North Central London Inclusion Health Needs Assessment

People in Inclusion Health groups face the most significant health inequalities of any group in our population – often compounded by the impact of intersectionality/multiple disadvantage. Addressing health inequalities faced by inclusion health groups is a key component of the NCL Population Health and Integration Strategy and one of our locally identified PLUS populations from the CORE20PLUS5 framework, because the needs of these populations can only be solved by working together with our partners.

Tackling inclusion health inequalities requires integrated service approaches and partnership working at system, place and neighbourhood level to address the complex set of needs these populations experience. Integrating care around these underserved groups is fundamentally linked to improving how we use our resources most effectively. The annual cost of unplanned care for patients experiencing homelessness is eight times that of the housed population. The estimated annual cost across all agencies for people who sleep rough in North Central London (NCL) is £149m.

North Central London comprises the Boroughs of Barnet, Camden, Enfield, Haringey and Islington. Within North Central London, there are a number of excellent borough-based services providing care and support for various inclusion health groups such as outreach sexual health services and specialist homeless health services. However there was a real gap in systematic evidence and information for these population groups, in terms of demographics, health needs, service provision and gaps to inform strategic commissioning and wider integrated partnership working. Each borough had limited and varied information about inclusion health groups.

North Central London ICB working in partnership with Directors of Public Health for the five boroughs and borough leads for homeless and inclusion health developed plans for an Inclusion Health Needs Assessment (HNA). The aim was to better understand the demographics, health needs and barriers to healthcare for people in inclusion groups, with a focus on people experiencing homelessness, Gypsy, Roma and Traveller communities, sex workers, vulnerable migrants and those with a history of imprisonment. It made sense to work at a system level to collate the HNA as it enabled us to draw on the expertise, experience and relationships certain boroughs had developed with particular inclusion groups.

Conducting the Inclusion HNA

The Inclusion HNA was conducted in two phases. The first phase was a collation of available evidence and information on the inclusion health groups from a range of sources, including national databases, service data and Council-held data. Phase one Rapid Evidence Review identified the size and demographic profile, health needs, services and gaps for inclusion health groups. Phase two comprised extensive engagement with senior stakeholders and individuals with lived experience as well as a staff survey. The aim was to complement demographic data with lived and staff experiences. A total of 24 senior stakeholders from across health, Councils, housing and the voluntary sector were interviewed to get a broad strategic view on inclusion health across the system. Over 140 staff from health, housing, social care and voluntary sector completed the survey to share their experiences of delivering care and support to inclusion health groups. Twenty-four people with lived experience of inclusion health were interviewed by Groundswell (a charity supporting people experiencing homelessness) from across the five broughs and with varied lived experience of multiple disadvantage and social exclusion.

The Inclusion HNA highlighted a number of factors:

Across the five groups, evidence on people experiencing homelessness is the most recent, local and comprehensive, while there is limited local evidence on people with a history of imprisonment, undocumented migrants, sex workers and Roma communities.

There are overlaps among inclusion health groups, with many individuals facing severe multiple disadvantage and common drivers of social exclusion that push people into homelessness, sex work and prison.

Within the 5 broad inclusion health categories, there is also substantial diversity: people with a history of imprisonment; those engaged in direct (on and off-street), survival and indirect sex work; Romany Gypsies, Irish travellers, Roma people, travelling show people, new travellers and liveaboard boaters; asylum seekers, refugees and undocumented migrants; rough sleepers, statutory, single and hidden homelessness.

Inclusion health groups often have many similar health needs, particularly related to mental health, substance abuse, TB and STIs and untreated long-term conditions, leading to higher mortality.

Common barriers in accessing healthcare across groups include: fear of stigma and discrimination, lack of identification or proof of permanent address, lack of awareness of the healthcare system and entitlements, trauma triggers, language and digital exclusion. Sex workers and undocumented migrants face additional fears of prosecution.

