Inclusion health

Inclusion health (IH) is a research, service and policy agenda that aims to prevent and redress health and social inequities among the most vulnerable and marginalised people in a community. This includes people who are homeless, Gypsies and travellers, sex workers and vulnerable migrants.


Homeless health

Rough sleeping has risen. Government statistics show that in 2016 there were double the number of people sleeping on the streets compared with 2010. The charity Shelter estimates that over 250,000 people are homeless in England. Homelessness is associated with poor health and premature mortality. It is characterised by trimorbidity: mental ill health, physical ill health, and drug and alcohol misuse. This is often associated with advanced illness at presentation. The average age of death (opens PDF, 873.10KB) for homeless people is 47 years.

Homeless people are increasingly attending and re-attending secondary care due to ill health and lack of engagement with primary care. A 2010 paper by the Department of Health found that people who are homeless are five times more likely to attend emergency departments when compared with an age-matched, housed population. They stay three times as long as age-matched, housed patients due to illness, and lack of support and aftercare for rough sleepers. This results in secondary care costs that are eight times that of the equivalent housed population.


Standards for healthcare delivery

A multifaceted approach is needed to tackle the mortality and morbidity associated with people who are homeless. This includes addressing substance abuse, mental health disorders, physical ill health and homelessness itself. The Royal College of Physicians (RCP) has endorsed the standards of care (opens PDF, 900.07KB) for homeless people, travellers and sex workers produced by the Faculty for Homeless and Inclusion Health (FHIH).


Secondary care services

A tiered approach should be developed across all secondary care providers, depending on the size and need of the population served. This is shown in the table below. The Pathway care coordination approach (opens PDF, 450KB) has been demonstrated to improve patient care and cost efficiency for hospitals with significant numbers of homeless patients. This includes GP- and nurse-led ward rounds, multi-agency care planning meetings and involvement of care navigators. These Pathway teams have been endorsed by the RCP Future Hospital Commission report.

Tiered approach to secondary care services

All patients presenting to the emergency department should be questioned about their housing status and all street sleepers and rough sleepers identified immediately on arrival to any department at the hospital. All hospitals should have a system in place to support homeless people prior to discharge. No homeless patient should be discharged unsupported.

Tier 1

Hospitals with fewer than 30 homeless patients presenting each year

 

  • An identified member of staff who oversees the availability of  an information pack with signposting to local volunteer agencies for the homeless, hostels, food bank, the council,  free meals etc
  • A small supply of spare, warm, clean clothing

Tier 2

Hospitals with 30–200 homeless patients presenting each year

  • A dedicated housing officer with strong relationships with the council, hostels, charities etc
  • A named link hospital coordinator
  • An information pack for the homeless
  • Supply of spare clothing
  • Training and education of all hospital staff by the housing officer and named hospital coordinator

Tier 3

Hospitals with >200 homeless patients presenting each year


All hospitals should have protocols for discharge planning for excluded groups, based on guidance (opens PDF, 1.37MB) developed by St Mungo’s and Homeless Link. Hospitals should all be able to signpost to community services available to those who are homeless including walk-in clinics and in-reach services. Inclusion health is not limited to homeless people. It includes all those who are socially excluded including Gypsies and travellers, vulnerable migrants and sex workers. More information on health inequalities within these groups and the standards for commissioners and service providers can be found in the FHIH’s standards for commissioners and service providers (opens PDF, 554.2KB).


Training

There is currently no standardised training pathway in inclusion health. A large part of the knowledge gained by professionals is through learning on the job rather than formal education and training. It is, however, recognised that standardised training is needed (opens PDF, 3.02MB). The RCP has produced a CPD module on the social determinants of health