Citizen Advisors - Turning Point

Turning Point Connected Care Report 1
Citizen Advisors
Linking services and empowering
communities
Turning Point, October 2010

Turning Point Connected Care Report 2
Foreword
The future of public services depends on starting from the citizen’s perspective,
shifting power to communities, and opening up services to individuals in different
ways.
Communities have a role in achieving good outcomes from public services. We
also know that some communities need extra support to access services, and
often don’t receive support they need because they find it difficult to navigate their
way around services.
This report recommends a different approach, provided through Citizen Advisors,
to support people to interact and engage with services, and to build up their
resilience and community capacity.
It brings together and appraises the international evidence-base of citizen advisor
type functions. There are good examples of services performing different aspects
of these roles: but most have struggled to meet the challenge of both having the
confidence with the local community, and also providing a sufficiently strong and
acceptable mechanism for working with other professionals across public
services. Our vision is for Citizen Advisors to help people access the variety of
services they require to meet their needs. Citizen Advisors can help assess,
signpost and support people into local programmes while enabling them to
interact more effectively with services when they exercise their option for self
directed support and personal budgets.
Thus it is an approach which could help bring life to the Big Society ideal of giving
more opportunities for local citizens to come together and solve problems that
affect their lives and their community. Their grassroots knowledge can also
support the coalition government’s plans for Liberating the NHS with communities
acting as more active participants in public services.
At the heart of Liberating the NHS is the aim of opening up services to patients in
an unprecedented way. Its proposals focus on providing greater choice of
providers, choice of treatment and more transparent information on the quality of
local services. This ‘choice and information revolution’ makes the role of Citizen
Advisors essential if people are to navigate their way around the health service
and truly experience the best it has to offer.
Citizen Advisors could play a critical role in brokering the new relationships the
government is seeking to establish the relationship between health, social care
services and communities. There are a number of approaches that would support
this process. One solution would be for Citizen Advisors to support GP-led
consortia so that both GPs and patients know more about the range of local
services and community resources that might be available. A second approach
would see Citizen Advisors linking health services to the wider community to help
ensure more equal health and wellbeing outcomes are experienced across
different social groups.

Turning Point Connected Care Report 3
A third role would be in support of the integration of services with Citizen Advisors
providing the much needed link between often fragmented services that many
families currently find difficult to access as a joined up, coherent whole, available
at the right time and in the right place. Finally, if the newly proposed Health Watch
is to be the ‘Citizens Advice Bureau for health and social care’ then Citizens
Advisors can help makes this a reality by putting a community- based workforce
behind it. In our communities, and particularly those that are the most deprived,
there is huge benefit by having local experts by experience based at libraries or
communities centres or on the end of the phone, guiding others to seek the advice
and support they need.
The Big Lottery fund or other community investment could be a good source of
funding for this kind of work which would focus on building local capacity and
encouraging greater take up of services. Similarly, the Public Health ring-fenced
budget could be a mechanism for integrating Citizen Advisors into communities
and health improvement plans. The current imperatives for efficiencies and
delivering more for less mean that numerous funding streams should be
considered for supporting Citizen Advisors in fulfilling the roles in the health
service and wider community.
This report offers a set of principles to guide the development of Citizen Advisors.
I hope that it will reinforce the platform for implementing the model across the
country and thereby strengthen the delivery of more personalised and integrated
services that communities so urgently need.
Gerald Wistow
Visiting Professor of Social Policy, LSE and Chair of Connected Care Steering
Group

Turning Point Connected Care Report 4
Executive Summary
Empowering communities to do more for themselves and encouraging
individuals within a local area to come together and have a role in shaping and
delivering services are key components of the coalition government’s vision for
a Big Society, and in reframing the purpose of public services, particularly in
health and social care, with communities acting as more active participants in
creating better outcomes.
This co-production approach can build capacity, develop the skills of local
people and result in a more appropriate use of services. However, involving
people in the design of services may not be enough to truly build community
resilience and improve quality of life. Individuals will need support to help them
to interact and engage with services and to build their confidence so that they
are able to play an active role in their communities.
Turning Point Connected Care argues that a new approach to service provision,
Citizen Advisors, is best placed to provide this service and offer this type of
support for communities within a more integrated health system. The purpose
of a Citizen Advisor is to assist people in accessing the variety of services that
they require to meet their needs. Citizen Advisors would signpost people into
programmes in their local area and then support people through the process of
engaging with services.
This Turning Point report reviews a number of approaches to service navigation
and wider support, placing particular attention on those that join up health and
social care. This is important because integrating health and social care support
improves efficiency, the service user experience, and can produce savings. For
example, integrated health and social care initiatives can realise savings of
between £1.20 and £2.65 for every £1 spent (Turning Point, 2010).
The report finds that it is essential that citizen advisor type models are designed
and delivered in response to the needs and wishes of the local community. This
criterion is reflected in the fact that there are often differences between citizen
advisor services that have been set up in different communities, particularly
urban and rural areas. Citizen advisors in urban areas tend to focus on directing
people to statutory services, whereas citizen advisors in rural areas play a much
bigger role in community development and tackling social isolation.
However, in many cases individuals require both forms of support and there is
evidence to show that there can be practical difficulties when attempting to
deliver this. Often citizen advisors feel unable to fulfil both aspects of the role,
signposting to services and improving community capacity, and they prefer to
focus on one aspect or another, depending on their background and experience.
This is influenced to a large extent by whether the citizen advisor is a qualified
professional, or a local community member. It seems that this can have a large
impact on the credibility of the service, both with clients and with other
professionals. Local people working as citizen advisors tend to have a much

Turning Point Connected Care Report 5
better understanding of the local community and issues, and are able to build
trust and confidence amongst the community. Whereas, those with a
professional background, tend not only to get paid more, but have stronger
mechanisms for working with other professionals whose understanding and
knowledge of the citizen advisor service is critical to the success of the initiative.
In order to overcome some of these difficulties, Turning Point recommends the
establishment and rolling out of Citizen Advisor services across the country that
build on elements of existing successful initiatives explored in this paper.
Citizen Advisors will be a new approach to service delivery that is not ‘service’
focused but ‘people’ focused. Our vision is for Citizen Advisors that are recruited
from their local communities, setting themselves up in community owned social
enterprises based in the heart of local communities. They will operate at the
interface between primary care and the community, with a remit to provide a
joined up approach to multiple challenges, and to remove layers of bureaucracy
not add to it.
To fulfil this ambition, we recommend that Citizen Advisors have the following
characteristics:
1. Citizen Advisors should have first hand knowledge of the local
community and/or be experts by experience, not professionally led.
A quasi-professional Citizen Advisor role would entail recruiting local people
who are experts by experience. This makes training and shadowing statutory
services and local organisations of paramount importance and would result in
the role being complementary to, but independent of statutory services.
2. Their remit should be designed and developed by local communities to
help meet the specific needs locally.
Community engagement is a necessary prerequisite for Citizen Advisors to help
build up their resilience and empowerment locally. Citizen Advisor services
could be set up as community owned social enterprises, thus allowing local
people to have control over service provision and build their own skills.
3. Citizen Advisors should focus on supporting individuals who are in
greatest need of support and/or have not traditionally used local services.
Citizen Advisors should focus upon helping disengaged and marginalised
individuals to access services and to use services more appropriately. However,
the service should be inclusive and therefore also available more widely for
people with lower level needs.
4. The role of Citizen Advisors should not be limited to signposting to
existing services but encompass wider support across early intervention,
self care and building community capacity.

