Category: Multiple and Complex Needs

Stonewater and Fulfilling Lives South East- Supporting Women experiencing Multiple Disadvantage in Refuge

Fulfilling Lives South EastLeave a comment

In this blog we reflect on how effective partnership working can support new outcomes.

Stonewater and Fulfilling Lives South East (FLSE)

In 2021 Stonewater was awarded the new contract to provide refuge accommodation for women and children experiencing domestic abuse in Brighton and Hove

Stonewater is:

“…a leading social housing provider, with a mission to deliver good quality, affordable homes to people who need them most. We manage around 34,500 homes in England for over 76,000 customers, including affordable properties for general rent, shared ownership and sale, alongside specialist accommodation such as retirement and supported living schemes for older and vulnerable people, domestic abuse refuges, a dedicated LGBTQ+ Safe Space, and young people’s foyers.”

(source: https://www.stonewater.org/about-us/)    

The FLSE project, hosted by BHT Sussex, is one of 12 partnerships funded by the National Lottery Community Fund to provide intensive support for people experiencing multiple and complex needs (MCN), involve people with lived experience at all levels and challenge and change systems that negatively affect people facing MCN. While this eight-year project will soon be coming to an end, we recognised the value of collaborating with Stonewater.

At FLSE, we were keen to collaborate with the Stonewater team as we saw a real opportunity, when they were awarded the new refuge contract, to work together to share our learning of working in a trauma-informed way with women facing MCN and domestic abuse to help this particular group of women to better access and sustain their stay in refuge.

The importance of defining MCN or multiple disadvantage

There is much disagreement in this sector about the merits of having a unified definition of MCN or multiple disadvantage. There are concerns in some quarters around the negative effects of labelling on people experiencing multiple disadvantage. At FLSE we understand and respect this viewpoint. However, from eight years of learning, when it comes to the design and commissioning of services for this client group, we know that there is more risk in not naming multiple disadvantage than providing a clear definition. We feel this is important so that services are designed with the specific needs of this group, who are often excluded from services, in mind. For women experiencing intersecting needs including homelessness, mental ill health, substance or alcohol use, repeat contact with the criminal justice system and the repeat removal of children, when domestic abuse is added to this complex array of issues, it is vital that services are equipped to work with these women, who will all have experienced trauma and require an appropriate response.

Recently, FLSE worked alongside the Sussex Police and Crime Commissioner’s Office that led on the Needs Assessment – a requirement of the DA Bill – to assess the need for safe accommodation and support for victims/survivors of domestic abuse across Sussex. We coproduced a written submission detailing the specific needs of women fleeing domestic abuse using case examples from our client-facing work. We were delighted to read in the final Pan-Sussex Strategy for Safe Accommodation and Support for Victims/Survivors of Domestic Abuse that FLSE’s definition of multiple disadvantage was included and ‘responsive to multiple disadvantages’ was cited as a key priority in the Strategy. We recommend that all agencies in Sussex use this definition when commissioning or designing domestic abuse services and safe accommodation options:

Multiple Complex Needs (MCN) has a variety of meanings in services and third sector organisations, depending on the needs of the client group. In general, MCN includes people on the edges of society who are often excluded from or who cannot access who is experiencing 3 out of 4 of the following:

What we did together

The FLSE team and Stonewater managers discussed ways we could work together to support improved outcomes for women with MCN.

In April and May 2022 the FLSE team delivered two training sessions for refuge staff. The first session focussed on complex trauma; its causes and how it manifests in behaviours and tools to manage potentially difficult situations and was informed by the refuge team feedback in a pre-training survey.

The second session focussed on deepening conversations around:

  • The window of tolerance.
  • Dissociation – being the most misunderstood responses and the most common in women and children experiencing domestic abuse and how to recognise and work with it.
  • Practising some grounding techniques and tools.
  • The working together tool.
  • Further reading and training that staff can access.

Impact

Following the two training sessions, the Stonewater refuge team felt they had a better understanding of:

  • The meaning of MCN.
  • What women experiencing MCN and domestic abuse might need.
  • Different trauma-related responses.
  • How to take a different approach to clients affected by alcohol and substances, including ways to organise a multi-agency meeting involving clients.
  • A number of staff reported feeling confident creating and using a Working Agreement.
  • All staff reported that they felt ‘completely comfortable’ now with using grounding techniques.

The Stonewater team felt that the collaboration and sharing learning had a positive impact on their work, with one staff member sharing:

“The training was absolutely excellent, I felt as though I learnt a lot and I have already used the working together agreement and the window of tolerance work sheets in my case work sessions”.

Looking to the future

As FLSE is now reaching the final stage of the project, we are proud to know that Stonewater will continue influencing the system to make refuge accommodation more accessible to, and impactful for, women experiencing MCN.

Sandra Sylvester from the FLSE team reflected that “it is so positive to see what can be achieved when working in a strengths-based way with a partner such as Stonewater, who have been open to learning from our 8 years’ experience to develop the tools they need to successfully accommodate women with complex intersecting needs, but also how to give the amazing staff the space to reflect on the difficult work and to provide opportunities to attend relevant training. It has been an honour to be part of this project.”

Wendy Sheehan from Stonewater, shared how enthusiastic the staff were to attend the two training sessions and how they really appreciated them being in person.

“The support and training that the Refuge team have received from Fulfilling Lives has been invaluable. The training was tailored to the specific needs of the team and was based on real life case studies.  The feedback from the team has been extremely positive and has improved their confidence with supporting women with MCN’s.  This will ensure that we can support more women with MCN a group that is often excluded from accessing many refuge services.”

Sarah Pugh, also from Stonewater, is in the process of developing the organisation’s training package and is using the learning from the training and partnership to inform the content of this framework.

“Refuge has to be more than just bricks and mortar and the practical and therapeutic support survivors, including children, receive is crucial to their recovery.   Stonewater are dedicated to ensuring that refuge staff have the opportunity for continual professional development and are equipped with specialist knowledge and confidence to support the multiple and complex needs that residents present with.  The feedback from staff who attended this training is overwhelmingly positive and has whet their appetite for more!  Learning in the field of domestic abuse and its radiating impact on all aspects of its survivors lives is continuous and we’re working on a Domestic Abuse training plan for all Stonewater employees, incorporating what we’ve learnt so far and utilising all the resources you have provided.  Knowledge is power, and effective training results in knowledgeable, skilled staff resulting in improved outcomes for survivors.   Thank you Fulfilling Lives, for your time and energy!”

Authors:

Sandra Sylvester, Systems Change Officer

Rebecca Rieley, Systems Change Lead

For further information about Fulfilling Lives work in this area, please contact:

rebecca.rieley@sefulfillinglives.org.uk

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Co-Production……because it’s worth it! 

Fulfilling Lives South EastLeave a comment

In our previous blog posts and on our website, we’ve talked in great detail about the how, the when, the who and the what of Co-producing with people with lived experience.  We’ve also shared our learning around the potential challenges, how to overcome them and how to be creative when co-producing.  In our final blog, we’ll look at what is probably the most important piece of the co-production jigsaw puzzle… the why. 

So, why is it better for a service to change from their established way of working to co-producing with service users?  

