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Inclusion health groups: The ICB approach

health inclusion groups
By Victoria Vaughan, Editor
7 May 2024

Inclusion health groups cover people who are socially excluded, such as sex workers and vulnerable migrants, who can also experience other risk factors for poor health, such as poverty, violence and complex trauma. Healthcare Leader's Editor Victoria Vaughan talks to five experts about ICB work in this area. Alice Vickers, senior manager for inclusion health and asylum seekers and Shelley Ames, acting head of health inequalities both from Norfolk and Waveney ICB, Tessa Lindfield director of public health at Berkshire East public health hub and Martha Earley, programme director for partnerships and communities in North East Hampshire and Farnham Place and Dr Nick Pulman, Arden and GEM’s chief clinical information officer.

Choosing groups

Victoria Vaughan (VV): As part of the Core20PLUS5, integrated care boards (ICBs) could decide on which inclusion health groups they wanted to focus on. Which groups did your ICB pick and why?

Martha Earley

Martha Earley (ME): At NHS Frimley, we have very different population health needs when you look at the whole patch. We felt we needed to take quite a pragmatic approach so we came up with a process to identify the commonality across the five places and the two groups that really stood out were carers and people with a learning disability.

The main point for both was raising awareness about them being a plus group and that we need to make concerted efforts around identifying them. On the census, for example, there are over 15,000 carers, but on our Connected Care data system, we’ve only recorded 6,000. So, what’s happening and who are the others?

Part of our approach was collaborating with the voluntary sector, such as a local carers’ organisation Princess Royal Trust for Carers, and developing joint work with PCNs and specific GPs to create carers’ hubs. And we have carers’ champions who go out and speak to carers about their experiences so we can understand their journey and help inform us in how we reach and support other carers.

It’s about really understanding the challenges of the caring world; the responsibilities they have and that carers have far poorer health outcomes than the general population. There’s a human cost of that and that’s where compassionate care comes in. We need to be looking after our carers. They need emotional support and reduced social isolation, which came through very strongly as a key area of concern for our carers. And we know that social isolation also leads to poorer or health outcomes.

So, it’s identifying those carers, educating colleagues to be compassionate and to support them as fully as possible and then, obviously, connecting carers into available community services and support.

However, that said, within the smaller place areas, we’ve also got additional plus and inclusion groups. For example, in North East Hampshire and Farnham, we’re focusing quite a lot on vulnerable migrants, refugees, and asylum seekers because of the large asylum hotels that we have locally.

Tessa Lindfield (TL): As Martha said, there’s a big programme of work going on around the other inclusion groups already. For example, we’re doing quite a lot of work with our larger households in Slough because that’s a group we’ve identified in terms of our ethnic mix. We have loads of multi-generational households.

In Frimley, we wanted inclusion health groups to be a learning experience for us. We wanted to have quite a focused approach so we could learn from it and then apply it more broadly. We also wanted groups that we could identify through the data we had available so that we knew who to target and monitor outcomes.

For example, we know that the health check for people with learning disabilities is really important and sometimes we’re not quite as complete on that as we’d want to be. So, there was evidence of the impact and the different modes of communication in clinical services.

Dr Nick Pulman (NP):  Yes, the first problem really is getting the right data. There’s data all over the place, but often it’s in places where people can’t really get hold of it. In an ideal world, if you could get all of that data together, you could successfully identify a lot of people who are very vulnerable and would benefit from a whole range of interventions. One of the things we do is to try and solve some of that.

The analytic data platform we use at Arden and Gem is called Athena and it has a different infrastructure so that you can put virtually any data into it, which can be accessed by a whole range of people. It’s a kind of data mine and people can do all sorts of analysis. It’s all just starting to develop and it’s quite exciting.

It’s particularly helpful in terms of trying to identify and target people who might be at risk. This is a problem with inclusion groups – people at risk might be homeless, sex workers, or Roma groups – and there’s a really clever algorithm that takes literally thousands of different data sources and different codes and puts them into an algorithm and gives us a sort of stratifying assessment of who might be at risk.


On the census, for example, there are over 15,000 carers, but on our Connected Care data system, we’ve only recorded 6,000. So, what’s happening and who are the others?

Martha Earley

Shelley Ames (SA): There are a lot of existing strategies in Norfolk and Waveney that already talk to health inequalities so rather than writing another strategic high-level document, we’ve worked with our system to develop an action framework. Part of the process of developing that was defining our plus groups, and we’ve chosen to focus on inclusion health as one of them.

