Inclusion Health

Inclusion health seeks to prevent and address the health and social inequalities experienced by groups of people due to poverty, social exclusion and multi-morbidity.

Inclusion health can be defined as a service, research, and policy agenda that aims to prevent and redress health and social inequities among socially excluded groups. Interventions are designed to address the social determinants of health, such as the circumstances in which people are born, grow, live, work and age, and to provide integrated and comprehensive healthcare services that aim to drive improvements that meet the needs of socially excluded groups, and to support innovation and productivity, while also enabling the delivery of personalised and responsive care.

The importance of applying the inclusion health lens within policy and service provision was highlighted during the COVID-19 pandemic, during which people experiencing social exclusion were rendered especially vulnerable. An inclusion health approach guided the government’s response to the pandemic, which was based on enhanced cooperation between departments, agencies, and non-governmental organisations (NGOs).

This was greatly apparent in homeless services and services working with Traveller communities: socially excluded groups in congregated settings received priority action in terms of shielding, detection, case management, contact tracing and vaccination. These efforts greatly mitigated the risk of COVID-19 among these populations. This helped to flatten the curve and greatly minimised the case numbers below what was initially forecast, further demonstrating the benefits of collaborative working between government departments, agencies and NGO’s.

The Department is developing an Inclusion Health Framework. The department has contracted Inclusion Health Research Group (IHRG) in the College of Medicine and Health, UCC, has undertaken a consultation process to inform the development of the Framework. The consultation process involved an online survey, consultation events and consultations using the World Café methodology. The Inclusion Health Framework is currently being developed.

The Department of Health’s mandate in relation to homelessness is the provision and funding of health and social care supports for people who are homeless.

The Department of Health (DoH) has oversight responsibility for the health policy for people who are homeless and other socially excluded groups. Responsibility for the provision of health service falls under the HSE’s National Office for Social Inclusion, which works to improve access to mainstream health services, as well as providing targeted measures. DoH funds the HSE for the delivery of a range of health-related services and supports to homeless persons. Under the Health Acts, in particular the 1953 Act, the HSE has statutory obligations towards homeless persons; today this is understood to mean responsibility for the delivery of health and social care supports to homeless persons either directly or through section 39 funded services.

Suitable housing conditions are a key social determinant of health. Homelessness represents a state of extreme socio-economic deprivation and is associated with increased prevalence of behaviours associated with morbidity (smoking, alcohol and drug use), but also with increased psychological stress. We know that eliminating homelessness will fundamentally address the social determinants of health for people who are homeless. These tenancies provide homes for those with extremely complex health and social needs, whereby they receive wrap around supports as required.

Housing for All, the national housing plan, sets out the Government policy for reducing and preventing homelessness by 2030. This will be achieved by a housing-led approach as the primary response to all forms of homelessness. Eliminating homelessness will fundamentally address the social determinants of health for people who are homeless.

Housing for All contains five actions to support the health needs of people who are homeless and to achieve better health outcomes, including a reduced incidence of premature death. The actions build on the enhanced cooperation and coordination with the Department of Housing and the DRHE since Covid-19. Work is underway on extensive work is underway under each of these actions. They include:

1. Maintain Covid-19 public health measures and consolidate improvements in healthcare delivery
2. Continue to increase access to health supports and protections, with an individual healthcare plan for all people who are homeless and improved access to mental health services
3. Finalise a strategic framework to improve the health of people who are homeless – HSE service delivery model (published)
4. Strengthen integrated care pathways for those with chronic health needs based on an inclusion health model
5. 5. Expand Case Management Approach

The Government has prioritised a “housing-led” approach, where the provision of housing together with integrated wrap-around health and tenancy supports assist the person in maintaining a tenancy and optimal physical and mental health. Housing First initiatives are part of an overall integrated strategy to address homelessness and aim to provide direct access to long-term housing and support for the person in their home.

This approach prioritises direct access to housing for vulnerable individuals using homeless services over long periods of time, and those unable or resistant to accessing homeless services who may then become habitual rough sleepers. These individuals will often have complex high support needs such as mental or physical health problems, addiction issues or dual diagnosis (co-morbid disorders due to substance use and/or addictive behaviours along with the presence of mental illness). There are no conditions on attaining a tenancy relating to addiction or treatment issues. However, as they are housed, tenants are offered a multidisciplinary team of support workers that can address complex needs through services like drug and alcohol counselling or mental health treatment. Housing First is a client-led service and delivered by a team providing intensive supports. The individual’s choice is a core principle of Housing First programs; it requires clients to be actively involved in choosing their housing arrangements, being engaged in their treatment, and being able to pursue their individual goals.

Housing First National Implementation Plan, 2022-2026 provides for the creation of 1,319 additional tenancies over the period of 2022 - 2026. To-date, 1,000 tenancies have been created. The Department of Health is fully aligned with the Programme for Government commitment to ‘Create 2,000 Housing First tenancies to help eliminate long term homelessness’. This commitment is understood to be inclusive of the 1000 tenancies already in place.

Travellers have the right to the highest attainable standard of health as is the norm in Irish society. Traveller health inequalities reflect the social and economic disadvantages faced by this population group, referred to as the social determinants of health. Being a minority ethnic group can also be a predictor of poor health. Therefore, to reduce Traveller ill health, a comprehensive public health response is needed that provides tailored and affirmative measures to prevent disease, promote health and prolong life for this population group, and are delivered in partnership with Travellers. The National Traveller Health Action Plan (NTHAP) 2022-2027 launched in November 2022 and seeks to address inequalities in Traveller health. The plan has 4 goals, 9 strategic objectives and 45 actions.

The National Traveller Health Implementation Group (NTHIG) was established to drive implementation of the NTHAP, to support and monitor implementation and report to NTHIG. The Department of Health sits on the group and meet quarterly with its chair.

Primary Healthcare Traveller Projects are partnership projects between the HSE and Traveller organisations that provide ongoing support for Traveller families on the ground and act as an interface between mainstream health services and Travellers. They are a peer-led model using a social determinants of health analysis, community development approach to train Travellers to work as Community Health Workers, and this allows Primary Healthcare to be developed based on the Traveller community’s own values and perceptions.

The Department of Health has also funded a number of actions to improve Traveller health:

• Women's health (in conjunction with the Women's Health Action Plan)
• Initiative to address the social determinants of Traveller health (through the Slaintecare Healthy Communities Programme),
• Mental health services for Travellers (in line with Sharing the Vision)
• Traveller child health initiative

The Minister for Public Health, Wellbeing and the National Drugs Strategy Jennifer Murnane O’Connor recently announced €500,000 in recurring funding for improving Traveller child health. More information can be found here.