Firstly, it’s worth stating that the purpose of any service is to deliver that service to those who need it.  It should be accessible to everyone from any demographic.  In the context of our work, we are referring to housing, substance misuse, mental health, domestic abuse, and those related to prison release.  It can be difficult enough for someone to access any of these services even if they are experiencing a single complex need, and accessibility is a fundamental aspect of an effective service.  Service users are best placed to inform how the services aren’t accessible for them, either individually, or connectedly.  If they aren’t accessible for them, then the service hasn’t been designed for others in similar circumstances.  Working closely with the people who understand the needs of those falling through the cracks is the best way understand the service’s design flaws so the cracks can be filled.  They can tell you what needs to change and what they feel they needed from the service at that time in order to access the support on offer.  With every additional complex need, it becomes more difficult for someone to access a service on its terms.  Genuinely co-producing with people with lived experience of multiple and complex needs can help the service reach those in the most chaotic circumstances. 

If a service is co-produced from the start, it will be designed to be more efficient while making the best use of the resources available.  There will be fewer missed appointments due to improved accessibility, thus less wasted time and money while reaching more service users and increasing the chance of better outcomes. 

A service can be inaccessible even before attending an appointment.  The service’s reputation can help or hinder the staff who are offering support.  It may be that before someone walks through the front door and meets their support or key worker for the first time, they will have expectations that may be positive or negative based on word of mouth or service reputation.   If a service has been co-produced with those who use it, this will help to increase trust amongst the community it serves, leading to better relationships between workers and service users, and a greater chance for positive outcomes. 

Co-production can benefit service users not just by improving service provision.  Through the process of involvement, service users will be empowered with the opportunity to harness their experiences and direct them in a way that benefits others, providing purpose and a sense of belonging.  Furthermore, services who show trust and value in the co-production process can have a strong impact on the self-esteem, self-worth and confidence of the people taking part, while concurrently helping them to gain skills and experience.  This involvement can be a significant step in someone’s recovery journey.  It also represents a cultural shift in the way society views those with the most complex needs, paving the way for less stigmatising beliefs. 

There is a growing emphasis amongst funders to incorporate co-production into service design.   It is encouraged by procurement regulations and favoured by commissioners, so its value has been recognised.  Bids are likely to be seen more favourably when co-production is part of the service operation.  In these cases, it’s important that co-production is well understood so it can be implemented effectively. 

And finally, people have the right to be involved in their own care; professionals and service users working together to find the best path forward.  When someone is living in chaos, they may not feel they have much control over their own circumstances.  Working with someone in this way provides a sense of agency which can have positive knock-on effects in other areas of their life. 

Key Messages:

So, to summarise, co-producing with people with lived experience of multiple and complex needs is beneficial to the service and service user because: 

  • It is more efficient in the long run as the service will be set up to cater for the needs of all its users, with fewer wasted resources 
  • Outcomes will be better for service users and more sustainable 
  • Co-producing can lead to creative solutions to difficult, long-standing problems 
  • Involving people in their own care is the right thing to do and offers some control over their lives which may be lacking 
  • Service users gain skills and experience that can help prepare them for work 
  • Co-producing provides service users numerous psychological benefits such as a sense of belonging, purpose, and achievement, while building self-esteem, self-worth and confidence 

Below are some quotes from volunteers on co-producing pieces of work with Fulfilling Lives: 

“We had a voice, made me feel I’m not the only one who had experiences like I did at [service] as heard other people’s experiences doing this project, builds confidence. Not very often you have a voice. Hopefully speaking for people who don’t have a voice. We were trusted to do this – self-esteem, not being judged on our past” Service User Involvement Volunteer – FLSE 

— 

“Possibility to have a voice. Feeling valid. Being given agency. It felt good to take difficult experiences and turn them into something productive and taking the chance to step into a more active role, after a long time of feeling powerless and hidden”  Service User Involvement Volunteer – FLSE 

— 

“Everybody should be part of decisions and making a change. Lived experience brings unique perspective, emotional intelligence. Can’t learn it from a textbook. Think that trying to heal and overcome hard times is a difficult and long journey but it also gives incredible insights into yourself and the world, for better and for worse. When the experiences of hard times collide with social services police and other systems, I think that insight and emotional intelligence is particularly valuable if not essential as a window into the client base”  Service User Involvement Volunteer – FLSE 

The only question that remains then is “When are you getting started?” 

Author: Ian Harrison – Co-Production and Engagement Worker

Thanks to colleagues & volunteers at FLSE: 

Vikki Hensley – Co-Production and Engagement Worker

Aditi Bhonagiri – Co-Production and Engagement Worker

Kate Jones – Co-Production and Engagement Worker

Andree Ralph – Engagement and Co-Production Lead

Service User Involvement Team Volunteers

For further information about Fulfilling Lives work in this area, please contact:

ian.harrison@fbht.org.uk

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Clinical Supervision and how it can support the work of non – specialist client facing workers

Fulfilling Lives South East

What is clinical supervision?

Clinical supervision isn’t new, having been used for many years in a variety of healthcare settings, including mental health. Clinical supervision is a formal mechanism through which individual and professional development occurs by the worker reflecting and learning with the supervisor. People who receive clinical supervision have jobs that are emotionally demanding, in the case the of the Fulfilling Lives South East (FLSE) project supporting people with significant trauma histories and/or multiple and complex needs (MCN).  

A key piece of learning from the FLSE Perspectives Project and Perspectives Project: Part 2 work was how statutory mental health professionals could support non-specialist client-facing workers to safely hold high levels of risk. This blog shares learning and aims to illustrate the important role that clinical supervision can play, or could play, in providing a form of mental health specialist support via the worker to clients with a coexisting condition. In building confidence and knowledge in workers to understand the complex nature of this client group, develop appropriate methods for risk taking and sharing risk, managing worker wellbeing, and navigating complex systems when advocating for clients.

In what ways can clinical supervision help non-specialist frontline workers?

  • Feeling connected

Working in a role providing support to clients experiencing MCN on a one-to-one basis can be an isolating experience for the worker. The danger of vicarious trauma is more likely in this type of role when in your day-to-day work you are surrounded by complex trauma. Not having a space where you can discuss feelings and emotions that the work might be bringing up for you is an unsustainable approach that will lead to workers having to take time off sick. Clinical supervision offers a space for workers to process the emotional aspect of the work and understand the interplay in the client worker relationship. Being able to talk about what comes up when supporting clients to recognise transference and how this can conflict with your own attachment styles is vitally important.

  • Confidence and knowledge

Clinical supervision equips non-specialist client-facing workers with a framework of language that gives knowledge and confidence when adjusting to different audiences and situations. It can help workers advocate for clients using language that statutory mental health workers will recognise and listen to, as well more authoritative robust language to explain the risks and consequences of not responding to the needs of the client.

Additionally, clinical supervision supports workers to facilitate and lead multi-agency meetings that illustrate to partners trauma understanding and this helps other agencies work in the same way, modelling what good can look like when a multidisciplined team approach is adopted to working with complex needs clients.

Another way in which workers’ development of communication is important, is learning through clinical supervision how to interpret the client’s language as well as gauging what language is appropriate to use in response to a variety of situations that can and will arise when supporting MCN clients.

