High Mortality Rates within the Multiple Disadvantage Community

We review a report that highlights the deaths of people facing multiple disadvantage whilst supported by the Fulfilling Lives South East programme.


Introduction

It can be challenging to think and talk about death, to approach it with sensitivity and dignity whilst at the same time avoiding shying away from the topic. We may be familiar with the statistics that state the average life expectancy for the general population in the UK is at 79 years for males and 83 years for females. The distinct reality is that for people with multiple and complex needs (MCN), the picture is starkly different: life expectancy is at about 42 years for men and 43 for women. There are national studies available on why mortality rates are high within this group, however our own experiences as a service have compelled us to review the situation here in the South East of England.

The Current Landscape

There’s an element of ‘normalisation of death’ within the community of people who have multiple and complex needs. It’s a common occurrence that is often no longer surprising or shocking. Relatively high numbers of people experiencing severe multiple disadvantage, some of the most vulnerable in our community, are dying at a young age. These statistics are far from normal and we believe shouldn’t be viewed as such. At Fulfilling Lives South East (FLSE) we have provided intensive support for people experiencing multiple disadvantage and during this process, clients that we had worked with have died, some at home, some at hospital. As part of our legacy and review of the project we took a closer look into the deaths of our clients. What was happening here, were there any indications or signs that could have been spotted, how (if possible) can we stop this from happening in the future?

Within Sussex (Brighton & Hove, Hastings, and Eastbourne) a higher percentage of clients died whilst in our service compared to the national average (13% of FLSE clients versus 6% within similar MCN programmes nationally). We felt it was important to ask, comparatively, how was it that so many people are dying so young? We know that there are higher rates of deprivation amongst coastal communities. This goes some way to explain perhaps why rates in Brighton and Hove are higher than the national average.

We have produced a report that focuses on clients who died in hospital from ‘natural causes’, as there were no unusual circumstances reported. These natural causes however were due to illnesses related to long term alcohol and substance use, which with the appropriate support could have been avoided. We look closely on the treatable or preventable interventions steps that could have taken place. As well as the barriers around effective prevention, we also shine a light on good practices within progressive initiatives locally. Based on our experience and knowledge we knew we had to respond to the issues raised and highlight some key recommendations aimed at local authorities and healthcare services.

What We Found

The three main themes which ran across this client group based on our analysis were:

• Restricted healthcare access

• Lack of women’s healthcare

• Negative hospital experiences

Through in-depth analysis we found that restricted access to healthcare was a recurring theme in our casework. People experiencing multiple disadvantage often have problems accessing GP and outpatient appointments. For example, those who have had previous violent or aggressive episodes in a healthcare environment would be placed on a ‘Special Patients Scheme’ severely restricting healthcare future access (the system is under review). Additionally, when experiencing daily challenges and chaos in your life (as clients often face), making and attending a GP appointment with a pre-determined time slot is not always easy to stick to.

We also found that MCN clients have multiple long-term chronic conditions, with female clients experiencing more complex and chronic conditions compared to men, and that women are more at risk of premature death. Treatment for women is currently the same as it is for men. But with these glaring variances in health conditions, it should come as no surprise that FLSE along with many other support services have been arguing for women’s specific services for many years.

Finally, we found that negative hospital experiences are commonplace, and amongst those clients that died, our case notes show that the clients faced dismissive, apathetic and a one-size-fits-all type of response. What they required was a more patient, trauma-informed approach. There appears to be an element of being stigmatised that can be extremely unhelpful. In addition to negative encounters, when clients are discharged from hospital there’s a lack of communication between the healthcare providers and the support services clients transition to. These services need to pick up support without the visibility or clarity of what’s really going on with the client both physically and mentally.

Recommendations & Reflections

The top 3 tips to improve health services for people with MCN are:

  1. Providing services in a flexible way
  2. A collaborative approach between services (not just signposting)
  3. Investment in staff training and resources

The Brighton & Hove, Eastbourne and Hastings area has a number of healthcare providers that have been identified as sources of ‘good’ support. Their strategies included:

  • being more flexible with regards to access,
  • providing effective training,
  • offering a more human, kind and trauma-informed approach, and
  • involving people with lived experience to give feedback on both strong and inappropriate practices.

We strongly advocate for women-only spaces or women-specific provisions rather than the default status quo of a health and care system that one could argue is mostly designed by men, for men.

Finally, we highlight an inclusive and beneficial initiative called the Intermediate Care Step Away Project which is committed to ensure that when people with MCN enter hospital, they experience support that meets their multiple needs and that they consistently experience a discharge that includes the follow-up community care needed.

Read our detailed report HERE which fully explores the situation and includes reflections from a Clinical Services Manager and Nurse Lead, and case studies which demonstrate the reality of client journeys.


Authors: Nisha Vesuwala

Resources: How can we avoid treatable or preventable deaths of people facing multiple disadvantage?

For more information on this work please email:

charlotte.cooke@sefulfillinglives.org.uk

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Driving Change from Within

How Department for Work and Pensions managers (‘DWP’) at the heart of this partnership have driven change internally.


Fulfilling Lives is a voice that represents a group of people from our communities that often struggle to overcome barriers to access support services. The local DWP teams recognised this and wanted to go on a journey with Fulfilling Lives to explore improvements to service provision and access for customers with multiple complex needs. The DWP managers understood that Job Centres do not work in isolation and are integral to local support systems and important community partners across the sector. When viewed from this stance, Job Centres need to be welcoming, inclusive and provide equity of access to the opportunities they offer.

It is for these reasons the DWP embarked on a partnership journey with Fulfilling Lives that would empower and enable the workforce to better respond to complexity and, for the Brighton Job Centre Plus (JCP), to develop greater insight into often-misunderstood members of our local community.

Active feedback gathering – the outside looking in

To understand how the Brighton JCP were perceived in the local community, senior managers invited local services to several coffee mornings to share their clients’ perceptions of accessing the Brighton JCP. From these conversations, it emerged how the building itself and front of house at the Brighton JCP was a significant barrier to engagement, causing, fear, anxiety & stress to customers, particularly those with multiple complex needs. The physical environment was described by one attendee “as speaking louder than the Job Centre staff” and this was significantly hindering a proper conversation with customers or at worst was often seen as a trigger for incidents.

Rather than looking for short-term quick fixes, the management team sat with the feedback and decided to use this as an opportunity and platform for change.

Question for DWP partners: What were your initial reactions to the feedback you received at the coffee mornings?

The initial response from the management team for Brighton Jobcentre was of great interest as the feedback was not surprising but the consistency, scope, detail, and volume gave far more weight and impetus to making specific changes than had ever been received before when trying customer surveys and other routes to identify areas to improve

Finding partners to support change

They decided to approach a local partner who knew clients with multiple complex needs well, the Fulfilling Lives team, and develop a relationship to think about how we could address these issues collaboratively for the long term.

