Foreword

This tool will help Primary Care Networks to identify where need is greatest and will ensure that people from inclusion health groups get the care they need. These groups can sometimes feel excluded but now those working in primary care will have the resources and contacts they need to reach out to these communities and address any health inequalities.

The tool has been developed by Friends, Families and Travellers, Doctors of the World, National Ugly Mugs, Stonewall Housing and Homeless Link who have worked in partnership with NHS England and NHS Improvement over a number of years but have been crucial in the period covering the pandemic to ensure that the voices of those most in need are heard.

The Inclusion Health Self-Assessment Tool will help PCNs understand who their present services reach or don’t reach including those people with the worst health outcomes. It will highlight the voices they are not hearing and support primary care to reach out to those communities to hear their views and understand their challenges around services, supporting them to plan more accessible, responsive and inclusive services.

Developing services which work for people experiencing the sharp edge of inequalities will improve patient experience for all patients. For example, by ensuring services are accessible for people with low or no literacy, who are disproportionately represented in inclusion health groups, will also improve accessibility for 16.4% of adults in England, or 7.1 million people who can be described as having ‘very poor literacy skills’ (National Literacy Trust), but this will also make information easier to access for all patients.

Completing the tool can help GPs to prepare for CQC inspections, for their work in relation to “people whose circumstances may make them vulnerable”.

This tool is simple and quick to use and is a great starting point for PCNs or anyone working in Primary Care to identify what they are doing well and what they need to improve with a tailored report which has a multitude of resources to support next steps in reaching these communities and ensuring we are truly offering equitable services.

Dr Ursula Montgomery

Senior Clinical Advisor, Primary Care Provider Transformation, NHS England and Improvement

Introduction

Welcome to your own unique and tailored guide which has been designed to help your Primary Care Network to embed action on tackling health inequalities into its everyday activities. This guide has been developed by Friends Families and Travellers, Homeless Link, National Ugly Mugs, Doctors of the World and Stonewall Housing with support from NHS England and NHS Improvement, people from inclusion health groups, specialist inclusion health charities and representatives from Primary Care Networks.

Inclusion Health

Inclusion Health is a field which seeks to prevent and address the health and social inequalities experienced by groups of people at risk of or living with extremely poor health as a result of poverty, marginalisation, multi-morbidity and social exclusion. The reasons vary by group, but include the effects of stigmatisation and discrimination, the complex nature of health systems and the effects of the wider social determinants of health.

The four groups originally defined under the term “Inclusion Health” include Gypsies, Roma and Travellers, homeless people, vulnerable migrants and sex workers. However, the term is widely used to refer to populations at the sharp edge of health inequalities as a result of social exclusion and stigmatisation. This includes people in contact with the criminal justice system, people with learning disabilities and mental health needs and more.

Why are health outcomes for Inclusion Health groups so low?

There are a number of explanations which contribute to this, including:

• The effects of stigmatisation and discrimination on socially excluded groups;
• The complex nature of health systems and other barriers which prevent Inclusion Health groups from using them; and
• The effects of the wider social determinants of health (including income, education, accommodation and more) on Inclusion Health groups.

Why is it important for your Primary Care Network to improve your engagement with Inclusion Health groups?

The severe health inequalities experienced by Inclusion Health groups are unjust and avoidable – your Primary Care Network has an important role in addressing these at a neighbourhood level. Across England, Primary Care Networks are working in innovative and impressive ways to improve engagement with Inclusion Health groups. By reviewing the services your Primary Care Network provides and how these are provided, you can make small changes which will have a significant impact on the health and wellbeing of those at sharp edge of health inequalities in your neighbourhood.

Thank you for taking the time to complete the Inclusion Health Audit Tool. We hope that you will find this tailored guide useful in advancing your organisation’s engagement with Inclusion Health groups. 

Please note that you can save this document to your computer and share with colleagues by right clicking and selecting “save as” OR by entering the command ctrl + s OR by sharing the URL.

Section 1: Developing a clear understanding of inclusion health groups, and their needs, in your patient population

Question 1 – We asked, “Do your practices have a clear understanding of inclusion health groups in their patient population and their needs?”

You said, “<blank value>”

Section 2: Systematically adapting services to meet the needs of people most likely to experience health inequalities

Question 2 – We asked, “Are all services systematically adapted to meet the needs of people most likely to experience health inequalities?”

You said, “<blank value>”

Section 3: Developing targeted services to address unmet need amongst patients from inclusion health groups and/or groups experiencing deprivation

Question 3 – We asked, “Have targeted services been developed to address unmet need amongst patients from inclusion health groups and/or groups experiencing deprivation?”