  • Innovative, flexible, new approaches

Services can be risk averse which stifles creative approaches to working with MCN clients. Working with this client group requires new approaches and time to build the vital relationships that set the foundations for positive support work to take place. Training staff to have the confidence, knowledge, and skills to work in this way is key to working in a trauma informed way. Non-specialist client-facing workers having the opportunity to discussion innovative ideas in clinical supervision where thinking can be refined, and potential risks can be identified, and mitigation strategies can be worked though. Is incredibly valuable and reassuring for a worker to know that a specialist is endorsing their case planning and now leaving the worker exposed to holding the risk alone.

  • Wellbeing and burnout

While clinical supervision is not therapy, it can be used for times when workers are triggered and to think about why that may be. Sometimes these discussions do not happen with managers until the worker has to go off sick and the reason for absence must be disclosed. Clinical supervision offers a regular slot in a worker’s diary where the focus won’t be frontline operational priorities, rather a time to talk with someone who isn’t part of their day-to-day working life. This protected time affords the worker safety to disclose issues and feelings resulting from the nature of the intense client work. Any sense of uneasiness around disclosing feelings that may be perceived as weakness or make the worker feel shame is diminished by the containing space provided through clinical supervision.

  • Feeling valued

One of the main impacts that clinical supervision has is it gives a message to staff that the organisation genuinely cares about them and their work. Staff are aware that clinical supervision is something that professionals with specialist qualifications receive, so it sends a signal that the organisation is treating the vital work they do with seriousness. There is often a sense that non-specialist frontline workers are regarded as professionals with a small ‘p’. This kind of investment in staff is validating making workers feel that their role in the support system and the contribution they make is being rewarded by the organisation looking after their wellbeing and professional development.

Why we need to protect our workers?  

The current headwinds buffeting third sector healthcare settings are some of the most difficult we have faced. The system is more stretched than ever, the number of people requiring support continues to grow as the level of complexity people are presenting with increases. Coupled with staff shortages and reduced funding the sector is producing a workforce that is stressed, under pressure and poorly supported. Of course, the Covid-19 pandemic has amplified these long-standing issues in the system, while at the same time creating an opportunity to embed clinical supervision in the sector. Giving meaningful professional support and development to non-specialist client-facing workers would be a decisive and welcome contribution to the system.

To read more about how clinical supervision can benefit client-facing workers providing intensive support to clients with MCN, please read ‘The effectiveness of clinical supervision for workers supporting people experiencing multiple disadvantage’. Written by Juliet Hough, and independent researcher, published on the FLSE website in January 2021, the research found that the provision of regular one-to-one clinical supervision was highly beneficial to workers and to the FLSE programme. It was critical to workers trauma informed practice, and in supporting their well-being in the following areas: Increased workers’ understanding and skills around providing trauma informed care, helped workers to successfully advocate for support from other services, helped to protect staff from burnout and compassion fatigue, reduced sickness absence and staff turnover, benefited the people being supported

For further reading about how clinical supervision can play a vital role in our wider communities, please read an academic paper, ‘Could clinical supervision help us to support increasingly complex needs in the community?’ The paper is a collaboration between Kerry Dowding, FLSE Research and Evaluation Officer, and, Juliet Hough, an independent researcher. First published online 15th February 2022, this paper presents qualitative research exploring the benefits of clinical supervision for workers supporting people experiencing multiple disadvantages. The paper illustrates how clinical supervision supported worker wellbeing, lessened compassion fatigue, and created space for workers to think creatively, manage risk and develop trauma-informed and reflective practice.

Locally, the FLSE team have taken a deep dive into the ways in which clinical supervision has supported our Practice Development team as they trial new ways to engage with people experiencing MCN. We wanted to see to what extent clinical supervision could provide a form of specialist mental health support to clients, via the practice development workers. Read more here https://www.bht.org.uk/wp-content/uploads/2022/06/PP_clinicalsup_FINAL_21062022.pdf

Authors:

Alan Wallace, Systems Change Officer

For further information about Fulfilling Lives work in this area, please contact:

Alan.Wallace@bht.org.uk

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FLSE responds to the ‘Tackling Domestic Abuse Plan’

Fulfilling Lives South East

As Fulfilling Lives South East (FLSE) welcomes the government’s long-awaited Domestic Abuse Plan, we reflect on how far the measures go in meeting the needs of women with multiple and complex needs (MCN).

Specialist support in safe accommodation

Throughout our project work, FLSE have continuously advocated for access to appropriate housing options for those experiencing domestic abuse as one of several intersecting needs. We know that for those made homeless by domestic abuse, the path to stable accommodation is not easy, particularly for those experiencing MCN. Refuge referrals are frequently rejected on the grounds of clients’ mental health and substance use needs being too high. This results in women facing multiple disadvantage being excluded from accessing the current refuge service models, meaning many women are being forced to return to their partner and abuser or being placed in non-specialist accommodation settings.

We are particularly encouraged by the government’s commitment in the plan to provide funding for specialist support services in safe accommodation to ensure that vacancies are available to a greater number of victims and survivors, no matter how complex their needs. It is also heartening to see that the Ministry of Justice will look into introducing national commissioning standards across all victim support services and the Department for Levelling Up Housing and Communities’ Quality Standards for support in safe accommodation. This will ensure that the commissioning of support in safe accommodation for domestic abuse victims and survivors and their children will be subject to the same standards as all victim support services.

Training for non-specialist services

At a local level, FLSE have made specific recommendations for staff in non-specialist services supporting women with MCN to be equipped and trained to better respond to domestic abuse. We have evidenced the need for MCN specific domestic abuse training to be provided across Sussex, to ensure that police forces are more informed of the complexities facing women with complex needs experiencing domestic abuse.

As such, the provision of up to £3.3 million to fund the rollout of Domestic Abuse Matters training to forces which have yet to deliver it, or do not have their own specific domestic abuse training, is a welcome step. We also welcome the government’s commitment to provide £7.5 million to upskill healthcare professionals to identify and refer victims and survivors to support services and ensure that healthcare professionals are appropriately equipped to support those suffering trauma from abuse. We hope that these measures will be built upon, with the long-term view for all public services and non-specialist services to be able to respond appropriately to domestic abuse, with an intersectional understanding of the experience of women with MCN.

Collaboration and coordination across the sector

Women with MCN who are experiencing domestic abuse do not typically present at specialist domestic and sexual violence services. For example, they may present for help in the first instance at their Local Authority Housing Options Service, where clients can experience judgemental and stigmatising responses and unsatisfactory outcomes. Women frequently do not receive a service which reflects an understanding of the complexities, dynamics and risk issues of domestic abuse or receive a trauma-informed response.

As such, it is positive to see the importance of collaboration and coordination between and within statutory services in better supporting survivors recognised within the plan. We are hopeful that the government’s upcoming new Domestic Abuse Statutory Guidance, which will provide further details on the different types of abusive behaviours, will help to facilitate a common understanding of domestic abuse across the whole system, ensuring that women do not fall through the gaps in provision.  

The measures set out in the ‘Tackling Domestic Abuse Plan’ represents a positive step toward better coordinated and trauma-informed support services which can holistically meet the needs of the most marginalised women. The government must now bring lived experience voices to the forefront in decision-making forums when translating these objectives into practice and instigate the change that is truly imperative.

