Confronting complex needs

Recent research from charity Revolving Doors Agency raises important considerations for commissioners looking to improve services for people facing multiple and complex needs

Every frontline health worker, from primary care to A&E, knows those patients who have multiple complex needs. Those ‘revolving door’ patients they see time and time again, often combined with poor mental health, homelessness, substance misuse, and contact with the criminal justice system. Those patients never seem to get the help that they need.

Recent research from charity Revolving Doors Agency raises important considerations for commissioners looking to improve services for people facing multiple and complex needs

Recent research by LankellyChase Foundation found there are a minimum of 58,000 people experiencing a combination of homelessness, substance misuse, and offending all at once in England – usually linked to underlying mental health problems. An average local authority can expect 1,470 cases of people facing this kind of severe and multiple disadvantage each year.[1]

These individuals bump around between local services, and too often fall through the gaps. Mainstream services, focusing on one issue at a time, fail to respond to the complexity of their interacting problems, with nobody taking overall responsibility. People in this situation experience significant health inequalities:

The average age of death for a homeless person is 47 – or just 43 for homeless women.[2]
Offenders face a far higher prevalence of mental health needs than the wider population, with 72% of prisoners experiencing two or more mental disorders.[3]
Forty one per cent of homeless people in a recent survey reported long-term physical health problems.[4]

They also have a disproportionate impact on services locally, often failing to access planned healthcare but with high use of emergency interventions and crisis services. When combined with impact on other services and the criminal justice system, this situation generates significant costs to the public purse – recent research conservatively estimates that multiple needs costs £10.1 billion a year nationally.

Finding a better way
No wonder, then, that there is a growing consensus that something needs to be done. The government pledged in the 2014 Autumn Statement to drive forward improved coordination of services for people facing multiple and complex needs, while moving towards a more holistic approach and greater integration of commissioning are key trends in the health sector. As the NHS England Five Year Forward View states: “There is broad consensus on what that future needs to be. It is a future that empowers patients to take much more control over their own care and treatment. It is a future that dissolves the classic divide, set almost in stone since 1948, between family doctors and hospitals, between physical and mental health, between health and social care, between prevention and treatment.”[5]

Thankfully, there is also a growing understanding of how local commissioners can work together to develop a more effective approach. Reflecting on research published recently by Revolving Doors Agency, a charity for people with multiple problems, here are three considerations:

1. Understanding ‘what works’
Firstly, it is important to draw lessons from the growing evidence-based of ‘what works’ for people facing multiple and complex needs when commissioning services that provide support.
Our recent briefing Comprehensive Services for Complex Needs: A Summary of the Evidence 6 reviewed the evidence-base for three service models targeting individuals facing multiple needs:

Link worker: A delivery model involving the co-ordination of multiple areas of support for adults with multiple and complex needs. Link workers also act as advocates and consistent sources of support for their clients.[6]
Wraparound: A process of co-ordinating professional and community-based support for young people, underpinned by a focus on family strengths and the ‘voice and choice’ of young people and their families.[6]
Multi-systemic therapy (MST): An intensive psychological treatment programme that takes place in the family home. Therapists work closely with young people and their families to address the different areas which influence behaviour.[6]

Despite differences between the models in terms of their origins and primary target groups, there is a significant overlap in the approach that they take. In particular, all three models:

Work holistically.
Work intensively with service users.
Take a flexible approach.
Build positive relationships.
Build on client’s strengths.
Involve service users throughout the process.

Ensure a range of key outcomes are addressed and the client’s priorities are respected.
There is promising evidence that this approach provides better outcomes for people facing multiple and complex needs, including improved mental wellbeing and a shift in service user from repeated emergency interventions to service use to the planned engagement that is more likely to support long-term recovery. This generates savings through reduced demand on services in the long-run – two recent studies of the link worker model suggest monthly savings per client of between £347 and £958 to local services.

2. Working together to commission for better outcomes
In a time of shrinking budgets and increased demand across the public sector, it is important that a range of local commissioners come together to fund such services and contribute towards shared outcomes – including local authorities, police and crime commissioners, and directors of public health as well as clinical commissioning groups (CCGs). An outcome-focused approach that works across service boundaries promises greater efficiency, funding more effective services and reducing duplication.