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Citizen Advisors should seek to motivate and mentor individuals to build their
aspirations for change and to take responsibility for their well-being, to help
connect them with existing community networks, and ultimately remove their
reliance on statutory services.
5. Citizen Advisors must provide a holistic, flexible and responsive service
that is built around the needs of the client and able to meet people’s interconnected
needs.
Citizen Advisors should act as a single point of access to services to help
communities get the support that they need and help them to interact with
services. They should take on a more encompassing role than some traditional
services and recognise that offering wider support for people with employment,
financial, housing or community issues, for example, can provide a route into
supporting people’s health and social care needs.

Turning Point Connected Care Report 7
Contents
Foreword ....................................................................................................................2
Executive Summary ..................................................................................................4
Contents.....................................................................................................................7
1. Introduction ........................................................................................................8
1.1 Overview .......................................................................................................8
1.2 Policy Context ...............................................................................................9
1.3 Turning Point...............................................................................................12
2. Connected Care Navigators ............................................................................13
3. Local Area Coordination..................................................................................16
3.1 Australia ......................................................................................................16
3.2 Scotland ......................................................................................................18
3.3 North East of England .................................................................................19
4. Support for People with Complex Needs .......................................................21
4.1 Link Workers ...............................................................................................21
4.2 RightSteps...................................................................................................23
5. Early Intervention.............................................................................................24
5.1 Partnerships for Older People Projects (POPP)..........................................25
5.2 Care Navigators ..........................................................................................26
6. Rural and Community-based Models .............................................................28
6.1 Village Agents .............................................................................................28
6.2 Community Mentors ....................................................................................31
6.3 Community Agents......................................................................................32
7. Conclusions.........................................................................................................33
7.1 Recommendations ......................................................................................35
7.2 Future work .................................................................................................40
Appendices ..............................................................................................................41
Appendix 1 - Bibliography......................................................................................41
Appendix 2 - Search History ..................................................................................42

Turning Point Connected Care Report 8
1. Introduction
1.1 Overview
The aim of this report is to review different approaches to Citizen Advisor
services and to make recommendations on how future models could be
developed in the context of community empowerment, personalisation and
prevention.
People with a range of health and social care needs often find it difficult to
access information and appropriate services to support their needs. Currently,
Citizen Advisors are either professionals or local community members that help
people to access the services that they require to support these needs. An
important element of the Citizen Advisor role is holding people in services and
encouraging them to engage with services at an early stage to prevent the need
for more intensive support in the future.
A range of approaches to delivering this type of support exist. Although, the core
aim of the role is to enable clients to engage with services, the components,
target groups and locations of this approach vary widely. The rest of this report
considers the components of a number of Citizen Advisor models that operate to
support people through using and accessing services. The final chapter sets out
Turning Point’s vision for the future development of Citizen Advisor services,
which builds upon the examples discussed throughout the report.
The report is divided into 7 chapters:
Chapter 1 introduces the report and sets the policy context
Chapter 2 looks at Connected Care Navigators
Chapter 3 considers Local Area Coordination as it has been developed
around the world
Chapter 4 discusses citizen advisor type services for people with complex
needs
Chapter 5 focuses upon early intervention and prevention
Chapter 6 looks at rural citizen advisor type models
Chapter 7 summarises the findings of the review and makes
recommendations for the development of future Citizen Advisor services

Turning Point Connected Care Report 9
1.2 Policy Context
Empowering communities
One of the key aims of the new coalition government is to build a Big Society. A
Big Society is a society based around encouraging greater responsibility and
community activism so that individuals and families are able to take more control
of their own lives and local services. The principles of ‘the Big Society’ thread
through the majority of government policy, in particular the health service where
patients are encouraged to be more involved and have greater choice over
provider and treatment. The role of Health Watch will be particularly important to
ensure that people are able to be active participants in the system by having
access to all of the information they need to make a well informed choice.
In the Big Society, charities, voluntary groups and a new generation of
community organisers will help tackle some of the most persistent and
entrenched social problems and barriers that exist to accessing services. In
short, it involves giving greater power to both individuals and communities;
“The Big Society is a society with much higher levels of personal, professional,
civic and corporate responsibility; a society where people come together to
solve problems and improve life for themselves and their communities; a society
where a leading force for progress is social responsibility, not state control” 1
(Building a Big Society, 2010, pg.1).
Giving more control to communities and empowering local people to come
together and to take responsibility for addressing local issues is at the heart of
the Big Society. In particular, there is a real emphasis on providing the
mechanisms for local people to play a role in shaping and designing services
through co-production. According to nef and NESTA (2010);
“Co-production means delivering public services in an equal and reciprocal
relationship between professionals, people using services, their families and
their neighbours. Where activities are co-produced in this way, both services
and neighbourhoods become far more effective agents of change” 2 .
Big Society seeks to reposition individuals as active agents in the design and
delivery of services, recognising that they have valuable opinions and
experiences to bring to the table, which can be used to influence service
redesign.
Co-production is a workable mechanism for realising the coalition’s vision for the
Big Society as it brings together service users, providers and commissioners
leading to social action and change. Models of co-production, such as peer
research, bridge the gap between the community and services to arm service
users with the necessary skills to come together to address local issues.
1 Conservative Party Big Society manifesto. April 2010. pg 1
2 nef and NESTA (2010) Right Here, Right Now: Taking co-production into the mainstream. London:
NESTA

Turning Point Connected Care Report 10
However, community members may need some support to do this and
therefore, community engagement must be a crucial part of the effort to create a
Big Society. Furthermore, involving people in the design of services may not be
enough to truly build community resilience and improve the quality of life.
Individuals may need support to help them to interact and engage with services
and to build up their confidence so that they are able to play an active role in
their communities. Citizen Advisors are well placed to provide this service and
offer this type of support in communities.
Personalisation
Prior to the coalition government, there has been a national effort to transform
adult social care and provide more responsive, flexible and personalised
services for vulnerable people. The ‘Putting People First’ concordat released in
2007 put personalisation firmly on the national agenda. This commitment to the
transformation of adult social care, initially outlined in the Department of Health
White Paper, ‘Our Health, Our Care, Our Say: A new direction for community
services’ (Department of Health, 2006), set out a new vision for the development
of a person-centred approach to the delivery of services.
Personalisation means that the individual is put at the centre of the process of
providing care and support. As a result of personalisation, people are more in
control of the services and support that they receive, thus promoting
independence and increased quality of life. An important element of the
personalisation agenda is the move towards the setting up of Direct Payments
and Individual Budgets. These allow people to have financial control over the
services that they receive.
The commitment to ensuring personal choice started in social care but has since
expanded with the piloting of Direct Payments in health. The personalisation
agenda is also reflected in how Liberating the NHS proposes a more patient
centred health service based on the principle that there is ‘no decision about me
without me.’ With an increasing focus on patient choice the role of Citizen
Advisors within the health and social care sectors is particularly relevant.
In order to fulfil the government’s commitments to providing person-centred
care, a shift in the way services are provided is required and new ways of
working and job roles must be developed. A Citizen Advisor will give individuals
more choice and control over the services they receive, and encourage people
to seek the appropriate level of support for their needs.
It is recognised that it is very difficult for people to know which services to use,
how to access them and to find appropriate support in the local community.
Having a single person to contact, one who is there to explain which services
are available and how to access them, will be vital if people are to be more in
control of the support they receive. A Citizen Advisor role will use a personcentred
approach by helping individuals to access a tailored package of support
that not only includes statutory care services, but utilises the local community
and more informal resources - thus supporting the individual to help themselves.

