CGL Women’s Hub: A new Treatment Pathway?

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

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)

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

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

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

Within our contribution to the Sussex needs assessment, FLSE made a specific recommendation for women with MCN to be named and considered in the strategy. We are delighted to see ‘Responsive to Multiple Disadvantage’ listed as one of six key strategic priorities in the finalised strategy published in January 2022. This priority establishes the need for specialist provision to support victim/survivors with MCN, and makes recommendations for Sussex local authorities, specialist domestic abuse accommodation providers and support services to holistically support those with MCN, whilst ensuring accessibility of services.

We also raised concerns around limited and unsuitable move-on options for victims/survivors with MCN. We highlighted the benefits of adopting a ‘Housing First’ model paired with specialist DA wrap-around support, in ensuring accommodation is appropriate to MCN and simultaneously provides a long-term housing solution. As a result, the strategy commits to exploring accommodation and support options appropriate for the needs of survivors with MCN including short-term respite facilities, specialist housing, move-on pathways, and long-term floating support.

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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Training for future Social Workers

Positive Partnerships towards a Trauma-Informed Workforce


In autumn 2020, the Fulfilling Lives South East (FLSE) Area Lead, together with the Systems Change Officer reached out to Lucy Basterra, Senior Lecturer in Social Work at the University of Brighton, to offer training sessions around working with people experiencing multiple and complex needs (MCN) and experiences of repeat child protection processes. The idea was to influence social workers’ attitudes and behaviours before they start practising social work as their profession.

Issues faced

FLSE understands that Social Workers play a key role in providing support to people experiencing multiple disadvantages and MCN. Following our research and front line experience, we developed a Manifesto for Change, with emerging themes and commitments. One of which is about supporting women through repeat removals of children. Our commitment states: For women with MCN to not suffer stigmatising practice (e.g. from antenatal and post-natal healthcare providers, courts, police, GP and Social Services).

In our previous blogs on this theme, we have explored the gaps women with multiple and complex needs often fall through and the issues that arise when the working practices of social services don’t respond flexibly and creatively to these needs.

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. 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. 

Quote from our 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.” 

What we did

Our partnership with the University of Brighton, has provided us with a platform to reach future social workers and provide an enhanced understanding of multiple disadvantage, encouraging the students to consider the intersecting issues faced by their future clients and to respond in ways that are adaptive to the complex needs and informed by experiences of trauma.

FLSE delivered two guest lectures on the subject of ‘Trauma Informed Practice (TIP) and working with people experiencing multiple and complex needs (MCN)’ in November 2020 and January 2021. These sessions were co-produced with front line staff, project consultants, volunteers, experts by experience, the learning and impact team as well as the systems change team. Following their success, FLSE were invited to deliver the lectures again to the next year’s cohort of students. In January and February 2022, two guest lectures were held, one online and one in-person, which again received overwhelmingly positive feedback, highlighting the importance of teaching students about trauma informed practices, and working with people experiencing MCN.

Student feedback on the training sessions

I found this session really useful and was really comfortable to engage with the facilitators. I found this session to be a safe place to ask questions, be curious and think outside my box”.

I found the information provided about MCN and trauma very useful and will definitely look more into this and take it into the future. Also information around women and repeated pregnancies interesting, as it was topic I was debating recently”.

I really enjoyed the session, especially the way that each breakout group had an assigned practitioner as it allowed for a detailed group discussion. I was also really impressed with the passion each of the workers showed”.

The practice examples were really interesting, and I learnt some important skills for building relationships with service users who have experienced trauma”.

The need for trauma informed practice and unconditional positive regard for the client. Be strength and person focused. Work as part of a team around the person and celebrate small wins for the client. The need for long term approach”.

“I have learnt about the importance of considering language used (terms such as label) and how this can impact on the clients we work with.  Thus, learnt to challenge the use of such terms”.

“Thank you for the training. I am working with a mum who has had 2 children removed and has a learning disability, ADHD and poor mental health. I have often had tense, difficult conversations with her, and I think I may have been dismissive at times. Your presentation has opened my eyes and made me realise what she has gone through.  I feel better able to support her and her children. Thank you”!