Question for DWP partners: What did you find most helpful about the collaboration with Fulfilling Lives?

Most useful in the collaboration with Fulfilling Lives was the structure offered which became a framework that Brighton Jobcentre could use to facilitate change, the feedback from Fulfilling Lives consultants with lived experience and the fresh set of eyes from Fulfilling Lives painted a picture for Brighton Jobcentre that was incredibly illustrative.

Overcoming Barriers

We know that change is difficult. Therefore, by virtue, culture and systems change is difficult. So how did the DWP team address any barriers of challenges?

This is where the importance of developing safe spaces for staff really paid off. Spaces where new ways of thinking can be allowed to form and be challenged and, where tackling thorny conversations is indispensable. Spaces where trust and honesty can be established.

Question for DWP partners: What do you feel was the most effective way you helped overcome barriers to change?

The most important and effective way of overcoming barriers to change was to include as many Jobcentre staff as possible in the process of change and by doing this showing trust and honesty. This we feel prevented fear of change and gave confidence to exploring change.

  1. Sharing the vision: clear messages

Despite some staff understandably feeling displeased at being initially kept in the dark about mystery shoppers or assessments of the environment, and the unforeseen impact of coronavirus and the immense pressures and challenges that have come with it. The Brighton JCP team have stayed with us and continued to work as equal partners towards our common goal of improving the system for those customers with multiple complex needs.  

The team had a clear message about why the partnership with Fulfilling Lives was important and why changes were important

2. Engaging colleagues across the organisation

Two ways in which the DWP managers were able to leverage the learning from this collaboration to drive the change internally was through employee participation and effective communication.

Firstly, Brighton JCP staff had the opportunity to be involved in decision making through two working groups that were established to implement Fulfilling Lives recommendations. Additionally, when feeding back on the outcome of the mystery shopper and environment assessment the feedback was presented by Fulfilling Lives to the entire Brighton JCP staff team. Including the G4S security guard team. This approach set the tone that as a service we were all it in it together and we weren’t going to shy away from the tough questions we need to ask ourselves.

Secondly, this approach to openness and effective communication was extended to senior leaders.  The learning and momentum developed with the wider workforce established the platform to communicate in a way to DWP senior leaders that painted a clear picture of what was possible in supporting this group of customers going forward.

3. Supporting staff: training and development

By embedding a mandatory training resource in the induction process for new employees the DWP workforce will have better insight into trauma informed practice and complex needs. Leading to more confident, knowledgeable, appropriate, and empathetic responses towards customers presenting with complex trauma histories. 

4. Sharing the change with others

Creating a workforce development resource that is embedded into the DWP Sussex & Surrey district learning and development platform, presented a unique opportunity to share the learning beyond the Brighton JCP and aid the DWP to continue the drive for change from within.

We shouldn’t lose sight of the degree of effort culture and systems change requires generating the traction to make it happen. It needs people who can adjust to their audience and adapt the messaging to differing levels of an organisation and in doing so create momentum to bring people with them, and ensuring senior leaders understand the value of the proposition.

Question for DWP partners: Looking back on the change journey and partnership, is there anything you would do differently?

Although the change journey could not be fully envisaged at the outset, it would have been beneficial to link up with national DWP colleagues at an earlier stage. This would have started conversations about national roll out of training resources earlier as we have since found that navigating the national framework of training and development a complex task because of the differing agendas in different areas of the DWP.

Question for DWP partners: What might you say to other leaders looking to embark on large scale change?

We would say with a very high level of conviction “seize the opportunity and you have nothing to lose and everything to gain”. Also, we would say it is so important and powerful to begin to better understand how our services can be prohibitive and the benefits of removing barriers for people with multiple complex needs.

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Author: Alan Wallace

Should you wish to find out more about our partnership work or our systems change efforts, please contact:

Alan Wallace, Systems Change Officer: alan.wallace@sefulfillinglives.org.uk

Or

Rebecca Rieley, Systems Change Lead: rebecca.rieley@sefulfillinglives.org.uk

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How women and children are falling through the gaps and what to do about it  

Throughout 2021 Fulfilling Lives South East has worked with volunteers, experts by experience and partners to understand the impact of child care proceedings on women with multiple and complex needs. Our work culminated in publishing a Guide to Child Protection and Care proceedings as well as a leaflet for women and workers with the aim to help navigate a complex system. In this blog piece, we have decided to focus on Clare’s story to bring to light the missed opportunities the current support system perpetuates.


Clare’s story

Clare is an amalgamation of the stories we have heard and witnessed from our clients who have experienced the repeated removal of children into care. Through sharing this story, we hope to highlight four key missed opportunities. While the system continues to miss opportunities to support women like Clare, this cycle will continue.  

Missed opportunity 1 – Access to Mental Health Support 

Clares Story: Clare grew up in an unstable home with parents who used drugs and she experienced sexual abuse from a young age. After being removed from her parents and entering the care system age 11, she began using drugs as a teenager and left care to live with a man she was in a relationship with, where she was a victim of domestic abuse. While living in temporary accommodation with her abusive partner, Clare fell pregnant and concerns for the safety of herself and unborn baby meant she was moved out of area, to another temporary accommodation away from her support network. During her pregnancy, Clare’s drug use continued and despite having suspected depression and a possible personality disorder she wasn’t able to get a formal mental health diagnosis due to her substance misuse. Mental health services ask that referrals be 6 months sober before being added to their waiting lists. In addition, her new temporary accommodation was far away from support services. A care order was placed on her unborn child and after going into hospital to give birth, Clare’s baby was removed 3 days after birth. An emergency c-section meant that Clare wasn’t able to physically hold her baby during the three days they were both at the hospital. Clare didn’t meet the referral criteria of the Perinatal Mental Health Team as there was no plan in place for her child to return to her care, so she was ultimately discharged from hospital without support.   

Recommendation  

The gaps and barriers in mental health support are felt most at the intersection of overlapping disadvantage. We can see this in Clare’s case when she is unable to receive an assessment for support before she gives birth due to her drug use, and after birth when she does not meet the threshold for support from the Perinatal Mental Health team. The void in mental health support for women whose children are placed into care at or soon after birth has devastating effects.   

Linking women experiencing multiple and complex needs in with mental health support at this difficult time is essential. Referrals to other sources of mental health support should be made when women don’t meet the referral criteria for crisis care in primary care settings and at the very least the woman should be signposted to sources of support before she is discharged from hospital. Such a formative time for both mother and child should also not be overlooked and every effort should be made to allow mothers to bond with their new-born. Fulfilling Lives is not seeking to challenge decisions to remove children, but to identify and highlight opportunities for more supportive interventions to be considered. Tools like hope boxes can be used alongside other mental health support to help women to process and feel a sense of attachment to their child despite the circumstances. Many services offer mental health support, however siloed working and a lack of capacity mean that healthcare professionals are sometimes not aware of the support available to women. By developing channels of communications and a multi-agency approach across children and family services as well adult social care, services can work together to prevent women falling through the cracks and referrals can be made before the point of mental health crises.   