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Personalisation is also much broader than giving people more choice over the
care and support they receive. In a rough guide to personalisation the Social
Care Institute for Excellence (2010) describes personalisation as:
Tailoring support to people’s individual needs
Ensuring that people have access to information, advocacy and advice to
make informed decisions about their care and support
Finding new collaborative ways of working that support people to actively
engage in the design, delivery and evaluation of services
Developing local partnerships to co-produce a range of services for
people to choose from and opportunities for social inclusion and
community development
Developing the right leadership and organisational systems to enable
staff to work in creative, person-centred ways
Embedding early intervention, re-ablement and prevention so that people
are supported early on in a tailored way
Recognising and supporting carers in their role, while enabling them to
maintain a life beyond their caring responsibilities
Ensuring all citizens have access to universal community services and
resources – a total system response
For example, the personalisation agenda involves a strategic shift towards
prevention, early intervention and giving people access to the information that
they need to care for themselves.
Both the Big Society and personalisation and early intervention agendas are
important drivers for the development of Citizen Advisor services. Work carried
out by Turning Point and the Ippr set the context for this type of service in 2004.

Turning Point Connected Care Report 12
1.3 Turning Point
In 2004, the Ippr conducted research in conjunction with Turning Point 3 to
explore the reasons why some support services were failing to meet peoples’
complex needs 4 . They reported that health and social care services often fail to
recognise the inter-connected nature of people’s needs, thus resulting in a gap
in service provision.
In this report Turning Point and the Ippr set out a strategy for responding to this
issue and meeting complex needs. One element of this reform involves
developing new ways of working for health and social care professionals.
The report recommended that a role be developed to support people with
complex needs to navigate their way through services and around the health,
social care, housing and employment systems. A ‘service navigator’ or ‘Citizen
Advisor’ would have knowledge of mainstream and specialist services and
would work with the service user to develop a sustained pathway of care.
The Citizen Advisor would assist individuals to coordinate the provision of
support and services and to navigate their way around the health, social care
and housing systems. Their role will include facilitating and making connections
between individuals, agencies and the community, thus enabling people to
access the support they need. The report suggests that Citizen Advisors would
require knowledge of issues such as substance misuse, mental health, learning
disability, housing, benefits and employment law, as well as an insight into
different cultures and the particular problems of people of different ages,
offenders and the homeless. As well as having excellent knowledge of the range
of services and groups operating locally.
The following chapters review a range of different approaches to providing
Citizen Advisor services. These are summarised and reflected upon in the
concluding chapter, where a number of recommendations that build on these
examples are also outlined.
3 Turning Point is the UK’s leading health and social care organisation, providing services for people
with complex needs, including those affected by drug and alcohol misuse, mental health problems and
those with a learning disability.
4 Meeting Complex Needs, The Future of Social Care, Turning Point/ippr April 2004

Turning Point Connected Care Report 13
2. Connected Care Navigators
Connected Care is Turning Point’s model for community led commissioning; one
that integrates health, housing and social care. Connected Care works with
communities and commissioners to bring about solutions to health and social
care problems. The model of co-production used narrows the gap between
commissioner’s priorities and the community and delivers a joined up approach
to health, housing and social care.
The Connected Care project in Hartlepool was the first national pilot of
Connected Care and began in 2006. Community researchers in Owton ward,
one of the town’s most disadvantaged areas, conducted a Connected Care audit
to determine the needs and aspirations of local residents and their views on
health and social care services. The audit identified that people require better
information and more continuity and coordination in services. It also revealed
that it is often the small things that have big impacts on people’s lives, such as
the ability to change a light bulb, and that service responses should not overlook
low-level needs. It found that the local workforce needs to be responsive,
flexible and well trained, and to treat people holistically, individually and with
respect and dignity.
In response to these findings and drawing upon the recommendations made in
the Ippr report, a Connected Care service was set up in Owton, comprising of a
team of navigators, a virtual complex care team and low level support services,
delivered through a social enterprise managed by the local community and
supported by a transformational coordinator to oversee the project. In December
2007, three navigators took up their post in Owton working to improve access to
services in the local area. The navigators are local people who are responsible
for ensuring that care remains appropriate to the individual’s changing needs
and addressing unmet needs. The navigator role in Hartlepool is defined as:
“Care navigators, working on an outreach basis and probably recruited from
among local residents, to improve access, promote early interventions, support
choice, ensure a holistic approach, and integrate with universal and long term
support where necessary.”
The central purpose of the Connected Care navigator is to help people access
services. It is their job to coordinate the provision of support and services
around an individual and to help people navigate through the health, social care
and housing systems. Moreover, they have a crucial role in holding people in the
system once they have already started to access services, so that they do not
drop out or fall between services. The navigators provide a single point of
access, a single assessment process and a streamlined referral process. They
help people to access services who would otherwise, not know where to go.
Feedback from clients (who have mostly been under the age of 60) has
highlighted that the informal relationship with the navigators and the continuity of
the support that they provide is priceless. The success of the navigators is
attributed to the fact that they are recognised as caring, non-judgemental and
trustworthy members of the community that can provide assistance, though non-

Turning Point Connected Care Report 14
professional in their capacity and background. The navigators have currency
with local people because they are community members themselves, and
because they operate from the Manor Residents Association, a local community
organisation. Moreover, the service has emerged from an in-depth community
engagement process thus ensuring local fit whilst fostering ownership of the
service amongst the local community.
According to clients who were spoken to as part of the Hartlepool evaluation:
“Navigators were seen as friendly, informal and non-judgemental but as having
knowledge of and superior access to services which made them more effective
than other possible sources of support.”
These comments point to the importance of the personal characteristics and
background of the navigator team, as this has the ability to influence the
relationships that they form with members of the community.
Furthermore, it has become apparent that the links that navigators have with
other agencies and organisations can affect the service that the navigators
provide. For example, during the time that one navigator was on secondment
from Housing Hartlepool the team were able to provide much more effective
housing advice. This link was invaluable and since this person has left there has
been much less interaction with housing services. The Connected Care
navigators in Hartlepool, attribute much of the success of the project to having
good working relationships with partners in the town. This is illustrated in the
following case study:
Case Study
A young lady in Owton who had had three of her four children taken into care,
was in desperate need of help when she found out about the Connected Care
navigator service.
In the words of a Connected Care navigator, “she was coming off the top of a
very bad heroin addiction, no house – horrendous. Now she’s got a three
bedroom house, her children back, and we provide ongoing support and advice.
She’s off drugs, works for the local residents association, has done a level 2
youth work qualification and will go on to do a foundation degree next year. She
now gives advice to young people about drugs and alcohol abuse and has a
solid relationship with her partner. It wasn’t all down to the level of support that
we were able to give her – we didn’t do it on our own – we pulled in other
agencies. A lot of what it’s about is helping people know what’s out there –
getting people in as part of the solution and providing joined-up services”.
Source: Tyson (2009) Self Directed Support in Hartlepool 2006-2009
However, despite this individual success, a problem reported in the evaluation
was that the navigator service suffered from the fact other agencies lacked the
knowledge of Connected Care and the service on offer. There was some
scepticism about the navigators from other agencies, and thus there is a need to

Turning Point Connected Care Report 15
build the reputation and awareness of the service through an ongoing
communication strategy.
Since the inception of the navigator model in Hartlepool, the role has developed
from one centred on providing signposting and advocacy to one which involves
the provision of assessment. Navigators also have access to an Emergency
Fund to help people with immediate financial problems and to help people with
paying bills. This makes their role more complex than the basic advocate role.
The Connected Care navigators have become a service that is provided by local
people, rather than professionals, but is quasi-professional in terms of offering
assessments. There is also scope for the role to emerge further through the
introduction of navigators providing a brokerage service for people on individual
budgets.
Furthermore, given the particular needs of the people in Owton, much of the
navigators work has been centred on debt, employment advice and practical
problems which can be solved through the services of a handyperson. The
project has recognised that giving help and advice around debt problems can
provide a route into supporting people’s broader health and well-being. Indeed,
rather than focusing on health and social care, the service operates at the
interface between primary care and the community by providing low level
interventions and connecting people to community services and local networks,
thus removing the burden on primary care and social services.
Summary of the model:
The model in Hartlepool is a community led social enterprise which helps
people to access the services they need. The remit of the social enterprise was
developed in consultation with the local community.
Navigators have different lead responsibilities – campaigning, casework and
low level service development for the social enterprise.
Navigators should have a formal qualification to NVQ level in a relevant field
including health, social care, or community development and research.
Of equal importance is having experience of being active in the community
and an understanding of local issues and local services. Indeed, a commitment
was made that at least one care navigator would be a local resident of Owton,
whilst the others were residents of the wider Hartlepool area.
An important element in the success of the project has been the fact that the
navigators are trusted members of the community, rather than viewed with
suspicion as Council or PCT staff.
The navigators are funded by the PCT and Local Authority from the Health
Trainers budget. However, they have a significantly different role from health
trainers as their primary role is to help people access a range of services.
The navigators in Hartlepool are flexible and responsive to the needs of the
individual that they are aiding.
The navigators are a low cost model and evaluations of the service have
demonstrated the cost benefits of the service and the positive impact in reducing
demand on existing statutory services.

