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

Launch of Guide for Child Protection and Care proceedings, and Women’s Rights Leaflet

An example of co-production activity in action


Download the resources here

These are open-source resources, if you would like to host these resources on your own website please contact michaela.rossmann@bht.org.uk

In our Manifesto for Change, Fulfilling Lives South East (FLSE) identified that women experiencing multiple disadvantage going through child protection and care proceedings should be offered independent advocacy, with the aim of helping women understand each stage of the process, including what is going to happen next.

Our internal Project Group identified a lack of resources available to explain the process of what happens when Children and Family Services get involved.

In January 2021, FLSE created a sub-group which included volunteers, experts by experience as well as other team members to help prioritise the different discussions and we created a mind-map together, shown below.

As a team, and together with SpeakOut, we wanted to ensure that the information is accessible and available. Over the years, clients, front- line staff and experts by experience voiced the need for a leaflet and a simple explanation of the process of what could happen at different stages when social services are involved in childcare proceedings. Together with the sub-group we reflected on this and identified the lack of coordinated information and support. This really did highlight to us the importance of creating new resources to support women with MCN going through care proceedings. That is why FLSE has worked together across teams, with co-production at its heart, to develop and share our Guide to Child Protection and Care Proceedings as well as the new Women’s Rights leaflet.

We are also lucky to have dedicated volunteers and a passionate action group. Their input was crucial on how the resources have been created and designed.

Reflections

Reflections from Linda, a volunteer with FLSE:

The creation of these resources was the first project I helped to co-produce as a volunteer for FLSE from start to finish.


Co-production requires everyone’s involvement, ideas and feedback. Getting feedback on a piece of work that someone has done can be scary or upsetting and was something I was worried about. However, one of the highlights of the project for me turned out to be getting feedback from other volunteers, having them input ideas on how to make the design as accessible and useful as possible, as well as the thoughtful opinions and information provided by the frontline staff team.


I had the opportunity to experience the highs and lows of “getting things done” in a safe, pressure-free environment. It has given me an idea on how services operate (or should operate?) and helped me realise how teamwork is necessary to break down daunting tasks into more manageable steps, thus expanding what can be achieved by people in order to change, and helping people navigate various systems.

Reflections from Vikki, FLSE Engagement Worker:

It has been a privilege to work alongside Michaela and Linda creating this important set of resources. This work is a great example of co-production in action and the positive impact it can have – both on the work produced and the individuals taking part. Linda is a very motivated and reflective volunteer with many skills, and it was great to be working in a project where we place trust in volunteers to take ownership of pieces of work of their choosing and allow them space to shine. She was also able to identify development goals that she would like support to achieve during this process, such as presenting the work to groups of people and incorporating their feedback into the final product.

By consulting with frontline staff, systems change staff, managers and a diverse lived experience group we have ensured our final resources approach this sensitive and potentially triggering topic sensitively and that they will be useful to a wide range of people. Building relationships of trust across teams of staff and volunteers, and holding our meetings in a safe, boundaried, trauma-informed way meant that people felt comfortable using their voice and sharing their opinions.

This project is also an example of a volunteer having value beyond their lived experience – Linda used her lived experience perspective in creating the resources but also drew on other personal and professional qualities to take part in these pieces of work.


Producing such sensitive resources involved lots of conversations with FLSE’s project group, partners like SpeakOut as well as front-line staff and social workers.

For us it was crucial to use the full ladder of co-production to make sure we are inclusive, support people to voice their opinions, give them choices for how they take part, and offer chances to give feedback and build that feedback into the work.
To ensure accountability, our experts by experience actively fed into the design and content of the video, as well as deciding the content and colours of the leaflet. We are very happy that Linda took the leading role in designing the leaflet.

And we are now happy to launch the online guide to child protection and care proceedings together with the Women’s Rights Information Leaflet.

There is still a lot more work to be done to ensure women experiencing MCN and recurrent child care proceedings are being fully supported across systems and we continue taking steps to minimise this gap.


Authors:

Vikki – Project Consultant
Linda – FL Volunteer
Kate Jones- Project Consultant
Michaela Rossmann- Systems Change Officer

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

Housing Assessment – a guest perspective

Fufilling Lives South East has collaborated with the University of Brighton to conduct research on how local authorities can effectively support people with multiple and complex needs during the housing assessment process. The work draws together interviews with Fulfilling Lives Workers and existing academic research to present a detailed list of recommendations for local authorities.


