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If integrated care cannot tackle inclusion health, we should all be worried


This summer a huge restructure created 42 new NHS integrated care boards to plan and fund NHS services, and to deliver improvements on population health across an integrated care system. This is not a renaming of current ways of working but is intended use the new structures to work in new ways. Looking to next year, now is the time for the ‘so what?’ of system change – as the start-up focus on terms of reference subsides.

Inclusion health is a reasonably widely used term, even though its definition and exactly who it refers to may vary. What the different approaches have in common is a recognition that social exclusion impacts health outcomes, experiences and access, with stigma playing its part in that pattern. Typically, inclusion health groups include refugees and asylum seekers, those experiencing homelessness or substance misuse, prisoners, sex workers, and those from Roma or traveller communities. Health outcomes for these groups are dire and the approaches to service design and delivery that might help are often similar. They require statutory services to work differently, to include and involve better, and truly partner with the voluntary and community sector.

At first view, improvements made in inclusion health should be the ideal measure for the ‘so what’ of NHS reform. Multi-morbidity abounds and there is a need to shape offers of care at a hyper-local, neighbourhood level. That is why seven integrated care systems are collaborating to take an improvement journey focused on these populations. Three national organisations – Groundswell, Pathway, and The King’s Fund – are working with them.

Together each organisation brings expertise in how the health and care system works, in hearing the voices of those excluded, and in providing first-class homeless health services, in particular. The collaboration across ten organisations sees the potential, but also the inherent risk of the changes, dependent on the practicalities of how new systems choose to listen, to prioritise, and to experiment.

What does good look like?

A lack of evidence of what to do to improve inclusion health is not really the problem; guidance is mainstream enough to come from NICE. A cadre of the willing exist nationally, with 1600 local clinical leads and public health attention on this topic, and there is expertise among the client groups, through sharing their lived experience and in influencing and designing services. The pandemic illustrated that sometimes evidence can come to the fore in shaping services, and can challenge traditional beliefs about what can be done by community organisations. It remains to be seen whether those grassroot green-shoots can survive the recovery journey, as ways of working return to a different pace, steeper hierarchy, and fiscal restraint.

As the ten organisations highlighted above bring together evidence and practicality, experts and decision-makers, we face two inclusion health patterns commonplace across the country.

  • Some not all: in many communities, there probably exists a service of note: provision for people sleeping rough or those taking drugs, for example, that stands out. These beacons are important, but they do not represent the full cohort of inclusion health populations. Excellence in serving one group does not organically spread to other groups, despite principles being common.

  • Somewhere not everywhere: the same small-scale pattern applies geographically – a given ward or town may have outstanding provision, but that is not mirrored across a county or system. Rarely, in truth, do services fully reflect or reflect incidence.

This pocketed excellence often comes from a confluence of local leaders and fantastic third sector delivery, in a circumstance where a clinical team ‘gets it’. These are the conditions of localism. Nothing in scaling up should look to stymie that.

The challenge for systems is to nurture not standardise, maintaining the personalisation that the populations require. This means finding a balance between making ‘mainstream’ services accessible to all and providing particular provision for excluded groups. The inclusion health chapter of forthcoming integrated care partnership strategies has to embody proportionate universalism.

It is not all a set-up question though. We know that pilots and soft funding are often the urgent response. The improvement journey has to be built to last. That means recognising the expense of the status quo; a cost borne in late presentation and institutionalisation in health care, in lost contribution to communities and the wider economy. As bodies with multi-year allocations and a view across the local public sector budget, ICSs might break free from spot-funding ‘pet’ projects. Long-term certainty may unlock the inhibition to commit to this work – to shape research, education and service commitments – and go beyond inclusion health as an add-on to clinical careers.

Learning by doing

Alignment, incentives and teamwork need to be tuned just right for the opportunity to be delivered. That then explains why the ten collaborating organisations have chosen to learn by doing. We intend to find the real barriers and make them easier to surmount for those yet to start, tell a story as we go and find the honesty to assess what really is working.

Integrated care won’t succeed or fail either because of committee structures or a sincere intention to address exclusion. It is implementation that matters: creating integrated inclusion health systems gives us an opportunity to learn what it means to introduce population health at scale.