Introduction

Inclusion Health (IH) is a research, service and policy agenda that aims to prevent and redress health and social inequities among the most vulnerable and marginalised in a community (Luchenski et al, forthcoming). This includes people with experiences of homelessness, drug use, imprisonment and sex work, as well as Gypsies, Travellers and vulnerable migrants. IH target populations face common adverse life experiences and risk factors that lead to deep social exclusion, poverty and multiple co-morbidities, with extreme levels of morbidity and mortality across all categories of disease (Hayward et al, 2017) and poor access to mainstream services. From an intervention perspective, IH may be thought about in terms of access to, integration with and trust in essential systems, services and institutions to promote, protect and improve health (Luchenski et al, forthcoming). This chapter focuses particularly on homeless people as exemplars for IH.

A significant challenge is that poor physical and mental health is compounded by the failure of mainstream health and social care services to respond effectively. We often dismiss groups as ‘hard to reach’; this chapter considers the extent to which the services, and not the patients, are ‘hard to reach’, and how we might change this situation.

After prolonged exclusion, people on the margins of society frequently experience severe and complex ill health, often characterised by tri-morbidity: the combination of physical and mental ill health with drug or alcohol misuse (O’Connell et al, 2010). There is often a history of institutional care, including childcare and prison. The emerging concept of syndemic interactions may offer an approach to understanding the resulting complexity (Singer Merrill, 2009). The traditional biomedical approach is to consider each disease in isolation, so co-morbidity is two conditions in the same person, treated separately.

A syndemic is two or more diseases that interact, synergistically, to increase the negative health effects. Syndemics tend to occur in conditions of poverty, stress and health inequalities.

A core flaw in society's response is fragmented and inadequately funded health and social care systems, resulting in perverse incentives to protect budgets by refusing to provide services for people who never quite meet the criteria for inclusion.