You said, “<blank value>”

Section 4: Ensuring that your practices collect information from patients on how wider societal issues may put them at high risk of poor health or may affect outcomes of health interventions

Question 4 – We asked, “Do your practices collect information from patients on how wider societal issues may put them at high risk of poor health or may affect outcomes of health interventions? This might include information on housing status, benefits, country of birth and more”

You said, “<blank value>”

Section 5: Working collaboratively across your PCN to identify and address issues across the wider determinants of health in your neighbourhood

Question 5 – We asked, “Do you work collaboratively across your PCN to identify and address issues across the wider determinants of health in your neighbourhood?”

You said, “<blank value>”

Section 6: Supporting all staff members within your PCN to confidently signpost patients from inclusion health groups to relevant local voluntary sector organisations who can support them with their non-clinical health needs

Question 6 – We asked, “Can all staff members within your PCN confidently signpost patients from inclusion health groups to relevant local voluntary sector organisations who can support them with their non-clinical health needs?”

You said, “<blank value>”

Section 7: Supporting all staff members with templates and advice on providing medical evidence for housing, benefits and more

Question 7 – We asked, “Do all staff members within your PCN have access to up-to-date and comprehensive advice and templates to support people with benefits claims, housing claims and other things that support people with issues they are experiencing across the wider determinants of health?”

You said, “<blank value>”

Section 8: Providing letters relating to benefits, homelessness and other essential needs for free

Question 8 – We asked, “Do your practices give letters relating to benefits, homelessness and other essential needs for free?”

You said, “<blank value>”

Section 9: Carrying out disaggregated monitoring of inclusion health groups for satisfaction

Question 9 – We asked, “Do your practices carry out disaggregated monitoring of inclusion health groups for satisfaction?”

You said, “<blank value>”

Section 10: Using codes to manage patient data and specific needs

Question 10 – We asked, “Do services within your PCN routinely use codes when managing patient data to enable you to identify and reach those with the greatest needs?”

You said, “<blank value>”

Section 11: Ensuring your practices routinely offer longer appointments to patients with multi-morbidities, complex care needs, or communication needs

Question 11 – We asked, “Do your practices routinely offer longer appointments to patients with multi-morbidities, complex care needs or communication needs?”

You said, “<blank value>”

Section 12: Ensuring your practices make routine adjustments for people to support diverse communication needs

Question 12 – We asked, “Do your practices make routine adjustments for people with low literacy, people who have low or no fluency levels of English and those experiencing digital exclusion?”

You said, “<blank value>”

Section 13: Ensuring your PCN meets the appointment needs of people from inclusion health groups

Question 13 – We asked, “In order to meet the needs of people from different groups, does your PCN offer extended hours appointments, walk in services and flexibility in appointments for people who live unpredictable lives?”

You said, “<blank value>”

Section 14: Ensuring all services within your PCN are available to patients

Question 14 – We asked, “Are all services within your PCN available to patients, irrespective if they are able to provide proof of identification, proof of address and proof of immigration status?”

You said, “<blank value>”

Section 15: Ensuring patients can use their GP practice as a “care of” address

Question 15 – We asked, “Can patients use their GP practice as a care of address?”

You said, “<blank value>”

Section 16: Ensuring your practices have clear processes for contacting patients who have no fixed address or have no phone

Question 16 – We asked, “Do your practices have clear processes for contacting patients who have no fixed address or have no phone?”

You said, “<blank value>”

Section 17: Appointing a named person whose job it is to drive Inclusion Health within your PCN

Question 17 – We asked, “Do you have a named person whose job it is to drive Inclusion Health within your PCN?”

You said, “<blank value>”

Section 18: Providing service leaders and managers with objectives on their role in address-ing health inequalities in their locality

Question 18 – We asked, “Are service leaders and managers given objectives on their role in addressing health inequalities in their locality?”

You said, “<blank value>”

Section 19: Making sure the diversity of your neighbourhood is reflected in your PCN’s staff team, leadership and patient engagement

Question 19 – We asked, “Do you have mechanisms in place to make sure the diversity of your neighbourhood is reflected in your PCN’s staff team, leadership and patient engagement?”

You said, “<blank value>”

Section 20: Ensuring that there are pathways for your staff and volunteers to progress in their careers

Question 20 – We asked, “Do you ensure that there are pathways for your staff and volunteers to progress in their careers, in particular those from inclusion health groups?”

You said, “<blank value>”

Section 21: Developing the staff teams’ knowledge of inclusion health groups

Question 21 – We asked, “Have you taken steps to ensure that the staff team is developing its knowledge of inclusion health groups?”

You said, “<blank value>”

Section 22: Ensuring all staff members are on a real Living Wage

Question 22 – We asked, “Are all staff members within the PCN on a Living Wage?”

You said, “<blank value>”