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Severe multiple disadvantage (Multiple needs) (2019)

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Topic title Severe multiple disadvantage (Multiple needs) (2019)
Topic owner Jane Bethea
Topic author(s) Grant Everitt, Karan Kaur
Topic quality reviewed September 2019
Topic endorsed by Opportunity Nottingham Board July 2019
Topic approved by Opportunity Nottingham Board July 2019
Current version September 2019
Linked JSNA topics
Insight Document ID /d/a51r7IF

Executive summary


Severe Multiple Disadvantage (SMD) refers to people with two or more of the following issues: mental health issues, homelessness, offending and substance misuse. SMD can include other sources of disadvantage, for instance poor physical health, and for women, domestic and sexual abuse - and for Black, Asian and Minority Ethnic (BAME) people, community isolation. Nottingham has the 8th highest prevalence of SMD in England - currently it is estimated that over 5,000 of the City’s citizens experience SMD.

SMD mainly originates in adverse childhood experiences, approximately 85% of people facing SMD have experienced childhood trauma. This effects mental health which can lead to issues such as homelessness, substance misuse and offending. Services working with people facing SMD struggle to meet needs, because they are mainly set up to deal with single issues. The consequence for people facing SMD is their other issues prevent them successfully engaging with single issue treatment or support. For example substance misuse may lead to exclusion from a mental health service. Instead they tend to end up at “blue light services”: e.g. A&E, Ambulance calls outs, arrests and custody. The economic cost of this “siloed” and unconnected approach is high - one source estimates across England it is £10.1 billion a year.

Unmet need and gaps

Given the nature of multiple disadvantage there is not sufficient cross sector collaboration and coordination between mental health, housing, criminal justice and substance misuse services – as well as social care and the DWP. This lack of coordination and collaboration exists at all levels from ground level staff to strategy and commissioning. Part of this lack of collaboration is a lack of data sharing which causes people facing SMD to have to keep repeating their story and this contributes further to their alienation from services.

As SMD is primarily a consequence of trauma, a mental health response is central to meeting needs but often people facing SMD cannot get access to the mental health services they need especially psychological intervention. Nor is there sufficient psychological understanding of people facing SMD from the wider workforce.

Where SMD results in homelessness, appropriate housing solutions are not often available. Hostel provision has limited success especially for people facing SMD whose needs are most acute. Housing First has a good evidence base as an alternative but there is not enough provision.

Citizens facing the most acute SMD, can benefit from specialist support from a dedicated SMD service. Opportunity Nottingham aims to provide this until 2022 but after this a replacement will need to be found. Evidence suggests people facing SMD must be involved in developing their own solutions to the disadvantages they face. This includes individually through strength based approaches and collectively through ensuring the system is service user led or informed.

Recommendations for consideration by commissioners

The following measures for consideration by commissioners have the potential to reduce both the incidence of SMD and its negative impact. They build on the five Opportunity Nottingham System Challenges for Nottingham City – available here:

1. Once Opportunity Nottingham ends in 2022, continue to respond to multiple and complex needs by building on its legacy through considering developing a jointly commissioned specific SMD Service.                                                                                                                                                                                              This service will work with people facing SMD who have the greatest level of need and will build on the success and learning of Opportunity Nottingham and the Fulfilling Lives programme. Evidence therefore suggests it should be a multi-disciplinary team containing as a minimum the following elements:

        • A team of Coordinators/Navigators
        • Mental health specialists able to provide psychological interventions and support Psychologically Informed Environments (PIE)
        • A Lived Experience Team that includes staff to support Expert Citizens and Peer Mentors, and focuses on connecting people to positive social networks
        • Gender and Culturally specific elements – which may include posts hosted by specialist agenciesA Practice Development Unit – to promote good practice and collaboration more widely
        • A Social Worker working as a “trusted assessor” to support access to care service

2. Ensure the “system works as one” through development of a strategic “Board” responsible for reducing SMD beyond the end of Opportunity Nottingham in 2022.

This SMD “Board” should oversee service provision and continued system change. This is needed because resolving SMD involves different sectors (principally: mental health, homelessness, substance misuse and criminal justice, but also other sectors such as the DWP and Probation). SMD will only be reduced if senior representatives from these sectors collaborate to ensure a unified approach. Therefore, the highest priority must be given to ensuring genuine and consistent representation from all sectors, with time allowed for this by individual organisations. The Integrated Care System and other strategic initiatives should be used to lever support from all sectors.