The Problem

It is well-acknowledged that mainstream services often struggle to engage with people living in complex situations and people with multiple and complex needs often go without the help they need (McCarthy et al, 2020). At the forefront of the disadvantages experienced by people with multiple and complex needs is the difficulties they experience accessing appropriate housing. There are significantly reduced housing options for people with multiple and complex needs and they are increasingly difficult to access.

Throughout their work and research so far Fulfilling Lives South East found a significant knowledge gap on approaches to the housing assessment process and how it can best support people with multiple and complex needs. Most people with multiple and complex needs will be assessed by a local authority at some point to see if they are eligible for housing support. This assessment is a crucial step and often happens when a person is most in crisis and in need of shelter. The process can be frustrating, long winded and invasive, therefore this research sought to develop a better understanding of effective approaches to this pivotal process that demonstrates a positive impact on their lives.

The Solution

The three themes identified in the research lead to this list of recommendations for local authorities in how their housing assessments can best support people with MCN:

  • Follow a clear more concise assessment process, that doesn’t take too long to complete.
  • Ensure that the assessment process follows a trauma informed approach. This means being understanding of the trauma applicants may have experienced and ensuring the process is not re-traumatizing
  • Show compassion and kindness to the applicants. 
  • Maintain confidentiality throughout the assessment. This includes providing a safe and private environment to carry out the assessments in order for applicants to feel more comfortable sharing their situation and experiences.  
  • Take an interprofessional approach to the assessments, in which housing officers utilise the applicants existing support network. This could include working alongside the individual’s key worker who will know them well. 
  • Allow for flexibility in the application process, work creatively around the obstacles that may arise when assessing people with multiple and complex needs.

Read the full report: here.


Author: Izzie Bloxham-Shelley

If you would like to hear more about our work in housing, then please do get in contact with Rebecca in the Fulfilling Lives team:

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

Strength-based working and Multiple Complex Needs

During the spring of 2021, a study between Fulfilling Lives South East and the University of Brighton was conducted. With the client-facing work coming to an end for the project in June 2021, this study aimed to evaluate the use of strengths-based approaches FLSE and BHT Sussex staff employ, when supporting individuals experiencing MCN. This work drew together interviews with key workers and relevant literature to highlight the benefits and issues raised in a strengths-based practice.


A strengths-based practice is one that takes into account each person’s strengths and resources, abilities and skills, and, with the help of the practitioner, helps utilise them towards the attainment of personal goals (Rapp et al., 2005).

Good Practice

  • Strengths-based practice is not to just be nice or positive all the time, neither imposing a list of tasks on individuals, without them having a say in the process.
  • Instead, strengths-based practice is collaborative, with the practitioner acting as a facilitator for the recognition of skills and goals; it is trauma-informed, acknowledging not only the adversities someone has faced, but also the strategies they employed to survive; and it is based on a hope-inducing, honest, open-minded relationship between the practitioner and the service user.

Impact

  • On service users: it helps create a different narrative for themselves and their life, one with strengths, skills, and capabilities, instead of only problems and deficits.
  • On workers: reflecting on service user’s positive attributes, boosts practitioners’ resilience, can protect from burn-out, and improves their work.
  • On other services: with more positive narratives on their hands and training on strengths-based practice, this new approach  has only started to be embraced.

Challenges

  • Service users might at first have a hard time thinking in a positive light about themselves and reflecting on their strengths and capabilities.
  • Frontline staff need to have small caseloads and a lot of time on their hands, to build on a trusting relationship, which is rarely the case the way services are commissioned.
  • There is huge lack of knowledge and training in other services, as well as a lack for “one-stop-shops”, which will treat individuals holistically.

This study will hopefully be one of the first steps in providing evidence for the benefits of strengths-based practice, so it will be widely embraced and employed in all sectors, but, of course, further research and training is needed for it to be established.

My experience with Fulfilling Lives has definitely convinced me: Strengths-based practice is a way of seeing other people and ourselves, and I believe it should be taken up by any professional who wants to do good in their line of work – I know I will.

Read the full report: here.


