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Chapter Six: Improving practice and opportunities

Introduction

6.1. Having focused on the interconnected problems in service provision that undermine opportunities for people with multiple and complex needs, we now turn our attention to developing a positive service framework for addressing multiple and complex needs. In this pursuit we build on the literature review findings on what service users, professionals, commentators and policy makers have identified as key themes in good practice.

Increasing awareness of services

6.2. As noted in Chapter Three, people need to be aware of the existence of services that can help them. A number of studies have reported that finding out about available services, what they do, who and how they can help, is very difficult for existing or prospective service users. (see for example Scottish Executive, 2005e,f,g, and 2006a,b,c; Social Exclusion Unit, 2005a; Jarvis, 2005; Keene, 2001; Crisis, 2005 and Hardy et al, 1999).

6.3. While many people have difficulty in finding out what services are available, some are known to experience greater difficulties than others (Social Exclusion Unit, 2004a and 2005 a, b).

Access to information and advice

6.4. Overall, there is increasing recognition of the range of information and advice that may inform expectations and guide choices for people with multiple and complex needs. To maximise inclusion this requires access to the full range of information, along with the advice and support required to enable service users to participate actively and meaningfully in influencing their futures and the design of services.

6.5. The Social Exclusion Unit (2005a) explicitly addressed issues of awareness of service provision. It highlighted that there is no 'one size fits all' formula for effective provision of information and communication for disadvantaged groups, and that different approaches can benefit different people. While issuing a caution regarding the lack of robust evaluation evidence about the success of different approaches to information and communication with disadvantaged people, the report identified some key principles of best practice:

• Getting the basics right - making information easier to understand so that everyone using public services benefits
• Understanding customers - involving people and working with partners to get effective and efficient results
• Using new technologies and outreach - either to complement or to provide an alternative to text-based products (Social Exclusion Unit, 2005a, p40).

6.6. The literature points to the need for written information to be easy to understand and written in plain English. Principles "include the use of short sentences, simple punctuation and everyday language" (Social Exclusion Unit, 2005a) along with an understanding of what people need and of where people access information from.

6.7. The following case example demonstrates the benefits of comprehensive information being available.

6.8. One co-ordinated approach in promoting preventative advice for young people using some of the approaches employed in community development is highlighted below.

6.9. In some cases, services have sought to make more information available about their services through direct marketing, often aimed at groups who have been found particularly 'hard to reach'. The following example illustrates how learndirect sought to increase take up of services.

Improving access through creative targeting and flexibility

6.10. As reported in Chapter Three, the literature identifies organisational and structural barriers to accessing services, and these barriers operate whether or not people know of their existence. Best practice in overcoming the most commonly identified constraints is discussed below.

6.11. One prevalent constraint is that of waiting times to access services and the problems of inflexible services were identified in Chapters Three and Four, where it was clear that access arrangements are not generally convenient for people. Moreover, problems of access are particularly acute at times of crisis, which can often occur outside normal opening hours.

6.12. Increasingly it is argued therefore that single service access points that are accessible in relation to time and place should be provided.

"People with complex care needs require a single point of contact to mobilise support if there is an unexpected change in their needs or a failure in agreed service provision. Further work needs to be done to establish how this can be achieved on a 24/7 basis by, for example, linking case management with out-of-hours (Department of Health, 2006a, p116).

6.13. The Audit Commission (2002b) has identified long waiting lists for drug problem services as a national problem that has arisen due to the inadequate expansion in services in the face of increasing drug problems. This gap is exacerbated by inefficient bureaucracy and inflexible treatment regimes. The report concluded that:

"For the most part, an incremental approach to change, concentrating first on key blockages, such as long waiting times, is likely to be the best way forward" (Audit Commission, 2002b, p74).

6.14. Two examples of flexible service responses to needs are illustrated below.

6.15. While some people prefer not to use computer-based services, others find them useful, particularly if they are trained in their use. In relation to the constraints on access highlighted in Chapter Three, there is evidence that advantages can accrue for people who find it difficult to get to services because of disability, or because of rurality and distance from major centres. An example from the Modernising Government Fund Progress Report Round One (Scottish Executive, 2003 a, b, c) illustrates how use of new technologies can facilitate access to services, including for people with multiple and complex needs.