Turning Point Connected Care Report 16
3. Local Area Coordination
Local Area Coordination (LAC) is a model of navigation that has been adopted
in different parts of the world. Focussing on people with social care needs such
as people with disabilities, mental health issues, older people and carers, it
emphasises the importance of fostering links in the community and acting in a
preventative manner, as well as with directing individuals to services.
LAC is primarily a model of neighbourhood or community support, and perhaps
the most important aspect of the programme is that it is ‘Local Area’
Coordination. Local Area Coordination attempts to utilise the strengths and
resources of the local community to promote the development of supportive
social networks, and the model draws heavily upon the concept of social capital.
Social capital refers to the social connections amongst individuals and in recent
years it has come to take on a broader meaning which includes feelings of trust,
safety and belonging to an area. From a health and social care perspective,
building social capital involves promoting self-help and mutual aid within a
community, which helps promote well-being and reduces dependency on
expensive public services. There is now much focus on attempting to build
social capital in communities across England.
The following sections will consider the model as it has been adopted in
Australia, Scotland and Middlesbrough and Darlington, where particular
attention has been paid to helping individuals to get the support that they need
in their own community.
3.1 Australia
The Local Area Coordination (LAC) model originated in rural Western Australia
in the 1980’s to assist people with disabilities to plan, organise and access
support as they are disadvantaged by geographic distance from the majority of
services. By the mid 1990’s the programme had been extended to urban areas
in Western Australia and full coverage across the state was achieved in 2000.
The aim of LAC is to encourage people with disabilities to access services and
get involved in their local community by providing a fixed point of accountability
through the form of a Local Area Coordinator. In Western Australia, LAC is
available to people with intellectual, physical, sensory, neurological and/or
cognitive disability who are under the age of 65 at the time of their application. In
November 2002, there were 7,054 people with disabilities registered with LAC
across Western Australia, supported by 124 Local Area Coordinators.
Local Area Coordinators work to make local communities more inclusive and
welcoming for people with disabilities through education, advocacy and the
development of partnerships with local community members and organisations,
government agencies and businesses. Alongside this, Local Area Coordinators
also work with the people involved with supporting people with disabilities so
that they are strengthened and supported in their caring role.
The charter upon which the LAC in Western Australia is based reads as follows;

Turning Point Connected Care Report 17
“To develop partnerships with individuals and families as they build and pursue
their goals and dreams for a good life, and with local communities to strengthen
their capacity to include people with disabilities as valued citizens.”
The LAC model is unique in that it adopts a dual approach to helping people
with disabilities by focusing on helping users to develop natural links in the
community and encouraging them to utilise local services. As a result, the Local
Area Coordinators help to build social capital for people with disabilities by
encouraging them to be active members of the community, both through using
services and having an active social life.
Local Area Coordinators can help people with disabilities engage with natural
social networks by enabling them to visit a friend or family member rather than
attending a day centre. However, Local Area Coordinators recognise that
natural networks cannot assist with all personal requirements. Therefore, they
work to link individuals to services available in the community. These may be
disability specific services or community services available to the local
population, such as housing support or health services.
A review of the evaluations of LAC in Western Australia concluded that;
“On measures of consumer satisfaction, family/carer satisfaction, consumer
outcomes, service coverage and cost effectiveness, LAC has proven to be a
highly successful programme over an extended period of time.” (2003)
The most positive finding of the evaluations of the LAC in Western Australia is
that the programme is highly valued by people with disabilities and their families.
The LAC has given greater peace of mind and security, as well as more choice
and control to people with disabilities. In particular, it is clear that users have
enjoyed the relationships they have formed with their Local Area Coordinators. It
is seen as a trusted and reliable service that is ‘hands on’ in providing practical
assistance and information. Overall satisfaction with the service was higher in
rural areas than urban areas (88% compared to 76%). Similarly, in the
Australian Capital Territory (ACT) and Queensland, where LAC programmes
have been rolled out following the success in Western Australia, the respective
evaluations have indicated that users are pleased with the service.
It has also been calculated that the LAC model provides a cost effective way of
supporting people with disabilities. Comparisons with national benchmark data
indicate that Western Australia is providing services for a greater proportion of
potential service users at a lesser cost per person than Australia on average
(Bartnik and Psaila-Savona, 2003):
The overall cost of supporting people with disabilities in Western Australia
is $35,526, which is 35% below the national average (DSC Annual report,
2001).
Uptake of services is greater in Western Australia than in other states,
e.g. non-residential services had an 81% higher uptake rate than the
national rate.

Turning Point Connected Care Report 18
In the absence of the LAC programme (at a per capita cost of $3,316),
the current alternatives to providing support to disabled people would be
non residential services (at a per capita cost of $3,899) or residential
services (at a per capita cost of $61,944).
Criticisms of the LAC model in Western Australia focus on the promotion of the
role and workload of the Local Area Coordinator. For example, consumers felt
that there was a high turnover staff which prevented them from developing
relationships with the coordinator. There were concerns that the high workload
of the coordinator was having a negative impact on the time the Local Area
Coordinators have for direct work with clients. Furthermore, service users
reported that, whilst the overall standard of support was high, there was some
inconsistency in the service provided. Other issues raised included the lack of a
process to manage difficulties or disputes between clients and coordinators,
unrealistic expectations, accessing the service outside business hours and the
partnership opportunities that were not realised. It was also commented that
Local Area Coordinators need to work more collaboratively with other agencies
in order to forge working relationships and gain further knowledge of the local
services available.
Of most significance is the suggestion that there is lack of clarity with regards to
the Local Area Coordinator role. Local Area Coordinators themselves, service
users and other agencies indicated that they are unclear as to exactly what the
role entails and it was suggested that the programme needs to be better
communicated and promoted so as to avoid confusion.
3.2 Scotland
In more recent years the model has been utilised in Scotland to provide support
for people with learning disabilities. There are currently 59 Local Area
Coordinators helping people with learning disabilities in Scotland to enjoy a
fulfilled life in the community.
An evaluation of the LAC model in Girvan, Scotland has indicated that the
service is of vital importance to families. According to the report, people with
learning disabilities and their families view the Local Area Coordinators very
positively and they feel that they are always there to support them. Local Area
Coordinators have assisted people in lots of ways, including finding support and
services, getting a paid job, moving house and meeting new people through
introducing them to groups and social activities.
Stalker et al. (2008), in a study commissioned by the Scottish Executive which
examined the introduction and implementation of LAC in Scotland, found both
strengths and weaknesses in the implementation of the LAC model. They
reported that there was great unevenness across Scotland in the number of
Local Area Coordinators employed by local authorities and in their roles and
remits. Progress in community capacity building was slow overall and some
managers expressed mixed feelings about Local Area Coordinator's usefulness
in a climate of scarce resources.