Authors:

Emily Page, Systems Change Project Assistant

For further information about Fulfilling Lives work in this area, please contact:

emily.page@bht.org.uk

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Seeing the whole person: Reflections on a journey into employment

Fulfilling Lives South East

This blog post has been written by a colleague with lived experience of multiple disadvantage and is a personal reflection of the employment journey they travelled, including within their role at Fulfilling Lives South East. 

Citrus Ornge

My employment journey began over three years ago, when Rob Robinson who was working with me as part of the IPS (Individual Placement and Support) trial at a substance misuse service introduced me to Jason at Citrus Ornge. At the time I was volunteering, studying and taking part in wellbeing groups but I could not really visualise a pathway into employment for myself. Looking back, I realise I had internalised a lot of stigma and my self-esteem was quite low – I didn’t think anyone would believe in me enough to offer me paid employment. Many of my IPS meetings had been spent agonising over gaps on my C.V, which felt like a road block… something which even if I got to an interview I could be faced with trying to explain or apologise for. I felt I had wasted the career I had before.

Rob came with me to meet Jason informally. It took a while to absorb the fact I was in a room with a potential employer who was in recovery themselves and open about that, and that I was invited to be too. There was no need to explain gaps in my C.V or that my references would be from people I volunteered with rather than worked for. And so, I became the first employee of Citrus Ornge.

I had no media or business experience and did not even own a laptop, so Jason lent me one and I went to work one day a week. I was shown how to do what I needed to do – learning new skills in the process – and I did it. What I did know was that Citrus Ornge had a social mission that I admired and wanted to help with if I could.

Emotionally, it was a time of change and growth. Like many people in recovery, I had experienced trauma and feeling safe in different spaces was something I was working on. Sitting in an open office space surrounded by people with laptops from 9am to 5pm was something new, and I had to learn to be in that space. Facing anxiety and not letting it win, grounding myself in a place where I felt the acceptance of being with someone else in recovery. Continued regular IPS support was vital to keep me focussed on the positives, recognising my achievements and moving forward.

Jason introduced me to the idea that people in recovery have unique assets that should be valued by employers, and I learned from how open and honest he was about his own recovery that it is not something we should be ashamed of in professional spaces.  I wondered if other employers existed that thought about recovery this way.

Months on, Citrus Ornge had grown to a handful of employees. Someone at the service I was still volunteering with showed me an advert for a job at Fulfilling Lives. Having lived experience of multiple complex needs was a requirement for the role, much of my volunteering experience was relevant and I now had recent experience of employment. The project looked too interesting to let the opportunity pass by, so, I decided to apply for the role. I didn’t expect to get the job or even an interview and had prepared for that outcome with people in my support network but saw applying as a step in the right direction.

Fulfilling Lives

I started in a 3 day per week role at Fulfilling Lives and was then promoted to full time. I have been here 2 and a half years now. During my early months, I benefitted greatly from having regular supervisions where I could measure what I was learning against an induction checklist, raise any concerns and set goals. Having a list of what I was expected to achieve during my first six months was a reassuring, clear and objective way to look at my progress – this was important as I was tending to focus on my perceived failures and shortcomings at that time.

Like my experience at Citrus Ornge, I saw others being open about their lived experience but took time to feel I could start to do that myself. After building relationships of trust with my team, discussions in reflective practice sessions, and training about professional boundaries, I became more confident about judging what to share and when, knowing what I was comfortable with, how to speak from lived experience without sharing details I was not comfortable with, how to assert boundaries and making judgements about whether sharing something about myself would be of benefit to someone I was supporting or a piece of work. Over time I have started to make peace with my lived experience, integrate those experiences into my current identity, and rather than making a journey from a person in recovery to a professional, I have become a professional who is also in recovery.   

Monthly strengths-based, psychologically informed supervisions have facilitated development of my confidence and I am now able to recognise my own strengths and interests and more likely to take on new challenges at work. Being in an environment that genuinely supports me to perform at my best means I feel like my team are behind me even when I’m working as an individual. I know that if something is a challenge for me, I can view it as an area to work on rather than something I have failed at. As an example, the first time I had to stand up and speak in front of a room of people, I was so nervous I could not even stand up from my chair and a colleague delivered my part of the presentation. After working with my manager and development worker, and conversations with colleagues who were so non-judgemental and generous with their own stories of taking on challenges, I presented at a conference two weeks later. To date I have taken part in delivering training to hundreds of people.

This style of supervision has also positively influenced the way I mentor others within my role, by modelling a collaborative approach based on trust, building on and affirming strengths, supporting people to achieve their goals and creating safe strategies to cope with times resilience is tested.

I hope that anyone reading this gets a sense of how grateful I am for the IPS Trial, Citrus Ornge and Fulfilling Lives, and the impact they have had on my life. As I write this, I am about to start a new role and continue my employment journey – a journey I wasn’t sure would ever happen. We acknowledge the critical importance of believing in people whilst they are accessing support services and in the early stages of recovery, but recovery, learning, and growing never stop. Can we say we really believe in people if we only believe in them up to a certain point?

Learn more about employing people with lived experience of MCN

For those who are interested in Fulfilling Lives’ learning about employing people with lived experience of multiple complex needs such as my myself, we have created an employment toolkit which is available to download here:

Download here

For more information about Citrus Ornge and their social mission

Visit Citrus Ornge website

Authors:

Anonymous Fulfilling Lives Team Member

For further information about Fulfilling Lives work in this area, please contact:

Andree.Ralph@sefulfillinglives.org.uk, Co-production and Engagement Lead:

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CGL Women’s Hub: A new Treatment Pathway?

Fulfilling Lives South East

Ideas about who uses drug and alcohol services and how they use them need to be challenged. In Hastings, the CGL Women’s Hub has been quietly doing this. However, in the run up to the publication of a report on its work, the noises coming out of the Women’s Hub are getting louder.

In a way it’s a simple idea. Create a place where service users want to go, that meets their needs… and meet them there.

CGL (or Change Grow Live to give it it’s full name), is the main provider of drug and alcohol support services across Sussex. In August 2021, a new initiative with Fulfilling Lives saw the appointment of Rachel Payne, a practice development worker who identified a need for better treatment pathways for women. Nationally, treatment services have seen considerably more men access their services than women (69% to 31%, PHE 2020). For many this has reinforced the idea that men are more likely to need the service. However, there are a few working in these services who have been questioning whether the way a service is offered can be a barrier to more women accessing effective treatment. The CGL Women’s Hub seems to suggest this is the case.

Katie Lowe went to the weekly Women’s Hub to see first-hand what is happening at a service which is seeing a 78% increase in engagement compared with keyworker meetings and a nearly 300% increase in their participation compared to groups run out of their high street offices. As a psychology student on placement with Fulfilling Lives, Katie had no previous experience with drug and alcohol services and really didn’t know what to expect:

When I got there, I was given a warm welcome and encouraged to get involved in the craft session that had already started. I later found out this is run every week by one of CGL’s volunteers. What struck me early on was how much everyone seemed to want to be there. Not just the women but the staff too. Rachel filled me in on the details: The Hub meets every Tuesday at a local community venue. This allows the service to provide an inclusive women-only space. This neutral venue is not associated with medical treatment, men who may or may not pose a risk or the stigma of being seen walking in from a busy high street. Deciding to run it on a Tuesday was not an accident. Rachel mapped out the other services women might want to attend and found a space that didn’t clash. Staff at the Hub have encouraged women to try out these different services, with small groups arranging by themselves to go together. In some cases, their participation has gone from just turning up for a required medical appointment to attending multiple support groups across the week.

