The Scottish Government

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Chapter One: Introduction

Background

1.1. The primary motivation for the literature review came from the Scottish Executive's commitment to assessing the impact of multiple and complex needs and how a range of services can respond effectively, taking account of recent and ongoing national developments that are relevant to good practice. The study was commissioned to complement 2 current strands of work within the Scottish Executive:

1. Analysis by the Office of the Chief Statistician to explore the prevalence of particular needs and combinations of need among people belonging to various social groups
2. A funded series of pilot/demonstration projects to address multiple needs in relation to specific sectors, such as health and social work services, and the monitoring and evaluation of these projects.

1.2. The literature review is set against the backcloth of recent developments in social policy and related agendas and streams of work:

• The 'personalisation of services' agenda (Leadbeater, 2004)
• Developing better public services in Scotland through the Modernising Government Fund (Scottish Executive, 2003a; Scottish Executive, 2006a)
• The Social Exclusion Unit in the Office of the Deputy Prime Minister's ( ODPM) work on 'Improving Services, Improving Lives' project, and
• Proposals on the provision of social care to people as defined in ' Meeting Complex Needs: The Future of Social Care' (Rankin and Regan, 2004).

1.3. It is worth highlighting at the start that The Social Exclusion Unit has turned its attention to issues of multiple and complex needs and has noted that:

"Effectively meeting the needs of disadvantaged people - particularly those with the most acute/and or multiple needs can be expensive. In the context of increased efforts to make efficiencies, we need to develop the best possible understanding of the economic and ethical cases for investing in more intensive and longer-term support for those who need it." Social Exclusion Unit, 2005a, p16).

Aims and objectives

1.4. The overall aim of the review as commissioned was to identify, organise, evaluate and summarise key evidence from the research literature on a range of issues relevant both to service provision and to people with multiple and complex needs.

1.5. Further, the study had 5 key objectives, which were to:

1. Identify and define 'multiple and complex needs' and the groups most likely to require support
2. Explore awareness of services and options
3. Explore factors affecting access to services
4. Examine users' experiences of service provision
5. Identify best practice in service provision and lessons from implementation.

Research method

1.6. Given the scope and range of services (from health and social work to legal and financial services) and potential groups ( e.g. people with disabilities, people with low incomes and minority ethnic communities) to be considered within the terminology of 'multiple and complex needs', the size of the literature base on this topic is potentially infinite. In an attempt to limit the scope of the literature review to a manageable task within the short timeframe it was decided to focus in the main on:

• Literature on multiple and complex needs from Scotland and the UK, which was published within the past 5 years, i.e. since 1999
• Existing reviews and summaries of findings wherever possible
• Good practice guidance issued by the Scottish Executive Departments, Communities Scotland, the Office of the Deputy Prime Minister, Department of Health and other governmental departments
• Published and grey research literature including needs assessment reports, which refer specifically to multiple and/or complex needs in relation to areas of the research framework
• Research findings identifying both service user experiences and barriers to services or gaps.

Identifying relevant literature

1.7. An initial step in searching the available literature involved consulting key informants and organisations, in addition to conducting systematic reviews of library and on-line catalogues and databases. Given the interest in ensuring key relevance to Scotland and to policy and practice, 15 key agency representatives and/or individual 'experts' were contacted by email and telephone. A small number of face-to-face interviews also took place and a focus group was held with research and policy staff within the Scottish Executive in March 2006.

1.8. These included academics from a range of disciplines (disability, dementia, social policy, faiths and religion) at Edinburgh, Strathclyde, Stirling, Dundee and Ulster Universities as well as housing and community care organisations (including Community Care Providers Scotland, Turning Point Scotland. Homeless Link, Scottish Refugee Council). The interviews sought to investigate:

• Definitions of multiple and complex needs
• Whether issues of multiple and complex needs had emerged as a specific concern in their field or organisation
• Main client groups defined as having multiple and complex needs
• The key issues in terms of access to services, pathways in and through services
• Key implications for practice and policy
• Informant's knowledge of grey literature or key published documents to review
• The importance of focusing on multiple and complex needs.

1.9. Searches of relevant databases, internet sites and publication search sources were carried out in 2 stages: the initial trawl of literature sought to identify definitions of multiple and complex needs from the literature, whilst subsequent searches broadened this search to literature relating to the wider research framework that focused on service pathways and best practice. The focus on service pathways centred on the experience of people with multiple and complex needs in terms of 'getting into services, getting on within services and getting through or moving on within and through services'. Additionally the review sought to clarify associated best practice. Given these concerns, tables will be presented that summarise chapter findings at the end of Chapters Three, Four and Five, in relation to the stage of the service pathways covered, related processes and influencing factors and implications for service responses.

