Context

Inclusion Health is an approach which seeks to improve health outcomes of socially excluded people. People who are socially excluded are typically excluded from the social system and its rights and privileges, often as a result of poverty or the fact of belonging to a minoritized social group. They have greatly reduced access to education, occupation, accommodation and healthcare, even if these services are available free of charge.

Socially excluded people experience extreme health inequality, increased morbidity and mortality and their life expectancy is shortened by 20-50 years. Socially excluded people frequently experience homelessness, incarceration and sex work. They may belong to minoritized groups such as Travellers, Gypsies, Aboriginal or First Nation and/or may be  LGBTQI, have physical or intellectual disabilities and/or may be vulnerable migrants or refugees (1).

Various aspects of social exclusion may be experienced by the same person, and compound the harmful effects (this is called intersectionality). Levels of traumatic experiences in childhood and adulthood including sexual and physical violence and neglect are much higher in people who are socially excluded, and this results in much higher levels of mental illness, drug and/or alcohol dependence and poor physical health – this combination is known as tri-morbidity (1). Childhood abuse and neglect, in particular, have profound effects on how a person interacts with others and particularly with healthcare staff.

In 2020, RCEM highlighted the importance of inclusion health in the ED with the publication of both a best practice guideline and a policy briefing on homelessness in the ED (1,2). In part, this is to raise awareness of the statutory obligation on EDs in relation to the “duty to refer”. This relates to the Homelessness Reduction Act 2017 which states that EDs, Urgent Treatment Centres and hospitals providing inpatient care must notify a local housing authority if they believe a service user is homeless or are likely to become homeless in the next 56 days (3). There are over 280,00 people estimated to be experiencing homelessness in England alone (4). Multiple studies have shown that homeless people use EDs much more frequently than the general population, are admitted to hospital more often and stay much longer (2,5). In addition, people experiencing homelessness have greatly increased mortality; 7.9 times for men and 11.9 times for women (6). These patients often suffer multimorbidity and are at risk of fragmentation of care without anybody taking overall responsibility for the patients’ needs e.g. input from psychiatry, substance use teams, HIV team, social work etc. but nobody managing the patient holistically (7).

As well as social exclusion, sex workers face a particular set of challenges including sexually transmitted infections, violence, and mental illness. Despite this, studies have shown that they are reluctant to access healthcare, making them amongst the most marginal and vulnerable groups in society (8).

Gypsys and Travellers are a heterogenous group but they share poor health in terms of increased infant and child mortality, high levels of anxiety and lower life expectancy, all while facing discrimination and social exclusion (9). Although some travellers are settled, others remain transient. When they are moved on from camp sites to new areas, they suffer the loss of continuity of care and may become reliant on EDs for healthcare that would better be provided in the community (9).

Refugees and vulnerable migrants share this problem of moving frequently and not establishing a lasting relationship with healthcare services (10). In addition, many find it difficult to register with a GP or communicate with them due to language barriers, resulting in increased ED visits (10).

Bearing all of this in mind, it is imperative that we recognise the unique opportunity in the ED to assess the patient holistically; arrange appropriate accessible follow up and link the patient to the relevant services (1).

Every ED attendance “represents an opportunity to provide healthcare advice and offer information regarding accessing social and other support” (1).

Learning bite

Inclusion health involves the care of those who experience extreme health inequality such as homeless people, Gypsys and Travellers, sex workers and vulnerable migrants.

These patients have much higher morbidity and earlier mortality than the general population but despite this, can struggle to access appropriate care.