Aberdeenshire Council- Teaching Internet Use

6.16. Many older people are not familiar with IT, have additional needs related to disabilities, and may be excluded from established education resources. However, some services have specifically targeted their needs.

Improving the experience of service provision

Addressing whole person needs

6.17. Good practice guidance stresses the case for comprehensive needs assessments that considers the 'whole person' (Scottish Executive, 2001a; Rankin and Regan, 2004; Morris, 1999). Addressing needs holistically includes, for example, addressing needs for employment or meaningful occupation (see for example: SACDAM/ SACAM, 2003; Social Exclusion Unit, 2004a; Rankin and Regan, 2004; Department of Health, 2005a; Turning Point, 2005). Additionally, services should be designed around people's needs rather than them being "forced to fit around the service already provided" (Department of Health, 2006a).

6.18. An example of a service that addresses needs holistically is shown below.

6.19. The need for sensitive approaches by services that address the whole needs is demonstrated for people with learning disabilities, as discussed below.

6.20. In sum, 'whole person' assessments require a strategic approach that:

• Takes a longer-term perspective
• Makes every effort to take on board the views of service users and carers
• Is sensitive to particular needs
• Takes the time needed for effective dialogue with the service user and agencies
• Trains staff beyond singular professional visions to encompass a range of needs
• Reviews the process and outcomes over time. (Keene, 2001; Rankin and Regan, 2004; Baron, 2005; Humphrey et al, 2005; Noel et al, 2005).

Advantages of single entry points to services

6.21. In seeking to address the problems of service fragmentation highlighted in previous chapters, the concept of single access points or 'one stop' shops is increasingly being advocated. Here people can access a number of services either under one roof or by means of a single phone call, so making it easier for people to:

• Find out about available services and
• Access appropriate services to meet different needs (see for example, Scottish Executive, 2003a; Rankin and Regan, 2004; and The Social Exclusion Unit, 2005a and b.)

6.22. Such approaches can help to address a number of problems identified in the literature:

• Inappropriate service referrals (Social Exclusion Unit, 2004; George, 2000a)
• One or more problems getting lost in the referral process (Humphreys, 2005)
• People accessing services that only deal with one part of their needs (Keene, 2001)
• People being excluded from services because of additional problems, for example mental health or addiction issues excluding people from services for domestic violence (Humphreys, 2005)
• Difficulties in accessing services because of remoteness from them.

6.23. The single access point model for help and support is further developed by the model of the Connected Care Centre (as advocated by Turning Points). As highlighted in Chapters Four and Five, people living in the poorest neighbourhoods with the greatest needs are often the least likely to have access to the services and support which would help them improve their lives and life chances. Connected Care is a pilot programme that aims to tackle this.

6.24. Further information on the Connected Care centre model is given in Appendix 3 along with details of a single access service point involving the use of technology in Argyll and Bute, and another in Torry, a deprived area in Aberdeen.

Outreach services

6.25. As noted in Chapter Four, some people find it difficult to engage with services for various reasons. An alternative and/or complementary model to centre based services is of outreach services that actively seek out clients, rather than waiting until existing or potential clients find them. Many studies have identified active outreach as services that work well, and particularly so for clients who find it difficult to access services or whom service providers have described as 'hard to reach' (Edwards, 2003; Crisis, 2005; Rankin and Regan, 2004; Social Exclusion Unit, 2005a). The Social Exclusion Unit (2005a) defines outreach in the following way:

"We are using the term outreach to mean the provision of information about and support to engage with services in a way that is most convenient for the individual. It helps to build trust and provides support and encouragement to overcome the barriers that people may face in taking up services" (p54 ).

6.26. The Social Exclusion Unit found that the use of outreach has increased, with almost one in 3 survey respondents stating that they carried out some kind of community outreach in relation to the 3 disadvantaged groups who comprised the focus of the study. The biggest increase in the use of outreach had taken place in the statutory sector. Nevertheless, the report cautioned that outreach is resource intensive and is often subject to short term funding. This was also highlighted in Chapter Four in relation to Sure Start services in Scotland, while pro-active outreach has also been a central and broadly successful method of the Rough Sleepers Initiative in Scotland and UK-wide (Randall and Brown, 2002; Fitzpatrick et al, 2005; Reid and Howie, 2004). Fitzpatrick et al quote one homeless woman who wanted to access supported accommodation, who said, "But I couldn't be without my outreach worker. If it wasn't for her, you ken, I'd probably still be out on the street" (2005, p88).