We haven’t narrowed those down particularly because we do have pockets of all inclusion health groups and it has been pointed out to us that we still have 14 priorities for Norfolk and Waveney, which is quite a significant number, and perhaps not necessarily really honing in. But it is really, really difficult to eliminate any of the groups that we know are important. So, at the moment, we’ve kept them at that number.

Alice Vickers

Alice Vickers (AV): Yes, in terms of the inclusion health groups at Norfolk and Waveney ICB, we are covering all of them. Shelley has been doing lots of work around our health inequalities frameworks and we’ve got them listed in that. My role is to support with a strategic focus around inclusion health groups.

A lot of the work at the moment has been revolved around asylum seekers around the contingency hotels, and also in dispersal, as we’ve seen more and more people come across The Channel.

Asylum seekers

VV: Both ICB areas have mentioned asylum seekers. Could you speak a bit more about how you are is approaching this population?

ME: Some of the work that we’re doing in Northeast Hampshire and Farnham is in the ‘place’ area, but we obviously do have asylum populations in the other places as well. In North East Hampshire and Farnham, the work is predominantly with families.

We were able to see there were higher rates of pregnancy amongst those mothers who had been placed in the hotel, and poorer health outcomes. That was from visiting those families, talking to the local GPs and doing analysis around the patient outcomes by using the Connected Care system.

And we know from the Core20PLUS5 that black Asian minority ethnic communities, particularly migrants, is an area of vulnerability, particularly around maternity outcomes, so we wanted to be conscientious about that.

Some of the mothers, for example, were being placed quite late in the pregnancy. So, it was working with local health visitors, maternity services, and making sure care pathways were in place, and that the hotel staff were aware and sensitive to the needs of those families.

When I started, the hotel had a 20-strong workforce of men – only men, no female staff at all – so we started out with a health and wellbeing day for women, that quickly turned into a much wider day for the whole family. We had information about sexual health, contraception, wellness of women, screening advice, and nutrition support. And we had the local football association working with children outside to keep them occupied whilst parents were able to engage in those talks.

It was very obvious when we went into the hotel and meeting some of the children for the first time that some had very visible frontal tooth decay and were quite disheveled and overly excited. There were some concerns that these children were not integrated into the community and there were barriers to accessing mainstream support. So, there were much wider issues beyond the NHS. Citizens Advice worked with us and they were really helpful in engaging families and understanding some of the needs that were coming up.

TL: We mustn’t forget that we can’t clump all these people into a homogenous group. They’re really varied and they don’t just have one set of issues.

We also have to be really pragmatic about the information that we have available. Getting people registered with a GP is a really good start because as soon as we get people registered, the information starts flowing through. Early registration and the provision of an NHS number really helps in arranging the right care for people at the right time and in terms of that flow of information. You can’t really divorce the two is my point.

If we don’t have the local information, we look at the evidence out there and see what we can apply and model to the groups that we’re seeing. And, as a public health community, we’ve tried to share as much of the epidemiology and evidence base that we can. In the last 12 months, all three of the public health teams involved with Frimley have published joint strategic needs assessment profiles on these groups, which collects all the information and our local insights and makes it publicly available to help others.

For me, it’s about using the formal information we’ve got and capturing as much as we can informally and marrying the two together with the evidence base. Then, we’ve got a kind of triangulated view to help us make decisions on how best to support this particular population.

We mustn’t forget that we can’t clump all these people into a homogenous group. They’re really varied and they don’t just have one set of issues.

Tessa Lindfield

AV: In Norfolk and Waveney, we’ve got four contingency hotels, plus dispersal accommodation. We’ve got a People From Abroad team in our county council who’re social care based. They work with the school teams to make sure that the children have places and do a lot of integration with voluntary groups that want to offer support.

I’ve managed to organise for Naloxone training to be implemented at all the hotels because there are cases where people have a substance misuse issue and that’s become worse as they’ve integrated into UK. And because a number of the asylum seekers have been here a while, we have seen a lot of mental decline so now all the staff at the hotels have received Mental Health First Aid training.

We’ve also got asylum seeker healthcare teams. All our asylum seekers in Norfolk and Waveney are registered with a practice and the asylum healthcare team in the south of Norfolk has provided training to practices to understand some of the cultural differences. We have an inclusion health local commission service spec, which also provides some training for practices and allows them a bit of extra time to deliver the initial health assessments.