Turning Point Connected Care Report 19
Despite these views, individuals and families were extremely appreciative of the
support received and there was evidence that LAC had made a positive
difference to their lives; for example, in relation to increased inclusion, choice
and both formal and informal support.
There is a concern in Scotland that the LAC model is losing some of its
community based element by focusing too much on service provision. In a
report commissioned by In Control it is suggested that the Scottish LAC model
has placed an overemphasis on access to formal services at the expense of
encouraging people with learning disabilities to engage with the local
community. It is argued that “LAC is a community based model”, however,
“some Local Area Coordinators in Scotland have become very service focused”.
This may be because the Local Area Coordinators have more experience and
knowledge in helping people to access services, and they know relatively little
about the local communities of which their clients are a part. However, it may
also be due to how the model was implemented by the individual authority.
Either way, it is an important point to consider, as it implies that the service
delivery model utilised in some areas of Scotland may actually be removed from
the original Local Area Coordination model. Furthermore, it suggests that the
training of Local Area Coordinators is crucial and that knowledge of the local
community is paramount.
Moreover, echoing the sentiments in Western Australia, there is a concern that
the Local Area Coordination model in Scotland has suffered from a lack of
clarity, and that users and agencies in the community have little understanding
of the role, its purpose and how it can add value.
3.3 North East of England
Building on the success of the scheme in Australia and Scotland, the Local Area
Coordination model has also been adopted by two local authorities in the northeast
of England: Darlington and Middlesbrough. These two projects commenced
in 2010 and are in the early stages.
The LAC project in Middlesbrough places a large emphasis on prevention and
personalisation. The scheme aims to support people identified with low level
needs to gain access to community support to prevent them from having to
access more significant or statutory support in the future. The project
emphasises the importance of strengthening community capacity, and attempts
to steer people away from engaging with costly and in demand statutory
services, and instead directs them towards support in the community and
building bridges with family members.
The project is also committed to fulfilling the personalisation agenda, and is part
of the Putting People First programme in Middlesbrough. By simplifying the
system for clients and bridging the gap between existing services, the LAC
project gives individuals more choice and control over the support they receive.
The project will employ two Local Area Coordinators to cover three deprived
areas of Middlesbrough. The Local Area Coordinators are expected to have a

Turning Point Connected Care Report 20
professional background with a qualification in community development,
education, health or social care. However, the most important attribute of the
Local Area Coordinator is their ability to build good working relationships with
the families in the local area, as it is recognised that trust and credibility in the
community are essential to the success of the project.
Furthermore, Middlesbrough Council is committed to involving the community in
the development of the LAC scheme. Community members have been invited to
shortlist the candidates for Local Area Coordinator and sit on the interview
panel. The community was involved in the process of deciding the locations of
the Local Area Coordinators and the areas that they will cover. This involvement
of the community in the development of the project is likely to contribute to the
success of the scheme, by fostering a sense of local ownership and building
community capacity. In addition, it positions the Local Area Coordinator at the
heart of the community.
The emphasis on utilising informal support and building community capacity in
order to direct people away from statutory services is more explicit in this project
than in other schemes discussed in this report. Prevention, rather than
signposting people to existing services, is at the heart of this project.
In addition, in Darlington, a study is being conducted to assess the feasibility of
introducing Local Area Coordination in two wards in the town. The project is
reviewing how LAC might support individuals with low level support needs, in
particular. As part of the project, members of the public are being consulted on
the service redesign, and a cost benefit analysis is going to be undertaken to
assess the potential savings that can be realised through the scheme.
Based on the experiences of the authorities where LAC has been implemented,
the key challenges in Darlington and Middlesbrough will be managing large
caseloads and the capacity for the Local Area Coordinator to both fulfil a
signposting role and act as a facilitator for community building.
Summary of the model:
LAC strikes a balance between a community and service focused model.
The relationship between the Local Area Coordinator and the service user is
key to the success – “the relationship as central”.
The Local Area Coordinator works to generate social capital and make
connections within the community, both formal (services) and informal (social).
The programme recognises that individuals need both forms of support – from
services and from informal networks.
The service is designed for people with disabilities under the age of 65.
Prevention and directing people away from statutory services are important
components of the scheme, particularly in Middlesbrough.

Turning Point Connected Care Report 21
4. Support for People with Complex Needs
People with a range of needs can often find it more difficult to access the
services they require to maintain their well-being. Individuals who have multiple
interlocking needs that span health and social care issues are often referred to
as people with complex needs. According to Rankin and Regan (2004):
“People with complex needs may have to negotiate a number of different issues
in their life, for example, a learning disability, mental health problems, substance
abuse. They may also be living in deprived circumstances and lack access to
stable housing or meaningful daily activity. As this framework suggests, there is
no generic complex needs case. Each individual with complex needs has a
unique interaction between their health and social care needs and requires a
personalised response from services.”
Citizen Advisor services are especially important for those individuals who
require a range of services, and it is crucial that they are person-centred and
shaped to the needs of the client.
4.1 Link Workers
A link worker is a generic term for an employee whose job it is to connect people
in the community to services. Link workers provide support and help people to
access services in a number of fields e.g. education, family and health. For
example, Health Link Workers in Liverpool link people with relevant agencies
and are available to advise and signpost people to health services. Link workers
have also been used to introduce carers to support, e.g. the Locality Link
Worker project in Sefton. Link workers also often focus on cultural and language
issues which can include providing support to vulnerable and excluded groups.
Link workers can also assist in joining up support by acting as a gateway to a
number of different of services across sectors. They have been used to assist
people with complex needs and those who might need to navigate their way
around a range of services such as health, social care, employment, benefits
and housing, as well as navigate the criminal justice system.
The Milton Keynes Link Worker Plus scheme is one of 12 projects funded by the
Adults facing Chronic Exclusion (ACE) programme of The Cabinet Office. It is a
joint venture between Milton Keynes Community Safety Partnership, the charity
P3 and Revolving Doors. The scheme focuses on people living in Milton Keynes
who have complex needs and have had difficulty accessing or engaging with
services. The target group are individuals who are likely to be in crisis because
of a combination of mental health needs, housing problems, substance misuse,
repeat presentation at crisis services, offending and anti-social behaviour.
The Link Worker Plus scheme exists to facilitate the engagement of clients with
services which can maintain their long term well being. The Link Workers
support clients who have traditionally struggled to engage with support agencies
to access services appropriately. On a practical level their role includes
assessing clients, helping them to register with a GP, arranging referrals or

Turning Point Connected Care Report 22
signposting to agencies, helping to fill in forms and attend appointments etc. The
two Link Workers access and engage clients at crisis points in the system such
as police stations, prison, A&E, the Anti-Social Behaviour team. The Link
Workers also have access to a devolved budget which can be used to overcome
barriers such as a deposit for accommodation, basic hygiene or clothing needs,
and access to vocational or education pathways.
In August 2009, there were 83 clients registered with the Link Worker Plus
scheme (Matrix, 2009). The external evaluation of the project reported that, in
contrast to some of the other ACE pilots, the Link Worker Plus scheme helped
clients take responsibility for accessing services themselves. Rather than
removing the barriers to services for the clients, the Link Workers help their
clients to understand services, and how to better engage with them, so that they
can access them unsupported. This ensures that once clients are fully
independent they can continue to access the appropriate services, and will not
fall through the gaps in the support system. The scheme has led to improved
health and well-being outcomes amongst clients, as well as an increase in the
receipt of benefits, as clients begin to understand how to access the support that
they are entitled to.
An additional element of the Link Worker Plus scheme is a system of community
volunteer mentoring. This is intended to extend the reach of the project and
build community cohesion. Once immediate needs have been met by the Link
Workers the clients are offered the support of a volunteer mentor who helps the
client with long term system navigation, practical tasks, form filling, and helping
them to become part of a local community.
This emphasis on helping to build social capital is similar to the LAC model.
However, immediate service related need and longer term building of social
capital are dealt with by two different workers in the Link Worker model.
Furthermore, the Link Worker model does not take the explicit neighbourhood
approach as in Local Area Coordination. Rather, credibility and trust is gained
because the Link Workers are experts in dealing with people complex needs
and through the community mentors who may have has similar experiences to
their clients.
Summary of the model:
Link Workers have access to a devolved budget.
In the Link Worker Plus model, clients are encouraged to take responsibility for
the support they receive and Link Workers guide them in the right direction,
rather than doing the work for them. This brings about a long term, sustainable
approach
The Link Worker Plus model uses a partnership approach to service delivery
Focused on people with complex needs and those at risk of re-offending
Community volunteer mentoring is a further aspect of the Link Worker Plus
model which is designed to promote community cohesion
The Link Workers are professionals who have had previous experience of
working with people with complex needs.