6.27. In relation to Sure Start south of the border, the Department for Education and Sciences ( DfES) has issued new practice guidance to refocus the activities within children's centres, to ensure they collect data and information on the most excluded families and place greater emphasis on outreach and home visits to support these families. ⁹

6.28. The need for active outreach services to be culturally sensitive is further demonstrated in the following example of a service in Tower Hamlets.

Developing care or pathways plans

6.29. Good practice guidelines in community care stress the need for support to be delivered following comprehensive needs assessments, with the development of a care plan or care pathway that clearly sets out the services people need, and how and by whom they will be delivered (Scottish Executive, 2004 a and b). However the shortfalls of care planning were highlighted in Chapter Four, and it has been argued that "the process is now largely restricted to those on the cusp of institutional care" (Hudson et al, 2004).

6.30. Nevertheless, the benefits of systematic care planning are clearly evident, as the experience of some voluntary sector organisations shows.

Negotiating fragmented services

The need for link and co-ordination roles

6.31. Given that service fragmentation and its impacts cannot be resolved overnight, one corrective model developed by health and social care services is that of a 'service navigator' or link worker (Rankin and Regan, 2004; Turning Point, 2005). Such link roles have varied purposes and their common features are that they address multiple issues, cross service boundaries, promote and co-ordinate access and support, and aim to include those who are 'hard to reach'.

6.32. The role of link worker draws on the experience of implementing care management in the 1990s following the policy shift from institutional to community care, with its emphasis on user and carer empowerment and individually tailored services based on assessment need and the coordination of care across agency boundaries (Halliday & Asthana, 2004).

6.33. Another regularly referred to example of link work was developed by the Revolving Doors Agency that works with offenders who have multiple needs.

6.34. Evidence of the need to counteract fragmentation and link across services stretches beyond the UK, and one Australian study found that,

"Most effective interventions involved scenarios where there were links between the different programs being accessed by the individual, and collaboration among service workers. Clear boundaries and structures for the individual were also identified as effective" (Department of Human Services, 2003, p4)

6.35. The introduction of such workers has workforce development implications as "it is not evident that individuals with such qualities are readily available" (Hudson et al, 2004). Additionally, Keene (2001) sees the need for the development of a new type of professional who would specialise in clients with complex needs.

6.36. There is clearly some overlap between link roles and aspects of care co-ordination, as was noted in Chapter Four. New bridging roles are being created, such as the 'community matron', a model favoured by the Department of Health (2006a).

"Community matrons are case managers with advanced level clinical skills and expertise in dealing with patients with complex long-term conditions and high intensity needs. This is a clinical role with responsibility for planning, managing, delivering and co-ordinating care for patients with highly complex needs living in their own homes and communities" (p.218).

6.37. Such new health service roles are however criticised from a social model perspective. It is argued that the new community matron will fail to recognise:

"…the reasons why the health of people with long term conditions may deteriorate enough to result in hospital admission are more to do with socioeconomic, cultural, psychological and community factors than healthcare" (Hudson, 2005, p383).

6.38. Hudson also questions whether community matrons should or could carry out effective case management for people with physical and learning difficulties, for example, where there has long been a tradition of a social rather than a medical model of care. In a similar vein, Hunter (2005) had this to say of the Department of Health paper on supporting people with long term conditions:

"The 5 chapters, 3 annexes and 48 pages contain no mention of direct payments, and no reference to transport, housing benefits or employment. None of its good practice examples focus on social work, and people with long-term conditions are referred to as patients throughout. But the most obvious snub to social workers is the introduction of community matrons. Despite the wealth of experience among social workers who have case management roles, only those with a nursing qualification will be eligible for the new role" (Hunter, 2005, quoted in Hudson 2005, p383).

Information sharing to prevent service users having to repeat their stories

6.39. Single shared assessments, whereby all relevant services are involved in a joint process of assessing need, are designed both to improve inter-service co-ordination and to prevent service users having to repeat the same information, often of a sensitive or personal nature. These assessments were introduced initially for elderly people, and are now being rolled out across other community care groups, including people with multiple and/or complex needs (Scottish Executive, 2004a).

