Introduction
Inclusion health addresses
| the health and social needs of socially excluded individuals who face multiple overlapping risk factors such as poverty, violence, and complex trauma. These factors often lead to barriers in accessing healthcare, resulting in poor health outcomes and health inequalities, including a lower average age of death. Common barriers include low engagement with services, difficulties accessing services due to transport or technology, | challenges in understanding the healthcare system, stigma, negative past experiences, and language barriers. Inclusion health groups encompass people experiencing homelessness, people experiencing substance dependence, vulnerable migrants and refugees, Gypsy, Roma, and Traveller communities, individuals in contact with the justice system, victims of modern slavery, sex workers, LGBTQIA+ members, and other marginalised groups. |
Inclusion Health Needs Assessment
This needs assessment has reviewed both quantitative data and qualitative insights
| regarding the status of inclusion health groups in the East Riding. It incorporates feedback from professionals on their work with inclusion health groups and the challenges they face. The evidence was gathered through several methods, semi-structured interviews with professionals across East Riding to obtain in-depth views on current practices, challenges, and successes, a co-production initiative with HEY Smile Foundation, where we created a system map of health and VCSE services in Bridlington, identifying strengths, gaps, and areas for improvement; a consultation event with Public Health, HEY Smile Foundation, and local voluntary and community groups in Bridlington to gather local perspectives on inclusion health needs; and online surveys distributed to both professionals and the VCSE sector to collect broad feedback on inclusion health services. The semi-structured interviews also aimed to strengthen relationships with professionals, using their knowledge to guide our approach to working with those facing inclusion health challenges. The needs assessment is an iterative process and following its initial publication, a phase of consultation and relationship building with people with lived experience will be undertaken. These insights will help to develop an action plan around the recommendations in order to accurately understand and comprehensively address unmet needs. The East Riding Inclusion Health Needs Assessment document can be downloaded from this link or via the picture on the right. |  |
Inclusion Health Needs Assessment II
Community Engagement and Lived Experience Insights Report (March 2026)
This second inclusion health needs assessment highlights
 | that for socially excluded populations in the East Riding of Yorkshire, the quality and continuity of human relationships are central to engagement with health and social care services. Evidence from people with lived experience, practitioners and VCSE partners shows that while wider socioeconomic factors such as poverty, housing insecurity and structural inequality continue to shape long‑term outcomes, rigid, fragmented and digital‑first systems actively undermine access and continuity of care. This is particularly the case for people experiencing trauma, instability or mistrust of statutory services. Individuals face cumulative emotional, practical, identity‑related and systemic barriers, with social isolation emerging as a key risk factor for crisis and disengagement. In contrast, relational, trauma‑informed, community‑based and peer‑supported approaches, underpinned by effective multi‑agency coordination, enable sustained engagement and recovery. The assessment identifies specific insight gaps for some inclusion health groups and concludes that embedding inclusion health within population health approaches, alongside targeted outreach, advocacy and strengthened system coordination, is essential to reducing exclusion and improving outcomes. The East Riding Inclusion Health Needs Assessment document can be downloaded from this link or via the picture on the left. The main needs assessment document is also accompanied by a ‘Case studies and engagement sample’ file, downloadable from this link. |
Inclusion health: Useful Resources and Links
This section includes an interactive resource titled ‘Inclusion health data and intelligence resource for England: An overview of published data and intelligence’ and further down the page a table provides a list of useful resources
Inclusion health data and intelligence resource for England: An interactive overview of published data and intelligence
This is a collaborative project between DHSC OHID, UKHSA, NHSE with representatives from local government, ICB and VCSE to support work on inclusion health at a local level. Its purpose is to support informed decision-making and develop tailored solutions to the specific challenges these groups encounter, especially in the context of implementing the 10 Year Health Plan for England: fit for the future, and advancing the integrated neighbourhood health offer.
The resource below is interactive, please use the left and right arrow keys (towards the bottom of the screen) to navigate between the pages.
Table of useful links
| Inclusion Health topic area | Title and further information | Link to web page or report |
|---|---|---|
| Action on Inclusion Health | A national framework for NHS. Use this framework to plan, develop and improve health services to meet the needs of people in inclusion health groups. | Link |
| Health Equity Assessment Tool (HEAT) | Resources and e-learning to support systematic action on health inequalities and equalities. | Link |
| Inclusion Health and Mental Health | People in our communities ‘in Inclusion health groups’ are experiencing the extreme effects of inequalities and thus very poor mental health and wellbeing. This presentation aims to show why it is important that we consider inclusion health groups in public mental health strategies. | Link |
| Inclusion Health and Work | Inclusion health and work in North East and Yorkshire (October 2025). This file has been developed by North East & Yorkshire (NEY) OHID team and DHSC/ DWP Joint Work and Health Directorate Regional Programme Advisor to support work around work and inclusion health across the NEY region. | Link |
| Gypsy and Travellers | Gypsy and Traveller and Travelling Showperson Accommodation Assessment (GTAA) 2022. The East Riding of Yorkshire Council GTAA provides the latest available evidence to identify the accommodation needs of Gypsies and Travellers and Travelling Showpeople across the district . | Link |
| Prisons | The health of people in prison, on probation and in the secure NHS estate in England. The Chief Medical Officer for England identifies areas of good practice and areas of risk, and recommends actions to improve health outcomes for this population. | Link |