1.10. The searches identified below were conducted to maximise the scope of the review.

Table 1.1.: List of main databases and indexes sourced for the literature review

1.11. Keywords including 'complex needs', 'multiple needs', 'multiple and complex needs', 'multiple disabilities', 'multiple impairment', 'multiple disadvantage' and 'dual diagnosis' were used to search the databases at Edinburgh and Glasgow University libraries, the National Library for Scotland and online databases. In later searches these were combined with keywords representing aspects of service pathways (awareness, access, user experiences, outcomes) and best practice ( e.g. joint working, partnerships, holistic, person centred, one stop). In addition, reference and bibliography lists in key documents were scanned for further useful materials.

1.12. Two team members conducted the main searches of the literature, while all team members conducted reviews and produced summaries on each item reviewed. The literature covered was recorded, summarised and classified in terms of:

• Focus on particular client groups, policy and practice in Scotland, UK or wider
• Method - qualitative or quantitative
• How multiple and complex needs are addressed
• Definition of multiple and complex needs and related issues
• The focus on service user/non user pathways and experience
• Gaps, deficits and constraints identified
• Implications for policy and practice and
• Other relevant themes.

1.13. Key themes across the whole of the literature reviewed by each consultant were identified and discussed as the work progressed. This added to a cumulative analysis across all the literature and reflects the aims and objectives of the study.

The scope and limits of the study

1.14. The lack of consensus and consistency within the literature on defining multiple and complex needs posed a major challenge to determining the search parameters for the literature review. Additionally, the broad approach required meant that it was not possible to cover all areas in depth within the timeframe. While the research team have not intentionally left out material relating to specific groups or service responses, the review cannot claim to have achieved full comprehensiveness, or to have treated all the literature equitably. Overall however, it did strive to identify systematically the key themes running through the literature and to reflect where the balance lies within the literature.

1.15. On the scope and approach of this review, it is important to clarify that rather than focus on exploring multiple and complex needs from the starting point of particular needs groups (such as mental health, learning disability, older people, those in contact with the criminal justice system, or people with particular conditions), it was resolved to focus on common strands of experience in the context of wider constraints and opportunities for people with multiple and complex needs.

1.16. The broad approach required meant however that it was not possible to cover some areas in depth within the timeframe. While the research team have not intentionally left out material relating to specific groups or services, the review does not claim to be comprehensive and does reflect where the balance lies within the literature. There may therefore be inequitable treatment of some areas of literature.

1.17. Overall we found 3 broad categories of literature that addressed multiple and complex needs, which more or less, and from different perspectives, covered overlapping themes. The first group consisted of studies that addressed the service and policy implications of issues of multiple and/or complex needs. A minority of these studies provided an overview of the issues for people with multiple and complex needs, while most specifically addressed the multiple and complex needs of a defined client group. While certain studies offered very useful insights and leads in relation to the aims and objectives of this study, it was found that many studies did not systematically focus on people's pathways through services, which was a key focus of this research.

1.18. The second was a larger body of literature which used the terminology of multiple and complex needs, but this focus was not central to the study. Most relevant policy reviews and reports did not surface through initial literature searches, but required searches on a range of web-sites. The third was a far wider body of literature that this study could not quantify or address systematically, that addressed equivalent themes to those covered by the first 2 groupings, but without explicit use of the terminology of multiple and/or complex needs. Examples included where authors used terms such as 'multiple disadvantage' or 'severe exclusion' and then referred to the consequences of significant poverty and dependence on welfare benefits, coupled with the impact of homelessness, serious health problems and impairment, literacy problems, substance misuse, criminal justice issues and/or in some instances, institutionalisation and leaving institutions.

1.19. While this review has mainly focused on the first two categories of literature, where the research team was aware of other directly relevant material in the latter category, which shed light on access issues or pathways in and through services, or on good practice implications, this has been referred to and considered.

1.20. Another point that should be acknowledged is that, in the main, the literature reviewed represents published material based on academics and professionals' perspectives. Some of this represented 'grey' literature, including agencies' reports accessed directly or on the web. Overall it appeared that this could offer a fruitful source of description and insights, although it was not feasible to tap this theme comprehensively within the time available for this project.

1.21. One key point was that while Social Exclusion Unit reports and some Scottish Executive reports accessed have addressed multiple and complex needs building on the perspective and voice of service users, this was a clear gap in the overall literature.

Structure of the report

1.22. Chapter Two addresses the task of defining multiple and complex needs and it considers their prevalence. While the relevant literature draws on a number of perspectives, disability and social justice perspectives dominate. Chapters Three and Four review a range of literature covering pathways into and through human services, while Chapter Five focuses on summarising the gaps in services and clarifying what service users want. Chapter Six presents findings from the literature relating to ways of addressing the gaps and improving service responses to people with multiple and complex needs. Finally, Chapter Seven draws together the main themes raised through the literature review and discusses the implications of these themes for Scottish policy and practice.

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