6.40. To allow agencies to share data and to improve people's pathway or journey through services, new IT was developed and the resultant 'E-Care' plays a major role in the New Future's Agenda in Scotland. The links between information sharing, E-Care and Single Shared Assessments are described in more detail below.

6.41. Today there are increasing examples of 'E-Care'; some are listed below and others are outlined in Appendix Three:

• Services for older people with mental health problems and the use of Single Shared Assessment by NHS Lanarkshire along with North and South Lanarkshire Councils
• Joint equipment stores, such as in the Borders and Lothian
• Borders Police Information Networking for Family Protections Officers that gives the facility to share information already in several existing policing systems thus minimising data fragments as well as data entry and administration.

Joining up services

6.42. Holistic, co-ordinated and flexible approaches aim to counteract the impact of bureaucracy and fragmentation. The Modernising Government Report emphasises that such approaches need to be supported by 4 main components: technical, organisational, cultural and a framework for information sharing.

• Technical aspects include integrated technology and technical arrangements, "such as an integrated telecommunications infrastructure and interoperability"
• Organisational conditions include corporate and integrated organisational structures and arrangements and a corporate approach to information management
• Positive organisational and service cultures are also key to promoting integration and joint work and require "strong leadership in driving through the changes that join up services across organisational boundaries"
• Protocols must enable information sharing, control data sharing and protect privacy.

"There is also a need to deal with the important concerns over data protection, to ensure that alongside the drive to join up services and to share information there are strong controls that protect the privacy of the individual and the access to personal data" (Scottish Executive, 2003a, p3).

Increasing service user involvement and control

6.43. The literature highlights the need to work with service users in both the development and delivery of services (Turning Point, 2005; Rankin and Regan, 2004; Edwards, 2003; Leadbeater, 2004 and The Social Exclusion Unit, 2005a and b). As noted above, Turning Point (2005) advocate that at the point of development of Connected Care Centres, community audits should be carried out to ascertain the services that are most needed.

6.44. Much of the discussion on service user involvement in the literature on support and care relates to how best to involve individual service users to improve outcomes. Leadbeater (2004) for example, has outlined 'a few simple rules' that can help services to have a positive impact. All these rules involve the service user closely in planning their own pathway. In relevant cases, carers should also be involved.

• Set incremental goals, starting small and manageably
• Specify clearly what the user and the service professionals expect to do
• Keep joint records of achievement and performance to reinforce success
• Give users a mix of options through which they can achieve their goals
• Frame the policy in an aspirational way to excite ambition
• Provide role models and peer-to-peer support to build confidence.

6.45. Service user involvement may take place at a number of different levels. Hudson et al (2004) draw on Arnstein's long referred to 'ladder of participation' as shown below.

High	Users have the authority to make decisions
	Users have the authority to take selected decisions
	Users' views are sought before decisions finalised
	Users may take the initiative to influence decisions
	Decisions are publicised and explained before implementation
Low	Information is given about decisions made.
	(Hudson et al, 2004, p15, drawing on Arnstein S, 1969)

6.46. Rather than simply focus on levels of participation it is important to recognise that promoting and sustaining participation in practice requires a range of approaches and methods, as well as an appreciation of the factors and structures influencing participation. Davidson represented this in the form of a wheel of empowerment (Davidson, 1998).

6.47. Notwithstanding these different levels of involvement, there is a broad consensus in the literature that effective and responsive services need to ensure increased service user, and where appropriate, carer, involvement. One recent initiative to promote the involvement of people in their healthcare is the Expert Patients Programme (see Appendix 3).

Choice and enabling service users and carers to be co producers of their care

6.48. To enable user empowerment it is argued that service users must be seen as co-producers of their care (Claire and Cox, 2003; Rankin and Regan, 2004; Leadbeater, 2004; DEMOS, 2005; Turning Point, 2005; Scottish Executive, 2006b).

6.49. The following describes initiatives in the field of learning disabilities that allow for greater involvement in the planning and provision of care.

