On a bright September morning, a group of people gathered in a room in The King’s Fund building in central London. Most of them came from new Integrated Care Systems, the bold and the brave who had signed up – and been chosen – to be part of a new journey to work out how these new systems could improve the health of the most marginalised people in society. All of them were already doing brilliant work in their local partnerships, but wanted to learn from others how to go further and faster.

The evidence for the need for this work is well established but no less shocking for it. Inclusion heath groups are at the sharp end of our country’s health inequalities, with their experiences exacerbated by trauma and marginalisation. People experiencing homelessness are ten times more likely to face an early death than people who are housed. Street sex workers have high levels of multi-morbidity, with 100% of participants in one study having a long-standing illness or disability. Among vulnerable migrants, asylum seekers are five times more likely to have mental health needs than the UK population.

At the same time, there is a reasonably solid body of evidence on approaches that can best meet these needs. Much of this is captured in the recent NICE guideline on homelessness, the principles of which can apply to other inclusion health groups, and in literature elsewhere.

“This is where Pathway, The King’s Fund and Groundswell wanted to shine a light.”

Less well captured has been how ICSs, who are perfectly positioned to do so, can make a reality of the promise of integration for people in inclusion health groups. This is where Pathway, The King’s Fund and Groundswell wanted to shine a light.

The three organisations were approaching this from different but complementary perspectives. Pathway is a homeless and inclusion health charity, supporting a network of specialist homelessness hospital teams and the Faculty for Homeless and Inclusion Health. Seeing patients in hospitals having been so poorly served in the community, we are expanding our activity in system change, looking at what needs to be done beyond the hospital doors. The King’s Fund was, as Toby Lewis, then Senior Fellow, put it, the ‘midwife’ of Integrated Care Systems in the UK from Chris Ham’s time, and continues to lead the thinking on integrated care. And Groundswell’s deep experience in homelessness and health through the perspective of people with lived experience brought critical expertise in this important area.

Our participants, who all worked in different roles and at different levels of their organisations, took part in six sessions with us. They heard from expert contributors from inclusion health, housing and beyond,  to whom we owe a great debt of gratitude, who shared the latest evidence-based practice in improving access, outcomes and experiences for inclusion health groups, and ideas about the system changes needed to underpin this. We combined this ‘teaching’ element of the programme with creating space for our participants to think about their own contexts and how they could make a reality of what they had heard in their own areas.

“…many experienced the difficulty of shifting the system’s time, attention and resources to inclusion health groups in the face of so many other urgent and immediate pressures on the NHS.”

The ICSs who participated were all at different stages of their journey in integrating for inclusion health, but they grappled with a number of common challenges.  All had pockets of good practice  but faced the challenge of spreading services to a wider geographical footprint, while maintaining the principle of subsidiarity.  All had some services for people from a particular inclusion health group – often people experiencing homelessness – but had more to do to extend the thinking to other groups such as people who carry out sex work, and people in Gypsy, Roma and Traveller communities. And many experienced the difficulty of shifting the system’s time, attention and resources to inclusion health groups in the face of so many other urgent and immediate pressures on the NHS.

This was a theme in the Hewitt Review, which made the case that “prevention, population health management and tackling health inequalities are not a distraction from the immediate priorities: indeed, they are the key to sustainable solutions to those immediate performance challenges.” We would agree, as would our participants.

Certainly, system reform, driven at national level, is needed to make the task of ICSs easier. Data systems need an overhaul to address the invisibility of inclusion health groups in data, with its consequences for planning and commissioning. Workforce training and education needs to be updated to give the front line the skills and experience to work in a trauma-informed way. Housing precarity is a horrific drain on the spirits and the health of people in inclusion health groups and requires urgent Government (or devolved mayoral) action to provide more affordable and stable housing, with support for those who need it.

“ICSs do not need to wait to take action…”

ICSs do not need to wait to take action, however. Our programme showed many reasons for optimism, and that there are concrete, immediate steps that ICSs can take to tackle the sharpest of health inequalities experienced by people in inclusion health groups. We have captured the best of these from our programme in the report we’re launching today. The report outlines a roadmap for inclusion health – seven steps that ICSs can take to address their challenges and make a reality of the promise of ICSs.  Perhaps the least developed step is the last: to use the power of their Boards, and the reach of their partnerships, to test and evaluate whether services really are accessible and available to those most in need.

We offer this with a degree of humility. We know what works, but ICSs are still learning about how to operationalise it, and we’re learning alongside them.  Today, we are also launching a new network for leaders and managers in ICSs, to come together to share learning and experiences in how best to care for the most underserved people in their area. This is a new sub-group of our long established Faculty for Homeless and Inclusion Health, to be led by Jon Pritchard, Associate Director of Housing at Southern Health.

We will continue to gather these insights and hope to run another programme for another set of ICSs. In the meantime, we want to encourage you to read this report, and take the lessons into your own local system.  People in inclusion health groups, living daily with the consequences of the failure of our health and care systems to genuinely care for them, deserve nothing less.