Inclusion health is a catch-all term used to describe people who are socially excluded and those who typically experience multiple overlapping risk factors for poor health, including poverty, violence and complex trauma. Examples are 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 (Public Health England (PHE), 2021).
People in these population groups are also more likely to experience poor health because health care is not made as easily accessible to them, despite the fact that they are more likely to have several concurrent health conditions that put them at greater risk of dying young (Hwang et al, 2009).
Why should nurses and midwives know about inclusion health?
Nurses and midwives should be familiar with and understand the concept of inclusion health for people in their care because of the enormous implications this has on the way they deliver care. For example, if individuals from inclusion health populations are to improve their health outcomes and live longer and healthier lives, they must be able to receive timely, easily accessible and available health and care services.
Research shows that people from these populations often have the experience of being turned away from services or being badly treated. They may also find it difficult to understand the health and care system, which limits their ability to navigate it and connect with the services they need. Many people also find that their access is further restricted because the information is provided only in English, which may not be their first language.
Not having a permanent home address presents another challenge when trying to register with a GP. Because primary care is the entry point for health and care services in the UK, many people are therefore forced to use secondary care services, including hospital emergency departments (EDs). Their access to preventive, long-term care is also limited, and so ongoing health improvement, promotion and illness prevention is often not possible, which further exacerbates existing health inequalities (Luchenski et al, 2018).
Homelessness is an important aspect of inclusion health
Homelessness is the term used when a household has no home available that it is reasonable to occupy (PHE, 2019).
Although the term is commonly used to refer to people who are sleeping rough, it is also used to refer to ‘houselessness’, which is when people may have a place to sleep that is temporary, for example in an institution or a shelter, or they may live in insecure housing where they are under threat of severe exclusion due to insecure tenancies, eviction, or domestic violence. They may also be staying with family and friends in an arrangement known as ‘sofa surfing‘ or living in inadequate housing, including caravans on illegal campsites, in unfit housing or in situations of extreme overcrowding (PHE, 2019). These situations are exacerbated when the household comprises adults and children.
National statistics for homelessness and rough sleeping are often difficult to understand and do not provide the complete picture. The rough sleeping statistics are based on a snapshot of people identified as sleeping rough on a single night. In 2020 this coincided with the national lockdown and the ‘Everyone In’ scheme, which supported thousands of people to get emergency accommodation. The 2688 people estimated to be sleeping rough on the night of the 2020 national count, should therefore be understood in this context.
The way homelessness data are recorded changed with the implementation of the Homelessness Reduction Act in 2018. Although the data are not directly comparable, there has clearly been a significant increase in the number of households receiving a statutory homelessness service. The latest data available, for 2019, showed that there were 288 470 households receiving new prevention or relief duties services, which is four times the number of households owed the ‘main duty’ in 2017-2018 prior to the implementation of the Homelessness Reduction Act in 2018.
Ill health can be a consequence of homelessness and may also be the trigger for homelessness, if it contributes to job loss or relationship breakdown. The earlier in a person's life they become homeless and the longer it lasts, the more likely their health and wellbeing will be affected. This is reflected in the average age at which people who experience homelessness die, which was 46 years for men and 43 years for women in 2019. This compares with 76 years for men and 81 years for women in the general population (Office for National Statistics, 2020).
Online learning resources
Nurses and midwives working in all sectors of health and care will come into contact with people who are experiencing homelessness and must be able to address their needs in a timely and effective manner if they are to help them improve their health and wellbeing.
To enhance nurses' and midwives' knowledge and understanding of how to care for people from inclusion health groups, including homelessness, PHE has published free online e-learning resources as part of a programme entitled All Our Health (PHE, 2019). Already being accessed by thousands of health and care professionals, the inclusion health and homelessness e-learning resources are available to help nurses and midwives consider available data, resources and services so they can act on this important area of practice.
Box 1 summarises the actions detailed in the All Our Health Inclusion Health resource that all nurses and midwives can take to increase their focus on this important area of practice.
Box 1.Actions all nurses and midwives can take to address inclusion health
- Ensure that you are aware of the health and social needs of the inclusion health groups in your area
- Undergo training in trauma-informed approaches to ensure that you are aware of the importance of trauma in health outcomes and that you feel able to support and refer individuals appropriately
- Ensure that you are aware that everyone can access primary care for free and who is entitled to free NHS services, including dental services
- Ensure that you are trained and confident in cultural competence and sensitivity
- Learn 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
- Ensure that you are aware of the best principles of health literacy and that you communicate with individuals in a way that they understand and can act on
- Ensure that you are up to date with ‘Making Every Contact Count’ training (www.makingeverycontactcount.co.uk)
- Learn how to identify and refer people who need support from local housing and health services, energy advice or the warm homes referral service
- Ensure that you are aware of and fulfil the requirements of the new public sector duty to refer a person or household that is homeless or who is threatened with homelessness
Building back better and fairer
As we start to focus on the recovery phase of the COVID-19 pandemic, it will be essential for our nursing and midwifery workforce to appraise the lessons learnt and to consider what changes need to be made to ensure that we genuinely build back better and fairer. This will require our profession to use the 2020s as a decade that sees transformation across our nursing and midwifery workforce, placing equal focus on both preventing disease and treating it. We will also need to have a sharper focus on addressing health inequalities, which will require us to challenge our thinking and approach if we are to make a difference.
As nurses, we can act as a force for change in supporting healthy communities and challenging policy and practice for the greater good. As the largest and most trusted professional workforce, we have the potential to make change happen.
Case study
Sandy is 20 years old and is mother to 4-year-old Bella. Sandy and Bella have spent the past 4 years living with a foster family in Cornwall, but following a disagreement Sandy has relocated to London with her boyfriend. They are living temporarily with her boyfriend's family in a two-bedroom flat.
Sandy attends the ED because Bella has burnt her legs with a hot drink. Sandy does not have a red book (personal child health record or PCHR), so you do not have any up-to-date information about Bella's healthcare history, including the immunisations she has had. Sandy has not yet registered with a GP, so you are not able to identify the name of the health visitor. Bella looks sad, her clothes are dirty and do not fit her very well.
You are concerned because the dressings will need to be changed in 2 days and, without access to a GP, Bella will have to return to the hospital outpatient clinic.
Having recently completed the inclusion health module from the All Our Health e-learning programme, you know that engagement with health services is easier if the health professional can develop a relationship with the client (PHE, 2019). In Sandy's case this seems even more important because, for the first time since becoming a parent, she does not have anyone to help her care for her daughter. If Sandy and Bella attend the hospital outpatient department, they will see a different nurse each time, and this will make it difficult to establish a professional trusting relationship.
You spend time playing with Bella and talking to Sandy in the playroom, and Sandy tells you the address where she is living and that she has been taking Bella to the local children's centre to play with other children. The ED has a list of children's centres in the local area and the paediatric liaison health visitor manages to identify the health visitor who regularly attends the centre.
The health visitor agrees to meet Sandy at the GP surgery to help her register, and she arranges for the general practice nurse (GPN) to change the dressings. This means that Sandy and Bella can see the same nurse each time the dressing is changed. This will make it easier to check that the wound is healing and for the GPN to offer Sandy and Bella additional health and care services.