“In social work we focus on the children and keep them at the centre of our practice.  This has helped me consider the wider impact on the parents”.

Feedback from Lucy Basterra, Senior Lecturer in Social Work at the University of Brighton

“It has been a pleasure collaborating with the Fulfilling Lives team, and it is clear from the feedback that the team’s expertise and passion has made a positive impact on students’ learning.  From my perspective, as a lecturer in social work with a practice background in working with people experiencing multiple disadvantages, it is vital that we bring the voices of an often-marginalised group of people into the teaching and training of social workers.  Fulfilling Lives were able to do this by putting together a session which kept service users at the heart of the content, while also offering expert knowledge from a practitioner perspective.  Linking the themes that were covered with broader concepts of trauma-informed care means that the learning is applicable to any setting our students go on to practice in. The resources and case studies that Fulfilling Lives have shared will continue to be put to good use across our programmes where applicable and will add depth and insight into the experiences of people with complex needs as well as the practice tools and approaches best-placed to support practitioners in their work”.

Reflections from the facilitators

Participating as a facilitator in the training as a volunteer with FL has been an invaluable experience that I am proud I was part of. An important part of healing and growing is the ability to use past experiences, good and bad ones, in order to help and support others, but that’s not always easy. I thought taking part in this training would help me gain some confidence and trust in myself.  I’m really grateful I got to do that in a very professional and human environment, working alongside staff members while being supported step by step.

I think the training was a highlight for everybody involved, and it was great to read the feedback left by students, it made me realise what a great achievement to have been part of shaping, through our efforts, a next generation of a trauma-informed social workers”. – Linda, FL Volunteer

As a member of the Service User Involvement team with lived experience of MCN it has been extremely rewarding to play a role in the development and delivery of training for social work students. In addition, mentoring volunteers to develop new skills they are interested in, and working together on them achieving each step to get to where they want to be, is a part of my role I feel really privileged to be doing.

Linda has worked with Fulfilling Lives as a dedicated volunteer for a year and a half and seeing her get to the stage of presenting slides in training to a room of people is testament to how hard she has worked. People with lived experience can bring a unique and valuable insight to our work, but beyond that learn and bring skills that have really supported our project in achieving its own goals. I would like to thank the volunteer involved for being part of our team and congratulate her on her achievements.

This training has been a great example of co-production in action. Bringing together the expertise of frontline staff, diverse lived experience voices, and knowledge from our systems change work. It’s great to hear the feedback that the training was valuable to the students.” – Vikki, FL Engagement and Coproduction Worker

Legacy

One of the main objectives of Fulfilling Lives nationally and locally is to work in partnership with organisations and institutions to nurture system change to help with the development of accessible, responsive, flexible and coordinated approaches for those with the most complex needs.

We are conscious that social workers and social work students are key to how social services are being delivered and perceived from a service user point of view. We are keen to help develop skills and approaches for future professionals.

The positive impact of the collaboration between FLSE and the University of Brighton has resulted in a commitment to continued use of Fulfilling Lives resources on MCN, Trauma and the repeat removal of children into care. Having these key resources being integrated into educating our future workforce is a legacy we are proud of and shows the importance of collaboration. 


Authors:

Eve McCallam, Systems Change Officer

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

Systems Change Officer

eve.mccallam@sefulfillinglives.org.uk

Rebecca Rieley, Systems Change Lead:

rebecca.rieley@sefulfillinglives.org.uk  

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Building inclusive goals in Sussex  

Engaging in the development of a Pan-Sussex Strategy for Domestic Abuse Accommodation and Support


Setting the scene

Part 4 of the Domestic Abuse Act, which achieved royal assent in April 2021, placed a new statuatory duty on local authorities to assess the need and commission support to victims of domestic abuse (DA) and their children in safe accommodation services in their areas. Local Authorities were required to conduct a local needs assessment and prepare and publish a strategy for the provision of such support, and to monitor and evaluate the effectiveness of this strategy.

At Fulfilling Lives South East (FLSE), we know that women who have multiple and complex needs (MCN) are disproportionately affected by DA yet are often felt to be the most challenging to reach for consultation activity and service design and as such, are most at risk of not having their voices heard and needs met. This is a group that services most struggle to build trusting relationships with, and as a result often fail to provide appropriate, person-centred, empathetic support. This is why FLSE is passionate about sharing these women’s voices through coproduction.

