Whatever happened to Inclusion Health?

In these nasty times as the government tries to divide us into the deserving and undeserving – organisations who support some of the most excluded need all the help they can get. There is an existing Department of Health/Cabinet Office programme “Inclusion Health” that should be empowering champions in this area – but it has little profile at the moment. Why is the Department of Health not promoting it more assertively? I was reminded of Inclusion Health when reading one of the NHS Future Forum Publications and came across a reference to it tucked away on page 27 of  the “NHS role in the public’s health”. It’s not surprising it’s there; as well as being the NHS Future Forum Czar Steve Field is also responsible for Inclusion Health. Inclusion Health was commissioned by the last Labour Government and due to the championing of Steve and some excellent civil servants it survived the change of Government and has been endorsed by Ann Milton (Hansard column 755 18th Oct 2011) – the current Parliamentary Under Secretary of State for Public Health. It focusses on looking at ways to improve the health of some of the most easily ignored groups in society. People whose health outcomes are far worse than the England average – they include:

• Gypsy and Travellers – only 30% of Irish Travellers live beyond 60
• Homeless People – consume 8 times more hospital inpatient services than people of a similar age and are 40 times more likely not to be registered with a GP
• Street Sex Workers – over 80% report using heroin or crack cocaine
• Adults with a learning disability – 58 times more likely to die prematurely than the general population

Some really good work was done on the evidence and on working out what action could be taken. Much of this work is summarised in “Inclusion Health – How we meet the primary health care needs of the socially excluded”  This is where the data above comes from. You will note that the only version I can find on the web is the ‘Labour Government’ one. Some of the actions described emerged from collaborations between organisations such as  hospital trusts and the voluntary sector.  There is a case study that gives a great insight into this on page 12 of ‘Integration’ another NHS Future Forum Publication. A slightly abridged version of the case study is here – with highlighting by me: “Jim and the London Homeless Pathway Jim was brought into A&E at University College Hospital (UCH) in London with alcohol withdrawal seizures and malnutrition, having been found by paramedics collapsed in the ground floor common room of his hostel where he had been unable to climb the stairs to his room for two days. Upon admission, it was discovered that he also had alcoholic fatty degeneration of the liver, cerebral atrophy and symptoms of cerebellar ataxia and peripheral neuropathy (alcohol related brain and nerve damage); he also had many old scars of self‐harm. The usual practice would be to get Jim back to his “baseline” and discharge him as rapidly as possible back into the community. Since 1995 Jim had attended A&E at UCH 155 times; had been admitted to hospital 11 times and spent a total of 62 days as an in‐patient. Usually this had been related to self‐harm or alcohol‐related damage. Having been homeless for the last seven years with periods of rough sleeping, he had never been deemed to have social care needs and medical care had been reactive. All of his mental and physical health problems were dismissed as alcohol‐related. The London Homeless Pathway integrated service team befriended Jim, and arranged to replace his soiled clothes. Talking to him, it was clear that much of his agitation was due to ongoing alcohol withdrawal symptoms and an increase in the dose of his medication was negotiated. Instead of the usual rapid discharge, assessments were arranged with an occupational therapist and a physiotherapist. Jim was supported on a daily basis and involved in decisions about his care. His medical history and current findings were summarised in a report by the Pathway team GP and a referral to social services was made. The accumulated information clearly showed significant care needs and he was placed by the local authority in a residential unit, where he settled well and considerably reduced his alcohol consumption. Jim has not needed to attend A&E at UCH for over 12 months.” If you dig deeper into the story of the homeless pathway we see that it includes the use of peer volunteers (see section on Healing) who help medical and social services keep in touch with service users and helps prevent reactive crisis led responses. A few points.This work is exciting and important because:

• it recognises that complex challenges require integrated solutions involving a wide range of agencies and solutions
• it is positive and optimistic about individuals desire and ability to change
• it recognises the importance of listening to the client
• it understands the importance of being connected – and has worked out a way of involving volunteers to facilitate this.
• it has been initiated by those organisations who experience the problem – the providers of last resort – rather than the commissioners, primary care providers or public health. These are the organisations usually hospital A&E or front line voluntary organisations who people turn to at times of crisis when other services have ignored them.

But what about Inclusion Health? If you search the web for ‘Inclusion Health’ you will only find a few old references to this initiative. Apparently work is still going on– I understand this includes:

• A National Inclusion Health Board chaired by Steve Field  I can find no public minutes or indication of when it last met. (I know he is a bit busy at the moment)
• Four working groups
• Working relationships have been established with representative organisations across 4 priority groups
• Updated Data Packs
• Support to two ministerial groups on homelessness (no record of activity since September 2011)and Gypsies and Travellers (I can’t find any public agenda or minutes for this group).

This is all tremendous stuff – but the most up to date public reference to Inclusion Health that I can find is from the 7th of July 2011 where Steve Field praises the launch of Grant Shapps’ “no second night out” which aims to reduce rough sleeping. Unfortunately on the 17th of October the National Housing Federation, Shelter and the Chartered Institute for Housing produced a pretty damning indictment of Government Housing Policy “The Housing Report” which gave a red traffic light  progress on homelessness stating that: “…the increase in homeless acceptances and use of temporary accommodation is troubling.” The lesson is clear – To be credible Inclusion Health needs to be better at providing authoritative independent public challenge to government policy as well as support when it is merited.  SO

• Inclusion Health is a really important initiative. It draws attention to the needs of people we ignore too easily and provides a template for action.

• Its is tremendous that it continues to be supported by the Department of Health.

BUT

• If it is to survive and make a real impact we need the Department of Health to prioritise promoting it and publicise its existence and to do so soon.

• We need to understand which organisations are involved – so that we can support them, lobby them and hold them to account.

• Despite his commendable support it would help the development and sustainability of Inclusion Health if it was clear that it was supported by a wide range of organisations outside government and not just by Steve Field and the Department of Health. This is because the NHS Future Forum is increasingly perceived as providing “cover for the governments efforts to privatise the NHS”.

What do you think?