Turning Point Connected Care Report 23
4.2 RightSteps
RightSteps is a care management system developed by Turning Point to deliver
the IAPT (Improving Access to Psychological Therapies) programme. It
demonstrates the benefits of taking a holistic approach to service design and
delivery. It is a service which exists to support people who feel unable to cope in
their daily lives and may be suffering with depression, anxiety or phobias, for
example. It is a low level intervention which is designed to prevent individuals
from deteriorating and requiring more intensive mental health support in the
future. It works ‘upstream’ so that the demand on higher threshold services is
reduced and resources are focussed on where they are most needed.
Although, it is not strictly a signposting or Citizen Advisor service, Well-being
Coordinators do provide case management to support, motivate and mentor
individuals through the RightSteps programme. They provide bespoke support
to help clients through whichever issues are affecting their mental well-being
such as employment, debt, housing and family issues. Some of this work will
involve liaising with other agencies and directing clients to other services. This
holistic approach is achieved by giving clients a single 360 degree assessment
which is clinical and includes mental health, substance misuse and learning
disability, but also, social relationships, employment and debt.
Indeed, a key feature of the RightSteps service is the sub-contracting of local
voluntary sector organisations to deliver a range of wraparound services under
the IAPT umbrella. The Community Capacity model (diagram below) is a
framework for this which ensures that RightSteps is focussed on the needs of
the individual rather than the diagnosis of a mental health condition.
Figure 1: Turning Point’s RightSteps Community
Capacity model
Summary of the model:
Holistic low level intervention for people with mental health needs.
Well-being Coordinators respond to the range of complex needs that
individuals with mental health problems may have.
Community capacity model brings a range of local agencies together to ease
signposting and referral process.
Single 360 degree assessment focuses on the person as a whole, and not
their mental health diagnosis, involving a range of agencies.

Turning Point Connected Care Report 24
5. Early Intervention
Supporting people early on and in a way that is appropriate for them is a
cornerstone of Putting People First and the personalisation agenda. Local
authorities and NHS trusts across the UK are working hard to make a strategic
shift towards prevention and early intervention.
Prevention and early intervention can have different meanings across the
health, social care and housing sectors and it can also mean different things
according to the level of need. As a result, it is quite difficult to define, although a
useful definition provided by Wistow et al. (2003):
i) Preventing or delaying the need for high cost care as a result of ill health or
disability due to ageing, and
ii) Promoting and improving the quality of life of people and their inclusion
within society and community life.
Currently, the evidence for the effectiveness of preventative approaches in
health and social care is growing stronger. For example, the Department of
Health’s Partnerships for Older People Projects (POPP) and the Department for
Work and Pension’s LinkAge Plus programme have illustrated that by providing
low level support in the community a real difference can be made to the quality
of life as well as to the demand for statutory services.
“The POPP programme has significantly increased the evidence base about the
effectiveness of preventative approaches, particularly where these are
undertaken as part of joint working between health and social care” (Department
of Health, 2010).
Such programmes have also added to the growing body of evidence which
shows that early intervention focussed, integrated health and well-being
services can realise significant financial benefits. For example, studies have
illustrated that integrated early intervention programmes can generate resource
savings of over £2.50 for every £1 spent (Turning Point, 2010).
The following examples have been designed in order to promote the
independence and quality of life of people with health and social care needs and
thus prevent reliance upon higher level services.

Turning Point Connected Care Report 25
5.1 Partnerships for Older People Projects (POPP)
The Partnerships for Older People Projects (POPP) are designed to deliver
local, innovative schemes for older people. At the centre of the POPP
programme is a recognition that prevention and early intervention must be at the
heart of the vision for future care and support.
The Independence First programme in East Sussex is a community facing
project funded by POPP. Independence First is designed to address low level or
preventative and specialist needs, recognising that one without the other
provides much less effective support.
The navigator service is one part of the Independence First project in East
Sussex and aims to reduce the risk of older people being admitted to hospital or
institutional care. The East Sussex navigator service is a free (at the point of
delivery) service aimed at helping people aged 60 and over to live independently
at home for as long as they choose. It is provided by existing voluntary sector
organisations in the East Sussex area, such as Anchor Staying Put and
delivered by local community workers.
Staff visits identified clients in their own homes to assess their health and social
care needs and home safety. Signposting from a pre-agreed menu of ‘simple
community services’ and/or referral to specialist services then takes place. This
menu of simple/community services is crucial in providing the low-level support
that makes a real difference to people’s daily lives and routines. As much as
possible these services are provided free or at a reduced cost to the user. The
navigators help people by providing information and directing them to the
following support and services:
Handyperson service - getting small jobs done around the home.
Smoke detector fitting and home safety checks.
Security advice and community alarms.
Aids to help individuals move around their home.
Community transport and carer services.
Home and garden maintenance.
Benefits advice.
Finding local community groups e.g. internet club or exercise group.
The navigator service is provided by a voluntary organisation and the navigators
are trained in how to use the assessment tools and to navigate older people to
appropriate services. They are also given budgets to purchase equipment for
clients.
Although, their primary aim is to prevent the need for more intensive service
use, the East Sussex navigator service differs from the Local Area Coordination
model implemented in parts of Australia and Scotland because it focuses on
supporting people to access services that help them to live independently.
Whilst this may involve referring people to social clubs or activities, the service

Turning Point Connected Care Report 26
does not explicitly aim to promote community involvement and engagement
through the establishment of social networks.
There is also potential for navigators to provide some of the services that they
currently signpost people onto. For example, low level support, handyperson
services, or house and garden maintenance could be provided by the navigator.
This would increase the continuity of the support provided and offer some
ongoing contact for the client.
Summary of the model:
Run by a voluntary sector organisation.
Early intervention/low level support in order to prevent the need for higher level
or acute care.
Service focused model, as opposed to community based model.
Eligibility - the navigator service is for older people only.
5.2 Care Navigators
Self care is about individuals taking responsibility for and managing their own
and their family’s health and well-being. Self care is particularly important for
people who live with long term health conditions, as it can bring them
independence and increased confidence to manage their health. The Your
Health, Your Way (Department of Health, 2009) paper sets out the care that
patients with long term conditions can expect to receive. An important element
of this policy is the right to choose to be supported through self care and the
self-management of long term conditions. Promoting self care is a crucial way
for long term conditions to be managed and it is important that it is promoted at
an early stage so that it can be an effective mechanism for preventing or
delaying the need for more intensive care and support.
For example, Community Care Navigators in Newham (London) have been
introduced to support early intervention and to help people to proactively
manage a long term condition, rather than reacting to it. The community care
navigators project is designed to aid the early identification of chronic illness,
increase knowledge of long term conditions and support people through selfmanagement
so that they are able to take care of their own health. The project
in Newham was set up in response to data, which indicated that the residents of
Newham have complex health and social care needs and tend to be intensive
users of health services. It has been reported that 17% of people in Newham
have a limiting long-term illness.
The community care navigators are employed by the local Primary Care Trust
and engage with people in a range of locations such as GP surgeries and at
local events. They not only advise people on how to access services related to
their health, but they assess individuals, check blood pressure, weight, blood
glucose and discuss behaviours such as smoking, drinking and diet. From this
assessment referral plans are created, tailored to the needs of the individual,
and a range of advice and help is offered. Alongside this, the community care