What we did

In August 2021, FLSE submitted a report to the Sussex Local Authority Project Team in the Office of Sussex Police and Crime Commissioner (OSPCC), which focused on the needs of women with MCN, to support the development of the Brighton and Hove City Council, East Sussex County Council and West Sussex County Councils, Pan Sussex Accommodation Based Support Needs Assessment. When writing this report, we adopted a co-produced approach by including staff and volunteers with lived experience of complex needs and domestic abuse in the process, including attending and participating in planning meetings, in-depth research of our case study database and in writing the final report. The evidence presented was gathered from our client work and FLSE volunteers and staff to express both the needs of this group of women as well as their reflections on how the wider housing and support system can be developed.

Members of the FLSE team also attended an online market engagement event to consult on specialist refuge accommodation for those with MCN, hosted by East and West Sussex County Councils. We reflected on the needs of women with MCN who experience domestic abuse and facilitated discussions on the various operating models for refuge provision and the factors that need to be considered when designing these services.

Upon the release of the draft Pan-Sussex strategy for domestic abuse accommodation and support in October 2021, the FLSE project group presented a subsequent report to the OSPCC, to support their public consultation. This expressed our impressions of the draft strategy, identifying what we were pleased to see and areas for improvement. Project group members also completed the online survey conducted by the County Councils to share feedback on behalf of our organisation.

Measuring our Impact

Within our contribution to the Sussex needs assessment, FLSE made a specific recommendation for women with MCN to be named and considered in the strategy. We are delighted to see ‘Responsive to Multiple Disadvantage’ listed as one of six key strategic priorities in the finalised strategy published in January 2022. This priority establishes the need for specialist provision to support victim/survivors with MCN, and makes recommendations for Sussex local authorities, specialist domestic abuse accommodation providers and support services to holistically support those with MCN, whilst ensuring accessibility of services

We also raised concerns around limited and unsuitable move-on options for victims/survivors with MCN. We highlighted the benefits of adopting a ‘Housing First’ model paired with specialist DA wrap-around support, in ensuring accommodation is appropriate to MCN and simultaneously provides a long-term housing solution. As a result, the strategy commits to exploring accommodation and support options appropriate for the needs of survivors with MCN including short-term respite facilities, specialist housing, move-on pathways, and long-term floating support.

Reflections and Recommendations

Engaging and consulting in the development of the Pan-Sussex strategy for domestic abuse accommodation and support provided space for FLSE to have an open channel with local commissioners to share our learning and support the commissioning teams to engage with discussions about the needs of those who experience domestic abuse as one of several complex and intersecting needs. We believe that this was best achieved by giving prominence to the voice of those with lived experience:

‘’The contribution and time invested by the team in providing Sussex with the lived experience work demonstrated to us and further strengthened the importance of ensuring better support is provided to survivors with MCN…by being given the opportunity to corroborate our findings with lived experience feedback was invaluable and helped provide a more meaningful evidence base for our recommendations’’ – Commissioning Project Manager, OSPCC

With the strategic goals in place, we are hopeful that many women with MCN experiencing domestic abuse will have improved opportunities to access appropriate safe accommodations and would be more likely to reach out for help and support. However, in order to break down current barriers experienced by those women with MCN, local authorities, commissioned services and the wider support system must develop tangible action plans that will operationalise the commitments made within the strategy and bring the voices of experts by experience to the forefront.  


Authors:

Emily Page, Systems Change Project Assistant

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

Systems Change Project Assistant

emily.page@sefulfillinglives.org.uk

Rebecca Rieley, Systems Change Lead:

rebecca.rieley@sefulfillinglives.org.uk  

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How Multiagency Forums Can Influence Systems

The Fulfilling Lives South East’s (FLSE) ‘Perspectives Project’ researched what good psychological support can look like for people with co-existing mental ill-health and substance use, prior to accessing formal substance misuse treatment. The aim was to identify new ways of working through learning from professionals who support individuals experiencing multiple and complex needs (MCN), providers or commissioners of substance misuse and mental health services, and sector leaders.