Insights and impacts

The Inclusion HNA has received enormous support and input from stakeholders across the system, including the Borough Partnerships, Health and Wellbeing Boards and the NCL Population Health Integration Committee. The Inclusion HNA has enabled us to improve cross-borough equity of service provision within NCL and has provided the evidence for system-wide opportunities related to particular inclusion health groups. The findings from the Inclusion HNA has encourage place-based discussions to identify Borough Partnership priorities for inclusion health groups.

• Based on the evidence and insight from the Inclusion HNA, one of the boroughs will be hosting an Inclusion Health Summit for later in 2023 with the aim of raising awareness on inclusion health, sharing information and facilitating collaboration across services.
• NCL ICB has commissioned a project on participation for individuals with lived experience of homelessness, multiple disadvantage and inclusion health to enable them to contribute to service design as equal partners.
• A pan-NCL Homeless Health and Care Community of Practice was launched in May 2023 to enable sharing of good practice, collaboration and partnerships across the system as this was a gap highlighted in the Inclusion HNA. The aspiration is to extend these to cover other inclusion health groups over time.
• A focus on inclusion health has ensured equity of primary care provision for people experiencing homelessness across the five boroughs through the commissioning of additional specialist homeless GP services in two boroughs.

Feedback on the Inclusion HNA

NCL director of Public Health, “Well done to the team for this excellent piece of work. Look forward to continuing to work on this including through the health inclusion summit we have planned.”

In relation to the case studies and lived experience within the Inclusion HNA, NCL joint commissioning lead, “This is a sobering read”.

Key NCL ICB stakeholder, “Inclusion health has to be embedded in the clinical strategy and reviewed in the context of the system and its governance. That brings in financial conversations and resource conversations; for example, the Health Inequalities Fund which can support key programs of work.”

Tips for success and lessons to take forward

The combination of demographic and published data alongside lived experience and staff experience provides valuable insight and opportunities for the system to focus on. The addition of journey-maps and case studies of individuals with lived experience within the Inclusion HNA portrays the complexity of inclusion health and multiple disadvantage, highlighting the different factors, services and interactions that impact on a person.

There were a number of limitations and lessons to take forward.

For lived experience interviews:

• It is important to work with charities and experts with lived experience of specific inclusion groups when conducting peer research, as these experiences may not be translatable across the groups.
• Engaging with sex workers and GRT communities was particularly difficult, requiring more time and resource which was not available. For example, to properly engage with the Roma community, researchers who speak Bulgarian are needed.
• Additional resource and capacity for translation should be factored in.

For demographic profiles:

• Demographic profile data for inclusion groups is challenging to collate, varies according to source and coding methodology and, fluctuates over time as inclusion health groups are often transient. Consistency in coding and data collection across services and organisations is important for service planning, delivery and evaluation.

Next steps

There are a number of additional plans in development based on the findings of the Inclusion HNA:

• A focussed piece of work on improving access and experience for sex workers and vulnerable women in inclusion health groups is planned. This will include experts from the voluntary sectors as well as services that support women with a history of offending and violence against women and girls (VAWG) to ensure a relatively broad scope.
• Build on the pan-London co-occurring conditions programme to improve service provision for individuals in inclusion health groups.
• Improve coordination of care and support for prison leavers (e.g. GP registration, access to substance use and mental health and wider support services) to reduce risk of re-offending.
• Develop plans to improve access to dental care for inclusion health groups.
• Focussed, culturally and linguistically appropriate engagement with asylum seekers and Gypsy, Roma and Traveller communities.

There are planned regional workshops around Primary Care and Homeless and Inclusion Health that NCL will be co-producing. These include reviewing Locally Commissioned Services (LCS) for homeless and inclusion health currently in practice across London. There is considerable crossover in terms of unmet need between multiple inclusion health groups and the Inclusion HNA report provides valuable contextual background that can help shape conversations in terms of what should be included within the context of LCSs going forward, in the interest of formulating a framework for best practice.

This links to framework principle 2

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