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What is inclusion health?

Taking a psychologically informed approach with the guiding principle of harm reduction is necessary for treating marginalised patients.
Hello, my name is John Budd. I’m a GP in Edinburgh, and I work in a practise that is set up for those people who are in homelessness. Presenting today, along with my colleague, Wez Steele. Yes, my name’s Wez Steele. I’ve got previous experience of chronic homelessness and substance use, and I’ve also worked in front-line services for about five years. And I’ll be speaking a little bit after John has finished his presentation. Thanks. So we’re going to be talking a little bit about providing health care and services to those who are socially excluded, and on the margins of society. So if I can work out how to set myself up, I will be good to go.
So we’re going to be– we are going to talk a little bit about inclusion health, or providing health care services and care for those people who are socially excluded and really on the margins of society. We’ve known, for a long time, that health is predominantly socially determined and this is a quote from the Engels, Fredrick Engels, the psychic for Marx, back in the 19th century. More recently we’ve had reports from the WHO Commission, on the Social Determinants of health, outlining how the social circumstances in which people live, are born, grow, live, work, and age, are the things that actually have biggest impacts on health experience. And also, sadly for many, cause the extreme early loss of life.
So in terms of those people who are on the margins of society and experienced the most adverse effects of the social circumstance, it’s been
found that three main groups: those involved in homelessness services and experience, those involved with the criminal justice system, and those who have substance use difficulties, really experience the worst of health, and the most extremes of marginalisation. And this is from a report, the Hard Edges report, looking at homelessness and marginalisation back in 2015. We found poverty and poor mental health to be almost universal amongst these groups. And what we have increasingly– evidence has shown, and has become a public health issue, is that early life experience, in particular, a background of poverty and early life adversity for children has a very significant long-term effect, in terms of health and social outcomes.
And some of those effects we see played out through the use of substances.
American study, which found that childhood adverse experiences, and for that we’re really thinking about things like child neglect, physical, emotional, or sexual abuse, parental incarceration, parental mental health problems - these are the adversities that this research is referring to. For those children that experienced four or more of these so-called ACEs, than the outcomes were particularly significant. And you can see that the risk of actually falling into injecting drug use, you have a tenfold increased risk for those with four or more ACEs, have a significantly increased risk of mental health problems and suicide, a 10-fold risk of suicide.
Now in my patients, who are experiencing homelessness, this translates into a very heavy burden of disease. And when we did a detailed audit some years ago, looking at a whole range of health outcomes and service utilisation experiences, we found that 86% of our patients had chronic, long-term health difficulties; with the average number of conditions three per patient. And this is in a patient group, the average age of just under 40. And we found that 70% of our patients had the triple morbidity of chronic physical, mental, and substance use problems.
And you can see that many of you would actually be coming into contact with homeless folks, through acute services, within one year we had over 30% of our patients admitted to hospital. And this health burden equates with what you’d expect more to see in a population in their mid to late 80s. And, unfortunately, this translates into the ultimate burden, with very premature loss of life. In our practise, the average age of death is actually just under 47, with women having an even younger average age of death.
And, as I said, this also translates into increased hospital admissions and attendances at emergency departments, with significant financial implications as well, for health service provision.
So given that the group we are talking about, that those who are most marginalised and excluded in homelessness, that is through the criminal justice system, and those with significant substance use problems.
If we are going to provide services which is going to enable our patients to make use of what we have to offer, then we need to be thinking of setting ourselves, how we set ourselves up in relation to our patients. And, for that, we need to be thinking in psychological terms, recognising that it is the relationships that we establish with our patients, that is the most significant thing in terms of enabling them to make use of what we have to offer And one of the things that Wez will, no doubt, highlight further on, is that the impact of early life adversity and trauma has a very significant disruptive impact on the ability of a child, and then an adult to establish trusting relationships.
And Centrality of Relationships, this is a quote from Julian Tudor Hart, probably the UK’s most famous GP towards the end of his career recognising the centrality of relationships in terms of providing health care to those on the margins. And, for us, that might mean moving away from trying to blame or label our patients who, perhaps, come to us with the most extremes of behaviour or difficult behaviour. So rather be thinking more about what’s wrong with you to what’s happened with you. To actually be taking an interested approach, and one that enables us to try and understand what is being communicated through often very difficult situations and behaviours.
I thought I’d very briefly touch on the philosophy of harm reduction, which many of you would be familiar with. Here, in Scotland, we have not only an epidemic of COVID like the rest of the country, but we also have an epidemic of drug related deaths. And many of you work in infectious disease units will be coming across patients who have infections related to– complex infections related to injecting. And just to highlight the importance of a harm reduction approach, offering opiate substitute treatment at whatever point patients come into contact with the health service.
One highlight, which I might just have time to of very briefly mention, from COVID for us, has been the establishing of an intermediary care unit, a step-up step-down unit, to try and free hospital capacity for COVID patients. And this has been a wonderful addition to the services we’ve been able to offer those who are in homelessness with complex needs here in Edinburgh. Both reducing re-admissions, offering appropriate treatment, whether it’s a continuation of IV antibiotics, in a less clinical setting, that enables people to complete important treatment courses. And concluding, we need to meet people where they are.
The establishment of relationships is key to enable us to offer health services and care to those who struggle the most to make use of services. And that means taking a psychologically informed approach with the guiding principle of harm reduction. Thanks.

Here, we discuss and explain the importance of caring for patients who are often on the margins of society, which is known as inclusion health.

Why this matters

Providing healthcare and services to those who are excluded and on the margins of society is vitally important. Those who are often seen as being excluded from society often have unfortunate situations such as homelessness, substance use and, are part of the criminal justice system. Poverty and poor mental health are often universally seen across individuals in these circumstances.

What are ACEs?

Adverse childhood experiences (ACEs), especially those that include poverty, neglect, physical and emotional abuse, and/or incarceration of parents, cause significant long-term effects in terms of health and social outcomes. These effects can manifest into a number of situations including:

  • Suicide
  • IV drug use
  • Alcohol dependence
  • Depression

The impact of homelessness on disease

Homelessness results in a large burden of disease with 86% of homeless individuals having, on average, 3 chronic long-term physical conditions before 40 years of age. Homelessness can result in a very premature loss of life at an average of 46 years for men and 41 years for women.

These patients often have increased hospital admissions which has increased financial implications. Providing services specifically for these patients is important and relies heavily on establishing good relationships and being psychologically informed. ACEs have a significant disruptive impact on patients which often results in difficulty trusting others. This highlights the importance of understanding what has happened to the individual rather than pointing out what is wrong. Harm reduction is a key aspect of providing services for these patients, such as the opioid substitute treatment for IV drug users. Intermediary care units allow for a less clinical setting which frees up spaces in hospitals and has links with appropriate housing and community support groups.


Overall, relationships are essential, and taking a psychologically informed approach with the guiding principle of harm reduction is necessary for treating patients who are often excluded by society.

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Infection Prevention for Vulnerable Patients

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