Author: Dora Soulantika

If you would like to hear more about our work in healthcare, then please do get in contact with Michaela and Rebecca in the FL team:

Michaela Rossmann, Systems Change Officer: michaela.rossmann@sefulfillinglives.org.uk

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

Cracks in the system – Part II

In April 2021, FLSE  published a blog about concerns in how the healthcare system responds to people experiencing multiple and complex needs (MCN). These concerns were logged between January and March 2021, and then reviewed by our client-facing specialist workers together with the Systems’ Change team as part of the OOPS (‘Overcome Obstacles, Provide Solutions’) Project.


Following Up

This blog article captures our learning on this topic between April-June 2021 and acts as a follow up to our first reflection in March. this feels timely for our specialist workers because our front line support services come to a close at the end of June and even though our workers have championed the needs of our clients, there’s still improvements that can be made to the system to ensure people with MCN receive appropriate access to and support in healthcare services.

Similar to previous OOPS project learning, the last three months have shown that people experiencing MCN fall through the gaps and during the ongoing challenge of the Covid-19 pandemic, are missing out on valuable support services.

Concerns raised

Between April and June 2021, the following five concerns were raised by our specialist workers:

  • Dentist registrationa client who wasn’t yet registered with a dentist in East Sussex wasn’t able to be taken on as an NHS patient to get emergency treatment in local dentist surgeries, so needed to access A&E instead

  • Lack of mental health supportone client was really struggling with their mental health and took an overdose on prescription medication. The client wanted to discharge themselves but was kept in the hospital under the Mental Health Act. A mental health assessment took place, but it was decided that the client wasn’t fitting the criteria to be sectioned. Unfortunately, this meant that the case was closed without a referral for further mental health support in the community. So, the client left hospital and continues to struggle with their mental health. 

  • Prescriptionsduring the last 3 months, one of our clients was released from prison but sadly, their prescribed medication was not prepared or organised prior to their prison release. Suffering from seizures due to anxiety, and being relocated to a new area, the client would need to see a neurologist to get these prescriptions. This had not been arranged as part of the release planning and the client did not have access to the necessary medication on their release. Shortly after release, the client had seizures. One of the seizures caused a fall, which led to a broken hand. Due to mobility impairments, the broken hand contributed to the client not being able to wash themselves. Unfortunately, another incident occurred and they broke their leg too.
    The client’s past traumatic experiences of hospitals have been overlooked by the prison medical team. The client is now in supported accommodation. Staff at their supported accommodation are trying to encourage them to go to hospital but so far unfortunately weren’t able to convince them.
    An official complaint has now been submitted to the Lewes Prison medical team.

  • Access and communication with GPs- One client was asked to book a GP appointment by phone to discuss a recent diagnosis. This diagnosis was communicated to the client by letter, without warning or preparation. The client wasn’t aware that his illness has progressed to a terminal stage which came as a surprise. This has meant that the client found out their terminal diagnosis via letter, not in person. Unfortunately the surgery wasn’t able to take their call to find out more because the phone line was busy and so the client asked the Fulfilling Lives specialist worker for help. This particular GP surgery’s rules didn’t allow the worker to make an appointment. Even the client’s social worker got involved and made numerous calls to the surgery to insist on making the appointment on the client’s behalf. The Social Workers persistent calls paid off and an appointment was made. The client then attended their appointment with support of the Specialist Worker.

Worker Reflections

FLSE has delivered client facing support for 7 years and during this time our workers have engaged with healthcare support systems and engaged with feedback and complaints systems. They have concerns about the effectiveness of these mechanisms to serve our client’s feedback and experiences. Two of our workers share their reflections below.

The NHS is really good at single issue solutions but when it comes to more complex/ dual diagnosis it’s a different story. Complaints processes need to be more personal, not one size fits all… because if the NHS isn’t fit for purpose for our clients, where can our clients go? They can’t afford to go private. (…) It is necessary for complaints systems to be simple, accessible and standardised. The current systems, such as PALS, doesn’t have the resources to deal with the number of complaints- especially if they are complex. Advocacy services also seem to be understaffed to help our client’s voices being heard. Resourcing is a big issue.’

‘A personalised approach is needed in which clients are supported to reflect on their experiences in their own words. The complaints’ systems are very fragmented, and our clients unfortunately seem to be bouncing around a lot.’