Women can come and go as they please, take part in any of the available activities or just sit and chat. It’s their choice. With an average of 2.6 hours spent at the Hub when they do go, it suggests they get involved in a lot. Local charity Dom’s Food Mission provides supplies for breakfast and lunch. There’s the 2-hour creative group which I dropped in to, often running alongside a beautician offering hair and nail treatments and once a month a hairdresser. After lunch there is an accommodation specialist on hand for drop-in advice, a space to generally chat and get support and regular visits from an NHS sexual health nurse (who reports being able to see as many clients in an hour at the Hub as a whole day trying to meet them in the community). Then there’s acupuncture with a guided meditation followed by a yoga session before everything ends at 3pm. Coming together in this way has allowed women to meet with friends and make new ones in a place that feels safe. It seems to restore social and relational experiences in a way that feels normal in a sector where treatment can be retraumatising for many women.

Friendships, community, meals and clothes are all things we can take for granted if we are not dealing with multiple complex needs. However, Rachel will tell you this busy schedule wasn’t always the plan. Local services have been as much drawn to the Hub as the women themselves, offering support and staff time, all focused on a shared desire for women to get the service they need. Outreach workers, care coordinators and keyworkers from CGL, Seaview and Project Adder have all been involved in running and planning activities. Others have provided quality clothes donations and the combination of a local branch of Tesco and the Hygiene Bank provided items to give to women for free.

Taking this approach has the potential to make a huge impact on the way substance misuse services are structured, and how clients access treatment. There are spaces at the Hub for care coordinators and outreach workers to meet confidentially with women. The Women’s Hub has also been used by occupational therapists, domestic violence workers from Respite Rooms, HomeWorks and the Rough Sleepers Initiative, to meet clients and connect them to CGL’s treatment pathway. So far there’s been cases of women accessing CGL treatment by coming along to the Hub, assessments being carried out at the Hub, and this has even led to women going to detox and rehab. In a way it’s a simple idea. Create a place where service users want to go, that meets their needs… and meet them there. The statistics back this up as a place women with multiple and complex needs want to go. Since it began in November 2021, the Hub has seen 47 different women with an average attendance of 63% – no mean feat for a weekly programme with a service user group often considered ‘difficult to engage.

With Rachel’s own interest and the years-long investment of Fulfilling Lives in specialist women’s services, this approach made sense. However, there is already talk of how this approach might better meet the needs of other marginalised and minority service user groups who are not accessing treatment at CGL’s main offices. With 65% of service users accessing treatment by self-referral or through family and friends (PHE 2020), creating spaces that feel safe for marginalised people will be vital to genuinely inclusive treatment pathways.

Providing the service is inexpensive, with activities and groups being offered free of charge by the different services involved. Many of the staff can use the space to do work that they would have been doing anyway and reach several clients at the same time. There is a small cost for venue hire and arts and crafts projects but that is easily justified by the reach of the service. Creating and chatting with other women is what makes the Hub what it is. Rachel and the team are using these activities to engage with some of the most marginalised and excluded women, reaching out and connecting in a meaningful way.

It’s early days but all the indications are that the Women’s Hub is demonstrating a model of drug and alcohol treatment that is meaningful. There are many positives to this approach; building a safe, inclusive environment for women to access services which otherwise might have felt unsafe. Of course, moving from centralised office spaces would be unfamiliar to most in substance misuse services. There are also some logistical challenges to booking suitable community venues (made easier in the wake of the pandemic as bookings dried up leaving space for new initiatives like this). However, the early signs present an exciting challenge to drug and alcohol services that will be hard to ignore.

Authors:

Katie Lowe, Psychology student on placement with Fulfilling Lives

David Garret, Practice Development Coordinator

For further information about Fulfilling Lives work in this area, please contact:

david.garret@bht.org.uk

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How Multiagency Meetings Can Join Up Support

Fulfilling Lives South East

Reflecting on the impact of joint working protocols and how they can build bridges between mental health substance misuse services

Joint working protocol

In 2017, Fulfilling Lives South East (FLSE) developed and implemented a joint working protocol between Hastings mental health and substance misuse services to improve experiences for clients who need access to both services. The protocol aimed to meet clients’ needs as a whole, through a combined approach, rather than separating mental health and substance misuse as distinct issues and was shaped and informed by representatives from both services.

In the intervening years the Joint Working Agreement has grown and evolved. There is now a wider multiagency meeting called the Co-occurring Substance Use and Mental Health (COSUMH) Conditions forums held monthly in both Hastings and Eastbourne that has helped further strengthen joint working and shared client support planning.

These forums are an opportunity for agencies to discuss any of their clients who have mental health needs, are using substances and whose current situations are felt to be particularly high risk. The aim is to work across agencies to ensure the client does not fall between the gaps and for the group participants to agree who will do what tasks and lead in what areas to best support the client, and further joint working approaches.

A range of agencies attend the forums including Adult Social Care, CGL, Housing, SWIFT, Staying Well, FLSE, Oasis, Optivo, Health in Mind, Probation, UCL, Psych liaison, Rapid Response, Rehab Pathway, Assessment & Treatment Service, and Crisis Resolution Home Treatment Team (CRHT).

How did the Joint Working Agreement start?

The Joint Working Agreement was the product of collaboration between CGL Star (The East Sussex Drug & Alcohol Recovery Service), East Sussex Mental Health services and the local Hastings FLSE team. First raised at the Hastings Dual Diagnosis meeting in 2016 (now the Co-existing Conditions Steering Group), the initial idea was to organise joint training sessions between the two services, so that workers would become more aware of how the other service worked.

It quickly became clear that ambitions for the partnership and the Joint Working Agreement went beyond training and that both services wanted to find a way to offer clients with co-existing conditions a better pathway to treatment; one which was person-centered and holistic.

What was included in the Joint Working Agreement?

The initial Joint Working Agreement included the following three aims:

  • Improve the experience of people who need to access both Mental Health and Substance Misuse services.
  • Enable clients to have their needs met, through a combined approach, which is informed by the expertise of both services.
  • Ensure that the client is treated as a whole person with overlapping support needs.

The Joint Working Agreement also set out detail of how agencies would address three key areas of joint client working: consent, assessment, and communication.

  • The Joint Working Agreement considered it to be good practice for workers conducting assessments to gain client consent to share information at the first opportunity. And that consent should be used purposely in a task-specific manner to ensure that information is shared between services when needed. Information sharing should be proportionate to risks and needs, ensuring that safe and appropriate treatment is provided.
  • The Joint Working Agreement recognised assessingclients who have enduring mental health problems, while also using substances, would take more time. To gather a full picture of who the person is and who they might wish to become an active, collaborative, engaging process was used. While acknowledging that recording the details of co-occurring mental health and substance misuse presentations would need to take place at separate meetings, each led by a specialist practitioner. Attempting to address problems in each of these areas required different models of treatment and different styles of engagement, enabling services to learn from each other by observing one another’s professional practice.
  • The Joint Working Agreement anticipated that mental health and substance misuse provision would need to be co-ordinated across services with one agency taking the lead, and that the lead agency might change as the client progresses through treatment. Good communication would be a pre-requisite between practitioners from both services so cases could be regularly reviewed and updated.  