Missed opportunity 2 – Advocacy support for Court Proceedings

Clares Story: Care proceedings began, but the process of going through care proceedings wasn’t explained to Clare. This additional stress led to a decline in her mental health and drug use which meant that she missed meetings with social workers. Professionals interpreted her absence as a lack of engagement instead of seeing it as an opportunity to provide information about advocacy services in the area that could talk her through the care proceedings and represent her voice during multi-agency meetings. The child protection case went to court, in a different town to where Clare was now living in temporary accommodation, so she was unable to attend, and her child was placed into foster care.   Quotes gathered from FL research: “I felt very alone through the whole process.”  “I lost trust in the system.”    

Recommendation

In our experience, women often feel disempowered throughout the process of working with social services, not understanding their rights or having a firm grasp of what is happening at each stage. Many women have also had negative experiences of social services in the past, often as children themselves, leading to a distrust and disengagement from services. Many women don’t have an Adult Social Care key worker and are only interacting with Children’s Services, whose main priority justifiably is the safety of the child. This leads to a lack of support for the women experiencing repeat childcare proceedings. Our clients have reported that they felt like passive recipients of a process that is making permanent decisions about their own lives and those of their children. 

We would advocate that accessible information be made available to women, including an information pack with leaflets for support services and a simple guide to their rights and care proceedings. All women experiencing multiple and complex needs should be offered independent advocacy services to help to represent their voice, explain the process and support them with the practicalities, for example financial support to cover the cost of transport to meetings and hearings. This time is often one of crisis for women and having continuity of care and a clear source they can go to for information and support is pivotal in maintaining their well-being. The assertive outreach model means that this support would also reach women who are isolated and perhaps not on the radar of other services.

Missed opportunity 3 – Collaboration between Children’s and Family Services and Adult Social Care

Clares Story: In order to have contact with her child, Clare was expected to be abstinent from all substances. Without therapeutic aftercare for the loss of her child, Clare used these drugs as a coping mechanism for her trauma and grief and continued to have relapses during this period. Clare felt like the requirements services put on her in order to be able to have any contact with her baby are designed to set her up to fail. Getting help for her mental health isn’t possible while she is still using drugs so her Emotionally Unstable Personality Disorder remains undiagnosed.  Quote from FL client: “I feel like everything is going to come crashing down around me. <…> I feel I haven’t been given enough time to turn my life around it’s just not fair. How can I be expected to just stop using and attend all these appointments without any period of lapse?  I’m not perfect.” 

Recommendation

The exclusive focus on the child seems to often come at the cost of supporting the mothers. Our partnerships with services that support women through this process highlight that a whole family approach is beneficial for both the women and children and their wider support networks. However, this needs to be the product of a coordinated effort by social services to collaborative and open working. The differing requirements put on women by services can be very overwhelming, and when they aren’t able to meet these, they feel judged, punished and like the opacity of the system is being used against them. We understand the pressure that social workers are under but by building an understanding that people with complex needs require a creative, flexible and joined-up approach from the professionals supporting them, women are given an active role in the decisions that affect them, empowering them rather than punishing them for seeking out support.  This trauma informed approach can lead to better outcomes for mothers and children.  

Missed opportunity 4 – Long-term Therapeutic Aftercare

Clares Story: After 6 months of waiting for the final court case and a ruling on the contact Clare will be able to have with her child it is decided that an adoption order will be applied, before which there will be a final contact opportunity for Clare. Clare didn’t have a support network or professionals that she engaged with who could help her emotionally prepare for the final contact, which was extremely difficult for her. Without continued therapeutic aftercare, Clare expressed that she doesn’t feel life is worth living without being able to see her child.   

Recommendation

Many of the women working with Fulfilling Lives have histories of Adverse Childhood Experiences (ACEs) and abuse, many are care leavers themselves and so the loss of their child in this way compounds their trauma, doing immeasurable damage to their well-being and sense of self-worth. The complex and lasting impact of these experiences can manifest as ‘challenging’ or difficult’ behaviours and the coping mechanisms that women develop such as drug use are seen as further justification for the removal of their children.    

Better access to open-ended therapeutic aftercare for women in this position allows time and space for the symptoms of trauma to be addressed and for these experiences to be reflected on in a meaningful way. Specialised support can help to develop women’s understanding of their relationship to motherhood and their bodies and look at what healthy relationships and attachment means to them. These trauma-informed and relationship-based therapeutic interventions are not quick fixes but instead offer ways of breaking the cycle of trauma and the repeat removal of children and build tools for resilience that women can access in themselves for a lifetime.    

Quote from FL client: “I still want to fight for my baby and maybe in a few years when I feel better after having the anger management and by entering the steps programme we could look at appealing.” 

From these recommendations, we have six system-wide calls to action –    

  • We would like Adult Social Care and Children & Family Services to collaborate and communicate with each other throughout the child care proceedings.  
  • We would like resource put in place which allows the Perinatal Mental Health team to support mothers who have their children removed after birth, independent of whether the child returns within 12 months.  
  • Reduce siloed working practices and create multi agency wrap around support for women experiencing MCN and care proceedings, including creative, flexible and assertive outreach. 
  • For staff to be trained in trauma informed approaches.  
  • An investment into advocacy services which leads to improved understanding of care proceedings. 
  • Long term, open ended specialist therapeutic aftercare for women who have experienced having a child removed from their care.  

Our active participation locally

We have published a Guide to Child Protection and Care proceedings as well as a leaflet for women and workers with the aim to help navigate a complex system. These resources are available for free here and received some positive feedback already: ‘Thank you so much for sharing these, what great resources, especially the video which I’m going to share with someone this morning! I’m so glad you reached out to us, I think your work is amazing and so needed for the women in our community.’ Nicola Johnson, Advocate, SpeakOut.  

We also published a blog about FLSE’s front line workers witnessing a direct child removal and how difficult this can be for workers, let alone mothers and discussed the importance of joined working when supporting women who experience recurrent child care proceedings.     

Link to Looking Forward report   Looking_Forward_Report_08_Final-09.12.21.pdf (bht.org.uk) 

Links to resources    Launch of Guide for Child Protection and Care proceedings, and Women’s Rights Leaflet – Fulfilling Lives South East Partnership (fulfilling-lives-se.org) 


Authors: Michaela Rossmann, Eve McCallam

For more information on this work please email: rebecca.rieley@bht.org.uk or eve.mccallam@bht.org.uk

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Employment and the road to recovery

Meaningful work is right up there among the activities known to help wellbeing, support successful maintenance of recovery and reintegration and to help people with lived experience of multiple complex needs (MCN) move forward with their lives.


