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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Working with the DWP (not against them)

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


Co-Production and driving change

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

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

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

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

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

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

Coming up

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


Author: Alan Wallace, Ian Harrison

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

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

Or

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

For more information sign up to our newsletter:

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Making Systems Change Stick   

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


First Steps

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

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

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

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

The first stages of working with the DWP

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

Creating Partnerships

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

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

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

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

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

Changing Culture and Outlooks

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

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

Changes

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

Coming Up

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


Author: Alan Wallace

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

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

Or

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

For more information sign up to our newsletter:

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A New Approach: The Trauma Stabilisation Pilot  

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


The Problem

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

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

The Complexity

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

The Pilot

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

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


Author: Gemma Harfleet

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Fulfilling Lives Responds to the Domestic Abuse Act 2021

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

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

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


Time to reflect, review and re-think

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

Naming ‘Multiple Complex Needs’

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

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

FLSE Manifesto for change

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

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

Sandra, Systems Change Officer

A spotlight on ‘safe accommodation’

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

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

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

What next?

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


Author: Emily Page

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

Unfamiliar places – The impact of out of area placements

Looking at out of area accommodation placements and the impact on people with multiple complex needs


In the last seven years, Fulfilling Lives has supported people with multiple and complex needs (MCN) to get access to suitable housing. The particularly acute housing shortage in the South East means that higher numbers of people with multiple and complex needs are being placed in unsupported temporary accommodation, including out of area placements, and are remaining in this accommodation for longer.

This crisis of supply has led to local authorities placing some people who require housing out of area. Fulfilling Lives client data shows that out of area placements were offered by a local authority to our client group 20% of the time. This presents people with multiple and complex needs with impossible decisions around choosing between receiving the support they need or accepting accommodation out of area.  As a result, only 10% of out of area placement offers made to our clients were taken up.

The Issues

Relocating away from their local area creates a range of issues for people experiencing multiple and complex needs, such as –

  • Being unable to benefit from outreach services
  • Support workers are unable to effectively monitor well-being
  • The area is unfamiliar, so it is difficult to find services and facilities
  • Financial problems e.g. travel costs and council tax
  • Living away from social and personal support networks

In 2015, a Supreme Court ruling brought greater attention to the issue of out of area placements. Titina Nzolameso, a single mother of five children, was evicted from her home in Westminster and after making an application for housing support, was offered a house in Bletchley, Milton Keynes (approximately 50 miles away). Ms Nzolameso turned this offer down on the basis that she had already been a resident of Westminster, had on-going health concerns and did not want her children to have to change schools. Nzolameso decided to take her case to the Supreme Court, and the Court ruled in her favour. The case has impacted housing practice across the country and many local authorities subsequently reviewed and updated their allocations policies following the ruling.

Recommendations

A report completed by Fulfilling Lives and the University of Brighton reviews the policies relating to out of area accommodation placements of Brighton and Hove, Eastbourne and Hastings local authorities and sets out recommendations for how these policies can better support people with multiple and complex needs. 

Key recommendations:

  • All local authorities should publish their Temporary Accommodation Allocation policies publicly online. This provides greater transparency and clarity in order to avoid misinterpretation in practice and to ensure that clients and their support networks are aware of the allocations criteria.
  • Out of area placements are rarely suitable for people with multiple and complex needs and local authorities should make every effort to house this group in their local area.
  • The Nzolameso case should be revisited by local authorities and the learnings reviewed to ensure compliance with best practice in all areas.
  • If people with multiple and complex needs are offered a placement out of area and they refuse it, they should not then be considered ‘intentionally homeless’ and the local authority should continue to carry out its duty to house the person.
  • Should an out of area placement be unavoidable, the local authorities should maintain regular contact with the host local authority to ensure that there is continuity of care and intensive support available to people with MCN.
  • There should be cross county discussions between local authorities around supporting each other with out of area placements. There are similar challenges named by each local authority and we feel dialogue between local authorities and the production of joint working protocols would be useful steps.

