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Systemic safety inequities for people with learning disabilities

A study examining safety inequities experienced by people with learning disabilities in English health and social care, drawing on lived experiences from focus groups and patient feedback narratives.

Key statistics 

  • people with learning disabilities in the UK experience substantially reduced life expectancy, with earlier mortality linked to avoidable or preventable conditions 
  • prior evidence cited in the study shows deaths occurring on average 22 years earlier for men and 27 years earlier for women compared with the general population 

Key messages 

  • people with learning disabilities experience systemic safety inequities when accessing health and social care services 
  • health and social care systems are often rigid and poorly adapted to the complex needs and communication requirements of people with learning disabilities 
  • failures in communication, information accessibility and reasonable adjustments increase risks to patient safety 
  • discontinuities in care, staff shortages and poor interoperability between services contribute to avoidable safety risks 
  • family members, carers and advocates frequently act as informal safety buffers within the system 
  • reliance on social support networks creates additional inequities for individuals who lack strong advocacy or family support 
  • improving safety requires system-level change, including better service design, staffing, training and coordination across health and social care 

Policy implications 

  • improve implementation of reasonable adjustments for people with learning disabilities across health and social care services 
  • increase specialist learning disability roles such as liaison nurses across care settings 
  • strengthen continuity of care and coordination between services, including better information sharing systems 
  • invest in accessible communication methods such as easy-read materials and personalised care plans 
  • develop stronger advocacy provision to support people with learning disabilities when interacting with services 
  • address workforce shortages and training gaps affecting safe care delivery 

Gaps 

  • demographic characteristics of participants were not extensively collected, limiting analysis of how inequities vary by factors such as ethnicity or socioeconomic status 
  • qualitative findings provide strong insight into experiences but cannot quantify the prevalence of specific safety issues 
  • more research is needed on interventions that effectively reduce systemic safety inequities 

Commentary 
This study explores systemic safety inequities experienced by people with learning disabilities when interacting with health and social care services. Rather than focusing solely on mortality data or adverse events, the research examines lived experiences of care to identify structural factors that contribute to unsafe or inequitable care. 

The analysis identified three overarching themes: health and care system rigidity, systemic gaps and traps within services, and the reliance on ‘dependency work’ undertaken by families, carers and advocates. These findings suggest that inequities are often produced by structural features of health and social care systems rather than by individual-level factors. 

System rigidity was a key issue. Health and social care services often required people with learning disabilities to adapt to standardised systems rather than adapting care to individual needs. Participants reported difficulties with communication, inaccessible information, insufficient time during appointments and environments that could be overwhelming or distressing. These barriers increased risks to patient safety and reduced the ability of individuals to participate fully in their care. 

The study also highlighted systemic gaps within services. Participants described inconsistencies in support provision, limited staffing capacity, poor coordination between services and failures in information sharing across organisations. These issues often led to fragmented care and repeated retelling of medical histories, which created additional burdens for individuals and families. 

A particularly important finding concerns the role of family members, carers and advocates in compensating for systemic weaknesses. Family members, carers and advocates frequently acted as informal safeguards by interpreting information, advocating for reasonable adjustments and ensuring that care needs were understood. While this support was valued, the study emphasises that reliance on social capital can create additional inequities for individuals without strong support networks. 

In terms of care equity, the study shows how structural barriers within service design, staffing and coordination contribute to poorer safety outcomes for people with learning disabilities. Addressing these inequities therefore requires system-level change rather than relying solely on individual staff training or local adjustments. 

Overall, the findings suggest that improving safety for people with learning disabilities requires more flexible service design, better communication practices, stronger advocacy support and improved integration across health and social care services. These changes would help reduce systemic safety inequities and improve care experiences for this population.

Addressing inequalities in dementia diagnosis and care 

A national study exploring practical solutions to reduce inequalities in dementia diagnosis and care across England, drawing on workshops with people with dementia, carers, professionals and third sector organisations.

This study uses the term inequalities. In this Evidence Hub, inequities is used where differences in access or outcomes reflect avoidable and unfair structural barriers in health and social care. 

