Alison Petch reviews a study into how effective 14 pilot projects have been in improving services for people with multiple needs.
Authors Andy Hirst, Joke Delvaux, Sini Rinne, Christina Short and Alan McGregor
Institutions The first four authors work for Cambridge Policy Consultants and the fifth for the Training and Employment Research Unit, Glasgow University
The Scottish government (then the Scottish executive) launched the Multiple and Complex Needs (MCN) Initiative in 2006 to find ways to improve services for people with multiple and complex needs. This report, commissioned by Scottish Government Social Research, considered the impact of 14 pilot projects which received £4.8m funding between April 2006 and December 2008.
Multiple and complex needs were defined as any combination of at least one intense service need (such as homelessness, severe long-term illness or disability, severe mental health problems or low basic skills, particularly literacy and numeracy) and at least two complicating factors (such as substance abuse, a criminal record, caring responsibilities including lone parenthood, a history of economic inactivity or a first language other than English).
The 14 projects were designed to support a diverse range of groups, including older people from ethnic minorities, ethnic minority families with deaf children, male carers and adults leaving prison.
They focused on different types of gaps in provision: non-existent or insufficient provision; a service available but not accessed by clients; some needs not identified; or scope for matching service provision more closely with needs. Two broad approaches to addressing these service gaps were identified: direct service delivery to service users and change management projects.
Only half of the projects had an element of direct user engagement, while the others focused on staff and their role in service redesign. The evaluation sought to uncover what did and did not work in terms of improving service access, the individual’s experience of the service, and service user outcomes.
The programme evaluation took account of individual project evaluations and included three rounds of interviews with project managers, staff and partners; a series of workshops and training sessions; and 12 interviews with Scottish government officials on service redesign for individuals with multiple and complex needs.
Eight of the 14 MCN projects sought to address access for service users. The biggest improvements occurred in projects that had adopted a “proactive outreach” approach, supporting the individual to the point of access.
The needs assessment process was the target for five of the projects. All responded positively to training sessions, but there was less evidence of changes in staff attitudes or services.
Change was more likely to be achieved when training was embedded in a wider process of working with staff; staff were given time to discuss practice changes with peers; training was practice-focused and included strategies for raising sensitive issues; and when there was input from the target group.
Seven of the projects focused on improving the quality of service provision itself: positive outcomes – in particular, increased empowerment – were associated with provision of peer support, and there was further endorsement for training embedded in a wider process of collaborative working, and for giving a clear voice to the service user.
Other features identified as being more likely to facilitate change included face-to-face time between staff and the change manager; resources to support the learning process; ensuring the change process adhered to organisational priorities; a “change champion” within the organisation; and positive staff engagement with time for collective discussion. The authors emphasised that these features were not new but the key was to facilitate their implementation.
Service managers were identified as key and two checklists were provided for this group. The first focused on engaging service users, seeking evidence on who was being missed; whether it was a priority for the service; and identifying barriers to access and what can be done to remove them. The second considered possible changes to service delivery, including “light-touch” improvements in communication and interaction, identification of those who might benefit from specialist provision or (peer) advocacy support, and encouragement of the factors that would lead to improvements in service delivery.
The importance of this work is twofold. It is an important reminder that for a significant group of people their needs are not readily corralled within a single category – they are indeed multiple and complex.
They are those who in England have been the focus of the Social Exclusion Task Force since the publication in September 2006 of Reaching Out: An Action Plan on Social Exclusion. In 2007 three pilot schemes were initiated: 12 projects focusing on Adults Facing Chronic Exclusion; 10 family nurse partnership pilots; and 10 multi-system therapy projects consisting of interventions for young people at high risk of being taken into care or custody.
Public Service Agreement 16 on socially excluded adults has also been introduced, focusing on young people leaving care, offenders under probation supervision, people receiving secondary mental health services, and people with moderate to severe learning disabilities. There are two core aims: to increase the number of people in settled accommodation and in employment, education and training.
Most importantly, however, the study seeks to isolate the elements in the service improvement process that are likely to lead to positive change. People are understandably wary of “projectitis” and of the danger that repeated findings are not implemented. For example, “the importance of proactive outreach to engage harder to reach clients, partnership working and a flexible, client-centred approach” has been well-documented.
The strength of this evaluation is its analysis of how these elements might be achieved and ways in which barriers might be overcome. Nonetheless, it is only when such knowledge is incorporated routinely into ongoing implementation and is translated from one initiative to another that the full benefit of such programmes is achieved.
The identification of service managers as key players in the service improvement agenda, the detailed checklists for them to work to, and the specification of the evidence base on which they should draw provide a model for driving change which should help to address a range of traditionally intractable issues.
Alison Petch is director of the Institute for Research and Innovation in Social Services in Scotland.
LINKS AND RESOURCES
● The Evaluation of the Multiple and Complex Needs Initiative can be accessed at
● The Social Exclusion Task Force has published four reports on the theme of understanding the risks of social exclusion across the life course. These draw on a range of data sources, applying the Bristol Social Exclusion Matrix, with separate reports covering families with children, youth and young adulthood, working age without dependent children, and older age
● Two research reports were commissioned to support the ACE pilots: Better Outcomes for the Most Excluded, University of Nottingham; and Service Responses and Outcomes for Adults Described as Having Chaotic Lives and Multiple Needs, University of Keele
COMPLEXITY OF NEED
Traditional service provision is often defined by individual user groups, which can be unhelpful to those whose diverse needs can span several categories. Commissioners and providers need to accommodate the needs of each individual rather than work to a standard configuration.
Effective change management is key to many aspects of the transformation agenda. Initiatives should map what is known about the change process itself and apply it to specific priorities rather than starting each initiative from scratch.
There should be opportunities for staff to engage collectively with the situation and for input from service users.
An individual in the role of change champion can make a significant contribution to managing the change process, facilitating consultation and leading the agenda.
To capitalise on previous learning there should be effective mechanisms for knowledge exchange which allow for ready access and transfer of key messages.
In programmes of this type, which could incorporate several individual projects, there should be clarity about evaluation goals at both project and programme level, with collaboration across individual project evaluations to ensure the utility of the data collected is maximised.
Often, evaluations end when the pilot project is about to close or transfer to a different structure. There is a danger that many of the lessons learned will fall by the wayside unless there is an effort to corral them. Those commissioning any evaluation should ensure that continuity is maintained.
Published under the heading ‘Easing access to services for people with complex needs’ in the 29 October 2009 issue of Community Care