Key messages

• Edmonton, Enfield is implementing integrated neighbourhood approaches drawing together health, social care and voluntary sector partners to tackle local inequalities and improve wellbeing
• place-based partnerships emphasise community involvement in service design, delivery and evaluation to make services more responsive to local needs
• local engagement work, including Community Powered Edmonton, brings residents, service users, voluntary organisations and statutory partners together to identify priorities and co-produce solutions
• practical actions include targeted campaigns on safety, poverty, social isolation and other determinants that shape health and wellbeing beyond clinical care
• integrated models combine multi-disciplinary teams from primary care, mental health and community services with community partners to support holistic health and reduce inequities.

Policy implications

• neighbourhood health and care planning should embed community engagement and co-production, not just organisational collaboration
• addressing wider determinants (poverty, isolation, safety) alongside clinical services is key to reducing health inequalities
• partnerships need sustained resourcing and governance structures that include voices from voluntary and community sectors
• shared information, workforce development and co-located services can strengthen integrated working at neighbourhood scale.

Gaps

• local documentation and community engagement reports are largely descriptive, with limited consistent outcome measurement
• evidence of long-term impact on health outcomes or inequalities at neighbourhood level is limited
• systematic evaluation of integrated models in Edmonton and similar boroughs is needed to inform broader policy.

Commentary
The Edmonton area within Enfield offers an example of how neighbourhood health and care integration is being shaped through community engagement and partnerships, involving residents, voluntary organisations, local councils and health and social care providers. This place-based work brings into focus people’s lived experience and local priorities, recognising that health is shaped by social determinants such as poverty, safety and isolation, not only clinical care.

Community Powered Edmonton demonstrates the value of co-production. By bringing community members into discussions about what matters for health and wellbeing, including through workshops and focus groups, partners aim to design services that reflect local needs and strengthen trust. Such approaches align with equity goals by centring not just on access to services but responsiveness to diverse lived experience.

Partnership structures in Enfield, as outlined by the borough partnership approach, seek to integrate workforce, planning and digital resources to support neighbourhood teams. While this local practice reflects broader neighbourhood health ambitions, persistent inequalities and resource constraints highlight the need for sustained investment and evaluation to understand impact on outcomes.

From a care equity perspective, Edmonton’s experience shows the potential of an asset-based, community-informed neighbourhood working to reach populations that traditional models struggle to engage. However, without consistent metrics and long-term evaluation, it remains challenging to quantify the extent to which integration initiatives reduce inequities over time.

Key messages 

• Inclusion health groups are populations who experience extreme social exclusion and very poor health outcomes, often due to overlapping disadvantages such as poverty, stigma, unstable housing, trauma, and barriers to accessing services. The term is widely used in UK health policy and research. 

• inclusion health groups experience some of the most severe health inequities in the UK, with life expectancy estimated to be around 20 years lower than the general population 

• people within inclusion health groups often experience overlapping forms of exclusion including homelessness, poverty, stigma, trauma and discrimination 

• integrated and collaborative approaches across health, social care and community organisations are required to address these complex needs 

• the report identifies promising practice areas including co-production with people with lived experience, strategic leadership for inclusion health, prevention-focused approaches, improved safeguarding and workforce development 

• neighbourhood and integrated care models can support inclusion health when services are coordinated and shaped around local needs 

• fragmented services and lack of coordination across organisations remain major barriers to improving outcomes for excluded populations 

Policy implications 

• integrated care systems should embed inclusion health priorities within system planning and commissioning 

• services for inclusion health groups should be co-designed with people who have lived experience of exclusion 

• stronger cross-sector collaboration between NHS services, local authorities, housing providers and voluntary organisations is required 

• improved data collection and evaluation are needed to understand local needs and measure progress 

• workforce development and training may help staff better respond to the needs of people experiencing severe exclusion 

Gaps 

• the report highlights variation in how inclusion health approaches are implemented across integrated care systems 

• limited consistent evaluation of inclusion health initiatives makes it difficult to compare outcomes between local areas 

• data on inclusion health populations remain incomplete in many health systems 

• further research is needed to understand which integrated models are most effective for different inclusion health groups 

Commentary 
This report draws on learning from a national inclusion health leadership programme involving Integrated Care Systems and partner organisations. It explores how collaborative approaches can improve outcomes for people experiencing severe social exclusion. 

The report highlights that inclusion health groups, including people experiencing homelessness and other forms of extreme marginalisation, often face complex and overlapping health and social needs. Fragmented services and poor coordination across sectors can make it difficult for individuals to access consistent care and support. 

A central theme of the report is the importance of collaboration across organisations. Integrated working between health services, social care, housing providers and voluntary sector organisations is presented as a key mechanism for addressing the structural drivers of exclusion and improving service access. 

From a care equity perspective, the findings emphasise that people experiencing the most severe forms of exclusion often face the greatest barriers to accessing health and care services. Without targeted action, these populations risk remaining outside mainstream service pathways and continuing to experience poorer health and care outcomes. 

The report suggests that progress requires leadership at both national and local levels. Strategic commitment, improved data, stronger partnerships and meaningful involvement of people with lived experience are identified as essential components for reducing inequities in access to care and improving outcomes for inclusion health groups.