One of the Solutions

In our experience at FLSE, even if specialist workers understand the process of escalating concerns and are equipped to navigate the system, they often feel that the process is bureaucratic, ineffective, time consuming and slow. There is a sense of distrust that the complaints process has the welfare of patients at the heart.

Experience has shown that our Specialist Workers and clients prefer to solve problems right there and then in an informal way. Unfortunately, informal issues or complaints don’t get recorded and it is difficult to demonstrate impact or changes to the wider complaints system using these informal channels. PALS in Hastings was also identified as difficult to access during Covid-19 because there were no phone numbers and complaints needed to be made in person in the hospital office.

We have asked our Specialist Workers what difference it would make to their clients, if the official systems to challenge and escalate unsatisfactory responses and care would be easier to access.

The answers were pretty clear:

If there’s a simplified and standardised complaints system, that is fully resourced and trained to deal with a multitude of people, it would help clients with MCN to take control of their own care and support. It would empower them to demand better services and give them a voice to share their experiences with the system.


If you would like to hear more about our work in healthcare, then please do get in contact with Michaela and Rebecca in the FL team:

Michaela Rossmann, Systems Change Officer: michaela.rossmann@sefulfillinglives.org.uk

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

Reforming the Mental Health Act- our perspective

On the 21st April 2021, Fulfilling Lives South East (FLSE) fed into the latest Mental Health Act (MHA) consultation to reform the current mental health laws to make sure that the voice of people with multiple and complex needs (MCN) is being heard. During Mental Health Awareness Week we have taken a moment to consider how mental health legislation has developed over the years and consider what impact these laws have on local practices for people with MCN.


The MHA has come a long way since it was introduced in 1959, a decade after the NHS was established. There have been multiple reviews over the years and in 1983 the issue of consent was introduced, before the Mental Health Capacity Act was created in 2005. Since then, over a decade later in 2017, the government asked for an independent review of the MHA to be conducted and it concluded that the MHA doesn’t work well for patients or families or carers and 154 recommendations were made. The view was that the existing legislation went too far in removing autonomy and did not protect a person’s ability to make their own decisions in their own care and support.

The 2017 independent review created the basis of its latest national consultation and planned reform which FLSE fed into.

As a project, we welcome the new guiding principles of choice and autonomy, least restriction, therapeutic benefit and the person as an individual. FLSE is very aware that these principles are important but so is a clear definition of the threshold for when a person can and cannot be sectioned. In our experience, people with MCN going through a mental health crisis, having experienced complex trauma and with enduring mental health issues, don’t always meet the threshold. One of our Specialist Workers reflected on these principles with the following experiences:

‘This emphasis on autonomy has been interesting for me as a worker. In my experience, several of my clients have been detained under Section 136 by police whilst having a mental health crisis. They are then brought to hospital for assessment and later discharged based on not being ‘detainable’. Although this complies with the current regulation, some of these individuals have then gone onto cause significant harm to themselves, and sometimes others. These incidents have at times then been criminalised, and a client has been arrested and held in custody, a matter of days after being sectioned by police. Being detained in police custody was due to antisocial and aggressive behaviour, but this behaviour had been preceded by multiple overdoses and attempts to take her life. For those clients I have worked with, who have seemingly less detainable mental health issues like personality disorders and significant trauma, there have been times where not sectioning a person has resulted in them being in the community without appropriate support.’

As a project, we are concerned that the new MHA Reform does not address the government’s commitment to invest into mental health services and that it is left to local authorities to respond to the individuals support needs. This could create geographical mental health care provisions and inequalities. FLSE would call on the national government to set clear guidance for local authorities to avoid postcode lotteries and for national government to commit to funding services that are fit for purpose for people experiencing MCN.

We strongly encourage Advance Choice Documents to be consistently implemented, such as the Wellness Recovery Action Plan, and being able to choose a nominated person is also positive. With

both however, we are keen to see guidelines in place to ensure the patient is not coerced into nominating a specific person and that the patient is in a stable position when completing the Advance Choice Document.

We also welcome automatic referrals to the Mental Health Tribunal as well as more frequent reviews of patients to minimise the length of time a patient is sectioned- as long as there is appropriate community support in place. We would very much like to see a collaborative approach between mental health services and third sector organisations.