SA: During the pandemic, we initiated a pilot programme called Community Voices where we were looking at communities that experience inequalities and the barriers and enablers to accessing the vaccine. It was about upskilling members of the voluntary sector to go out and have conversations and support access to the vaccine.

Since that initial pilot, we’ve morphed it into a way of working and having conversations about a much broader range of issues and, recently, our public health team in Norfolk have commissioned a piece of work with refugees and asylum seekers. We’ve worked with around eight charities that are really active in the asylum seeker refugee migrant community space to build their confidence to have a combi-conversation about health and wellbeing. The asylum seeker project has just concluded so the analysis of all the conversations is underway at the moment.

A unique aspect of Community Voices is that every conversation is fed back through a centralised insight bank and very conversation we’ve had as a result of the programme has been captured. So, we’ve got loads and loads of really rich qualitative information and insights that help us to understand how to support people to access services and also why it didn’t happen in the first place. We feed all of that information into our strategic decision making, our planning, and governance structures in the ICB.


New approaches

VV: Can you talk about other health inclusion groups that you want to help and whether you’re trying anything new to reach them?

AV:  We’ve got a wellness on wheels bus with a range of services onboard that travels across Norfolk and Waveney. The premise is to bring services to people who don’t ordinarily access services easily. It generally targets areas of deprivation and inclusion health groups, and it taps into some of the plus communities as well.

We have had the learning disability (LD) team onboard the bus and we’ve targeted some of the LD schools. We’re now exploring how we’re going to have LD health checks onboard that bus because we know that, unfortunately, our levels of LD health checks are not great. A lot of those patients are quite scared of going to the GP practice, which is why we’ve taken the bus round and gone, ‘Oh, look, it’s a friendly unit and all the staff are lovely’. It’s not a scary place – the bus is colourful and welcoming – so we’re exploring that a bit further.

We went to an LD event in Norwich outside a forum and we had a blood pressure monitor and, because it was interactive and staff were so friendly as they were talking to the elderly patients about blood pressure, people loved it.

And it’s similar with carers. I’ve done a number of presentations about the well bus to different forums. Obviously, there are different types of carers and a lot of the unpaid carers won’t recognise themselves as carers so we have leaflets on board and tell people about the support that’s available. And because the bus is out in the community, we do often find that some of the conversations are actually quite open because it is a relaxed environment.

SA: We support a lot of work led by the voluntary sector in Norfolk and Waveney. For example, we’ve got a really active carers forum and, over the past couple of years, there’s been a significant piece of work to develop a carer’s passport to support access to services. That’s not just for the people being cared for, but for the carers themselves. And that’s across all of our trusts and primary care in the system.

We’ve not directly led that work, but we have supported and enabled and opened doors for that carer’s passport to be recognised within all of our NHS body organisations. It’s really been a good whole system approach.

Our health inequalities framework is looking at lifestyle factors and living and working conditions, which are the wider determinants of health. We’ve been working that up with our colleagues in public health and, over the next 12 months, we’re going to develop a robust healthcare inequalities programme where we’re going to look at them for each of those inclusion health groups – and indeed our plus groups. We’ll be doing some work with our Community Voices programme to really get under the skin of the barriers from a community perspective.

We’ll also work with our stakeholders across the system to better understand the systemic barriers as to why things exist in the way that they do and how we might be able to work better together to address them.

So the framework has really galvanised a whole system approach to addressing inequalities. But I would say that we recognise it’s a starting point. There’s been a huge amount of work in Norfolk and Waveney around inequalities, but it’s never been joined up. I think the integrated care system gives us that foothold to take an approach that hasn’t been there before and we’ve recognised as a system that we’re going to do it together – and really, genuinely do it together.

I think the integrated care system gives us that foothold to take an approach that hasn’t been there before and we’ve recognised as a system that we’re going to do it together – and really, genuinely do it together.

Shelley Ames

ME: In Frimley, we know that some of the access barriers people are experiencing in terms of coming to services are just too great. So, we’re trying to take the services to people.

For example, our local Nepali communities is one of the largest outside Nepal and we need to work in a very different way to reach our targets of multi-generational houses in areas of deprivation. We’re piloting the model of community health and wellbeing workers, which was developed by a public health consultant in Brazil and was piloted in Westminster. The model is about door knocking and outreaching into communities.