Our work

Since 2014 the Fulfilling Lives South East Project has employed a total of 41 individuals with lived experience of MCN, through its employment programme.

Throughout the employment program we sought to learn what it takes to successfully recruit and employ people with lived experience of MCN. We have adapted systems and processes, tested things out, reflected continuously……got it wrong sometimes and after seven years, gathered a wealth of information and evidence of what works and how organisations and employers can effectively recruit, support and develop people who have experienced disadvantage.

This period of intense learning has led to 39% of former employees moving directly on to other employment opportunities and 17% who gained employment within six months of leaving Fulfilling Lives. A total of 56% of former project consultants have successfully moved on from the project into new employment. Five people are still working in the project and three of them have already secured jobs to move on to when the project finishes in June next year!

Let’s be honest though, we could quote statistics and numbers all day.

But it isn’t just about numbers and data.  For Fulfilling Lives South East it’s also been a journey of discovery about how employees with lived experience of MCN can be supported to grow, thrive and excel in their roles, being proactive in taking on new challenges, leading on projects and seeing within themselves potential that previously may have been hidden.

The numbers will only ever tell us so much. To really understand why meaningful employment in a trauma informed environment and organisation can truly change lives, we need to hear from the people who have experienced it. So, we asked some of our team….

How have you benefited from being employed in the Fulfilling Lives Project?

“Working at FL has been an important part of my recovery journey.  It’s a large slice of my life that contributes to something positive, personal, and meaningful.  The job is the foundation for me to start over, while allowing me to work in parallel on the deeper issues that led me here in the first place.  The support and flexibility make it possible to do the difficult personal work whilst being employed”

I worked as a volunteer for 7 months before being employed by Fulfilling Lives. Prior to that, I had been unemployed for 2 and a half years and had really low self-esteem as a result. I had lost all my confidence; I was scared about everything and I felt hopeless and worthless. But this time around, I was determined to turn my life around and I received the support and guidance I needed through FL. I started taking on pieces of work where I was able to build on my strengths, tap into the recovery networks that I was a part of and apply the skills I had learnt before I fell ill. My negative experiences with my illness and with services didn’t haunt me anymore because I was able to use my lived experiences constructively. I started feeling less lost and FL helped me regain a sense of purpose. Most of all, I benefitted from meeting like-minded individuals and working in a team where each one of us had a story to tell. We had all been through a lot in our lives and FL became a conduit for our transformations. Now I have a different story to tell …of what it feels like to be on the other side of a trauma, illness and isolation.”

How has being employed in a trauma informed environment helped you?

“Recovering from trauma is a journey, not a destination. Working in a trauma informed culture has helped me gain a deeper understanding of my journey and to sharpen the tools I have, to survive and thrive after trauma. I’ve been supported to apply my skills in new situations and take on new challenges.  Working in a trauma informed way can result in sense of empowerment for individuals and create a trauma informed culture within an organisation.  Having regular space for reflective practice, focusing on growth and learning has really accelerated my development. Learning from each other’s’ strengths and experiences, being honest in a group setting and problem-solving challenges has been really useful.”

“I think trauma is something that sometimes we are working on our whole lives. There’s not a before point and after point it’s like continuous building and healing and resilience and coping skills. That’s maybe part of why even at the point of being employment ready we can still benefit from trauma informed culture because we are continuously developing. Always some processing, realising, healing, learning and growing to do”

“Life can be very cruel and many of us carry some kind of trauma that is unaddressed. Additionally, it is not uncommon to hear of workplaces that are exploitative towards the people that work for them. Working in a trauma-informed environment feels like some sort of rebellion against a work culture that doesn’t value kindness towards or the well-being of their workers. Being employed in an organisation that is trauma informed is nourishing. It creates a fertile ground for creativity, imagination and innovation, where people can explore their strengths, heal from their negative experiences and grow in a place where people truly care about you”

Are there any examples of trauma informed practices that really stood out for you while at Fulfilling Lives?

“Person-centred and psychologically informed supervisions have allowed me to develop my confidence and relationships of trust with people supervising and managing me. When I was new my supervisions were really tailored to my needs in terms of negative self-concept and tendency to magnify real or perceived imperfections. I learned to evaluate my performance more objectively by doing this with my supervisor and now I am able to recognise and speak about highlights and achievements, as well as raise areas I’d like to develop or work on without fear of punishment/harsh judgement. I feel I can be 100 % open and honest “

“I’ve never been in a job where I’ve needed to be so organised, chopping and changing between different tasks, taking different trainings, absorbing so much information.  It was very overwhelming having not worked for three and a half years.  It was a world I’d never experienced.  The induction period was very helpful.  I was able to ease into a work routine at a pace that worked for me.  I didn’t have to hit the ground running and fill my calendar with meetings.  It gave me time to settle in and get used to just being at work. It was low pressure with some guidance to keep me on track and focused on the right things.  There were development sessions which kept me on target to learning or re-learning key skills, normal workplace skills that I’d forgotten.  Thinking back, the induction period served as a safe place to start from scratch.  It really did feel like starting again.  My manager and supervisor were like guides who helped me to function in the world.”

“Having an attitude of learning and development in our team really helped me too. The skills I found challenging were reframed from things “I’m just not good at” to something I can improve at, practice and were achievable.  If something was a challenge, there was support to work on it”

So, what do trauma Informed practice and psychologically informed principles look like at work?

Well, it looks like any good employment should!

In reality, what we are talking about isn’t the proverbial ‘rocket science’ but it does need to be thought about properly, valued across the organisation and embedded in everything.

It means creating supportive and accessible workplaces; in a nutshell, getting the culture right! 

The values of Trauma-Informed Practice, Psychologically Informed Environments and Co-production should underpin everything.  It’s also about recognising the undeniable link between wellbeing and performance and embedding activities and processes that promote and maintain wellness for all employees throughout the organisation.

These principles and values need to be part of all the policies and processes that an employee with lived experience of MCN (and in fact any employee) will have to navigate and be a part of: The recruitment process and application form; attending an interview and being recruited; going through Induction; succeeding at any probation period and participating actively in supervision and professional development throughout their role.

Really though, shouldn’t we be striving for this anyway? In all roles?

And it’s a two-way street too! Our project has benefitted enormously from employing people with lived experience of MCN.  Bringing their commitment and unique engagement qualities and skills, this team has been crucial in the development, implementation and success of our systems change, engagement and co-production objectives.

In a series of blogs around employing people with lived experience of MCN, we want to unpick some of the key elements and practices that make employment successful, both for the employee and for the employer. 

We are also currently creating a resource for employers around employing people with lived experience of MCN and how to do it well. If you would like a copy of this resource once it’s published, please contact andree.ralph@sefulfillinglives.org.uk or nelida.senoran-martin@sefulfillinglives.org.uk


Authors: Andree Ralph

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Further reading and resources

Review on Drugs – will change happen for people with Multiple Complex Needs?