Key messages 

  • people with dementia and their carers experience multiple inequalities affecting diagnosis, access to care and support 
  • these inequalities arise across three levels: individual characteristics, community and social networks, and wider societal and system factors 
  • stakeholders identified a range of potential solutions focused on strengthening community support and improving health and social care services 
  • proposed interventions included dementia link workers, improved workforce training, community awareness programmes and culturally appropriate services 
  • stakeholders emphasised that no single intervention can address inequalities in dementia care and that coordinated actions are needed across multiple levels 
  • improving integration between health and social care services is essential to support people after diagnosis 
  • increasing public awareness and reducing stigma were identified as priorities for improving help-seeking and earlier diagnosis 

Policy implications 

  • develop link worker or care navigator roles to help individuals and carers navigate services and support after diagnosis 
  • improve integration and communication between health and social care services 
  • increase workforce training to improve dementia knowledge across health and social care settings 
  • create clearer career pathways within the social care workforce to support recruitment and retention 
  • expand community awareness programmes and dementia-friendly initiatives 
  • improve culturally appropriate services and accessible information for diverse communities 
  • strengthen national coordination and accountability to reduce regional variation in dementia care 

Gaps 

  • the proposed solutions were identified through consultation and require further evaluation to assess effectiveness 
  • people living with dementia were less represented than carers and professionals in the workshops 
  • some demographic groups were under-represented in the consultation process 
  • there is limited evidence on the long-term impact of many proposed interventions 
  • further research is needed to evaluate the cost-effectiveness and scalability of suggested solutions 

Commentary 
This study explores practical ways to address inequalities in dementia diagnosis and care through a national consultation involving people with dementia, carers, professionals and community organisations. The consultation involved 131 stakeholders who participated in workshops across England to discuss the barriers people face and identify possible solutions. 

The findings show that inequalities in dementia care arise from multiple interacting factors. These include individual circumstances such as income or ethnicity, community-level influences such as stigma or limited social support, and wider structural issues such as service availability and coordination between health and social care systems. 

Many of the proposed solutions focused on improving support after diagnosis. Stakeholders highlighted the potential role of dementia link workers or care navigators who could help people and their families understand their diagnosis, navigate services and access appropriate support. These roles could help address some of the structural barriers that currently create inequities in access to care. 

Community engagement was also identified as important. Participants emphasised the role of dementia-friendly communities, peer networks and local organisations in raising awareness and reducing stigma. Improving understanding of dementia within communities may encourage earlier help-seeking and improve access to support. 

Workforce development was another key theme. Stakeholders identified the need for better training for health and social care professionals, as well as clearer career pathways within the social care workforce. Improving workforce knowledge and stability may help reduce inequities in the quality and availability of dementia services. 

From a care equity perspective, the study highlights that inequalities in dementia care often reflect avoidable structural barriers within systems and services. These inequities can affect who receives a diagnosis, how quickly support is provided and the quality of care available after diagnosis. 

Overall, the study suggests that reducing inequities in dementia care requires coordinated action across multiple levels. Interventions targeting individuals, communities and health and social care systems need to work together to ensure that people living with dementia can access timely diagnosis and appropriate support regardless of their background or location. 

A community powered NHS

A national report outlining principles and case studies showing how community participation can support integrated care and address wider determinants of health.

Key messages

  • community participation is presented as central to effective integrated care
  • neighbourhood-level approaches benefit from drawing on community assets and local knowledge
  • case studies show how co-production can improve service responsiveness and trust
  • addressing social determinants of health requires collaboration beyond traditional health services
  • community-powered approaches support prevention and early intervention.

Policy implications

  • neighbourhood health and care models should embed co-production as a core principle
  • partnerships with voluntary and community sector organisations are essential
  • service design should reflect local priorities and lived experience
  • integrated care systems may need to shift power and decision-making closer to communities.

Gaps

  • evidence is largely descriptive and based on case studies
  • limited use of consistent metrics to assess impact
  • lack of long-term evaluation of outcomes and equity effects.

Commentary
This report positions community participation as a foundational element of neighbourhood health and care. By emphasising co-production and asset-based approaches, it reframes integration as something built with communities rather than delivered to them.