The focus on having the patient’s voice being heard and offering more advocacy could open up a more peer-led and expert-by-experience approach. We strongly recommend that any commissioning of new services needs to have coproduction through and through.

In addition, we would like to see separate regulations for prisons and immigration removal centres. We also think that people with learning disabilities and autism have different needs and as such should be looked at separately.

Feedback mechanisms and complaints procedures for patients are unclear and we would like to see dedicated specialist mental health services for people experiencing multiple and complex needs that incorporate trauma informed approaches.


If you would like to hear more about our work in Mental Health, then please do get in contact with Michaela and Rebecca in the FL team:

Michaela Rossmann, Systems Change Officer: michaela.rossmann@sefulfillinglives.org.uk

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

Cracks in the system?

A deeper look into concerns about the healthcare system’s response to people with multiple and complex needs


Our learning so far

Fulfilling Lives (FL) is committed to supporting Systems Change in Healthcare services and structures for people with multiple and complex needs (MCN). We recognise that it isn’t an easy task to influence large systems like the NHS  but at the same time we would like to encourage workers from all organisations and services to feel confident in escalating concerns about the healthcare system on behalf of their clients as we see this as an opportunity to bring about positive change: it is a way to log learning, share it and look to explore resolutions That is why one of our goals is for ‘Workers who support clients with MCN will be informed and empowered to use official systems to challenge and escalate unsatisfactory responses and care.’

Over the last six years, our specialist workers have supported numerous clients in Brighton and Hove, Eastbourne and Hastings to access primary and secondary healthcare services, including psychological healthcare services.

According to our workers, it has been clear that our clients have low expectations when it comes to healthcare support. This includes how they expect to be treated by staff. Sadly, some of our clients’ experiences only reinforce these low expectations.  For example, one client was transferred from temporary accommodation into a care home setting. Within 24 hrs, the client’s GP cancelled the daily prescriptions without giving the new GP and pharmacy time to transition his care effectively and get the prescription ready. Other examples include stigmatising practice observed by the specialist workers and challenges for clients to access the care they need. Not all our clients’ experiences are negative. On a different occasion, one of our support workers encouraged a client to make an appointment at a GP practice – something they were fearful of doing. On arrival at the surgery the client was reluctant to check in with the receptionist, but with some persuasion he did. In contrast to his expectation the receptionist welcomed him and understanding his anxiety stated we could wait in the quieter areas of the waiting room and she would come and get us when he was called in. Then, the nurse and GP saw this client as a person (not just a file) and this whole experience gave the client the confidence to return for the follow up appointment and make and attend several more.

How we are responding and why bother?

We value our specialist workers and their role to not only find solutions to healthcare issues faced by our clients on a daily basis but we also appreciate their role in advocating on their behalf and raise concerns when they observe concerns. But we needed more data to check if concerns are isolated cases or whether these concerns are more frequent across the local areas and pointed to something more systematic. That is why FL has launched the internal ‘OOPS’ (overcome obstacles, provide solutions) Project in December 2020, where specialist workers can log observed concerns, get peer support through regular Sub Group meetings and identify trends of concerns and solutions to these concerns together.

The Systems Change Team was keen to understand better the concerns that our Specialist Workers have when it comes to supporting clients through healthcare issues. These concerns might not always be about writing an official complaint to a healthcare professional, but to observe daily obstacles within the system. This might range from not being able to make an appointment with a GP on a client’s behalf, to keeping track about hospital discharges happening on a Friday afternoon for those who are homeless. Usually, these frustrations aren’t recorded but we see them as small cracks within the wider healthcare system. 

The OOPS Project launched in December 2020 and between then and early March 2021 we recorded 7 key concerns in Brighton, Hastings and Eastbourne.