When multiagency planning can work well

The Joint Working Agreement aims, and objectives have evolved and the COSUMH Forum is now a valued junction point in the support system, providing a space for joint working, joint problem solving and a place to plan support for people who have coexisting substance use and mental health needs.

Recent feedback from Forum participants has shown that staff working across services in East Sussex value the forum for the following:

‘The forum has been a fantastic help in raising the profile of our project and clients’ needs/role, as well as in getting to meet all the right people. We know this has helped us to get referrals, so in that sense, there’s a very clear benefit to us as a project and to the people who are getting support that they didn’t have before.  I like the presentations and I’m really grateful to the forum – for welcoming and including us – it’s hugely appreciated. Getting a holistic view of individuals we talk about is invaluable, the way everyone talks about things at the forum is very different – it doesn’t have formality of case meetings – and the willingness of professionals to be open, share thoughts and bounce ideas around in a caring and safe environment is very rare, refreshing and much valued.  There are so many people with different knowledge and skills and the way it is set up is very effective.’

(Quote from an attending professional)

However, the group remains ambitious and want to develop the Forum further. The Forum chair shared their thoughts on what they would like to see happen next for the meeting:

‘I enjoy having the opportunity to develop and maintain positive relationships across services in East Sussex through the COSUMH conditions forum network. The forums have strengthened understanding between partner agencies and their roles in supporting recovery, this happens not only through the forum presentations, but also during the referral discussions. We have a core group of professionals from SWIFT, Adfam, Oasis, SPFT and Probation who attend every forum. I would like to see this replicated across all agencies so that we have passionate advocates for our clients living with COSUMH conditions in every service across the county. I am delighted that the forums have been recognised as good practice and am now working with West Sussex to set up something similar.’

(Susi Whittome, Forum Chair)

Reflecting on the importance of multi-agency meeting spaces in support systems

AT FLSE, we believe that fostering new collaborations and creating new meeting spaces is a way to foster systems change.

This method of systems change involves creating new connection points to bring together previously unconnected representatives of agencies who hold the power to change the way the system is structured and operates. The process for this can include mapping existing multi-agency meetings and identifying gaps where it would be beneficial to bring unconnected stakeholders together in a new forum.

These new forums should nurture collaboration and foster learning and result in tangible positive actions that impact on the recipients of support systems. The COSUMH Forums are a good example of this in action locally.

Challenges of this method include the time and resilience needed for the new forum to become an effective catalyst for change, an initial over-reliance on key individuals to engage and breaking down barriers to sharing information that may be traditionally viewed as commercially sensitive.

However, the benefit of this approach includes increased cross-agency partnership working; increased access across the system to new skills and knowledge; and a shared access point for raising gaps and barriers in systems and joint problem solving. This is particularly useful when responding to new systemic challenges that are unlikely to have existing forums for conversations and nurturing collective action.

To read more about how multi-agency meetings can foster systems change, please read our blog on the Brighton & Hove and East Sussex Coexisting Conditions Steering Groups here

Author:

Alan Wallace, Systems Change Officer

For further information about Fulfilling Lives work in this area, please contact:

Alan Wallace, Systems Change Officer:

alan.wallace@sefulfillinglives.org.uk  

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Journeys towards a Psychologically Informed Environment (PIE)

Fulfilling Lives South East

There is a growing interest in the support sector to operate Psychologically Informed Environments (PIE) and to adopt trauma informed practice, but this is hard to do. In this blog we reflect on Brighton & Hove City Council’s (BHCC) PIE journey that Fulfilling Lives South East (FLSE) supported with experts in this field and what we learnt from the experience.

What sparks collaborations?

After conversations between the FLSE team and BHCC about changes to language and policy seemed to stall in the face of detailed revisions and large authorisation processes, the FLSE team decided to re-group and re-evaluate priorities. We reflected that we actually wanted to support larger-scale changes beyond the immediate policy in question and that we were passionate about encouraging PIE and trauma informed practices across the service.

We shared these reflections openly with the BHCC managers and this unlocked a different mode of conversation. We were able to discuss broader principles and values of the department and we found this was a much more open dialogue, welcomed by both ourselves and the BHCC team.

What happened in the journey – ‘How about a mystery shop?’

In a meeting that followed sharing our reflections, a volunteer said: ‘how about we do a mystery shop?’ He reassured the groups that this was a learning opportunity, with an established process which had been carried out in the Hastings Housing Department to support their service development too. The BHCC Managers embraced this opportunity and a month later we were training up volunteers to carry out a mystery shop and conduct environment assessments of the housing customer service centre.

To find out more about mystery shopping please read our toolkit here. The learning from these activities was shared at both a managers’ level and with the whole department. These meetings and presentations were co-produced and co-delivered with people who have lived experiences of multiple and complex needs (MCN) and we highlighted positives as well as areas we felt could be developed. Paired with this, BHCC housing managers made time for staff to reflect on the learning and share hopes and aspirations for the Department. They wanted staff to have space for de-brief and dialogue.

The BHCC Housing Department was starting to shape its vision and plans for the future using the learning from the mystery shop and environment assessment paired with staff feedback.

Following this, the Department reached out to Dr Peter Cockersell to support with staff training in PIE and trauma informed approaches. Peter is a leading expert in this field and one of the co-authors of the national guidance on PIE. Peter worked in collaboration with FLSE, partnering with volunteers and experts by experience to design the training which was then delivered by the team. This programme saw over 100 staff participate in training across the whole of the BHCC Housing Department.

Following this, in late 2020/early 2021, the Department released its revised strategy, which included a commitment to becoming a department that operates as a PIE.

Covid-19 has obviously put all housing departments under huge strains, and we hope that as the world takes steps to recover from the pandemic that the BHCC team can have space to revisit this work and time for non-crisis activity.

What impact did this have?

Having the mystery shopping exercise and environment assessment as the foundation for this partnership, centred the voice of lived experience and helped to shape BHCC’s plans for the future around the service-user.

One volunteer who was key to shaping FLSE’s involvement in the partnership shared their reflections on this work:

“So my interest in the work was to do with the fact that the first time I was homeless I went through the system, and it was decided that they had no duty of care. So I just wanted to see if the system had changed or not.

I do think that the majority of the staff [at the council] were very open minded.  The few staff members who did object at first did eventually came around after we managed to convince them that the work was about testing the system and not them.

I don’t know about all the staff, but I do remember one lady who said that as a result of the mystery shops that she had re-evaluated the way she worked, and that after it, when she was meeting with people she made sure that she had some water and tissues in case they were needed.”

Learning

Based on the learning and values of the Project, there are golden threads that run through all of our systems change work. We share these below as useful starting point for anyone looking to spark or support a journey of change similar to the one we reflect on above.