The case studies illustrate how engaging residents can improve trust, relevance and responsiveness of services. From a care equity perspective, these approaches are particularly important for addressing social determinants of health that sit beyond the reach of clinical services alone.

The report also highlights the role of voluntary and community organisations as connectors between statutory services and local populations. Their involvement can support prevention, early intervention and more holistic responses to need.

However, the evidence base remains largely qualitative. While the principles are clearly articulated, there is limited evaluative data on outcomes or how community-powered approaches reduce inequalities over time. For neighbourhood health and care, this underlines the importance of pairing community participation with robust evaluation to understand impact and sustainability.

Community-based interventions and mental wellbeing in the UK

A systematic scoping review mapping community-based health, social and wellbeing interventions in the UK and their reported mental health and wellbeing impacts.

Key messages

  • the review identifies a wide range of community-based interventions across health, social and wellbeing settings
  • interventions include peer support, self-help, exercise-based programmes and digital approaches
  • many studies report positive effects on mental health and wellbeing outcomes
  • some interventions incorporate elements of social integration and social care support
  • outcome measures are uneven, with fewer studies examining harder endpoints such as hospitalisation or mortality
  • limited attention is given to equity and subgroup analysis.

Policy implications

  • community-based interventions may support neighbourhood health and care goals around prevention and wellbeing
  • neighbourhood models could benefit from drawing on existing community and voluntary sector provision
  • more consistent outcome measurement would support commissioning and scale-up
  • equity considerations should be more explicitly built into intervention design and evaluation.

Gaps

  • lack of standardised outcome metrics across studies
  • limited evidence on long-term or system-level impacts
  • fewer studies examine impacts on service use or clinical outcomes
  • minimal focus on differential effects across population subgroups.

Commentary
This scoping review highlights the breadth of community-based interventions operating within the UK that contribute to mental health and wellbeing. The diversity of approaches reflects the range of ways communities support health outside formal clinical settings.

From a neighbourhood health and care perspective, these interventions align with preventive and place-based ambitions. Peer support, exercise and self-help initiatives can complement statutory services by addressing wellbeing, connection and resilience within local communities.

However, the review also exposes weaknesses in the evidence base. Outcome measures vary widely, making it difficult to compare interventions or assess their contribution to system-level outcomes such as reduced service use.

The limited focus on equity is particularly notable. Without subgroup analysis, it remains unclear which interventions work best for different communities or whether benefits are distributed evenly.

Overall, the review suggests that community-based interventions have potential value within neighbourhood health and care, but stronger evaluation and clearer attention to equity are needed to inform commissioning and integrated service design.

Delivering integrated neighbourhood services: commissioning and service design

Interim findings on how commissioning processes and service design at Place level support delivery of integrated neighbourhood health and care services in England.

Key messages

  • current policy emphasises Place-level commissioning to support more integrated health and social care at neighbourhood scale, aligning with the 10 Year Health Plan’s shift towards community-based care
  • Places are intended to be sub-Integrated Care Boards (ICB) geographies where integrated services are planned and delivered around local populations
  • commissioning responsibilities were delegated through the Health and Care Act 2022 without prescriptive structures, leading to variation in local approaches to Place-level commissioning
  • literature suggests factors that enable effective Place-level commissioning include clear governance, strong relationships, shared priorities, workforce capacity, pooled resources and collaborative planning
  • there are recurring tensions between integration aspirations and the legacy organisational, structural and policy divides that continue to shape commissioning practice.

Policy implications

  • commissioning systems need clarity on how responsibilities at Place level sit within wider Integrated Care Systems (ICS) structures
  • effective neighbourhood health and care depends on governance arrangements that support collaboration rather than siloed action
  • workforce development, information sharing and resource alignment should be prioritised in commissioning design
  • national policy should continue to support local adaptation while providing frameworks that encourage consistency in integrated commissioning.

Gaps

  • limited empirical evidence on how Place-level commissioning directly affects integrated service delivery outcomes
  • variation in how neighbourhood and Place commissioning has been interpreted complicates comparison across local sites
  • much of the evidence is early and descriptive, with limited long-term evaluation of integrated neighbourhood initiatives.