Concerns raised

Here are the type of concerns raised:

  • Health provision in prison – Not being able to get an appointment with the mental health assessment team to review our client’s treatment.
  • Access to pharmacies and dispensing during Covid 19 – Dispensing bulk prescriptions, such as methadone, during lockdown instead of individual dosages.Another client has been banned from most pharmacies and the only one our client can access is 2 hrs drive away.
  • Transitions between GP surgeries – One of our clients has been transferred into a care home in a different area which meant that the GP has cancelled all prescriptions within 24 hrs of the move due to being out of area.
  • Access to the perinatal mental health team – One of our clients has had a child removed after giving birth and the perinatal mental health team can’t support the client as they only work with mothers who keep their children.
  • Support staff response to client engagement challenges – A client with a coexisting condition of substance use and mental ill health was referred to SPFT for mental health support. The worker tried to contact the client 3 times but wasn’t able to reach them which resulted in a frustrated email to our specialist worker. However, the client did leave a message for SPFT but the message wasn’t followed up on. 
  • Hospital discharge and follow on rehab – Our team felt there has been a lack of effective joining up of services for a client being discharged from hospital due to alcohol cirrhosis and the rehab services. After the detox in hospital, the transition was not as smooth as it could have been – consuming alcohol could have fatal consequences and this was a high risk.

Raising concerns in the context of the pandemic

It’s now been a year since the pandemic hit the UK and in March of 2020 there was a push to get the homeless communities into emergency accommodation, which created its own issues and problems. Some organisations blanket prescribed a two-week supply of methadone to recipients but ceased face to face appointments, testing and offered limited phone contact.

With most services suspending all face to face interactions with people and an emphasis placed on the wider use of digital devices and phone contact, those with MCN have been left to manage with minimal or no support from the statutory and many non-statutory health services. This has meant that clients and services often relied on FL specialist workers who continued face to face support to escalate concerns and advocate on our clients’ behalf. The pandemic has shown the health inequalities in our society and people experiencing MCN fall through the net. Raising concerns, when resources are thin on the ground, involves having emotional energy and lots of patience as well as time to get them resolved. With FL client-facing work ending in June 2021, FL specialist workers continue to focus on the best outcome for their clients, which in some cases means circumnavigating the system because complaints’ systems are felt to be slow and difficult to navigate.

One of our Specialist workers said: “The NHS closed everything from GP surgeries to wards, with their focus on Covid-19.  Initially it was impossible to contact any NHS services and as time went on this did not get any easier, again there was a desire to make everything online.  I found accessing my GP, virtually, easy but then I have access to a computer and the internet, as do many other people but many of our clients do not have smartphones or access to the internet, many are not computer literate and some find having a conversation by phone to be very distressing.  I supported a client to make an appointment to see his GP, yet despite me speaking with the surgery about the difficulties he experiences when talking on the phone, the surgery arranged a phone consultation, which resulted in my client feeling he had wasted everyone’s time and he did not discuss what he wanted to with the doctor. The media also created fear and a sense that the NHS was not to be disturbed, so many clients and members of the public in general ignored health issues.”

Useful resources when making a complaint

Obviously, sometimes an official complaint needs to be made and there are different guidelines on how to make a successful complaint. We’ve listed ways to do this below to help client-facing workers have a useful summary of the existing support and guidance to do this.

Local hospitals have a Patient Advice and Liaison Service (PALS). This service can give you information about the hospital’s complaints procedure.
It is important that you complain directly to the person or service (such as your GP or dentist). 

A challenge is often finding out what a services complaints procedure is, obviously there is a generic NHS complaints policy.

As a worker or individual, you can also complain to your local Clinical Commissioning Group (CCG), who funds the local healthcare services. This would be after all other options have been exhausted.

The Advocacy People (formerly SEAP) is the commissioned health complaints and advocacy service for East Sussex.  During the Covid-19 restrictions making referrals has become more difficult and at times communication with the service has been limited.

If the above has failed, then there’s also the option to contact your local MP.

Your local Citizen Advice Bureau or Healthwatch can support you and guide you when making a complaint.

The Ombudsman can also help if a complaint is first logged with the provider directly but the outcome hasn’t been satisfactory. They can make independent and impartial decisions on complaints and they have created a useful leaflet with the top 10 tips on making a complaint to the NHS England.
Tips on making a complaint to the NHS in England | Parliamentary and Health Service Ombudsman (PHSO)

What next?

We plan to continue with the OOPS project for a further 3 months and use this learning to further inform our understanding of the gaps and barriers in the healthcare system facing people with MCN. However, we hope to pair this learning with conversations with partners to explore how we can shed greater light on key concerns and start conversations about how we can collaborate to resolve them.


If you would like to hear more about our work in healthcare, then please do get in contact with Michaela and Rebecca in the FL team:

Michaela Rossmann, Systems Change Officer: michaela.rossmann@sefulfillinglives.org.uk

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