  • Drivers for change: At FLSE we have found it useful to reflect on and write down what drives all our efforts and partnership work. These are a useful reminder on a challenging day about why you do the work. 
  • Guiding principles: We have worked to certain values, principles and practices and this has helped shape what we do as much as how we do it. For FLSE, these have been:
    • Co-production
    • Trauma-informed practice
    • Naming Multiple and Complex Needs (and multiple disadvantage)
    • Using project management tools to guide activity
  • Building trust: Making concerted efforts to build trust between all stakeholders who need to be involved in a PIE journey or further systems change activity is crucial.  We’ve learnt that this is a bedrock of all good partnership working and when we have built trust effectively, this has led to the most impactful outcomes.

Author:

Rebecca Rieley, Systems Change Lead

For further information about Fulfilling Lives work in this area, please contact:

Rebecca Rieley, Systems Change Lead:

rebecca.rieley@sefulfillinglives.org.uk  

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Health Inequalities: Contributing to national and local consultations

Fulfilling Lives South East

Contributing to national and local consultations

For Fulfilling Lives South East (FLSE), engaging in formal consultations is a way of influencing systems change and connecting with key decision makers.

Engaging in consultations provides a way of informing and influencing the development and delivery of a project or programme, the commissioning or delivery of a service, or the development of a strategy or policy. Consultations offer the opportunity to engage with national Governmental agencies and public bodies, Local Authorities and Commissioners, in a dialogue to help them better understand your needs and opinions, which they will consider when developing policy and delivering services. Engagement in formal consultation provides one of the greatest opportunities for marginalised communities and voices to be heard in spaces which are not traditionally accessible.

The Kings’ Fund advocates that ‘people and communities using health and care services are best placed to understand what they need, what is working and what could be improved.’ Formal consultations provide an opportunity for those using services to have their say. 

The FLSE team has used opportunities to participate in consultations for this reason; to promote the voices, experiences and views of people with experiences of multiple and complex needs (MCN). In our work to tackle health inequalities, we participated in and contributed to the following four health-related consultations nationally and locally:

We have welcomed the opportunity to address and highlight inequalities for people experiencing MCN and feel that these consultations are symptomatic of a system that is ready for change and looking to listen to lived experiences. 

This blog contains an overview and summary of our responses, our messages and reflections on how the system can continue to improve. We also share our way of engaging with health-related consultations to encourage more agencies to engage in these opportunities as a way to champion the views of, and improvements for, the people they support.

Co-production and consultations

For all our responses to consultations, we have worked with the Service User and Engagement Team, volunteers and experts by experience, to build and shape our messages and recommendations. We think it incredibly important to represent our clients and amplify their voices when feeding into consultations and help tell their stories to demonstrate what impact (positive or negative) current local and national policies are having on their lives.

Louise Patmore, Programme Lead Participation Mental Health Collaborative with Sussex Health and Care Partnership, who we have closely worked with says that

‘‘Co production is so important in the transformation and development of our services in health. For many years we have had a “doing to” way of working and people have not been able to have effective choice or control over their health care. It is recognised that health seems to have a very specific problem about providing patient needs versus organisational want, be that financial saving or accommodating new services. Co production enables – or should – enable us to be able to hear from those that actively use services and its impact. We need to be open hearted and minded to the voice of people, especially those that have specific needs. Society is always judged on the way it treats the less able. We need to be able to think differently and using coproduction to be able to shine a light on our issues, become more transparent about them and work together in a diverse way to find solutions can only help to improve our services and provide better, more efficient ways of supporting people and reducing pressures on the system and making sure that people get the right type of treatment at the right time. It will help us with efficiency and economy but only if we truly coproduce and share power.

The people who participate benefit from inclusivity and services are known to become better the more involvement there is. It helps us to grow a listening culture and a more empathic culture that also supports staff wellbeing.’’

Similar sentiments have been expressed by Ian Harrison, our Coproduction and Engagement worker:

“Co-producing consultations with people with lived experience is a must.  Our review of the Mental Health Act would not have been as in depth or as targeted without the contribution of one our volunteers.  The breadth of knowledge from their personal experience and their past work with people of this cohort surpassed our own by a large margin in particular areas.  Without their expertise and detailed knowledge of specific parts of the system and its effects on those it is designed to help, valuable information during a pivotal moment could have been lost, and the opportunity to affect change in a key area would have been missed.”

1. The Mental Health Act- review

Since our submissions and previous blog post, the government responded to the Mental Health Act (MHA) review and we are happy to see an acknowledgement that the MHA doesn’t always work for patients, their families and carers. Our full blog to comment on the government’s next steps can be found here. We welcome the new guiding principles of choice and autonomy, least restriction, therapeutic benefit and the person as an individual in the Mental Health Act Review as the focus is now shifting to a more person-centred approach. 

However, we are uncertain how the proposed changes in the MHA can lead to increased funding into services and equity in place-based mental health care provisions and hope the Government can clarify this during 2022. 

2. The East Sussex Mental Health Inpatient Consultation

The FLSE team was keen to participate as we know that over 75% of FLSE clients have a self-identified disability, of which 84% had a mental health problem. We contributed extensively to the East Sussex Mental Health Inpatient-consultation and our suggestions and recommendations have been incorporated into the future service design plans for a new inpatient facility that will be built in Bexhill by 2024.

After multiple consultations and workshops throughout 2021 with the East Sussex Mental Health Inpatient Consultation team, we had representation from volunteers and experts by experience, the full report has been published.

”In best practice public consultation, understanding the potential impacts of proposed changes to public services on vulnerable individuals and groups is vital. While every effort is made to reach out to these groups during consultation and engagement, there are often challenges and barriers to hearing first-hand feedback; this is perhaps particularly the case for those with multiple complex needs who may be experiencing crises or difficult personal circumstances.

In this context, the support and input of organisations like Fulfilling Lives South-East are invaluable; in a recent consultation around inpatient mental health services, the FLSE team took the time to take part in an interview with Opinion Research Services (ORS) researchers and a workshop for stakeholder organisations, and to prepare and submit a detailed response for inclusion in the final feedback report. The combination of professional expertise and lived experience that FLSE were able to bring to bear meant that the insights they provided via ORS contributed valuable evidence for conscientious consideration by senior leaders and decision makers in the NHS.”

Charlie Wilson, ORS Senior Researcher and Public Consultation Lead, sharing his reflections on the impact of the FLSE engagement with the consultation.

3. The Women’s Health Strategy

Throughout 2021, there was a call for evidence to inform a new national Women’s Health Strategy. This call for evidence has now closed and the government has published its Vision for the Strategy in late December 2021.
The Vision document identifies six key areas of improvement: 

  • Menstrual health and gynaecological conditions
  • Fertility, pregnancy, pregnancy loss and postnatal support
  • The menopause
  • Healthy ageing and long-term conditions
  • Mental Health
  • The health impact of violence against women and girls

The full Strategy will be published in spring 2022 but in the meantime, we have written a letter to Maria Caulfield MP to share our reflections and recommendations to improve the health of women with MCN for, namely:

  • Women experiencing MCN are underrepresented in consultations;
  • We are concerned that women experiencing MCN have not been named as a separate category in the strategy;
  • We would like to see training on trauma informed approaches and a less siloed approach between physical and mental health throughout the NHS, adult social care and the third sector.

4. B&H Mental Health Crisis House Service- survey

In August 2021 we contributed to the B&H Mental Health Crisis House Service survey organised by the Brighton & Hove Clinical Commissioning Group. This service aims to provide short-term intensive support and care (e.g. 7 days) to patients to avoid hospitalisation.