Read the full report on out of area placements here: https://bit.ly/3zTiV5h


Author: Eve McCallam

Hospital discharge – a road to recovery?

Reflections on the experiences of patients with complex needs and thoughts on how discharge approaches can be developed


At Fulfilling Lives South East, we’ve seen how hospital discharges can be a challenging time for patients with multiple and complex needs (‘MCN’). Our client casework has shown us how clients are often discharged to unsuitable accommodation, or to the street in the very worst of cases.  The NHS is a complex system, and in the area of discharge this complexity is compounded by the fact that there is a shared responsibility with Adult Social Care for discharge planning in complex cases.

Hospital discharge – Case example:

S is a female homeless client who had been in hospital for five weeks. She was diagnosed as suffering from endocarditis, with damage to the mitral valve, two thalamic infarcts and two cysts on the brain. At the beginning of week six, despite her being homeless, it was recommended that she be discharged and that she “go home and gain further weight and return after a month to review her health ahead of a referral for heart surgery”.

In April 2021, FLSE and the Brighton Healthwatch Hospital Discharge Project invited organisations from the Voluntary and Community Sector as well as the NHS to discuss how hospital discharge for people experiencing MCN can be improved.  The overarching themes identified were that community mental health support services are stretched and can be difficult for patients to access after hospital discharges but also that hospital discharge means different things to different organisations. We understand that the health, social and third sector are funded and set up quite differently and this runs the risk of services being fragmented which in turn contributes to the difficulties when supporting patients and clients. These difficulties include challenges around information sharing and communication between services and lack of knowledge on where to find the right support depending on referral criteria and thresholds.

At Fulfilling Lives, we have dug deeper into the processes and procedures of hospital discharge and challenged ourselves to articulate what a better hospital discharge system could look like. This involved a focus group of specialist workers who support people with multiple and complex needs, systems change staff and those with lived experiences of hospital inpatient and discharge procedures.  Our key thoughts are outlined below.  

Key Thoughts

Underpinning PrinciplesWe feel that all processes should be informed by the following principles

  • Support starts early when planning for hospital discharge with the first paramedic / GP / professional contact. These people help inform the patient’s needs and contexts that should be considered in discharge plans.
  • Treatment will be delivered in a Psychologically Informed Environment (‘PIE’) which respects privacy (i.e. no interviews in glass interview rooms) and client ‘agency’ i.e. respects the fact that the client is in the room and isn’t ‘spoken about’ as though they are not.
  • Being human   We want the best medical outcomes for clients and understand that this is best supported by recognising the humanity of the client and taking a trauma informed approach to their care and recovery.
  • Ensure that the client’s voice is heard early in the process and consistently throughout.
  • Hospital discharges for people with multiple complex needs will have clear accountability and oversight within the healthcare system.
  • Discharge planning takes patient’s outside circumstances into account and reflects their impact on health – this will require consistent consideration for health determinants not just the presenting clinical healthcare needs.
  • Recognition that in-patient treatment, including the impact of medication, can impact on a patient’s ability to make decisions.

Underpinning Behaviourswe believe that certain professionals’ behaviours enable successful hospital discharges.  

  • Demonstrating kindness and flexibility is key to providing reassurance to people with MCN who have had multiple negative experiences of support services.
  • Creating opportunities for friendly conversation is important to minimize the perception of care being perceived as ‘business like’ or the patient feeling unwanted in the hospital and helps to build trust.  The client will be alert to any signs that they are being judged in a negative way and will be at high risk of self-discharging.
  • Be mindful of one’s own stigmatising views and unconscious bias. Be aware that factors such as workplace stress and our own health and wellbeing will have an impact on our work.  Take active steps to maintain your equilibrium and expect the workplace to support your performance through supervision, reflective practice and other means.