In August 2020, Fulfilling Lives South East (FLSE) responded to a call for evidence to support Dame Carol Black’s Part 2 report that focuses on the treatment, recovery and prevention of substance misuse. FLSE’s Service User Involvement team also contributed directly to Dame Carol’s consultation through the National Expert Citizens Group. The report, which contains 32 recommendations for change across various government departments and other organisations, was published in July 2021 and the Fulfilling Lives’ team now reflects on how far the measures go in meeting the needs of those with multiple complex needs.


Time to reflect and review

The Review is momentous on several counts and relevant to the work FLSE undertakes. When reflecting on the recommendations we made in 2020, altogether, we found 14 recommendations out of the total 32 that speak to our asks related to multi-agency working and integrated services; trained workforces providing trauma-informed support; the criminal justice system/repeat offending; housing and employment support; treatment and access needs for co-existing conditions; healthcare inequalities; assertive outreach; peer mentoring and recovery communities. The Review contains findings that are compelling and serve as a reminder that organisations working to improve systems for people with multiple complex needs are not lone voices.

For example, our research found that substance misuse problems always exist in a wider context so it can’t be addressed in isolation. Overlapping complex issues need to be considered when providing support in a trauma-informed manner because addiction is often a response to deep trauma. We were pleased to see that the Review acknowledges that mental health problems and trauma (physical, sexual and psychological) often lies at the heart of drug and alcohol dependence and views them as “co-morbidities rather than separate problems for ‘dual diagnosis’”.

An overwhelming majority of our research respondents strongly felt that peer support and mentoring had been essential to their recovery and peer mentors should be assigned to those finding it difficult to engage with services. In response, the Review recommends that services recruit or include people with lived experience of drug dependence working as recovery champions, recovery coaches and peer mentors, which speaks to our work with the DWP. It further states that they should also provide networks of peer-based recovery support and establish communities of recovery and mutual aid groups. We’re thankful that the Review also calls for increased funding to aid the expansion of local areas’ support for peer-led grass-roots recovery communities and peer mentoring in order to complement professionally led services.

Our Concerns

Whilst we welcome the Review’s recommendations on peer-based recovery support, we are disappointed in the lack of advocacy for more specific women-only recovery and refuge spaces in early recovery and intervention. Our Lived Experience Perspectives Report, which was drawn from a series of conversations with women that have experienced drug and alcohol misuse, highlights the need for women to feel safe while sharing a number of gender-specific intersecting needs and issues including (but not limited to) the experience of coercive and abusive relationships, removal of children by social services and sexual exploitation. Many women we spoke to felt that mixed settings in hostels and temporary accommodation pose a risk to women who may have experienced complex trauma and valued ongoing participation in women’s groups:

“We share and see emotions in a different way to men, so it is essential to be in a safe space where women have similar ways to understand and to communicate emotions.”

Fulfilling Lives South East submission on ‘Lived Experience Perspectives’ for the Independent Review of Drugs by Professor Dame Carol Black

Despite the acknowledgement of overlapping and complex issues, we still feel there needs to be an explicit definition of multiple and complex needs within Dame Carol Black’s part 2 report. We believe that the complexities of overlapping and multiple disadvantage should be named and adequately defined in order to provide more targeted support that is free from judgement, stigmatization or unfair treatment and exclusion.

How will these measures impact those experiencing drug/alcohol misuse and complex needs?

The recommendations – if enacted – have the potential to radically change the way someone with multiple complex needs experiences the support system while on their path to recovery. Agencies working together would reduce the likelihood of service users being left out in the cold or reaching an impasse where no service assumes responsibility. The suggestion of consideration (unfortunately not a requirement) that the NHS target those with substance dependencies, and that commissioned substance misuse services incorporate select mental health treatment, would finally allow those suffering mental ill-health and substance dependency to engage in treatment that is designed to target both at the same time, rather than neither, as is the case for many. This is the official stamp for what many in the sector have been championing for a long time.

Increasing the number of well-trained mental health professionals is a necessary complement to combined mental health and substance misuse treatment, and a trauma-educated workforce would help to build trust with those they support, the importance of which should not be understated. With many mental health professionals and psychotherapists holding the view that early relationships are a significant contributor to mental health problems and addiction, it follows that they are also an important part of someone’s recovery.

The review recognises that the criminal justice system isn’t the most appropriate place for someone with substance dependency, and rightfully suggests that treatment is the most suitable outcome. It goes on to recommend that upon release, everyone has identification and a bank account, with access to benefits services and community drug treatment as soon as possible after release from prison.  If these recommendations are enacted, those already stigmatised could avoid further stigmatisation and damage to their sense of self, the additional barriers that result from incarceration, and the effects of being institutionalised by the prison system.

Although the review didn’t go on to recommend any direct action to improve housing for those with substance dependency, it was a step in the right direction to suggest the relevant government departments work together to gain a better understanding of the needs of this cohort. Similarly, regarding health inequalities, there was no proposed solution, more of a stern word to the government to get a plan together by the end of 2021 to integrate specific health service provisions for this group into the local integrated care system.

Final reflections

The recommendations vary in their assertions and don’t always provide direct solutions. Regardless, the Dame Carol Black review has laid bare the barriers faced by people with multiple complex needs who suffer from addiction. The proposals are a clear message to the government to take responsibility for the systemic shortcomings that, at best, hinder recovery and at worst, add to the physical and psychological decline of the most vulnerable in society. The announcement of a 10-year drug strategy provides the government with the opportunity to implement the recommendations put forth in this report, ensuring that the road to stability for people experiencing addiction and associated problems would be smoother and easier to navigate than ever before.

“The government’s 10-year strategy looks great on the surface, with commitment to delivering on all recommendations laid out in Part 2 of the report being a highlight. There is some cause for concern though. It doesn’t reflect the lack of control faced by people with substance addiction, as judges will still be able to issue custodial sentences for non-compliance of community sentences. The ‘tougher consequences’ line is also baffling. Tough consequences don’t deter people from using drugs and the idea of taking away someone’s passport/driving license is bizarre. They haven’t alluded to what other ‘tough consequences’ are being considered, so that is a bit of a worry. It also would have been nice for the government to legitimise the role of peer supporters by referring to the post as a paid role’’

– Engagement and Co-Production Worker

Authors: Ian Harrison, Emily Page, Aditi Bhonagiri

Resources:

Lived Experience Perspectives Report: Fulfilling-Lives-Lived-experience-Dame-Carol-Black-Independent-Review-of-Drugs.pdf (bht.org.uk)

Dame Carol Black’s Part 2 report that focuses on the treatment, recovery and prevention on substance misuse: Review of drugs: phase two report – GOV.UK (www.gov.uk)

For further information about Fulfilling Lives work in this area, please contact Rebecca, Systems Change Lead: rebecca.rieley@sefulfillinglives.org.uk

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Interrupting cycles of reoffending – through trusted partnerships

How can we effectively interrupt cycles of repeat offending and in doing so create spaces where appropriate interventions can be co-ordinated by the Probation Service and other partners including the Voluntary and Community Sector?