User purchasing systems

Direct Payments

6.50. Support for the principle of direct payments through legislation ( i.e. Community Care (Direct Payments) Act 1996 and the Health and Social Care Act, 2001), alongside evidence of the positive difference direct payments can make to people's lives by providing the flexibility and control that service users seek, has not translated into the transformation expected (Leece and Bornat, 2006; Witcher et al, 2000). Additionally we have seen that for various reasons there has been a lower take-up in Scotland (Pearson, 2006) and that take up has been relatively low amongst people with mental health problems (Ridley, 2006).

6.51. Recent research on direct payments for mental health service users in Scotland points to the obstacles of misunderstandings about eligibility; lack of person centred approaches in community care assessments; perceived threats to the funding of services; concerns about people's ability to manage, especially if they experience fluctuating health problems; and a lack of adequate support organisations (Ridley, 2006). There is therefore a need for targeted information and education to counteract the obstacles of low awareness, lack of understanding and concerns about the impact of direct payments on service users and professionals such as care managers. Advocacy support is also required to encourage those eligible to take up these payments.

6.52. The literature overall emphasises the advantages to be gained from direct payments for those who take them up as well as for service providers.

"A significant feature has been how the quality of life of the disabled person has improved: the sense of feeling in control has been a central aspect in all the findings…choice and flexibility were the other themes. The other significant point is cost effectiveness compared with in-house direct service provision" (quoted in Hudson et al, 2004, p27).

6.53. Direct payments and Independent Living Fund Options should be systematically offered as an option by care managers when doing community care assessments, as legislation now makes direct payments mandatory not discretionary. From another perspective, it has been pointed out that direct payments may cause conflicts and tensions with "the development of strategic, whole systems approaches to local service commissioning" (Hudson et al, 2004, p28). In Canada and the USA, the shift towards individualised planning and funding options has been understood more positively as a "move from service and placement towards capacity building and participation" (Hutchison et al, 2006).

Access to Advocacy

6.54. The need for advocacy has been highlighted in the literature and policy documents across various client groups including: learning disability (Scottish Executive, 2000,); mental health (Ridley and Jones, 2002), people with co-occurring substance use problems and mental health problems ( SACDM and SACAM 2003) disadvantaged people and those with complex needs (Scottish Exclusion Unit, 2005a; Rankin and Regan, 2004; DEMOS 2005).

6.55. The Mental Health (Care and Treatment) (Scotland) Act 2003 gives a right to access advocacy to people suffering from mental illness, dementia, learning disability, autism, brain injury/damage, or personality disorder. Other people can access advocacy services, but do not have a legal right.

6.56. The benefit of advocacy is shown by the case of one young woman. She had been brought up by foster parents and is now at university. When she was 13, she got in touch with Who Cares Scotland, which helps young people in care to have their voices heard.

"Without Who Cares services may have been ill-coordinated and Ann's voice may have been drowned out. Ann is not just a client of social work services she has become a participant, contributor and investor, of her own time and effort" ( DEMOS, 2005, p15).

6.57. While national and local policy makers have taken the need for advocacy on board and more funding has been channelled into advocacy, it will be important to monitor its local availability for equity reasons and to ensure that policy is translated into practice.

6.58. Additionally, it is important to recognise that people with a legal entitlement to advocacy may present to services via homelessness services or refugee services. Access to advocacy should be considered in respect of multiple service points.

6.59. For some people, peer advocacy has been found to be particularly effective, as shown below.

Community development, collective empowerment and partnerships

6.60. There has been more attention paid in the literature and guidance to service user participation at the individual level, rather than to participation as collective consumers or citizens. To promote collective rights and empowerment there needs to be attention to community development, collective advocacy approaches, and their links with social inclusion. Essentially such approaches require a partnership perspective to inform the ways in which professionals relate to service users (Barr et al, 2001; Henderson, 2005).

6.61. While most community development focuses on empowering local residents to clarify and articulate their collective views on local needs and services, the same aims are relevant to people with multiple and complex needs as service users.

6.62. One example of collective user involvement with positive outcomes focused on people with learning disabilities through a Best Value review. The same approach, however, could be relevant to other client groups.

6.63. A community development approach, working in partnership is further illustrated by another recent initiative in Glasgow.

