Fulfilling Lives South East has reviewed how people with multiple and complex needs experience the Special Allocation Scheme (‘SAS’) and considered the healthcare system the SAS sits in to produce a report on the challenges and benefits of this scheme for patients. This report also shares a set of recommendations for how the Scheme could evolve to better meet the needs of those facing multiple disadvantage.

What is the Special Allocation Scheme (‘SAS’)?

Special Allocation Schemes throughout England were created to ensure that patients who have been removed from a practice patient list can continue to access healthcare services at an alternative, specific GP practice. According to NHS England, patients are placed on the SAS following an incident where a GP or member of staff has feared for their safety or wellbeing, resulting in the incident being reported to the police.

Perspectives of the Scheme

Our Specialist Workers have supported clients on the SAS to access primary healthcare via GPs and to date 12% of Fulfilling Lives South East clients have been active on the Scheme. This had highlighted some challenges clients on the SAS had experienced around the frequency and nature of reviews – when placed on the SAS, some felt they were destined to stay on the Scheme for a long time and for others, they were unaware that reviews should take place. Some clients also felt stigmatised by the Scheme. As such, we wanted to look at this further.

“Some felt they were destined to stay on the Scheme for a long time.”

When we started to research the Scheme, we initially started with a focus on our clients’ experiences and perspectives, however, we soon saw a bigger picture of challenges from different viewpoints and started to also look at the Scheme through the lens of commissioners and GP practices.

Commissioner perspectives: The name of this Scheme has changed over time from Violent Patient Scheme, to Special Patient Scheme to the current name of Special Allocation Scheme (SAS). Fulfilling Lives appreciates the change in name to make it less stigmatising for people on it and recognise how this reflects efforts to move towards a more supportive approach to helping people stay connected to healthcare services.

Locally, the Sussex Clinical Commissioning Group commission the SAS practices and currently there are three GP practices in Sussex delivering the scheme, which explains why some of our clients need to travel long distances to their appointments. However, we understand that not all CCG areas have dedicated SAS practices so the distance travelled here is less than others in England.

We also understand that when SAS services are put out to tender that they do not always generate interest from large numbers of GP practices and as such, Commissioners have to work with a small pool of interested practices.  

Lived experience perspectives: Our Experts by Experience, people with lived experience of MCN and Trauma, consistently emphasise that the most impactful and positive services to them are those that have focussed on the individuality of the person, treated them politely and respectfully and took the time to understand what their needs are. This includes reception staff welcoming them into the surgery.

One of our Specialist Workers however observed the following: “The way staff spoke to my client was unprofessional… I was also saddened by the disrespect shown towards my client and myself, added to this shocked that the security guards thought it was appropriate and acceptable to lock us both in a stairwell.”

The Commissioning team have reassured Fulfilling Lives that SAS practice staff receive training on Conflict Management and Fulfilling Lives are exploring ways that we may share our training on Trauma Informed Practice and Psychologically Informed Environments with these staff groups too.

Clients and patient perspectives:  Reviewing the official regulations provided by the “Primary Medical Care Policy and Guidance: Commissioning a robust SAS” it recommends a variety of reviews that people placed on the SAS should receive. However, nowhere in the document does it state that reviews are held together with patients and decisions regarding their continued placement on the scheme are made without their involvement. This is something our clients and Experts by Experience would like to see changed.

Another Specialist Worker says that “My impressions of the SAS in Brighton are that it is very good. Clients are given a 20-minute appointment, usually at lunchtimes and depending on what type of appointment they have may be encouraged to attend with a professional. To some degree I have to support clients to access the SAS and have their healthcare needs met. I have to remember that we are fortunate in Brighton in that health services for people who have MCN are largely good, do reflect upon how they could improve and do try and be fit for purpose. I think it really helps if I am able to see the positive side of a service such as the SAS because as well as acknowledging the negatives that the client sees about a service, it is my role to motivate them enough to attend appointments. Some clients like the surgery and others are less keen on it. Perhaps there is an element of shame attached to having to attend a surgery under the scheme but in my mind the scheme allows clients to have access to a GP instead of just being barred. ”

“Clients…feel they don’t receive the information about what it means to be placed on the SAS and information about how to get back into the mainstream healthcare services.”

Another challenge some clients experience is that they feel they don’t receive the information about what it means to be placed on the SAS and information about how to get back into the mainstream healthcare services. We understand that it is tricky for GPs to send information by post when some clients live in temporary accommodation and move around a lot. This has been identified as the main obstacle to undertake reviews and one of the reasons why some people stay on the SAS longer than anticipated. We also know from experience that clients change their phone number regularly and that a multi-disciplinary approach is needed to maintain communication and engagement with clients.  Our Specialist Worker observed that “there is an opportunity to communicate directly with patients when they attend appointments but sadly this does not appear to happen consistently and a chance to review how the patient could work towards ‘step down’ …is missed.”

‘Step down’ – a path back to mainstream primary healthcare access points?

Through research into the SAS and conversations with Commissioners we have learned of  a ‘step down’ system to support patients leave the SAS by keeping these patients connected to the SAS practice after being taken off the Scheme to provide continuity, independent of whether they are registered there or live in the area.

Through our work with people who have multiple and complex needs we view this ‘step down’ approach positively as we know that building, sustaining and enabling longer-term relationships with support services is important.

Recommendations for the future

Fulfilling Lives South East sees the potential of the SAS to be a gateway for people with multiple and complex needs into the mainstream NHS healthcare services, especially for those who are often thought of as ‘hard to reach’ and those who feel excluded from mainstream NHS services.

That is why we would like to recommend the following:

• Create one consistent model of best practice on how SAS practices should be set up.
• Have clear guidelines on the frequency and content of patient reviews and share these guidelines widely
• Involve the patient proactively in their own review to have their voice heard.
• Offer therapeutic services for people with multiple complex needs to support re-integration into the mainstream primary healthcare routes.
• Support key staff in the SAS practices with training in Trauma Informed Practice and Psychologically Informed Environments.
  
  
• The summary of our research and context of these recommendations can be found in our co-produced report Special Allocations Scheme: Recommendations for Systems Change https://www.bht.org.uk/wp-content/uploads/2020/12/Recommendations-for-SAS-system-change-FINAL_v4-21.12.20.pdf

Who are Fulfilling Lives South East?

Fulfilling Lives has supported clients with Multiple and Complex Needs (MCN) since the start of the project in 2014. Funded by the National Lottery Community Fund, as one of 12 partnerships across the UK, we are funded to:

(a) provide intensive support for people experiencing multiple disadvantage,

(b) involve people with lived experience of multiple disadvantage at all levels and,

(c) challenge and change systems that negatively affect people facing multiple disadvantage.

Fundamental to the project’s ethos is the belief that the involvement of people with lived experience of complex needs is an essential part of the solution and to promote trauma informed practices. Further information about our project can be found here https://www.bht.org.uk/fulfilling-lives