Commentary
This interim report provides early insights into how commissioning and service design are shaping integrated neighbourhood health and care in England. By focusing on Place-level mechanisms, it highlights how national policy intentions are being interpreted and operationalised in local systems.

The shift towards neighbourhood-based integrated commissioning is situated within broader NHS reforms, including the 10 Year Health Plan and statutory establishment of Integrated Care Systems (ICS). In this context, Place offers a scale at which health and social care services can be joined up around people’s needs rather than organisational boundaries.

Key enabling factors identified in the literature signal that commissioning for integrated neighbourhood care requires more than structural arrangements; it depends on trust, shared priorities, effective governance and aligned incentives. These relational and organisational elements mirror themes seen in other neighbourhood health evidence that integration is as much cultural as structural.

However, the report also underscores the early and uneven nature of Place-level commissioning practice. With permissive policy frameworks and variable local interpretation, there is a risk that integrated neighbourhood services remain patchy in reach and impact. Strengthening evidence on what works, for whom, and in what contexts will be essential to ensure that neighbourhood health and care contributes to equity rather than reproducing existing disparities.

Designing a neighbourhood health service

A design and governance blueprint proposing neighbourhood health centres as the core delivery model for neighbourhood health and care.

Key messages

  • the report proposes neighbourhood health centres as co-located hubs integrating diagnostics, rehabilitation and mental health support
  • centres are envisaged to operate extended hours, opening 12 hours a day, six days a week
  • workforce pooling and shared budgets are presented as mechanisms to support integrated delivery
  • community participation is positioned as central to improving equity and responsiveness
  • neighbourhood-based design is framed as a way to shift care closer to home and reduce pressure on hospitals.

Policy implications

  • neighbourhood health and care models may benefit from clear physical hubs that anchor integrated teams
  • pooled budgets and shared workforce arrangements could support more flexible service delivery
  • community involvement in governance and design may strengthen equity outcomes
  • implementation would require alignment between commissioning, estates and workforce planning.

Gaps

  • the report is advocacy-focused and not peer reviewed
  • no empirical evaluation of neighbourhood health centre models is provided
  • limited evidence on feasibility, costs or workforce capacity
  • lack of outcome data on access, experience or equity.

Commentary
This report presents a clear and ambitious vision for neighbourhood health and care centred on neighbourhood health centres. By proposing co-located hubs with extended opening hours, it emphasises accessibility, continuity and integration across physical, mental and rehabilitative care.

From a care equity perspective, the focus on shared budgets, pooled workforces and community participation and elements of co-production is significant. These design principles aim to reduce fragmentation and give communities a stronger role in shaping local services, potentially improving access for groups underserved by traditional models.

However, the report is primarily normative rather than evaluative. While it offers a coherent blueprint, there is limited evidence on how such centres would operate in practice or how they would affect inequalities across different neighbourhoods.

Overall, the report contributes to the neighbourhood health and care debate by expressing a concrete service model and governance approach. Its value within the hub lies in shaping discussion about design and equity, while highlighting the need for empirical evaluation to assess feasibility and impact.

Evaluation of Central Locality Integrated Care Services (CLICS), Bradford

An effectiveness evaluation of a place-based integrated care intervention combining social prescribing and general practice to improve health outcomes in a highly deprived and ethnically diverse area of central Bradford.

Key statistics

  • CLICS engaged 917 patients, matched with 3,668 controls based on age, gender, ethnicity and comorbidity status.
  • Odds of unplanned hospital admission were 17% lower in the CLICS group compared to matched controls, though estimates were imprecise.
  • Sub-analysis indicated a 49% lower odds of unplanned admissions for White British patients receiving CLICS compared with controls; no reduction was observed for Pakistani heritage patients.
  • Wellbeing (SWEMWBS) increased by an average of 3.6 points among CLICS participants; health-related quality of life (EQ-5D) also improved on average.

