By Lauren Bennett, Jan Pusiak, Sophie Wilson, Susannah Wilson, and James Rees*

In a recent paperDemos CEO Polly Mackenzie argues that the pandemic has created a tipping point for public services, because of increased need, reduced resources and capacity, and changed public expectations. Arguably these trends have been in place a good while - but they have been accelerated by the pandemic. Demos argue we need to:

“...move on from the transactional model that has driven public service reform thinking for generations: a model that treats people as individuals, instead of part of communities; a model that is obsessed about processes instead of outcomes; a model that disconnects professionals from citizens instead of connecting them together. We need public services that establish and nurture strong relationships both with and between people, both to help prevent problems, and to manage them more successfully.”

Broadly, we* welcome this focus and call for change. However, as the debates and appetite for system improvement have been around for some time, it seems timely for us to take stock and ask: what have we learnt?

We want here to reflect on our experience in a wide range of work that is focused on the question of whether crucial public services are appropriately focused on the needs of some of the most marginalised people in society — those facing multiple disadvantage. Our research has particularly focused on the experience of this cohort in Birmingham and the West Midlands.

Our hope in writing this blog is that by really focussing on the lessons learnt from the engagement of public and voluntary sector services with people experiencing multiple disadvantage, we can share good practice that might improve services for everyone.

What have we learnt?

One of the key arguments for focusing on people with multiple disadvantage has traditionally been that they ‘cost’ the most to the system, so if their needs are addressed, public resources can be saved. However, there is also a strong social justice argument which points to the fact that the disadvantage faced by people with multiple needs means that they often fall through the gaps of the system that should be there to support them.

Despite frequent calls for ‘systems change’ to assist people facing multiple disadvantage, our research highlights the ways in which people who have combined needs around poor mental health, substance use, homelessness and offending behaviour all too frequently find themselves bounced between services, having to constantly re-tell their stories, and facing significant barriers to accessing the right support.

Recognising ‘trauma’

In particular our research with people with lived experience of multiple disadvantage, has uncovered a system that does not account for, nor address, the complex and traumatic experiences of individuals which are often rooted in childhood. Their experiences as they move through their life course too often sees this early trauma compounded by a lack of ‘psychologically informed’ service provision.

Recent research based on interviews with individuals experiencing multiple disadvantage in the West Midlands found missed opportunities to intervene at an early stage both at home and at school. Participants reported both positives, e.g., person-centred, accessible services, and negative experiences such as slow processes and a failure to recognise their multiple needs. They found that peer support was highly valued and considered integral to the recovery process and reintegration into society. The report concluded that:

“Statutory and voluntary services, supported by peer mentors, need to be coordinated to provide the most effective support for individuals with multiple and complex needs.”

Where services are encouraged to understand the impact of adverse childhood experiences (ACEs) and are supported to create psychologically informed environments that recognise past trauma, the impact can be profound. Research into psychologically informed environments (PIE) amongst BCFT organisations found that the PIE approach enabled staff to interact appropriately and meaningfully with clients, and that training helped improve self-awareness of why people may behave in a certain way, and what could ‘trigger’ this.

We believe that there is a strong argument for continuing to build a ‘trauma-informed’ system at every level.

Navigating the ‘System’

Despite examples of multi-agency work aimed at improving the way that organisations work together, it is fair to say that for many people facing multiple disadvantage, the system remains impenetrable. An oft-cited example is the challenge for those with a ‘dual diagnosis’ of poor mental health and substance use being unable to access the necessary support, because help for mental health issues is refused until substance misuse issues are addressed. The complexity of the system creates a need for professionals who have the skills and knowledge to help clients to navigate their way through it.

Learning from the evaluation of Birmingham Changing Futures Together (BCFT) highlighted the effectiveness of the ‘navigator’ role in supporting people with experience of multiple disadvantage.

Navigators aim to give people the confidence and resources to be able to access and stay in contact with support services, which creates independence and long-term resilience. Navigators are unique as they are not bound by a remit of one organisation or type of service.

This work has demonstrated the need to tackle a set of interlocking barriers at different levels:

  • Individual barriers: people are not aware of services, do not understand the language professionals are using and forget appointment details.
  • Service barriers: services operate in a way that makes it difficult for clients to engage independently. They have limited capacity to engage people with complex needs and strict eligibility criteria prevent people accessing the support they need.
  • System barriers: statutory and voluntary services do not always work together and coordinate support, so advice can be contradictory, and support is ‘disjointed’.