Turning Point Connected Care Report 27
navigators offer information on local services and explain the health system to
clients. By talking clients through the services available to maintain a healthy
lifestyle they are empowered to manage their own condition.
However, challenges reported in implementing the community care navigators
surrounded the lack of support and buy in from local GPs who did not feel that
the service could offer anything additional in terms of improving health.
Care Navigators in Barnsley provide a service to support people when they are
diagnosed with a serious illness or long term condition. The care navigator is
able to guide people through what can be a complex health and social care
system, and is there to ensure that clients gain the knowledge and information
so that they can organise their own health and social care. People are usually
referred to a care navigator by their GP or consultant when they are diagnosed
with a long term health condition.
Unlike, some of the previous roles, the care navigators in Barnsley are
professional, experienced staff who are able to link clients into specialists. Being
professionals, rather than community members gives the care navigators more
credibility with other health professionals and enables them to use their
networks more effectively. However, care navigators may have less knowledge
of the community and voluntary services which may be of more help their
clients.
In the long term, this service helps to prevent people presenting with high level
needs further along the line because they have been unable to manage their
condition. Moreover, having a care navigator can prevent people from becoming
anxious or developing further health problems due to the fact that they feel
unable to manage their condition or are unable to access the appropriate
services for their needs.
Summary of the model:
Health and well-being focused model of navigation.
The emphasis is on prevention and helping people to identify and manage
their own conditions.
Promotes behaviour change.
Care navigators tend to be experienced health professionals, giving them
access to other professionals. However, there have still been problems with
buy-in from GPs in some areas.

Turning Point Connected Care Report 28
6. Rural and Community-based Models
The majority of the Citizen Advisor models already discussed have been applied
in urban areas and respond to the problems in areas where services are readily
available but a lack of information is preventing people from accessing them.
However, the issues facing people living in rural areas are different. People in
rural areas requiring services may face problems such as isolation, poor
information, a lack of transport provision and a limited availability of services in
their local area.
Moreover, the population in rural areas is generally quite widely dispersed. This
means that health and social care professionals who support the needs of the
population, have to cover large geographical areas. The effect of this is that it is
more difficult for workers to spend time with clients and the information that
people in rural communities require might not get through to them.
One potential problem with using a Citizen Advisor model in rural areas is that
there may not even be enough services to facilitate effective navigation. This
was an issue raised in a discussion of the Sooke navigator project in Canada
(Anderson and Larke, 2009), which was designed to improve access to mental
health and substance misuse services and to increase the connections between
primary care and the mental health provision. The lack of services and transport
provision in the area were a limitation to the service and the navigators found it
difficult to meet some of the needs of isolated individuals with mental health
problems in rural areas.
However, the Citizen Advisors in the following case studies responded to this
problem by actually helping local residents to set up groups to support their
needs. They were unable to influence statutory health or social care provision
but they were able to set up social activities and community exercise groups.
6.1 Village Agents
The village agent model in Gloucestershire, in response to research which
identified that rural residents are less likely to access council services than
people living in urban areas. In Gloucestershire, this low rate of engagement
with services is attributed to a general lack of awareness. This assumption is
supported by research conducted by the Gloucestershire Rural Community
Council (2002) in three rural parishes, which found that 83% of people would go
to someone they knew and trusted in their community for information and
advice. It was found that people in rural areas, particularly older people,
preferred to go to a trusted, local person for information. Village agents were
developed as a way of bridging this gap between public services and people.
In Gloucestershire, the scheme is currently managed by the Gloucestershire
Rural Community Council and is funded by Gloucestershire County Council and
the local Primary Care Trust. However, the scheme began in 2006 as a pilot
project funded by LinkAge Plus in conjunction with the Department for Work and
Pensions.

Turning Point Connected Care Report 29
The aim of the village agent service is to provide older people in rural
communities with easier access to information and services. The village agent is
an accessible and approachable local person whom older people can go to for
advice on services. Village Agents bridge the gap between communities and
organisations that are able to offer help or support. As this project is focused on
older people it is important that the Village Agents are members of the local
community because older people are more likely to source information and
access services from someone that they know and trust.
The village agents provide information, promote access to a wide range of
services, carry out practical checks and identify unmet needs within their
community. The Village Agents are paid staff that are recruited locally and
receive training on the services and support that is available so that they can
advise and signpost people to services, organisations and agencies that are
relevant to their need. Each month they have representatives from different
agencies speak to them to inform them about the service that they provide.
Village Agents are in regular contact with a Rural Advisor to keep up to date on
local issues and services and build their knowledge base.
A web based Gateway referral system has also been developed which enables
Village Agents, as well as partner organisations, to directly access services,
information and support for clients from providers across the county. The graph
below shows the referrals made by village agents in January 2008:
General Support
4%
0%
2%
8%
1%
8%
0%
32%
Adult Helpdesk
Warm and Well
Volunteering
Transport
Other
Figure 2: Village Agent referrals,
January 2008
Benefits
25%
9%
5%
0%
6%
Fire and Rescue -
Smoke Alarms
Age Concern
Care and Repair
Flooding Support
Housing
The case study below is an example of the work conducted by the Village
Agents. It demonstrates that people often need help with relatively mundane,
simple tasks such as having smoke alarms or grab rails fitted, making telephone
calls, writing letters, and how support in doing these activities can make a big
difference to their lives:

Turning Point Connected Care Report 30
Case Study
Elsie contacted her local village agent to ask for some help with understanding
letters from the Council.
1. The first letter from the council was in response to Elsie informing them that
her son had moved back to live with her. It was not clear what, if any, effect this
would have on her council tax payments. The village agent rang the Council and
confirmed that the letter meant that there was no change to her payments.
2. Elsie was also concerned about a letter from the county Community
Equipment Service asking for aids to be returned. Her late husband had been
loaned equipment – all of which Elsie had made use of to assist her mobility and
safety around the house since his death. The village agent spoke to the Adult
help desk at Gloucestershire County Council, who contacted the original
occupational therapist to see if she could keep the items. It was agreed that
Elsie should have an assessment for needs to ensure she received the
appropriate support and equipment
3. As a result of these conversations, the village agent noticed that the client
was paying Basic Rate tax on her widows pension. The village agent
investigated this and discovered that she had some unused Personal Allowance
which could be set against this income to reduce the tax. The village agent also
arranged to have the clients tax code changed to reduce her future tax and
wrote a couple of letters, for Elsie to sign, requesting a reassessment of tax paid
in the previous tax year and provide the necessary documents. Elsie received
some money back for her overpayment and her pension was increased.
In the words of the village agent, “Elsie was very appreciative of the assistance
offered. In particular she had no idea about income tax and what she should be
paying. Although sorting out this situation took a number of visits, phone calls
and letters, it just shows how looking at the overall picture can reveal benefit
that was not the original request. This was only possible because Elsie gained
confidence in me. We have become good friends.”
Source: www.villageagents.org.uk
A further important element of the village agent programme is that it is designed
to help build communities. People living in rural areas can be very isolated and
rather than needing high level health or social care support they may be in need
of opportunities to socialise or to take part in activities with other members of the
community. Village agents have set up social activities and clubs in response to
the needs of the older people in the community. For example, they have set up
library clubs, lunch clubs, an internet café, tai chi classes, quiz nights, bingo and
fortnightly minibus outings. These activities have helped to enable older people
to feel part of a community, which is of the utmost importance for maintaining
good mental and physical health.