6.64. Drawing on these examples and the wider literature, enabling conditions for promoting collective empowerment at policy level include:

• Ensuring that people with multiple and complex needs are treated as citizens with rights of self-determination and participation, and with a contribution to make
• Policies and practice built on the 'social model'
• Active promotion and support (capacity building) for empowerment through proper resourcing of sustainable mechanisms for collective participation. (Barr et al, 2001; Wren et al, 2004; Morris, 2005; Hudson, 2005)

Ensuring smooth transitions

6.65. Bureaucracy and fragmentation mitigate against straightforward and positive transitions, whether these are caused by changes in age or in circumstances, such as leaving institutions or hostels. Unmet needs arise not only because of service gaps, but also because of existing services' client criteria. People with multiple and complex needs may fall between the criteria employed by child and adult services, or mental health and criminal justice services, or housing and support services, for example (Social Exclusion Unit, 2005b).

6.66. The following example highlights the benefits to be gained through accessible, flexible and co-located service arrangements to facilitate continuity of support.

6.67. Regarding transitions caused by leaving institutions or moving on from homelessness or being a refugee, once again this alerts us to the need for person centred support as well as co-ordinating and linking roles to facilitate positive resettlement and follow on support.

6.68. More generally the constraints on effective resettlement, and the potential for unsettled pathways at least for a period, have been found to include individual, situational and structural factors, including:

• A scarcity of housing or accommodation that matched need, including accessible and sustainable accommodation for people with physical health problems or disabilities
• Problems with practical issues such as paying bills, obtaining furniture, accessing information, or applying for a tenancy
• Lack of continuing support of the right kind, including low level housing support and support to address for example, mental health problems that may relate to prior abuse or trauma and be exacerbated by substance misuse; or people may be involved in continuing, increasing or relapsing substance misuse
• Negative social environments, where for example there is the fear of abuse or violence or pressured social networks
• Challenging or anti-social behaviour by the individual and associated reactions
• Lack of social networks and isolation and loneliness
• Lack of opportunities to move on through education, work or meaningful and structured activity (McNaughton, 2005; Rosengard et al, 2002; Petch et al, 2000)

6.69. In turn, effective resettlement has been found to require a variety of approaches.

Service outcomes

6.70. In defining positive outcomes for people with multiple and complex needs from service provision, it is not possible to offer more than generalised statements, given the range of people the terms 'multiple' and 'complex' refers to. Additionally, given the significant shortfalls identified in current service provision ( Chapters Three and Four) and identified good practice, quality of outcomes will be contingent on:

• The extent to which agencies have a strategic and holistic approach
• How well they listen to service users' views on their needs and preferences
• The extent to which they are pro-active and persistent in reaching and sustaining contact with service users
• How effectively they are linked with relevant service networks
• The effectiveness of joint working on the ground
• Their flexibility and capacity to acquire the best options for service users in the context of resource constraints.

6.71. Rather than seeing quality of outcomes as being determined by the breadth and or intensity of people's needs, it should be seen as a routine challenge for services to work holistically to address the full range of service users' needs, and to assist people in moving on from the service provided. It is however important to recognise that while service commissioners and many service users, including those with more intense needs, may only conceive of a good service outcome in terms of exiting from it once their needs have been met, this expectation may be inappropriate in the context of long-term, continuing needs. For a minority of service users with long-term continuing needs, who do not have families to care for them, and who require continuing accommodation and support, their current service, such as residential care, may be their 'home'. Providing that the existing service maximises their rights, meets good practice standards, enables people to develop and 'move on' within and through services and to maximise their quality of life, there may be no good reason for this not to be 'a home for life'.

6.72. The 'maintenance' approach, as described by Keene (2001) accepts some people's preferences for not changing their status quo and proposes that ongoing support coupled with crisis-avoidance strategies should recognise such preferences. However, where the status quo involves significant risks it should not be accepted easily by professionals, without active exploration with service users of what is achievable.

6.73. Notwithstanding those caveats, Hudson et al (2004) identified high level outcomes that will be outlined below (paras 6.89 and 6.90). Rather than being quantifiable, these outcomes relate to quality of life as perceived by the service user. This approach to outcomes is similar to that adopted in the DOH White Paper ( DOH, 2005a) (see Appendix Three). Hudson et al state:

"It is important to be clear about the conceptual framework that comprises an outcomes - based approach. Outcomes refer to the effects or impacts on the welfare of service users and should be distinguished from outputs which are, strictly speaking, service product" (Hudson et al, 2004, p4).