Toolsenabling factors that will support positive hospital discharges

  • The hospital will keep details of the client’s support network.  This will include details of community-based professionals trusted by the patient to help them communicate with the hospital and likely provide care post-discharge.
  • Published policy regarding MCN patients including standards relating to discharge planning.
  • Explicit monitoring, and management of hospital discharges for patients with MCN.
  • Training in trauma informed care for staff at all levels of the hospital to support effective engagement, communication and support for patients with MCN.
  • Mechanisms for feedback that enable feedback from the voices people with lived experiences to be easily captured and learnt from with minimum bureaucracy.
  • A strategy to tackle ‘self discharges’ and unplanned exits from hospitals.

Ideas

Ideas for hospital discharge protocols – tangible practices that we feel can inform hospital discharge protocols for patients with MCN

Admission

  • Patients with Multiple and Complex Needs (MCN) should have a risk assessment and support plan to improve the prospects of the patient engaging with the full course of treatment and reduce risks of unscheduled discharge.
  • The client’s admission paperwork will include the contact details of support staff who can help the patient communicate with the hospital and articulate their views. For patients with MCN, this may include social workers, mental health nurses, GPs, probation workers and members of the voluntary sector. The ward staff are encouraged to help the patient liaise with that support network to ensure that they are included in the whole process.
  • The admission will take an overview of their housing situation, pets, family and medication. The client may need help to pack a bag or provide themselves with the things they need for a stay in hospital. 
  • In an unplanned admission the multiple and complex needs of the patient will be recorded by the Accident and Emergency team (or earlier where the patient has received an initial assessment by a paramedic) and communicated to ward staff when that patient is admitted to a ward. 
  • At admission, or preferably before, there will be an assessment of the patient’s safety and needs.  This assessment will include drug and alcohol use, issues concerning visitors and issues of domestic abuse.            
  • We would also recommend informing the patient’s GP of the hospital admission.

As mentioned in the Mental Health Act Review 2021 (Chapter 4), we support the idea of strengthening the patient’s right to refuse and choose treatment.

We would like patients to have:

  • greater influence over decisions about their care and treatment,
  • their wishes and preferences respected and followed
  • the opportunity to challenge their care and treatment if their wishes are not followed. 

FLSE would like to see an ‘advanced choice document’ across all healthcare sectors, physical and mental. With a system in place that communicates between services, information sharing is increased which in turn helps patients to feel more confident and less stigmatised.

We would strongly encourage for the healthcare system to introduce this trauma informed approach.

To read more about how we contributed to the Mental Health Act Review please see our blog post here.

Discharge

  • We would strongly suggest that prior to discharge of a person experiencing MCN, Adult Social Care is required to assess the patient’s needs. This would include closer collaboration between discharge coordinators, social workers in hospital and Adult Social Care.
  • Ideally, a multi-agency health and complex needs forum is created to discuss more vulnerable patients. This is to make sure that a support system is in place prior to discharge. This includes informing GPs and other non medical support networks of the discharge and we are aware that in Brighton & Hove there is such a forum to discuss patients with complex needs to support their care in the community – this is an approach we support.
  • In our experience, patients with MCN being discharged on a Friday is difficult. This is because there is sometimes not enough time to organize and set up support for the weekend and the accommodation they may need, especially when at risk of homelessness.
  • The patient’s GP would be notified of the discharge and given the community care/discharge plan.

Monitoring

  • There will be a specific record kept of the steps taken to include the patients voice including specific details of what they have done differently to capture innovation.
  • Patients with MCN will be recognized throughout the patient record data systems and accountability will sit with an accountable person within the hospital staff team for hospital admission and discharge of those patients with MCN.
  • There will be a loop for patients to be able to provide feedback and suggestions to improve interactions.

Hopes for the future hospital discharge system

During the Connectivity Meeting, it was clear that communication between different services (NHS, social care and the Voluntary and Community Sector) is difficult.

We discovered that hospital-based social workers don’t automatically collaborate with community based social workers and information isn’t being shared with other non-medical support networks. We also learnt that the Voluntary and Community Sector services, as well as mental health services, have long waiting lists and that their services are stretched.

The group has also identified that the different systems feel silo-ed and there are few opportunities for collaboration and smooth discharge transitions into the community.

