Inclusion pays: preventing crisis, reducing cost and improving flow
7 July 2026
An inclusion health refugee and asylum seeker service reduced pressure across urgent and acute care in Sussex while delivering up to £13 return for every £1 invested.
Primary care
Community
Finance
Health inequalities
Overview
Alliance for Better Care (ABC), a GP federation supporting 77 practices, developed a specialist inclusion health refugee and asylum seeker service providing trauma-informed, community-based care for a fluctuating population of more than 3,000 people across Sussex. The service has reduced pressure across urgent and acute care while delivering up to £13 return for every £1 invested.
Key results
- Returns of up to £13 saved for every £1 invested.
- 95 per cent of patients treated within the service did not require onward urgent care.
- 42 supported discharges completed with medication, GP registration and follow-up in place.
- 100 per cent of new arrivals screened for communicable diseases and offered vaccination.
- 94 per cent of patients reported improved wellbeing.
What the system faced
People seeking asylum and refuge often arrive with complex physical and mental health needs, disrupted healthcare histories, trauma, language barriers and limited understanding of how to navigate NHS services. They are among the groups most likely to experience delayed access, fragmented pathways and avoidable escalation into urgent and acute care. Without coordinated support, conditions frequently deteriorate before people access appropriate care.
The local system was seeing increasing pressure linked to:
- avoidable emergency department attendance
- delayed diagnosis and treatment
- challenges supporting safe discharge from hospital
- fragmented continuity of care
- safeguarding concerns
- increasing demand across primary, community and acute services.
Traditional healthcare pathways were not designed around the realities faced by inclusion health populations. At the same time, acute and primary care services were managing growing operational pressure, requiring approaches that could improve hospital flow, strengthen prevention, and reduce avoidable escalation into higher-cost care pathways.
What ABC did
With the support of Surrey and Sussex Integrated Care Board, ABC developed a specialist inclusion health model built around prevention, coordinated community-based intervention and integrated partnership working. The service brings together primary care, personalised support, safeguarding, public health interventions and partnership working across NHS, voluntary and local authority organisations through a connected, trauma-informed approach.
The model was designed to replace reactive, hospital-led pathways with earlier intervention, improving outcomes while reducing avoidable cost and demand across the system.
Key elements included:
1. Community-based, primary care-led intervention
ABC shifted care away from hospital settings wherever possible through:
- flexible multidisciplinary outreach across non-clinical and temporary accommodation settings
- proactive screening and vaccination
- personalised care support
- trauma-informed care including mental health support
- onsite wound care and burns management
- coordinated maternity and safeguarding support
- rapid GP registration and navigation support.
This enabled patients to access care earlier and more appropriately, reducing avoidable escalation into urgent and emergency pathways.
2. Integrated partnership working
Built around collaboration between more than 35 NHS, local authority, and voluntary sector organisations.
The service worked closely with acute hospital teams, safeguarding teams, public health services and community organisations to create more joined-up pathways for people who would otherwise struggle to access or remain engaged with care.
3. Data-led delivery and prevention
ABC used coded clinical activity, inclusion health dashboards and NHS benchmarking data to track activity, identify risk and demonstrate measurable system value.
This supported earlier intervention, reduced avoidable escalation, and improved use of NHS resources.
Results and benefits
Over a 12-month period, the service supported 6,695 patients through more than 11,000 patient contacts, while demonstrating measurable impact across urgent care avoidance, hospital discharge, public health, and prevention.
Urgent and emergency care avoidance
- 95 per cent of patients treated within the service did not require onward urgent care
- Only three emergency department re-attendances for the same presentation over 12 months
- 92 per cent of burns cases managed without referral to a specialist burns unit
Hospital discharge and flow
- 42 supported discharges completed with medication, GP registration and follow-up in place
- average discharge delays reduced by two days, releasing acute capacity for other patients
Public health and prevention
- 100 per cent of new arrivals screened for communicable diseases and offered vaccination
- 11 active TB diagnoses identified early - preventing late-stage presentation and outbreak
- 27 blood borne virus and STI diagnoses detected and treated
- 17 new HIV diagnoses identified through coordinated pathways
Mental health and personalised care
- 329 patients received personalised care support
- 94 per cent of patients reported improved wellbeing
- 60 per cent of mental health consultations involved suicidal ideation, with the majority managed safely within the service
Financial and operational impact
Using NHS national reference costs, ABC modelled the impact of replacing hospital-led pathways with coordinated community-based intervention. Examples included:
- burns management pathways delivering 70 per cent system savings
- scabies pathways reducing costs by 92 per cent
- earlier access to termination of pregnancy support reducing costs by 53 per cent while enabling patients to access care up to four weeks earlier
Across the pathways analysed, the service demonstrated returns of up to £13 saved for every £1 invested.
Advice for other systems
- Inclusion health is a smart public investment. When health services reach people before crisis, the system works better - and costs less.
- Earlier, coordinated intervention improves hospital flow, reduces avoidable demand, and enables NHS resources to be used where they deliver the greatest value.
- Build partnerships around people, not organisations. The strongest results came from integrated working between NHS providers, primary care, community teams and voluntary sector organisations. Leaders should focus on enabling flexible, cross-system collaboration around patient need.
- Equally value data, operational insight and lived experience.
- Combining clinical coding, operational data, patient experience, and NHS benchmarking enabled ABC to build a more complete picture of the impact of inclusion health interventions across the system.
- Looking across the full patient journey helped demonstrate how earlier, coordinated intervention improves outcomes, strengthens hospital flow, and reduces avoidable demand.
- When services are designed around people facing the greatest barriers to access, the whole system benefits. Flexible, trauma-informed models support earlier intervention, improve hospital flow and reduce avoidable demand across the system.
Further information
For more detail about this case study, contact:
Lena Abdu, Director for Inclusion Health and Transformation, Alliance for Better Care CIC.