6.74. It is important to recognise that outcomes measuring quality of life may be in tension with a target driven approach that characterises many services. For people with multiple and complex needs a rigid adherence to outcomes of abstinence or length of time in accommodation, may lead to them being defined out of the service.

6.75. The importance of achieving softer outcomes as part of a process of moving towards achieving harder outcomes has been well recognised in Scotland. In the evaluation of the New Futures projects, additional assistance was offered to counteract the barriers people faced in accessing employment, such as addictions and homelessness, to enable people to enter or move nearer to the job market (McGregor et al, 2005). This is consistent with the approach of measuring distance travelled, as shown below.

6.76. Some of the literature stresses the needs for aftercare to be available if people are to sustain benefits of service engagements. This has been identified as particularly relevant to substance misuse services (Scottish Executive, 2002 b,c,d; SACDM & SACAM, 2003; Scottish Executive, 2006b), and to young people engaged with employability projects (McGregor et al, 2005).

Joint working

6.77. Joint or partnership working is critical to addressing the problems of fragmented services resulting in poor service outcomes, and a number of initiatives described above have joint working at their core - for example, e-Care and the Argyll and Bute initiative, and in the case of In Control, a partnership between service users, carers and statutory services.

6.78. Joint working is required at different levels - first, at the strategic service level, such as knowing the overall population with needs and what services are required, planning and commissioning services, and secondly, at operational level (see for example, Keene, 2001 and 2003; Rankin and Regan, 2004; DOH, 2006; Kennedy et al, 2001b).

6.79. As so little is known about the overall population with multiple and complex needs, it is argued that relevant services across health and social care should collect and share information about populations or clients that they have in common (Keene 2001, Rankin and Regan 2004). Rankin and Regan further propose that "a statutory duty should be placed on the NHS and local authorities to collect data and monitor multiple service use" (p73).

6.80. There are signs of movement in this direction in England, with the Department of Health stating that:

"The Director of Adult Social Services and the Director of Public Health will carry out regular needs assessments of their local population. This will require analysis and interpretation of data held by PCTs, local authorities, youth offending teams, the police, independent providers, voluntary and community organisations, Supporting People, the Department for Work and Pensions, census data and other data sources. This will enable the establishment of a baseline of current population needs in order to effectively plan for the future and provide the information needed to stimulate and develop the social care market" ( DOH, 2006, p166).

6.81. An example of operational joint work that reflects the need for professionals' awareness of diverse community needs is shown below, and a further example is shown in Appendix 3.

6.82. Joint work requires appropriate resourcing and training for those involved in new ways of working. Commenting on care management in 2002, Stalker et al concluded that very little joint training had taken place, but that this was found beneficial where it had.

"Borders was one of the few authorities in Scotland to have organised joint training specific to care management, which had been independently evaluated. Staff reported that this had promoted a greater understanding of each others' roles". (Stalker et al, 2002, p6).

6.83. Other recent studies in Scotland similarly indicate a high level of need for staff training to meet co-occurring and multiple needs better. (Scottish Executive 2006c). Additionally, guidance has increasingly emphasised the need for change in professional culture and values to promote the successful delivery of person-centred, creative and individualised approaches, as has recently informed guidance on mental health nursing (Scottish Executive, 2006g).

6.84. This targeted training initiative illustrates the vision and the level of strategic and resource commitment that is required from policy makers, managers and staff to turn around professional values and approaches to promote new ways of working and to maximise rights, choice and control for service users.

Joint budgets

6.85. Rankin and Regan (2004) point out that positive and effective joint working will require procedures to rationalise funding streams and that the increasing popularity of pooled budgets indicates there is a will to act on this. The following example indicates the benefits of pooled budgets.

Targeting services and resource issues

6.86. Targeting and prioritising multiple needs and disadvantage is an intrinsic feature of social policy ranging from tackling areas of multiple disadvantage (areas for priority treatment) to the personal social services. Increasingly, various policy reports relating to people with complex/and or multiple needs specify a tiered approach to service provision. Although the number of tiers or levels deemed to be appropriate vary, all are based on the principal that people require different tiers or levels of service, depending on their needs (see for example SACDM and SACAM, 2003; Cox et al, 2004; Department of Health, 2005a).