The Board would oversee implementation of point one above but also ensure coordination of the wider number of people facing SMD, who will benefit from a coordinated approach but whose needs would not be sufficiently high to qualify for the new SMD service as described in point one above.

3. Increase over time the number of Housing First Units in Nottingham to 200 as part of the legacy to support SMD once Opportunity Nottingham ends.

This figure is based on evidence from Homeless Link that Housing First is suitable for approximately 10% of people facing multiple exclusion homelessness. So, 200 units would be sufficient for approximately 10% of the Nottingham SMD 3/4 cohort. To ensure this is a successful initiative it will need to be linked to the wider housing strategy, especially housing supply and be backed by tenancy support operating at a low resident to worker ratio.

4. Understand the centrality of addressing mental health issues to enable people to move away from SMD. This will be underpinned by the wider goal of ensuring Nottingham becomes a city where the wider workforce apply a psychologically informed approach.

This will include:

    • All services working with people facing SMD taking a psychologically informed (sometimes referred to as trauma informed) approach. This should not only include any specific SMD services, but also single issue services that work with people facing SMD including; homelessness services, substance misuse services and the DWP. The use of a psychologically informed approach should be monitored through use of an appropriate tool, such as the PIZAZZ or the Homeless and Inclusion Health standards for commissioners and service providers (Pathway, 2018).
    • Mental health specialists should be included as part of a multi-disciplinary approach in any service substantially working with people facing SMD. This includes substance misuse services and the Rough Sleeper Outreach Team
    • The recommendations from the CCG funded research by Sheffield Hallam University: Understanding the Mental Health Needs of Homeless People in Nottingham (2018) should be implemented

5. Ensure flexibility in the way we work with people facing SMD by providing gender and culturally responsive support in recognition of the diverse forms multiple disadvantage takes.  

Evidence suggests the mainstream definition of SMD (mental health, homelessness, offending and substance use), can lead to some group’s disadvantages being overlooked, including women and BAME people. Therefore, services need to be gender and culturally responsive and commissioners should monitor this. Additionally, gender and culturally specific services able to work with people facing SMD service should be considered.

6. Support the long-term wellbeing and independence of service users by challenging stigma and by building on their strengths, skills and positive networks.  

Ensure that positive outcomes are sustained by commissioning services that take a strength based approach, focus on skills development and enable supportive positive networks. Without such emphasis, people facing SMD will not be able to build their own resilience and the costly and ineffective “revolving door” experience will be in danger of continuing.

7. Minimise the likelihood of SMD occurring by recognising the origins of SMD mainly begin in early life, and by equipping services for children to respond.

Eighty five percent of people facing SMD have early life trauma and adverse childhood experience. The best long term solution therefore is early intervention through better services supporting children and young people. These should respond to ACE’s and trauma and identify and support young people at risk of moving into the SMD group.

8. Ensure the system works as one and tackles stigma through a “no wrong door” approach, by continuing the work of Opportunity Nottingham to increase data sharing.

This involves supporting systems to improve data sharing (where consent is given) that prevents constant retelling of stories and enables more efficient interagency working, speeding up delivery of services. The inclusion of “Facts about Me” (a form to record hopes and aspirations) will also contribute to tackling stigma and focussing on strengths.

9. Develop a service user led system, whereby people facing SMD are able to directly have a significant say in how services should be working.

This includes ensuring participation is meaningful, is supported with time and resources and is backed by a widely accepted participation standard for Nottingham City.

10. Ensure the Criminal Justice system is fully engaged in and trained to reduce SMD, recognising that people facing SMD can present anywhere.

In economic terms it is in the criminal justice system where a positive approach to reducing SMD will make the biggest difference - this is where the greatest cost savings will be made. The previous nine measures listed above if implemented, will reduce offending. Where it does occur and a prison sentence is given, “Through the Gate Support” (meeting prisoners at the point of discharge) is also an essential component of any coordinated support network for people facing SMD.

Key contacts

Jane Bethea, Consultant in Public Health


Grant Everitt, Evaluation and Learning Lead, Opportunity Nottingham


Data Officer, Opportunity Nottingham

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