Following the survey, the Council has put together an ambitious specification and contract for the new Crisis House service and commissioners are now in the process of reviewing applications from the tender.

Looking through the service specification, we are happy to see Multiple and Complex Needs defined in a similar way to FLSE’s definition; as people who experience several problems at the same time, such as mental ill health, homelessness, drug and alcohol misuse, offending and family breakdown.

However, we noted that the new service will predominantly take referrals from the existing mental health trust services (SPFT). We would have liked to see the referral pathway to be widened beyond the SPFT Mental Health Urgent Care Services, with GPs and third sector organisations also being able to refer into the service. The service will have single rooms with en-suite bathrooms and we welcome this and included a recommendation on this as part of our feedback in August, However, we are concerned that there are no female only spaces required in the new specification. The Contract refers to specific patient cohorts who will be a priority for improving access to mental health crisis services, but MCN is not one of them.

On a positive note, there is a commitment for the service to provide support, which is Psychosocial and Trauma Informed, and includes a comprehensive training package for staff on trauma informed care and dual diagnosis. (p.22) We support these approaches as our work highlights how valuable this approach is to building trusting and supportive relationships with people who have MCN.

We are also pleased to see that it is part of the acceptance and inclusion criteria that people can access this service if they are ‘ready to engage with the Recovery Model and have consented to stay at the Service’ (page 17), so that people with a co-existing substance use and mental health needs aren’t excluded. And that the service will link patients with other statutory and voluntary sector services to support a patient’s health, substance misuse, mental health and social care.

Key messages for the healthcare system

Chief Medical Officer, Prof. Chris Whitty, is calling for a national strategy for public health as well as an increased investment in prevention and spending that supports population health to improve the health and wellbeing of coastal communities. The Kings Fund is also calling for a cross-governmental strategy to reduce health inequalities for people with MCN.

FLSE supports both of these national developments and calls locally for:

  1. MCN, or multiple disadvantage, to be named in local and national healthcare policies, strategies, and service contracts and paired with an expressed commitment to meeting the needs of this group. Due to the stark health inequalities faced by people with MCN, their needs must be factored into local Equalities Impact Assessments and given the same profile as other protected characteristics.
  2. Setting up a local review process to monitor deaths of people experiencing MCN and assess progress in improving health inequalities for this group.
  3. Offering choice to patients with MCN as crucial to increasing access to primary healthcare. We call for increased community-based primary care that enables engagement through walk-in clinics and drop-ins as well as healthcare professionals providing outreach into communities to build relationships and deliver care outside of traditional spaces. This can be enabled by scaling up existing good practices as suggested in the FLSE Bright Spots report.
  4. Integrating frailty scores as a routine clinical assessment tool with rapid access clinics to respond to these high frailty scores. This will enable the coordination of care for complex conditions for people with MCN.
  5.  A dedicated funding stream within Sussex’s new Integrated Care System to support the needs of people experiencing multiple disadvantage. This would be a vehicle to promote the commissioning of a cohesive, joined up healthcare response to meet the needs of this distinct group of people. 
  6.  Trauma-informed practice training to be delivered to all healthcare staff members to help improve communication with and service approaches for people experiencing MCN.

Reflections on the benefits and limitations of consultations

FLSE is aware that consultations provide an excellent opportunity for changing and influencing key decision makers. We have however noticed that the way they are being advertised for is inconsistent, irregular and at short notice. It can take the form of completing online questionnaires and surveys, and drafting reports in response to calls for evidence.

We understand that some organisations don’t have the resources or capacity to participate in the consultation process. Nevertheless, engagement in formal consultation provides one of the greatest opportunities for marginalised communities and voices to be heard in spaces which are not traditionally accessible.

Authors:

Michaela Rossmann, Systems Change Officer

For further information about Fulfilling Lives work in this area, please contact:

Michaela Rossmann, Systems Change Officer

michaela.rossmann@sefulfillinglives.org.uk

Rebecca Rieley, Systems Change Lead:

rebecca.rieley@sefulfillinglives.org.uk  

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The Intermediate Care ‘Step Away’ model

Fulfilling Lives South East

A holistic community support approach with testing of frailty score-based interventions

Sharing learning

In 2021, the Brighton Homeless and Inclusion Health Specialist Service with Sussex Community NHS Foundation Trust secured funding from the Department for Levelling Up, Housing and Communities and Brighton & Hove City Council to deliver an Intermediate Care ‘Step Away’ programme. This required a multi-agency approach between medical experts, nursing and other allied health professionals to provide support for homeless and insecurely housed patients in the community after being discharged from hospital.

Fulfilling Lives South East (FLSE) is committed to improving systems and services locally for people experiencing multiple and complex needs and a partnership has been formed between our teams to share learning with the wider system by establishing a Steering Group for the agencies involved in the ‘Step Away’ service.

Our data collection gives an overview of the patients supported by the ‘Step Away’ service:

  • Between May 2021 and January 2022 a total of new 33 patients have been referred.
  • Most patients were aged 40 to 59.
  • Two thirds were male.
  • 55% of patients had further support needs such as drug and alcohol dependency and mental health issues.
  • Most patients lived in hostels, temporary accommodation, emergency accommodation or sleeping rough.

FRAILTY

One element in particular has stood out in the Step Away service data:.  patients were a lot more frail than the average population in the same age category. The Step Away team and FLSE started to focus our attention to this element of the service and build up a better picture of the patients.

The Edmonton Frail Scale, has been used as the chosen assessment tool for frailty and anyone trained is able to use it not just healthcare professionals. The Edmonton Frail Scale covers cognition, general health status, functional independent, social support, medical use, nutrition, mood, continence and functional performance.

Our findings were worrying – more than half the patients had moderate and severe frailty.

OUR LEARNING

We have shared our learning from the ‘Step Away’ service at the Pathways from Homelessness Conference in March 2022 to a wide audience.

We know that a small group of complex patients have more intensive support and care needs. The frailty score is a key tool to identify people’s level of support and care needs, incl. poly-pharmacy issues and raising concerns around personal care needs and mobility.

It is a tool to communicate well the health and care needs of another person to different parts of the wider support system, such as housing and adult social care teams, without too much clinical language. This makes it more accessible across professional teams sitting in different parts of the system. It also helps younger patients to better understand their own frailty and the implications this may have on their lives.

WHAT WE WOULD LIKE TO SEE NEXT

  1. Frailty scores need to be integrated into housing options assessment tools to help allocate care and support 
  2. Investment in a one-stop-shop clinic to respond to the moderate and severe frailty scores (especially for patients with multiple and complex needs) – this will improve accessibility to services and lead to better diagnosis and clinical investigations 
  3. Long term substance use to be seen as a chronic health condition – this impacts on frailty of patients. We support the recent Dame Carol Black review where she called on the government and society to recognise addiction as a chronic health condition

The full presentation the team delivered at the Pathways from Homeless conference 2022 can be found here.

Authors:

Michaela Rossman and Rebecca Rieley

For further information about Fulfilling Lives work in this area, please contact:

System Change Officer

michaela.rossmann@sefulfillinglives.org.uk

Rebecca Rieley, Systems Change Lead:

rebecca.rieley@sefulfillinglives.org.uk  

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