The below was an attempt to map the different services involved in hospital discharge and how these relate to each other. It prompted us to reflect on the commissioning of services to support hospital discharges and how there is an opportunity for commissioners to improve linkages between services and help the support system organise in more joined up and efficient way.

Image showing connectivity in the system

However, the group also suggested that it would be useful to improve communication between hospital, social care and community teams by introducing joined access meetings. These meetings would focus on all aspects (medical and non-medical) of the patient’s support system and that the patient would be able to join this meeting.

Our conclusion is that the hospitals need to review their discharge protocols and develop revised ways to support patients with MCN through the system. This needs to include mechanisms for joint planning with the patient and their closest support networks.


Author: Michaela Rossmann & Rebecca Rieley

Independent Review on Drugs: Perspectives of women and creative recovery groups

In 2020, the Service User Involvement team at Fulfilling Lives South East fed into the public consultations towards the Independent Review of Drugs by Dame Carol Black, commissioned by the Home Secretary. This blogpost outlines the process of gathering the unique lived experience perspectives of women who had used the substance misuse services as well as creative recovery groups. The findings from our submission have now been published into a report which provides the local context of accessing drug treatment and recovery in East Sussex.


Context

In February 2019, the Home Secretary appointed Professor Dame Carol Black to undertake an independent review of drugs to inform the government’s thinking on what more can be done to tackle the harm that drugs cause. The study took place in two phases; the first phase was published in February 2020 and included a rigorous and ground-breaking analysis to understand the complex and overlapping markets for illegal drugs, which can be read here: https://www.gov.uk/government/publications/review-of-drugsphase-one-report/review-of-drugs-summary.

In July 2020, public consultations began for the second part of the review and focussed on understanding the challenges involved in drug treatment, prevention and recovery and opportunities for improvement. Fulfilling Lives South East Partnership (FLSE) fed into the public consultations though the National Expert Citizens Group (NECG), who were approached to gather the views of people with experience of substance misuse as well as other intersecting complex needs such as mental ill health, homelessness, domestic abuse, and removal of children.

The NECG is a partnership of people connected to all of the 12 Fulfilling Lives projects across the country, who also have direct experience of multiple disadvantages. Their aim is to raise the bar on co-production and to demonstrate how lived experience leadership and insight can change systems and services.

Collecting Insights

As part of our contributions, team members from FLSE’s Service User Engagement team conducted a series of 1-2-1 and group discussions to collect unique perspectives from women who have experienced drug and alcohol misuse as well as with mixed gendered peer-led creative recovery groups. The conversations centred around four questions:

1. How can we make it easier for people to access drug treatment and recovery services, and stay in contact with those services?

2. How can we ensure the mental health needs of people in treatment are met?

3. What is the best way to meet the employment and housing needs of those in treatment and recovery?

4. What else stops people recovering and why might they relapse? What would help?

Summary of Findings

Throughout these conversations there were common threads; regardless whether the individuals were currently using services, had used them in the past, or were themselves providing support at present. These consistent messages highlighted the following:

1. Trauma needs to be addressed as part of any treatment.

2. The need for a holistic approach to treatment and support; mental and emotional health, access to employment and housing, community support, etc.

3. The importance of personal development; rebuilding one’s identity, develop self-esteem, focus on assets, learn healthy interactions and relationships.

4. The power of peers; they act as role models, inspiration and aspiration.

5. The impact of the Recovery Community; that it’s not necessarily focussed on addiction, develops creativity, sense of community, enjoyment and fun.


Author: Aditi Bhonagiri and Nelida Señoran-Martin

The full report on FLSE’s submission with in-depth findings on the lived experience perspectives from our target group for the Independent Review of Drugs by Professor Dame Carol Black can be found here: Fulfilling-Lives-Lived-experience-Dame-Carol-Black-Independent-Review-of-Drugs.pdf (bht.org.uk)

Dame Carol Black’s recommendations on the second phase of the Review can be found here: https://www.gov.uk/government/publications/review-of-drugs-phase-two-report