Similarly, an evaluation of the SIFA Fireside Resettlement project highlighted the importance of each client being allocated to a single worker who has oversight of the client’s journey. Another crucial insight is the need for patience and long-term thinking: building relationships and trust takes time (and cannot be achieved within specified timelines) but is critical to working successfully with clients who have multiple and complex support needs.

Involvement of people with lived experience

Our research has highlighted the importance and value of involving people with lived experience in the design, and delivery and evaluation of services. BCFT piloted and evaluated a Peer Mentoring service. The findings showed that compared to clients that had a support worker without lived experience, clients who worked with a Peer Mentor with lived experience engaged with the service for more time, reduced their use of crisis services at a higher rate, saw a greater increase with their use of planned services and saw a greater improvement of their wellbeing assessments.

Similar success can be found elsewhere. For example, a review of the NHS England Liaison and Diversion peer support Pathfinder sites found that peer supporters made service users feel understood and respected, whilst showing a sense of persistence from the peer supporters to keep users in contact with the service.

Collaboration and Partnership Work

As we have already alluded to, the complexity of the system means that collaboration and partnership working is imperative. We have found that disparate parts of the ‘system’ share a strong willingness to work together, but there is no doubting the challenges they face in doing so. Sharing information, working outside of siloed organisational boundaries (and having permission to do so) and attributing value and time to joint working is often a challenge for busy professionals working with high caseloads.

However, our research strongly suggests that partnership working and collaboration can be the lynchpin of long-term effective systems change. The power of partnership working was ably demonstrated in the first lockdown, where political will and local partnerships combined to get ‘Everyone In’ in Birmingham.

The concerted effort of local partners (from across the voluntary, community, faith and social enterprise) to ensure that rough sleepers in Birmingham were housed during lockdown demonstrated huge enthusiasm for the newfound spirit of collaboration driven by a ‘can do’ attitude. It showed how having a shared vision, sense of equity and removing unhelpful bureaucracy (such as onerous commissioning processes), enabled outcomes to be achieved over a short few weeks, rather than years. We would urge policy makers and partners to take learning from this experience.

The valuing of partners’ different skills and knowledge was also facilitated by the rapid move to online meetings and data sharing necessitated by Covid-19, as well as a sense of extreme urgency that won’t necessarily be repeated. Yet many people say the learning has endured.

A further example of collaboration and partnership working ‘in action’ is the No Wrong Door Network developed through the BCFT programme in Birmingham. The No Wrong Door Network is a whole system approach whereby a partnership of 14 service providers work together to support people with multiple and complex needs and reduce avoidable health and wellbeing inequality.

The 2019 BCFT research into the No Wrong Door network highlighted the importance of multiple organisations working in tandem to ensure a client’s support is delivered in a coordinated and seamless manner. Those interviewed suggested that having a partnership of multiple organisations meant that people were less likely to “fall through the gaps”, but as discussed earlier, a Navigator role is still required to ensure support is received in a timely, holistic manner.

The Resettlement Team at SIFA Fireside also found that collaboration was crucial to its success in supporting people to live settled, healthier lives. The partnerships developed have been critical to ensuring clients, who are moving on from a background of homelessness and disadvantage, get access to employment support and help to address wider needs such as mental health issues. Although collaborative working has enhanced understanding amongst the partner organisations, there is scope to share this learning wider.

Top 4 takeaway lessons

  1. Services need to account for the (previously overlooked, or under-appreciated) role of trauma in early life, through sustained and effective early intervention and approaches such as Psychologically Informed Environments.

  2. There is a need for Navigator roles, to support people with multiple disadvantage overcome the range of interrelated barriers that prevent them from accessing and engaging with support services.

  3. Taking on board the lived experience and experience of the ‘system’ that clients/users have is key to ensuring that system and service redesign meets their needs and is fit for purpose.

  4. Partnership and collaboration are key to success, both across sectors and between like-minded organisations.

* We are based at: Revolving Doors Agency, Birmingham Changing Futures Together (BCFT), BVSC Research, and The Institute for Community Research and Development at the University of Wolverhampton, and have worked together on a number of research projects since 2019