Championing inclusion health: Local government’s key role

In its election manifesto, the Government committed to “tackle the social determinants of health, halving the gap in healthy life expectancy between the richest and poorest regions in England.” While there is currently a 6- to 7-year gap in healthy life expectancy between regions, the inequalities faced by inclusion health groups are even starker. For example, the average life expectancy for those experiencing homelessness is just 43 years for women and 45 years for men – shockingly, this is 40 and 34 years lower than the national average, respectively.

As these case studies show, local government plays a vital role in championing inclusion health for our most vulnerable communities. These are people who face social exclusion, whether due to homelessness, substance dependence, or cultural marginalisation or numerous other factors, and often face significant barriers when accessing essential services. Councils are stepping up their efforts, implementing innovative strategies and working with partners and communities to bridge these gaps through targeted outreach initiatives and co-designed services that reflect community needs.

However, to effectively tackle these issues, councils need more support. Central government must provide additional funding for targeted work with inclusion health groups, who experience some of the most severe health inequalities in our society. These groups often have undiagnosed and untreated long-term conditions, leading to higher healthcare costs and poorer outcomes.

Local councils are committed to addressing these disparities through their public health responsibilities alongside their traditional functions in housing, planning and community engagement. Yet, addressing the core building blocks of health (such as housing, education and access to green spaces) that impact life expectancy, requires sustained investment.

We hope this report serves as a call to action. With additional resources, local government can expand its work on the ground, delivering the tailored and integrated services needed to create healthier, more equitable communities across England. Together, we can improve health outcomes for everyone, especially the most vulnerable.

The case studies compiled in this report offer tremendous insight in optimal ways of working with inclusion health populations, but they also shine a light on the scale of work required to improve healthcare for a diverse range of people across England.

It remains vital that local leaders of health and care systems design services for people who are socially excluded. Inclusion health groups face stark inequalities when it comes to life expectancy - living around 20 years less when compared to the rest of the population - so we must continue to work tirelessly together to address these injustices and strive for equitable access, excellent experience, and optimal outcomes for everyone. 

That is why NHS England has inclusion health groups at the heart of our priority populations in the Core20PLUS5 approach to reducing healthcare inequalities, and also why there is in place a national framework, developed through collaboration with partners, for action on inclusion health. The framework stresses the need for robust partnerships and provides five core principles for inclusion health improvement:

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.

NHS England has worked closely with NHS Integrated Care Systems to embed these five core principles in their plans to actively support inclusion health groups in their local areas. 

In practise, this is through creating a contract of trust between leaders of local health and care systems and the people that they serve by providing compassionate personalised care, ensuring joined-up action to mitigate universal policies which can disproportionately affect marginalised groups, and by working closer than ever before with the voluntary community and social enterprise sector to understand health inequalities at a grassroots level.

The learning from community-centred interventions and action outlined in this report clearly demonstrate the positive impact systems can have when focussing on inclusion health in communities, and improvement can only be achieved through collaboration, contribution and compassion. 

‘Inclusion health’ is a term used to describe people who are socially excluded and typically experience multiple overlapping factors for poor health such as poverty, violence and complex trauma. This can often lead to barriers in accessing health services and poor health outcomes. 

Inclusion health groups include people who experience homelessness, people with 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, among others. 

These people can experience significant health inequalities, with lower healthy life expectancy and a lower average age of death. For example, according to the NHS England national framework on inclusion health, the average age of death for people experiencing homelessness and rough sleeping is 43 years for women and 45 years for men. Gypsy and Traveller communities are estimated to have life expectancy of between 10 and 25 years shorter than the general population. Female sex workers in London have a mortality rate 12 times the national average. 

Councils are working with their partners in health and in the voluntary, community and social enterprise sector to remove some of the barriers experienced by inclusion health groups, as illustrated by the good practice case studies in this resource. These barriers can include not knowing how to access or navigate the system, difficulty accessing services due to transport or technology issues, having negative past experience of services, not speaking English, and not being able to read or write. 

The work underway includes system mapping and identifying gaps in provision; asking communities about their experiences; targeted outreach such as health promotion vehicles, pop-up clinics and specialist support workers; using ‘trusted providers’ as a gateway to other services; peer support; and co-design of services.   

These case studies focus on the following inclusion health communities: 

• People in Worcestershire with drug and alcohol dependence who do not engage with conventional services. 
• Rough sleepers in Portsmouth with drug and alcohol issues. 
• People in Nottinghamshire who are experiencing severe multiple disadvantage. 
• The Boater community living on Wiltshire’s waterways.  
• Inclusion health groups in the East Riding of Yorkshire. 
• Children in asylum-seeking families housed in York. 
• Vulnerable community groups in Cheshire West and Chester. 
• Cornwall’s fishing community and its Gypsy, Roma and Traveller community. 
• Women involved in on-street sexual exploitation in Luton. 
• Sex workers in the London boroughs of Camden, Islington and Haringey. 

While some of the case studies focus on very specific community groups, much of the experience and learning can be applied more broadly across the inclusion health agenda. Some of this work is at a very early stage, but each example illustrates partners working together at a local level to reach out to vulnerable community groups, listen to what they have to say and begin to adapt services to better meet their needs – ultimately improving health outcomes and reducing health inequalities.