However, it is crucial to ensure that the outcomes prioritised reflect what people want and need, and that funding mechanisms used do not hinder delivery. Outcome-based funding approaches such as payment by results (PbR) may seem attractive.
However, as our recent report Adding Value?: Reflections on Payment by Results for People With Multiple and Complex Needs shows, PbR can pose particular challenges when applied to services for people facing more complex needs.[7]

The report argues that savings with people in the ‘revolving door’ situation will come from pooling funds, reducing duplication, and working together to provide more effective and responsive services, rather than processing people towards unrealistic and oversimplified outcomes more effectively.
Outcomes should be set in conjunction with service users, reflecting their priorities and needs.

3. Listening to service users
This brings us to our final principle: the need to work closely with service users in the design and delivery of services, and listen to what service users themselves identify as important.

Our new report A Good Life: Exploring What Matters to People Facing Multiple and Complex Needs presents findings from research with members of our National Service User Forum, all of whom have experienced multiple needs.8 Participants predominantly wanted fairly simple things: stability; a decent and secure home; and services that were compassionate, responsive and treated them without stigma and prejudice. They also stressed the importance of some of the wider determinants of health and wellbeing to their recovery – including relationships outside of traditional service provision, such as links with family and peer support networks.
However, a key finding was the complex and highly personal nature of people’s journey towards recovery. The report concluded that services must provide genuinely personalised support, involving service users in setting their priorities and outcomes.

A role for CCGs
Of course, it is not for CCGs to take on this challenge alone. However, with a duty to reduce health inequalities and an incentive to reduce demand on costly emergency services, health commissioners have a key role to play. By investing in the kind of holistic and intensive support that works for people facing multiple needs, and working with other commissioning partners across local government, criminal justice and public health, it is possible to have an impact on this problem, and to develop services that are effective and responsive to what people facing multiple and complex problems want and need.

With shrinking funds across the public sector, and significant challenges for health commissioners, we cannot continue with the preventable situation of a small group of people placing a significant demand on services without getting the help they need to tackle their underlying problems. Health commissioning has an important role to play in joining up to achieve change.

Shane Britton is policy manager at Revolving Doors Agency.

References
1.   Bramley G and Fitzpatrick S. Hard Edges: Mapping severe and multiple disadvantage Lankelly Chase Foundation 2015 http://www.lankellychase.org.uk/assets/0000/2858/Hard_Edges_Mapping_SMD_FINAL_VERSION_Web.pdf (accessed 27 March 2015).
2.   Thomas B. Homelessness Kills: An analysis of the mortality of homeless people in early twenty-first century England Crisis, 2012. http://www.crisis.org.uk/data/files/publications/Homelessness%20kills%20-%20Executive%20Summary.pdf (accessed 27 March 2015).
3.   Revolving Doors Agency. Balancing Act: Addressing health inequalities among people in contact with the criminal justice system London, 2013. www.revolving-doors.org.uk/documents/balancing-act/ (accessed 27 March 2015).
4.   Homeless Link. The unhealthy state of homelessness: Health audit results 2014 London, 2014. http://www.homeless.org.uk/sites/default/files/site-attachments/The%20unhealthy%20state%20of%20homelessness%20FINAL.pdf (accessed 27 March 2015).
5.   NHS England. Five Year Forward View 2014 http://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf
(accessed 27 March 2015).
6.   Revolving Doors Agency. Comprehensive Services for Complex Needs: A summary of the evidence London, 2015. http://www.revolving-doors.org.uk/documents/comp-services-complex-needs-summary-of-the-evidence/?preview=true (accessed 27 March 2015).
7.   Revolving Doors Agency. Adding Value? Reflections on Payment by Results for People With Multiple and Complex Needs London, 2015. http://www.revolving-doors.org.uk/documents/adding-value-reflections-on-payment-by-results/ (accessed 27 March 2015).
8.   Revolving Doors Agency. A Good Life: Exploring What Matters to People Facing Multiple and Complex Needs, London, 2015. http://www.revolving-doors.org.uk/documents/good-life/ (accessed 27 March 2015).