Inclusion by Design in NHS Community Services: Moving Beyond Reasonable Adjustments
In NHS community services, “inclusion” often gets reduced to a list of adjustments made once someone is already accepted onto a caseload. That approach misses the point. Inequalities are usually created earlier: at the point of referral, triage, booking, assessment and communication. Inclusion by design means building access and delivery routines that work for people with the greatest barriers, not only those who can navigate standard systems. This article supports the wider Health Inequalities, Access & Inclusion focus and links directly to NHS Community Service Models and Pathways, because pathway design determines who is reached, who is missed, and how safely risk is managed.
What “inclusion by design” means in day-to-day NHS operations
Inclusion by design is a practical operating principle: if a pathway requires high literacy, digital confidence, stable housing, fluent English, or unbroken phone access, it will exclude people who do not have those conditions. Services then spend time dealing with non-attendance, complaints, deteriorations and escalations—symptoms of exclusion rather than “non-compliance”.
Inclusion by design therefore starts with the pathway mechanics: multiple access routes, assessment formats that can flex, communication methods that reflect sensory and cognitive need, and delivery routines that are safe for people whose lives are less predictable. It also requires clarity about risk: inclusion does not mean lowering safeguarding standards, but it does mean proactively identifying and mitigating exclusion-related risks (missed contact, misunderstood plans, failure to engage, and unrecognised deterioration).
Operational example 1: Redesigning triage to avoid exclusion of people with cognitive or communication barriers
Context: A community mental health interface service triages referrals using a brief phone assessment and expects the person to describe symptoms, risks and goals within a single call. People with mild learning disabilities, acquired brain injury, or early dementia frequently “fail” the triage because they cannot articulate needs quickly or get overwhelmed.
Support approach: The service introduced a two-stage triage for flagged cases: (1) a short initial contact to establish safety and preferred communication; (2) a structured follow-up using a simplified question set and, where appropriate, involvement of a carer, advocate or trusted referrer.
Day-to-day delivery detail: Referral coordinators apply a standard “inclusion flags” checklist (cognition, sensory loss, language, literacy, homelessness, domestic abuse risk). Where flags apply, the booking team offers appointment options (home visit, video with support, or community venue) and allocates longer assessment slots. Clinicians use an easy-read “what happens next” sheet and confirm understanding using teach-back rather than relying on verbal agreement alone.
How effectiveness or change is evidenced: The service audits triage outcomes monthly, comparing acceptance rates and completion of first assessment for flagged groups. It tracks “did not attend” rates, recorded understanding of care plans, and safety events within 30 days. Improvement is evidenced by reduced triage drop-out for flagged cohorts and fewer crisis escalations linked to missed assessments.
Operational example 2: Building inclusive appointment systems to reduce non-attendance without blaming service users
Context: A community therapy pathway experienced high non-attendance among people living in temporary accommodation and among carers with unpredictable schedules. The standard process relied on letters and a single text reminder, with discharge after two missed appointments.
Support approach: The pathway moved to “contactable booking”: multiple contact methods, flexible locations, and a graded response to non-attendance that distinguishes exclusion from disengagement.
Day-to-day delivery detail: Booking staff confirm preferred contact (text, call, email, letter via GP/hostel, or VCSE keyworker). For people with unstable housing, the service offers a fixed weekly drop-in slot at a community venue plus pre-booked appointments where possible. When someone misses an appointment, staff follow a standard script that checks practical barriers (travel cost, childcare, safety, phone access) and offers alternative formats rather than immediate discharge. Safeguarding prompts are built into the non-attendance workflow where there are known risks (domestic abuse, self-neglect, exploitation).
How effectiveness or change is evidenced: The pathway reports non-attendance by deprivation and housing status, monitors rebooking success within 14 days, and reviews any safeguarding concerns triggered by loss of contact. Evidence of impact includes improved attendance for previously high-DNA cohorts and a reduction in inappropriate discharges that later re-present through urgent care routes.
Operational example 3: Inclusion through communication design for sensory loss and limited English
Context: A community nursing service found that people with hearing loss and people who use British Sign Language were receiving inconsistent communication support. Separately, people with limited English were frequently agreeing to plans they did not understand, leading to medication errors and failure to follow wound care instructions.
Support approach: The service implemented a communication assurance standard: identification of communication need at first contact, guaranteed interpreter booking processes, and written/visual materials adapted to need.
Day-to-day delivery detail: At referral intake, staff record communication needs as a mandatory field and the system blocks appointment confirmation unless support is arranged when required. Clinicians carry a standard visual “care instruction” pack (pictures, step-by-step prompts) and use short written summaries after each visit. For interpreter use, staff book through an agreed provider and confirm attendance in advance; if an interpreter is unavailable, the appointment is rescheduled unless there is an urgent clinical need, in which case a senior clinician authorises an alternative approach and documents risk controls.
How effectiveness or change is evidenced: The service reviews incidents and complaints for communication-related factors, audits interpreter booking compliance, and samples care records for evidence of understanding checks. Impact is evidenced through reduced medication/wound-care errors and improved satisfaction feedback from people who previously reported feeling excluded.
Commissioner expectation: Inclusion must be evidenced through pathway performance, not statements
Commissioner expectation: Commissioners increasingly expect services to show that inclusion is built into access and delivery metrics. This means demonstrating who is (and is not) reaching the pathway, how long different cohorts wait, and where drop-out occurs. Commissioners also expect evidence of actions taken when disparities appear, including pathway redesign, targeted outreach through VCSE partners, and adjustments to eligibility and triage that protect safety while improving access.
In contract management, inclusion is typically tested through practical questions: How do you prevent inappropriate discharge for non-attendance? How do you ensure interpreting and accessible information are reliably delivered? How do you evidence improved access for people in deprived areas, people with disabilities, and marginalised communities?
Regulator / Inspector expectation: Safe, responsive services that recognise exclusion as a risk factor
Regulator / Inspector expectation (CQC): CQC expects services to be equitable and responsive, with particular attention to how people with protected characteristics or additional needs experience access and delivery. Inspectors will look for evidence that services identify who may be disadvantaged by standard processes and that they have reliable mitigations, not informal workarounds. They also expect governance oversight of risks linked to exclusion (loss of contact, misunderstanding of care plans, failure to access urgent support) and learning from incidents and complaints.
Governance and assurance mechanisms that make inclusion real
Inclusion by design requires routine governance, not one-off projects. Effective mechanisms include:
- Monthly access dashboards showing referral sources, acceptance rates, waiting times and drop-out by deprivation and relevant protected characteristics where data quality allows.
- Structured review of rejected referrals and discharges due to non-attendance, with senior sign-off where exclusion risk is suspected.
- Quality sampling of care records for communication need identification, interpreter booking evidence, and understanding checks.
- Joint pathway reviews with system partners (GPs, discharge teams, VCSE) focused on friction points and redesign actions.
Critically, these controls must link to action: pathway rules are adjusted, staff practice is supported through supervision, and learning is documented so improvements are auditable.
Making inclusion defensible: outcomes, safeguarding, and positive risk-taking
Inclusion by design is not permissive practice. It is a safer, more reliable model because it anticipates barriers and reduces the chance that people fall out of contact unnoticed. Where inclusion increases contact intensity or flexibility, risk management must be explicit: who is responsible for follow-up, what escalation routes exist, and how safeguarding is triggered when contact is lost. Positive risk-taking is also relevant: services may need to meet people in non-traditional venues or use flexible appointment models. These approaches must be supported by clear lone-working procedures, safeguarding frameworks, and managerial oversight so that inclusive access does not create unmanaged staff or service-user risk.