Key messages

  • the CLICS intervention, which integrates social prescribing with general practice, shows promise in reducing unplanned hospital admissions and improving wellbeing and quality of life in a deprived, diverse population
  • early evidence suggests differential effects by ethnicity, with White British patients showing greater reduction in admissions than Pakistani heritage patients
  • social prescribing, as delivered within CLICS, can support personalised care that addresses both clinical and non-clinical needs through connections with community resources
  • evidence on cost, long-term outcomes and mechanisms of effect remains limited, and causality cannot be established with certainty.

Policy implications

  • integrated neighbourhood services that link clinical care with community and social resources may reduce demand on acute services and support quality of life improvements
  • evaluation designs need to include ethnicity-sensitive analyses and explore how interventions can reach and benefit diverse population groups equitably
  • place-based initiatives should consider referral and recruitment pathways to ensure high-risk groups are engaged
  • longer follow-up and comparative evaluation are necessary to inform commissioning decisions and scalability.

Gaps

  • no causal inference due to observational design and lack of control data for wellbeing and quality of life measures.
  • early estimates are imprecise with wide confidence intervals on key outcomes
  • subgroup findings suggest potential inequities that require more in-depth study
  • limited evidence on sustained impacts beyond 12 months and on cost-effectiveness.

Commentary
This evaluation contributes to neighbourhood health and care evidence by examining a real-world integrated service that deliberately combines clinical primary care with community-oriented support through social prescribing. It aligns with place-based approaches that seek to address both medical and social determinants of health in deprived urban settings.

The finding that CLICS may reduce unplanned hospital admissions is promising, particularly in the context of cities with high baseline rates of acute service use. However, the differences observed by ethnic group raise important equity questions about why benefits appear stronger for some populations than for others. This reflects broader concerns in neighbourhood health that services must not only be integrated but also culturally accessible and inclusive.

Improvements in wellbeing and health-related quality of life suggest that integrating social prescribing and primary care has potential benefits beyond service utilisation. These outcomes are particularly relevant for place-based strategies that aim to support resilience, self-management and connection to community resources.

However, the evaluation’s limitations (particularly its observational design and short follow-up) mean that evidence of effectiveness remains tentative. For policymakers and local teams investing in integrated neighbourhood services, this highlights the importance of building evaluation into programme design and ensuring that data collection supports equity-focused analyses.

Equity and access to extended GP hours hubs

A quantitative study examining access and equity implications of evening and weekend GP hub appointments in England.

Key messages

  • attendance at extended-hours GP hubs declines sharply with increasing distance from the hub
  • geographic proximity is a stronger predictor of uptake than area-level deprivation
  • deprivation alone did not explain differences in use of hub appointments
  • hub-based models may create access barriers for people living further away
  • digital access or outreach support may be needed to avoid inequitable access.

Policy implications

  • neighbourhood health and care models should consider geographic accessibility alongside service availability
  • reliance on centralised hubs risks disadvantaging people who live further away
  • digital access and outreach services may be needed to complement hub-based provision
  • access planning should assess who benefits and who is excluded from extended-hours models.

Gaps

  • no subgroup analysis by ethnicity or income
  • limited insight into longer-term outcomes or patterns of repeat use
  • observational design limits conclusions about causality.

Commentary
This study highlights the importance of place in shaping access to neighbourhood health and care services. While extended GP hours hubs aim to improve access, the findings show that distance is a key determinant of use, with attendance falling sharply the further people live from the hub.

For care equity, the results suggest that extended-hours provision does not automatically improve access for all groups. Although deprivation alone did not predict uptake, geographic convenience appears to play a dominant role, potentially disadvantaging people in less well-connected areas. The findings also raise important questions about hub-based neighbourhood models. Centralising services may improve efficiency, but without complementary digital or outreach approaches, these models risk producing inequities in access.

The study also highlights evidence gaps. Limited subgroup analysis and short-term outcomes mean it remains unclear how extended-hours hubs affect different population groups over time. For neighbourhood health and care, this underlines the need to design access models that account for both geography and inequality, rather than assuming increased availability leads to equitable use.

Frontline barriers to integrating primary and social care

A qualitative study exploring frontline perspectives on barriers to integration between primary care and social care in England.

