working with communities to co-produce services and interventions.

Making Every Contact Count is an approach to behaviour change that uses the millions of day-to-day interactions that organisations and people have to support them in making positive changes to their physical and mental health and wellbeing.

Friends, Families and Travellers has produced Reducing Health Inequalities for People Living with Frailty: A resource for commissioners, service providers and health, care and support staff. This was commissioned by the Department of Health and Social Care, Public Health England, NHS England and NHS Improvement as part of the Voluntary Community and Social Enterprise (VCSE) Health and Wellbeing Alliance.

Vulnerable migrants

The Migrant Health Guide is a free-to-use online resource designed to support primary care practitioners in caring for patients who have come to the UK from overseas. It includes information on migrants’ entitlement to the NHS, guidance for assessing new patients, tailored health information specific to over 100 countries of origin and guidance on a range of communicable and non-communicable diseases and health issues.

The Doctors of the World Safe Surgeries initiative supports GP practices that commit to taking steps to tackle the barriers faced by excluded groups in accessing primary healthcare. The initiative provides a range of support, including:

• resources to support practice staff
• simple guides to NHS entitlement
• translated patient-facing posters
• training for clinical and non-clinical staff on migrants’ entitlement to NHS care common barriers and good practice

The No Recourse to Public Funds (NRFP) network is a national network that supports councils to prevent homelessness, alleviate child poverty, promote integration within local communities, and to operate cost-efficient services for destitute families, adults and care leavers who are unable to access benefits due to their immigration status.

NHS England has produced leaflets to support people with registering with GP services if they are homeless or vulnerable migrants.

Homelessness and Rough Sleeping

For specific resources on homelessness and health see the Homelessness: applying All Our Health resource.

The Association for Young People’s Health has produced a toolkit and learning resource focussing on addressing health inequalities in homeless children, young people and families.

Modern slavery

The UK Modern Slavery Helpline and Resource Centre provides access to information and support for victims, the public, statutory agencies and businesses on a 24/7 basis.

PHE has published a research and analysis page on modern slavery and public health which discusses what role public health can have in tackling modern slavery.

The Royal College of Nursing has resources that provide guidance and advice for anyone who may encounter people impacted by modern slavery.

Criminal justice

Public Health England (PHE) has produced a suite of toolkits to support local teams to undertake health and social care needs assessment of people in contact with the criminal justice system.

Gypsy, Roma and Traveller communities

Friends, Families and Travellers developed a guide for tackling health inequalities in Gypsy, Roma and Traveller communities, commissioned by NHS England and NHS Improvement.

A publication by Walshaw and Ireland draws attention to health inequalities in the Traveller community and discusses some simple actions that dental practices can take to engage more effectively with the Traveller community.

Health literacy

PHE and the UCL Institute of Health Equity have produced a practice resource on improving health literacy to reduce health inequalities for local health providers.

NHS Education for Scotland has produced The Health Literacy Place, a website with health literacy information and resources in Scotland. The site provides online learning tools, existing evidence, good practice, techniques and tools for practice.

Training resources

PHE and Health Education England’s ‘e-Learning for Healthcare’ has e-learning sessions on homelessness, modern slavery and helping people living in cold homes to increase the confidence and skills of health and care professionals in these topics, to embed prevention in their day-to-day practice. Other sessions that may be of interest include cultural competence and the All Our Health resources.

Health Education England has produced Fair Health, a free educational resource for healthcare professionals in the UK to reduce health inequalities. Training includes modules on homelessness, childhood trauma and adverse experiences, Gypsy and Traveller healthcare, and domestic violence and abuse, among others.

Health Education England has produced training resources, including on health literacy, to support NHS workforce in preventing ill health and reducing health inequalities.

The Faculty for Homeless and Inclusion Health offers 6 free online training units for professionals with an interest in the health needs of people who are homeless, people who sell sex, Gypsies and Travellers, and vulnerable migrants.

Strong Mind offers a Trauma Risk Management (TRiM) course, a peer-delivered risk assessment and ongoing support system designed to help in the management of traumatic events.

One Small Thing provides trauma-informed programmes, including staff training.

Good practice examples

PHE West Midlands and West Midlands Association of Directors of Public Health hosted an engagement event on modern slavery in 2016. The event acted as a catalyst for a range of collaborative and informed local action, and a range of recommendations were produced around strategic partnerships, capacity building, sharing good practice, resources and tools and developing the evidence base.

A collection of community-centred practice examples put together by PHE is available from the PHE Knowledge and Library services. For example, Bright Beginnings: support for vulnerable migrant and refugee women during the perinatal period is a project that offers support during the perinatal period for women from migrant and refugee communities through 5 bilingual maternity mentors.

Surrey Heartlands (a collection of CCGs) has funded Surrey-wide projects for Gypsy, Roma and Traveller Health Outreach and Inclusion Health (for homeless families). These 2-year projects are delivered by Children and Family Health Surrey to address the health inequalities of these marginalised populations. The approach is based on a responsive, needs-led collaboration with communities and the development of peer support and health advocates. It also focuses on cultural competence training for acute and community health staff. The aim is to embed this service into mainstream practice.