Working with Probation

People who repeatedly cycle through the criminal justice system (CJS) are often identifiable as having multiple complex needs. Many have repeated contact with the police, courts, prison, and the Probation Service.  This can present acute challenges for people who may be homeless, use substances and experience poor mental health, as, due to the instability in their lives and the stigma they often face in services, they find it difficult to get the support they need.

By working closely with Probation colleagues throughout the lifetime of the project, Fulfilling Lives workers were able to evidence three key areas where creative and flexible partnership working helped to facilitate smoother transitions and longer intervals of consistent support in the community for clients. The areas focussed on in the Creative Practice report were:

1) flexible approaches around breaches allowing access to healthcare and housing interventions,

2) co-ordinated pre-release planning through prison in-reach and meeting clients at the gate, and

3) trauma and psychologically informed approaches to working.

Trusting Relationships are Key

Developing creative and flexible approaches to supporting clients with multiple complex needs requires professionals to establish relationships built on trust. Trust in others’ knowledge and expertise, and trust in others’ professional judgement. It is when we have created these trusting relationships that we can start to bring more creative thinking on how best we can work together to provide support to clients with multiple complex needs to ensure the client has the best opportunity for a positive outcome.  This flexibility around breach for Fulfilling Lives clients was predicated on Probation Officers and Fulfilling Lives frontline workers having professional relationships based on trust in one another’s area of expertise.

To Breach or not to Breach (that is the question?)

This can be a difficult decision for Probation Officers to make. In our report, we identified several examples where Probation Officers took thoughtful and considered approaches when working with Fulfilling Lives clients, striking a balance between providing support, as well as ensuring compliance with the relevant licence conditions/order requirements. The use of professional judgement from Probation Officers to not breach some individuals and take a more person-centred approach has had positive outcomes. Allowing clients’ relationships with community support services to remain more stable, bringing continuity of support and space to follow through on planned or preventative interventions to reduce reoffending and break the cyclical nature of imprisonment.

When Trusting Relationships Lead to Good Modelling

Fulfilling Lives and Probation jointly supporting clients within a framework of trauma informed practice has enabled both services to reflect similar therapeutic approaches when considering compliance to licence conditions. Fulfilling Lives workers were able to focus on building trusting relationships with clients who have experienced complex trauma and who are typically regarded as hard to reach or who are experiencing multiple and long-term barriers to treatment and appropriate support, leading to improved engagement and outcomes. It has been encouraging to see that this level of insight has also been demonstrated by some Probation colleagues enabling creative, trauma informed work to take place. Again, we can see that this flexible approach to compliance comes from a place of professional relationships based on mutual trust. Probation being able to trust Fulfilling Lives workers to fulfil aspects of the licence requirements requires a level of trust in each other’s expertise and judgement, ultimately resulting in a more positive outcome for the client.

Fulfilling Lives South East View

As workers supporting clients in the CJS we need to be continually asking ourselves how we can work in a more flexible way to achieve better outcomes for clients with multiple complex needs.

Trust between professionals to take positive risks is an important aspect of flexible working to achieve better outcomes for the client. When you trust professional colleagues, you have confidence in their integrity and their abilities, and their agenda and capabilities. Ultimately trust creates spaces where ideas can be shared and developed and resistance to change can be overcome. This has applied to both the approach taken by Fulfilling Lives as well as that of Probation. The kind of trust that was established between Fulfilling Lives and Probation Officers took time and effort to develop.

The challenge will be how can we create opportunities for greater partnership working, exposure to specialist training, creative interventions and reflective spaces within already stretched teams that are supporting increasing numbers of clients with complex needs.

The solution must be to take a broader, system-wide perspective and draw on resources outside as well as inside Probation services. By strengthening partnership working, we can hope to build greater capacity in the system to support individuals more effectively and ultimately enable more individuals to move away from cycles of reoffending.


Authors: Alan Wallace, Sandra Sylvester

Should you wish to find out more about our partnership work or our systems change efforts, please contact:

Alan Wallace, Systems Change Officer: alan.wallace@sefulfillinglives.org.uk

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Working with the DWP (not against them)

Using co-production as the foundation to drive positive change for people with multiple complex needs.


Co-Production and driving change

Brighton Jobcentre Plus (JCP) is not known for its inviting exterior or the promise of fond memories for those who cross its threshold. Its brutalist form sits stoic and unforgiving next to the Law courts and a stone’s throw from Brighton Police Station. The three front-mounted security cameras cast a suspicious eye over all who enter. Over the past 7 years, working with people with lived experience has taught us that approaching the Brighton Jobcentre can leave people feeling, nervous, fearful, judged, and powerless. For locals, Brighton Jobcentre has not – historically – conjured images of warmth, compassion, or community.  Well, that’s changing.  Right now.  Not the exterior though, sorry!

The Fulfilling Lives South East (FLSE) partnership with the Brighton Jobcentre began in the summer of 2019.  From the beginning, Fulfilling Lives (FL) project staff and volunteers worked together with Brighton JCP management to design a Mystery Shopper exercise to evaluate how the Brighton JCP staff engaged with customers presenting with multiple complex needs. As well as this we assessed the building environment with the aim of understanding how at times the Brighton JCP could have a confusing and negative impact on some of the service’s most vulnerable customers.

To assess the service at its most authentic, Fulfilling Lives and Brighton JCP management decided it would be best to conduct the Environment Assessment and Mystery Shopper evaluation covertly. Without informing the staff. Yep, that happened.  This decision – made at the start of our partnership – shows the humility of our local DWP partners and their willingness to address any power imbalance; it was a risk to assess their own service without informing their workers, it was a risk to partner up with a small project to help them do so.  Lived experience volunteers and FL staff took part in planning the mystery shops, writing character biographies, and acting out the roles. The environment was assessed for its ‘Psychologically Informed’ design, which includes highlighting potential triggers that might hyper-arouse visitors with complex trauma histories, as well as areas of comfort. The FL project team presented the findings and recommendations from both the Environment Assessment and Mystery Shops to the whole Brighton JCP staff team.

Despite some staff understandably feeling displeased at being kept in the dark and the unforeseen impact of coronavirus and the immense pressures and challenges that have come with it, the Brighton JCP team have stayed with us and continued to work as equal partners towards our common goal of improving the system for those customers with multiple complex needs.   