Many contributors stressed the importance and urgency of linking mental health and substance misuse provision more coherently, with one person reflecting.

I fundamentally believe that joined up working should be an absolute minimum… Operational teams shouldn’t be reliant on building good relationships with other agencies, collaboration needs to be built into service design.“


The objectives of both Brighton & Hove, and East Sussex Coexisting Conditions Steering Groups, echo The Perspective Project research findings and seek to strengthen working relations between mental health and substance misuse services at both operational and strategic or system level. In this blog we explore the journey of these Groups and reflect on their potential to positively impact the system in the future.

The Coexisting Conditions Steering Groups – formerly the dual diagnosis steering groups – in Brighton & Hove and East Sussex, are chaired by FLSE. The membership includes both statutory and non-statutory organisations including local commissioners, as well as leaders from mental health and substance misuse services and representatives from housing and the criminal justice system. The groups aim to be a source of learning and development to improve services for those who have coexisting conditions. The strategic overview that members of the groups have places a strong emphasis on deepening collaboration and partnership working across sectors. Through its membership the group promotes and shares relevant information, learning and best practice with the aim of increasing the knowledge and confidence of staff working with people who have coexisting conditions. As well as information sharing an important role of the group is to map the prevalence of coexisting conditions across Brighton & Hove and East Sussex. This involves working towards improving the identification and monitoring of coexisting conditions, leading to a better understanding of the gaps and barriers in our local areas and informing improved service responses.   

Prior to these forums, there was no dedicated space to discuss co-existing conditions in a multi-disciplinary setting.

As part of the group’s evolution, FLSE is supporting commissioners and group members to consider how these groups could sit within more formal local healthcare governance structures. FLSE believe the work of the current Coexisting Conditions Steering Groups should be integrated into local governance structures to enable coexisting conditions to be addressed more strategically.

What can the Co-existing Conditions Steering Groups offer the system?

We think there are three areas where the expertise and established relationships within the Coexisting Conditions Steering Groups in both Brighton & Hove and East Sussex can contribute to furthering the aims of a more co-ordinated approach to working with individuals experiencing multiple and complex needs. With the ending of Fulfilling Lives there is a need to find capacity within the local system to support and evolve this work.

Firstly, we think a local strategic plan is required to advocate for the needs of individuals experiencing MCN. The newly formed Integrated Care System, Sussex Health, and Care Partnership (SHCP) could lead on devising this plan. The Changing Futures Programme for Sussex is  well placed to provide additional resources to advise the ICS on policy requirements needed to realise the Black Review’s recommendations on re-establishing local partnerships.  The Coexisting Conditions steering groups could provide the space for such planning and reviewing the effectiveness of these plans.

Secondly, we think Multiple and Complex Needs (MCN) and Multiple Disadvantage should be clearly named in local healthcare policies, strategies, and service contracts and paired with clear commitments to meet the needs of this distinct group. Due to the stark health inequalities faced by people with MCN, their needs should be factored into local Equalities Impact Assessments and given the same profile as other protected characteristics. The Coexisting Conditions steering groups can advise on how these assessments could be accrued out and what would most need to be considered.

Thirdly, building on positive commissioning efforts dedicated Coexisting Conditions roles have been created in both substance misuse and mental health services across Sussex.  We call on the leaders of these teams and commissioners to consider co-location of these individuals. This would enable a more joined-up service response, pave the way for further development of joint working protocols and explore potential for a jointly commissioned service in the future. The Coexisting Conditions steering groups could help review the impact of these teams and guide future developments.

The Coexisting Conditions Steering Groups are a good illustration of the value local multiagency groups can play in championing continuous improvement and change. However, it is only when these groups become fully integrated into local governance structures that more systemic change for those experiencing co-existing conditions can be achieved.

In our next blog exploring coexisting conditions and multiagency forums, we will take a closer look at the ‘Coexisting Conditions’ operational forums held monthly in Hastings and in Eastbourne. These were set up to support operational developments and we will look at the impact they are having in shaping the system, promoting cross-sector collaboration and strengthening client support plans.


Author:

Alan Wallace, Systems Change Officer

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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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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