6.87. The level of service model is shown below in respect to the DOH model for people with long term conditions ( DOH, 2005a.). Further information on key aspects of the NHS and Social Care long term conditions model is given in Appendix 3.

DOH, 2005a, p10

6.88. The approach of targeting those in most need as a means of limiting eligibility for services in the context of budgetary constraints however is not without its critics. They alert us to the potential misguidance of a tiered approach that does not recognise that low level and early intervention can help to prevent crisis and worsening of people's situation (Hudson et al, 2004; DEMOS, 2005; Pratt et al, 2006).

Service principles

6.89. Having explored a range of good practice it is now relevant to focus on the principles that underpin good practice, and Hudson's recent work is useful here. Hudson et al (2004) have identified a series of principles that they relate to the preferred outcomes expressed in consultations with service users and other organisations. While these focused on older people their relevance to other needs has been examined and clarified. The principles stress that assistance and support should enable the following life opportunities and outcomes (Hudson et al, 2004):

• To access and sustain independence
• To be clean and comfortable
• To have a clean and predictable environment
• To be safe
• To access social contact and company
• To be active and alert
• To live healthier and longer lives
• To have an adequate income
• To contribute to the community
• To feel valued.

6.90. Hudson et al identify 10 key principles (presented as models), that seem to be broadly consistent with the good practice identified from the literature covered in this review.

• A whole person model that tackles exclusion on a broad front - from low incomes and poor housing to promotion of good health and participation
• A whole systems model that maximises joint working in service access and delivery
• A comprehensive model that is preventative as well as responsive and covers a range of services
• A user empowerment model that is rights based, builds on the social model and maximises individual and collective participation - so tilting the balance of power to the service user
• A reciprocal model that stresses the contributions that people with multiple and complex needs can make, rather than focus on their problems or disabilities and dependence
• A checks and balances model - whereby central government sets and assesses the outcomes framework and its implementation, while localities determine how best to achieve these. Another check and balance is for service users to be involved at the start and throughout. Hudson et al note that guidance may be useful on participation.
• A personalised service model that is tailored to people's needs and views service users as the experts
• A choice and diversity model within which providers can be responsive to users' choices
• A social capital model which recognises the value of existing forms of informal support and community and user networks and cooperation
• An implementation model that stresses a coherent vision; building effective partnerships and develops realistic plans for delivery.

(Hudson et al, 2004)

Key points - Chapter Six

• Information on service availability must be readily available and in formats that are accessible to 'hard to reach' groups
• Services should seek to minimise waiting lists and make sure that they promote maximum opportunities for access in terms of factors such as physical location and accessibility, opening hours and appointment arrangements. IT can help promote accessibility for some
• Whole person needs must be addressed and met, rather than treating people's needs in isolation, if personalised services are to be provided. Single shared assessments and tools such as person centred planning can be useful for maximising service users' choice and control. Care or pathways plans are useful tools for setting out goals and service responses to achieve them
• Longer-range training and development programmes may be essential to generate cultures that support more personalised and creative approaches
• Single access points such as 'one stop shops' can improve various aspects of service users' pathways into and through services
• Outreach services that 'seek out service users' and 'stick with them' are valuable alternatives or can complement centre based services, not least for 'hard to reach' groups
• Professionals with a remit to link and co-ordinate support services, such as key workers, link workers or service navigators can help minimise the impacts of service fragmentation
• IT and information sharing can significantly reduce the need for service users to repeatedly give the same information to different services
• Service users (and where appropriate, carers) should be involved at all levels of service planning, development and delivery. Some will require advocacy to empower them to become involved
• Community development and peer education approaches are positive routes to empowerment and to enabling service users to contribute to influencing services
• Targets set for services should recognise that good outcomes from service provision for clients with multiple and complex needs are often not measurable in hard or quantifiable terms
• Joint work and partnership arrangements can make a big difference to service users experiences
• Meeting the needs of people with multiple and complex needs is resource intensive and is likely to involve for example, the pooling of information, the pooling of budgets and joint training

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