Following the evaluations, working groups were setup with JCP and FL staff and volunteers to discuss the mystery shopper and environment assessment recommendations and how they could be translated to real change.  Due to having practically zero budget to work with, there was discussion of JCP staff donating their own personal items, such as cushions, to make the environment more welcoming. This commitment on such a personal level is worlds away from the impression many have of the Jobcentre as a cold institution. Art from the local Brighton & Hove Recovery College was hung on the walls, security guards were repositioned to appear less intimidating, toilet access was made easier, a reception desk was added, staff were given relevant additional training, private safe rooms were made available, and more. Fulfilling Lives went on to deliver workshops and webinars to over 350 JCP staff. And produce an eight video training series with lived experience volunteers to support the JCP staff to work more effectively with customers living with multiple complex needs. 

Instead of two organisations trying to further their own agendas, we wanted to embark on this relationship in the spirit of co-production; a single team made up of individuals with varied skills and experiences setting out to achieve a common goal.  As organisations, we are both working to make life easier for people who are struggling.  By working together instead of digging our heels in and fighting our respective corners, we have built a relationship of trust and reciprocity, where we understand each other’s roles, responsibilities, capacities, and capabilities.  With this attitude, the third-sector, local government, and people with lived experience have come together to create positive, social change, the influence of which has the potential to spread far and wide.

Coming up

In the next instalment of this blog series, we will hear more from the DWP managers at the heart of this partnership on how they leveraged the learning from this collaboration to drive the change internally.


Author: Alan Wallace, Ian Harrison

Should you wish to find out more about our partnership work or our systems change efforts, please contact:

Alan Wallace, Systems Change Officer: alan.wallace@sefulfillinglives.org.uk

Or

Rebecca Rieley, Systems Change Lead: rebecca.rieley@sefulfillinglives.org.uk

For more information sign up to our newsletter:

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Making Systems Change Stick   

What are the ingredients that can generate the momentum to make systems change possible?


First Steps

What made the local Department for Work and Pensions (DWP) managers agents of change? Are the DWP managers that Fulfilling Lives South East work with systems superheroes? The answer, unfortunately, is ‘no’ they are not. Sorry! But they are the type of people that are in short supply.

As systems changers there are signs, we should be on the lookout for so we can recognise when we’ve landed upon the ingredients required for successful and positive systems change. We need people who are willing to take a risk, people who can sit comfortably with having critical friends, where objective reflection of practice is understood as vital to the process. We wouldn’t call it a leap of faith, but we do need people who are open to the concept of change; people who understand the value that lays in the journey as well as the outcome.

Until people like this encounter an opportunity to exercise this instinctive attitude to give it a go, organisations all too often are on a set course. These are the people who act like hinges shining light into dark corners and forgotten corridors, enabling organisations to pivot and develop new paths and ways of looking at service provision.  

When we do find these people (they’re out there!), it leads to the types of relationships that encourage and motivate others to jump aboard. And ultimately, ushers in positive change of the nature achieved through the Fulfilling Lives South East and the DWP partnership.

The first stages of working with the DWP

Once we have realised that we have identified the necessary ingredients, how do we as systems changers seize the moment and start to cultivate the ground?

Creating Partnerships

Fulfilling Lives’ job is to help key stakeholders and potential new partners engage with service and systems challenges that have an adverse impact on clients with multiple complex needs accessing or participating with their service. In doing so, we can create a space where honesty and trust can be established. Working collaboratively in this way can shape a new vison of what the future could look like.

Simply put, we want to define the problem together and from this set out ways to solve challenges. In the case of the FLSE and DWP partnership we wanted to answer two questions:

  • How do we successfully and meaningfully promote and embed Trauma Informed Practice and, for the organisation to understand more coherently the support needs of customers with a range of complex health and social issues?
  • How do we provide staff teams with the right support, tools and, education to build confidence and resilience to safeguard staff wellbeing?   

Now that we’ve created a space where traditional thinking can be re-evaluated, it’s important that conversation does not get stuck discussing and thinking about theoretical frameworks of systems change. A fundamental component of Fulfilling Lives’ approach to supporting partners to understand the challenges faced by people with multiple complex needs, is through working within a co-production model and supporting Fulfilling Lives’ lived experience volunteers and staff to be involved at the heart of the systems change work we embark on.

The FLSE co-production model afforded the DWP a level of access to customers with multiple complex needs that they had not experienced before. It’s this approach that can profoundly alter perceptions, rooting the need for and direction of change in humanity and care. Feedback, at times critical feedback, can be difficult to handle. But with the right ingredients, in spaces where honesty and trust are reciprocal, and shared vision making is valued, the most candid of feedback is used as the next steppingstone to understand the problem more clearly and how to address it.

Changing Culture and Outlooks

In collaborating with DWP managers to understand the challenges through the eyes of customers with multiple complex needs, Fulfilling Lives provided a foundation for DWP managers to open up internal conversations on the most difficult aim of systems change, but likely the most influential and compelling: culture change. Alongside Fulfilling Lives, the DWP managers effectively communicated to the wider workforce how the organisation should be thinking about and supporting customers with multiple complex needs. This created momentum and professional curiosity that was evident through the positive engagement from the over 350 DWP workers that Fulfilling Lives facilitated online workshops and webinars for.

This learning and momentum created the platform to communicate in a way to DWP senior leaders that painted a clear picture of what was possible in supporting this group of customers.

Changes

The partnership and its foundations have enabled important activities that have supported a journey of change that is still evolving and developing as contexts change. We have compiled the key activities to illustrate the possibilities of close partnership working and to set out how we have approached putting systems change into practice together. This partnership journey can be viewed in detail here: Partnership Timeline.

Coming Up

In the next two instalments of this blog series, we will hear more from both the FLSE’s Service User Engagement Team on how they leveraged co-production practices to support systems change, as well as from the DWP managers at the heart of this partnership on how they leveraged the learning from this collaboration to drive the change internally.


Author: Alan Wallace

Should you wish to find out more about our partnership work or our systems change efforts, please contact:

Alan Wallace, Systems Change Officer: alan.wallace@sefulfillinglives.org.uk

Or

Rebecca Rieley, Systems Change Lead: rebecca.rieley@sefulfillinglives.org.uk

For more information sign up to our newsletter:

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A New Approach: The Trauma Stabilisation Pilot  

Gemma Harfleet shares her thoughts on the first few months of the new Trauma Stabilisation pilot; Outreach support for women who want to go to rehab but their trauma experience has made it difficult to get there or stay for as long as they need…  


The Problem

For years I have seen and felt the frustration of women with complex trauma and addiction being told they are too complex to access a service or they need to stop using substances to receive any support – as if they should somehow have held things together a bit better if they really wanted help. As a Specialist Women’s Worker with Fulfilling Lives, I’ve seen how tailored trauma stabilisation work in an outreach model can really make a difference and help those who’ve been all but written off. Training in trauma stabilisation shifted the way I was able to work by talking about the present symptoms of trauma and ways of managing this, so it doesn’t get in the way of achieving recovery goals. Now I’m excited to see what happens with a focus on trauma for women who want to go to rehab in Brighton. 

