Evidence Hub

Improving equity of access to primary healthcare for people with substance use disorders and/or homelessness

Quick-read summary

Sunderland has high levels of alcohol and drug related harms, poverty, unemployment and homelessness. People who use substances experience significant health inequalities, higher barriers to healthcare, and worse health outcomes.

Sunderland City Council wanted to explore new ways of reaching these groups of patients.

ARC NENC researchers worked with Sunderland’s public health team, Sunderland GP Alliance, and people with lived experience to co-design and evaluate an intervention called the Sunderland Health Bus. The pilot was funded via the North East and North Cumbria Integrated Care Board (ICB) and delivered by Sunderland GP Alliance.

The bus offered ‘walk in’, flexible primary care services in targeted areas across the city, including community settings and recovery services. The service operated between April and October 2025.

A clinician (GP or Advanced Nurse Practitioner), admin staff and relational peer workers (people with lived experience of substance use or homelessness) operated the service. All staff received ‘Recovery Ally’ training around stigma and working with substance use communities.

During the pilot, 164 patients accessed the service, aged 17 to 92. 34% of these were homeless.

96% of patients rated their experience as ‘very good’ or ‘good’. Patients valued the ‘drop in’ model, immediate access to care, longer consultation times, and the stigma-free, compassionate approach from staff.

The evaluation demonstrated improved access to primary care and increased re-engagement of patients with clinical care and wider support services.

Primary care staff reported increased confidence in working with patients with substance use disorder, and an early Social Return on Investment (SROI) analysis suggests a positive return (10p for every £1 invested).

The pilot has already influenced local system decisions: Sunderland GP Alliance has secured funding for a new, permanent bus via NIHR Capital Investment Funding, to support longer term legacy.

Who is this evidence useful for?

• Local authorities and public health teams
• NHS primary care providers and Integrated Care Boards
• Community, voluntary and lived experience organisations
• Policymakers working on health inequalities and inclusion health
• Commissioners designing community-based or outreach health services

What is the issue?

People who experience substance use disorders and/or homelessness often have multiple and complex health and social needs. Despite high levels of ill health, they frequently struggle to access traditional primary healthcare due to a wide range of factors including stigma, digital exclusion, financial barriers, and complex personal circumstances.

These barriers contribute to widening health inequalities and prevent timely care. New service models are needed that provide accessible, non judgemental care and recognise the importance of social and relational support alongside clinical treatment.

To address this, a six month pilot mobile health was co-designed and delivered in Sunderland, bringing primary healthcare directly into community settings already used by this population. The pilot was funded by the North East and North Cumbria Integrated Care Board (ICB) through a scheme to support targeted reductions in health inequalities.

Research summary

This study looked at how the Sunderland Health Bus worked in practice during a six month pilot. The aim was to understand who it reached, how it was delivered, what worked well, and what challenges were faced.

Researchers carried out a process evaluation, which means they focused on how the service was set up and experienced by patients and staff, rather than just measuring medical outcomes.

The research included:

• Looking at service data from all patients who used the bus (164 people), to understand who accessed the service and what health issues they presented with
• Patient surveys (112 people) to capture experiences of using the bus, satisfaction with care, and perceived benefits
• In depth interviews with patients who had used the bus and staff involved in planning, delivering or hosting the service
• On site observations of the bus in action (around 100 hours), focusing on how people accessed the service, how staff worked together, and how patients were supported
• A Social Return on Investment (SROI) analysis to quantify value for money

What did the research find?

• The SROI analysis found the programme delivered a 10% return (10 pence per each £1 invested).
• In a scale-up prediction it could deliver 100% return on investment (£2 per each £1 invested).
• Patients had very positive experiences of the service – almost all patients rated their experience of the bus as good or very good.
• Patients valued being able to drop in without an appointment and being able to talk about more than one health issue in a single visit
• Many patients said they felt listened to, respected and treated kindly, often contrasting this with past experiences of stigma or feeling judged in mainstream healthcare settings.
• Feeling comfortable and welcomed reduced anxiety and made it easier for people to seek help.
• The bus acted as a ‘first step back’ into healthcare for some people who had previously disengaged due to fear, poor mental health, past negative experiences or historic ‘flags’ for non-attendance on GP records.
• Peer workers added significant value, helping people to feel safe and understood.
• Patients and clinicians both highlighted that peer workers helped build trust and allowed the service to respond to wider social needs, not just medical issues.
• Staff felt the bus strengthened relationships between public health, primary care, community services and voluntary organisations.
• Primary care staff reported increased confidence and understanding in working with people with multiple and complex needs

Why is this important?

This study demonstrates that flexible, mobile, and relational models of primary care can reduce barriers and improve healthcare access for people who experience the greatest health inequalities.

How were people/community groups/patients involved in this work?

A Patient and Public Involvement and Engagement (PPIE) group of people with lived experience of substance use disorders and/or homelessness was involved throughout

Lived experience representatives contributed to designing the intervention, developing patient materials, shaping the evaluation, and interpreting findings. Peer support workers with lived experience were also embedded in service delivery.

Recommendations for policy and practice

• Create services that can provide flexible care within the community, in an easily accessible place.
• Work closely with other local services and organisations, particularly within the recovery community, to learn from and build on those assets.
• Provide both short- and long-term healthcare, alongside preventative healthcare, to address social determinants of health.
• Recognise the value that people with lived experience can bring.
• Services should understand the additional challenges for those with adverse life events and trauma, and mental ill health and neurodiversity.

This evaluation highlighted the value of using care models that reflect the complex health and social needs of the PLUS population through:

• ​Adopting relational peer support alongside clinical care.
• Using interdisciplinary teams, with a breadth of knowledge and skills.
• Utilising community venues with trust and pre-existing relationships with the PLUS population.

Future interventions and research should consider that the PLUS population do care about their health, however unmet social needs often take priority, and healthcare services should reflect this.

What happens next?

Findings will continue to be shared with local and national stakeholders.
Further research is recommended over a longer period to assess longer‑term outcomes and cost‑effectiveness.

Learning will inform future scaling or adaptation of similar models.  Following on from this pilot, the Sunderland GP Alliance plans to deliver a similar service using an NIHR‑funded vehicle. This aims to expand the model and support more people and wider groups across Sunderland.

Read the full research paper

Findings from the Process Evaluation of a Mobile Health Clinic Designed to Improve Equity of Access to Primary Healthcare for People with Substance Use Disorders and/or Homelessness in One Region in the North East of England, UK | MDPI

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