We’ve also worked with Surrey and Sussex Cancer Alliance to run targeted lung health checks, which is of course a national screening programme. For example, we need to focus on areas of deprivation where there are high numbers of smokers and significantly higher premature deaths caused by lung cancer. We’re co-hosting the smoking cessation service with the lung health checks in the local Tesco car park and, alongside that, we’ve planned some outreach interpreters at some of the other local services. So, it’s trying different ways to reach local people.

NP: I think this highlights the importance of multi-disciplinary team (MDT) working in the system.

When you look at interventions and what a difference you can actually make to the target cohort, in almost every case, you’ll find that an MDT approach is much better. I was a GP for 43 years in a fairly deprived area of Leicestershire and some of these brilliant initiatives couldn’t be done if you’re just a GP or a nurse sat in a surgery.

There’s something about the data helping to give us evidence. You know, you’ve identified somebody with a vulnerability – so, you know that diabetes is much more dangerous for those with particular ethnic mixes and that blood pressure control is often much poorer in the black ethnic minority groups than others and that a lot of migrant groups are very poor at accessing antenatal care – but what are you going to do about it?

It’s multidisciplinary team working that then brings things out. The reason that woman didn’t come for an appointment was because she couldn’t speak and understand English. She couldn’t understand your receptionist and was totally confused by the whole thing. Simple things like having printed antenatal plans in different languages across the system can make a big difference.

And I think we are starting to see a lot more sharing, which I think is really useful. Commissioning support units are in a great place to help do that, to share some of that detail behind interventions and the great work that’s been done.


VV: In terms of inclusion health groups, how does the funding work and are you looking at different ways of funding? And what do you hope to achieve with this work?

ME: We have been trying our best to work with our partners to pool some of our funding. We’ve received some historical funding – for example, contain outbreak management funding, and inequalities funding for specific areas – and we’ve been working with our public health colleagues in Hampshire and Surrey county councils to take a population health management approach and look at the areas of most need.

We’re using some of the public health funding for the community health and wellbeing worker pilot and the lung health checks that I mentioned. The difficulty is that we don’t have sustainable funding –  and that’s the challenge we all have across the system. So, the programmes and projects are limited in terms of time and funding, but we’re doing what we can with what we have in the immediate future.

TL: I think if we wait for the money, we’ll be waiting forever so this needs to be core business. I want every clinical service to be routinely inquiring if someone’s a carer and to be thinking about how they get fair outcomes for the different groups that they see.

NP: Everything in the NHS is resource based but, you know, a lot of this doesn’t actually need resource – a lot of it is just lack of awareness. It’s just taking an extra couple of minutes or it’s using services that we’ve already got. Focusing on things like social prescribing can be massively useful and it just sometimes needs tweaking towards the right target.

So I think let’s use evidence, let’s use data and let’s build it all and see if we can get better outcomes.

AV: We have different pots across the piece to support different projects. For example, we get money from NHS England to support our contingency hotels, and then we get other monies from the Home Office around supporting our Afghan communities, but that’s often tied up with other sorts of parts of the system. And then the funding for our wellness bus comes from another pot of funding.

I think for me, it’s about making inclusion health groups a priority for everyone. It should be integrated into almost everyone’s work as well as things like specifications and contracts.

We also need to have an outreach approach or open thinking. We often have feedback from inclusion health groups who say they don’t go to the GP because they feel judged for being a sex worker or being homeless.

Inclusion health groups should be a priority for everyone, integrated into almost everyone’s work as well as things like specifications and contracts

Alice Vickers

SA: Short termism is a problem for us and probably most systems. It would be really nice if our health inequalities allocations came with a ring fence around them, so that it was slightly easier at a local level to use them for new programmes of work rather than ongoing work.

I think we look to our health inequalities allocations as this kind of utopian budget that’s going to help us fix everything. But actually, we should be thinking about inequalities in every budget and every investment that we spend.

One of the things we’ve done – because we’ve heard it really loudly as we’ve engaged the system – is to instill the understanding of proportionate universalism. We’re not using that language; we’re using the language of ‘everyone needs something and some people need more’. In our action framework, we’ll have committed as a system to map our resources and think about how we pool them.

We’ve said we will come together – and that word ‘together’ being key for me –  to tackle those unfair and avoidable differences and we’ll do this by listening to communities. We must listen to what communities tell us would help them and then act on what we’re hearing. I’m really sold on the notion that the solutions must be derived from the communities themselves.

But the key bit is that we want to make tackling health inequalities everybody’s business and everybody has to take responsibility for doing it. That for me is what we really want to try and shift the dial on.


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