We have fewer women going into rehab but they are accessing community support. There isn’t much research on why this is and what can be done to improve women’s experiences in recovery. We’ve known for a long time that men seem more likely to need the support of rehab. However, not a lot of attention has been paid to voices questioning if this might also be because women’s needs are often different. We know men and women survive addiction and homelessness differently – which often leads to more complex trauma because of domestic abuse and sexual exploitation.  

The Complexity

Since the start of the pilot, I’ve been meeting with women in rehab, those with lived experience, with services that have supported them and those who work in rehabs. I wanted to know what preparation women had before going into rehab, what was their experience when they were there and what they thought was missing. Yes, I had this idea. But I wanted to check that it would meet the needs of women right from start. These women have been so generous with their experiences of addiction and rehab, sharing with the kind of infectious courage you get from people in recovery. We know more trauma support needs to be done with women in addiction but doing this survey made this even clearer. Particularly we are hearing how those supporting women can be understandably cautious about giving space to talk about trauma for fear of making things worse. However, I’ve experienced how building a sense of safety and having the training to talk about trauma (but not asking about specific experiences) can equip women with the understanding they need to start their recovery journeys. What women want is to understand their trauma, how it impacts them and those closest to them, to know it’s not because they’re broken and have a space to think about what they want to do about it. 

The Pilot

Of course, we learnt so much more from these journeys and we will be bringing that together in a report to help guide the pilot. I’m also reaching out to other services in the city that support women – to work together, share resources and show the strength of the networks of women they can be a part of. We are not alone. 

My thanks and appreciation go out to the BHT detox and recovery projects, CGL, Oasis, the Rita Project, Cascade Recovery, Nelson Trust, Jen at the Africa House café, Move-On, RISE and Threshold. None of them needed convincing, all of them have given their time and thoughts and many have also nominated women to the pilot. 


Author: Gemma Harfleet

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Fulfilling Lives Responds to the Domestic Abuse Act 2021

In June 2020, the Fulfilling Lives South East team responded to a call for evidence by the government on the draft Domestic Abuse Bill and published a blog detailing our response and thoughts on the subject. We called for

  1. a clear definition of multiple complex needs,
  2. access to appropriate housing options and specialist DA domestic abuse services,
  3. domestic abuse and complex needs training for non-specialist services, and
  4. lived experience voices to be included in the Bill.

As the Domestic Abuse Bill achieved Royal Assent in April 2021, the Fulfilling Lives’ team reflects on how far the measures go in meeting the needs of women with multiple complex needs.


Time to reflect, review and re-think

Perhaps the biggest impact that the Act will have on our client group will come from the new duty placed on local authorities to assess the need and commission support to victims of domestic abuse and their children in safe accommodation services in their areas. When the Fulfilling Lives team reviewed the new Act we also considered the corresponding statuatory guidance published by the Department for Levelling UpHousing and Communities (DLUHC), formerly the Ministry for HousingCommunities and Local Government (MHCLG). This sets out the operation of Part 4 of the Domestic Abuse Act to be delivered by local authorities, and what they should do to fulfil their statutory responsibilities and provides further clarity on how the new duty should be delivered on the ground.

Naming ‘Multiple Complex Needs’

As the Domestic Abuse Bill progressed through parliament last year, Fulfilling Lives South East called for the inclusion of a clear definition of multiple complex needs that expresses the needs of women who experience domestic abuse and complex needs. Whilst we welcome the widening of the statutory definition of domestic abuse to include emotional, coercive and economic abuse, we are disappointed in the lack of inclusion of a clear definition of multiple and complex needs within the Act. Nevertheless, we are pleased to see the direct inclusion of and frequent reference to ‘multiple and complex needs’ as a term, as well as ‘additional and/ or complex needs’, within the DLUHC’s corresponding statutory guidance. We know this is important because women who have multiple and complex needs are disproportionately affected by domestic abuse; In a snapshot in December 2018, 93% of the women on our caseload had experienced domestic abuse (25 out of 27 women), a prevalence that has been consistent throughout the lifetime of this project. Yet this group are often the most challenging to reach in terms of having their voices heard and needs met. So, the recognition of this group within the statuatory guidance is a welcome development in the delivery of support to victims of domestic abuse.

‘’In a snapshot in December 2018, 93% of the women on our caseload had experienced domestic abuse.’’

FLSE Manifesto for change

Despite this progress, we still feel there needs to be an explicit definition of multiple and complex needs within the guidance provided by DLUHC. As currently drafted, Local Authorities can use their discretion in defining multiple and complex needs, which creates the risk of fragmented, variable responses nationally and a postcode lottery of appropriate safe accommodation services for those who experience domestic abuse and complex needs. To ensure a cohesive support response to those with multiple and complex needs, where individuals receive the right help when needed, without being judged, stigmatized or unfairly treated or excluded, it is imperative for this group to be distinctly recognised in the form of a comprehensive explanation of their experiences in such statuatory guidance.

‘‘My hope would be that women on the edges of society who face multiple barriers and stigma on a daily basis, will now be seen as a distinct group of people, with distinct needs when experiencing domestic abuse’’

Sandra, Systems Change Officer

A spotlight on ‘safe accommodation’

Throughout the Bill consultation, Fulfilling Lives South East continued to advocate for access to appropriate housing options for those experiencing domestic abuse and complex needs. We hoped to see the Bill pave the way for creative forms of accommodation that provide emergency rapid-access accommodation with specialist wrap-around support. As such, it is positive to see a focus on safe accommodation for woman who experience domestic abuse and complex needs in the Act and statutory guidance and we welcome the new statutory duties placed on local authorities to provide safe accommodation for victims and survivors of domestic abuse. We believe that the inclusion of specialist, dispersed, and emergency accommodation that includes wrap around specialist support, including mental health and substance misuse support, in the DLUHC’s categorisation of appropriate safe accommodation to be a sign of considerable progress. We must now ensure that funding allocated to Local Authorities is ringfenced to support the provision of innovative accommodation options that are readily available for women who experience domestic abuse and complex needs.

‘’ I would hope that the complexity of these women will not be missed and do not end up slipping through the net and not receiving the help and support they so desperately need in a crisis”

Kate, Engagement and Co-production Worker
FLSE DA bill asks

What next?

Whilst Royal Assent of the Domestic Abuse Act was a pivotal moment for survivors and specialists in the sector, the legislation represents many beginnings as support systems locally and nationally review accommodation and support needs to shape future provision. We look forward to working with local statutory agencies to help shape a new local strategy to translate guidance into action and create the change needed to protect those women at the sharpest end of inequality.


Author: Emily Page

For further information about Fulfilling Lives work in this area, please contact Rebecca, Systems Change Lead: rebecca.rieley@sefulfillinglives.org.uk