Key messages

  • frontline staff identified three main areas where barriers to integration persist: access to social services, interprofessional relationships and infrastructure
  • difficulties contacting staff across sectors create delays in referrals and care coordination
  • hostile working cultures and siloed practices contribute to poor collaboration between primary and social care
  • overworked staff, inefficient multidisciplinary meetings and unclear responsibilities slow responses to patient needs
  • lack of interoperable information systems, absence of pooled budgets and misaligned managerial incentives compound structural barriers.

Policy implications

  • improving integration may require investment in interoperable information systems across sectors
  • pooled budgets and aligned incentives could reduce structural divisions between primary and social care
  • workforce strategies should address interprofessional relationships and organisational culture, not only processes
  • clearer accountability arrangements may help reduce diffusion of responsibility in integrated working.

Gaps

  • findings are based on London GP surgeries and may not reflect experiences in other regions
  • perspectives of social care staff are not included
  • limited insight into how barriers change over time or respond to policy interventions.

Commentary
This study highlights how workforce experiences shape the effectiveness of integration between primary and social care. Barriers are not limited to systems and structures, but are deeply influenced by relationships, culture and everyday working practices.

Difficulties in accessing social services and contacting staff across organisational boundaries delay referrals and disrupt continuity of care. From a care equity perspective, these delays may disproportionately affect people with complex needs who rely on coordinated support across sectors.

The findings also point to cultural and relational barriers. Hostile interprofessional relationships and siloed working undermine collaboration, while overwork and inefficient multidisciplinary meetings limit the capacity of staff to engage meaningfully in integrated care.

Structural issues, including non-interoperable information systems, lack of pooled budgets and misaligned incentives, further strengthen division between sectors. These barriers suggest that integration efforts focused solely on frontline practice are unlikely to succeed without also undertaking system-level reform.

Overall, the study shows that achieving equitable, integrated care requires attention to workforce conditions, organisational culture and infrastructure alongside policy and funding mechanisms. Without addressing these interconnected barriers, integration risks remaining aspirational rather than embedded in routine practice.

How integrated care systems address health inequalities

An analysis of integrated care system plans examining how they address health inequalities and the strategies proposed to improve equity.

Key messages

  • integrated care systems place increasing emphasis on health inequalities within strategic plans
  • place-based working and collaboration beyond traditional health and care boundaries offer potential to address wider determinants of health
  • integrated approaches may improve equity in access to services and support healthier behaviours
  • there is substantial variation across systems in how inequalities are defined, prioritised and addressed
  • many plans lack detailed strategies or clear metrics to evaluate progress on equity
  • in some systems, equity appears as a secondary aim rather than a central organising principle.

Policy implications

  • neighbourhood health and care approaches may need clearer accountability for equity outcomes
  • consistent frameworks and metrics could support comparability and learning across systems
  • partnerships with non-health sectors require deeper and more sustained engagement
  • equity may need to be embedded as a core principle rather than an add-on within system plans.

Gaps

  • limited evidence on whether stated strategies translate into measurable reductions in inequalities
  • lack of longitudinal evaluation of integrated care system approaches
  • limited insight into how neighbourhood-level action aligns with system-wide equity goals.

Commentary
This paper highlights the ambition within integrated care systems to address health inequalities through place-based and integrated approaches. The neighbourhood focus and emphasis on cross-sector collaboration provide a foundation for tackling not only access to services, but also the wider social determinants that shape health outcomes.

However, the analysis reveals uneven commitment and capacity across systems. While some integrated care systems articulate clear intentions around equity, others lack detailed strategies or measurable goals. From a care equity perspective, this variability risks reinforcing geographic disparities rather than reducing them.

The findings also suggest that collaboration with non-health partners is inconsistent. Where partnerships are underdeveloped, opportunities to influence housing, employment and community infrastructure may be missed, limiting the potential impact of neighbourhood health and care.

Importantly, the paper raises questions about whether equity is driving system design or being addressed retrospectively. Without embedding equity as a core organising principle, integrated care systems may struggle to translate place-based working into meaningful reductions in inequality.

Overall, the study indicates that neighbourhood health and care has significant potential to support equity, but this depends on the depth of strategic commitment, clarity of measurement and the strength of cross-sector partnerships within integrated care systems.