Turning Point Connected Care Report 31
Summary of the model:
Village agents are community members that are paid and trained by the
provider organisation.
Not only focuses on providing support to access services, but enables
individuals to get more involved in their local community.
Integrates health and social care.
Regular meetings are held with service providers and other organisations in
the area so that the village agents are known by other professionals and there is
a shared understanding of the service.
The village agents are supported by an online Gateway referral system, where
they can look up services and information from partner agencies. The village
agents enter the details of the client that the appropriate service calls the client
and arranges a visit.
6.2 Community Mentors
Social isolation can be a particularly big problem for people living in rural areas.
The Community Mentors programme in Devon helps to tackle isolation and lack
of service use in rural parts of the county. The service is for people who are at
risk of social isolation and losing their independence, or who are experiencing a
crisis in their lives due to personal circumstances. This might include
bereavement, redundancy, or ill health. It is for people over the age of 50.
The mentoring scheme helps people to access information and services when
they lack the knowledge or the confidence to contact them. The support they
receive meets their individual needs and helps them to develop a positive sense
of social identity. The aim is to re-engage people in meaningful social activities
and community life, in order to improve physical and mental well-being and
prevent health and social care needs emerging in the future.
There are similarities between this and the East Sussex navigator service which
is an example of early intervention navigation. However, whilst the East Sussex
service is focused on providing practical solutions to health and social care
problems, the Devon scheme emphasises the importance of signposting people
towards social and community-based activities. The local coordinators who run
the community mentoring signpost people to services or help people with more
acute problems over a longer period of time to enable them to build the
confidence and the networks to become involved in their community.
Summary of the model:
Navigators provide information on services, but the focus is more upon
building confidence, social capital and community cohesion.
Provided through voluntary organisations on behalf of the County Council.
The service is available to people over the age of 50, who are experiencing
social isolation or a downturn in their lives.
Community mentors are similar to befrienders, but in addition to providing
social support, they direct individuals to services and other social activities.

Turning Point Connected Care Report 32
6.3 Community Agents
Black and minority ethnic (BME) groups can find themselves isolated and
unable to find out about and access local services. Individuals from minority
ethnic groups can find using services problematic due to language, cultural and
transport difficulties. This was identified as a particular problem in rural areas,
such as Gloucestershire.
Community Agents follow in the footsteps of Village Agents in Gloucestershire,
but they provide support to specific BME communities and encourage them to
engage with services. This model is not necessarily restricted to rural areas, and
can be applied across both urban and rural districts. In Gloucestershire, there
are six Community Agents for groups including the Chinese, Polish and Bengali
speaking communities.
The agents are community based and spread themselves across large
geographical areas. There are some questions regarding the efficiency of this
approach, since the community agents must spent considerable amounts of
time travelling in order to cover the whole county. Furthermore, whilst the
community agent may have in depth knowledge of the issues of their ethnic
group, they may have less knowledge of the services available in all the areas
across their designated region. It could also lead to the agents having too great
a workload in order to provide an effective service to all clients.
In Bolton, Link Workers provide an advisory and translation service directed to
support the health needs of Asian people. Since this service is provided in an
urban area with a high concentration of Asian people, the link workers do not
face the same difficulty of combining service focused and ethnic community
focused support.
Summary of the model:
Community agents provide service-focused support that is tailored to the
specific needs of different communities.
Community agents are paid and trained by the provider organisation.
There is an issue regarding the geographical coverage of the agents and
whether it is possible for them to have an in depth knowledge of particular
places where communities reside.

Turning Point Connected Care Report 33
7. Conclusions
The table below summarises the Citizen Advisor models discussed above:
This review illustrates that signposting or Citizen Advisor services are an
effective way of ‘Putting People First’ and supporting the localism agenda. In
addition to giving people more choice and control over the services that they can
access, Citizen Advisors are an efficient mechanism through which individuals
can be encouraged to self care, change their behaviours and utilise the informal
resources of their local community. This reduces the pressure on statutory

Turning Point Connected Care Report 34
services. The following section summarises the successes and challenges that
face the initiatives reviewed above.
This report has found that in most instances a Citizen Advisor type service has
been of invaluable assistance to individuals who need help to access services
and build social networks in their local area. In particular, clients have found that
the relationship with their Citizen Advisor has had a positive effect on their
quality of life and enabled them to be more active on a day to day basis. Having
a single point of contact through the Citizen Advisor through which all needs and
enquiries can be discussed simplifies experiences of the health and social care
systems, and wider contact with other statutory and voluntary services.
Indeed, the human element of the Citizen Advisor service and the luxury of
having face to face contact are of fundamental importance to clients. The
relationship and the building of trust between the service user and the Citizen
Advisor is fundamental to the success of the role. The personality and character
of the advisor is crucial in terms of developing successful relationships with
service users as well as with organisations and agencies.
This review has also highlighted where tensions exist between the ability to
provide a community led, capacity building service and a professional service
that is well-connected with other agencies and services to enable the most
effective signposting response.
This tension is illustrated in the diagram below:

Turning Point Connected Care Report 35
It is important to overcome the difficulties faced in Scotland, for example, where
it was felt that the local area coordinators were unable to provide both a service
and community focused model of navigation. One possible way of overcoming
this could be by employing members of the community as they have a natural
understanding of local issues and need, whilst ensuring that they receive in
depth training on the services that are available locally, arming them with quasiprofessional
skills. This is discussed in more detail below.
In addition to the issue of balancing time between community building and
signposting, the report has also drawn attention to other challenges associated
with delivering a Citizen Advisor service, such as managing caseload size, and
ensuring that there is buy in for the service amongst local agencies and
organisations. As well as the workload of the Citizen Advisors, the caseloads of
the services that they are signposting too must be considered. If a Citizen
Advisor service operates successfully then it may be that organisations cannot
keep up with the demand for the services. Equally, there may be an increase in
benefits claims as Citizen Advisors help clients to get access to the benefits that
they are entitled to.
7.1 Recommendations
First and foremost, it is clear that any Citizen Advisor model must reflect the
local area and the needs of the communities and individuals within it. Therefore,
it is problematic to construct one single model for this type of service.
Below we have set out our recommendations which should inform the
development of a Citizen Advisor style service. Central to these
recommendations is the recognition that service delivery should be ‘people’
focused and that communities should be at the heart of both service design and
delivery.
1. Citizen Advisors should have first hand knowledge of the local
community and/or be experts by experience, not professionally led.
The local community should be involved in the delivery of a Citizen Advisor
approach to helping people to access services. The evidence shows that the
relationship between staff member and client is most likely to be successful if
the Citizen Advisor has credibility with the service user by being a member of
the local community or by being an expert by experience in the issues facing the
client in question, as illustrated by the village agent programme.
Having a member of the community as a Citizen Advisor embeds the
programme in the local area, and helps the local population feel ownership of
the project making it more likely to be utilised as a resource which will build
community resilience. For example, in Hartlepool, much of the success of the
Connected Care service was attributed to the fact that the navigators were not
seen as the Council or the NHS, but as local people. Likewise, the community
mentor element of the Link Worker scheme in Milton Keynes, wherein, people
who have previously used a wide range of services and who have a criminal
background, volunteer to support people in engaging with services, has met with

Turning Point Connected Care Report 36
success. This is undoubtedly related to the role of the community mentors as
experts by experience.
However, if community members, who may not be qualified, are to take on this
role, the support infrastructure and training provided to the Citizen Advisors is of
fundamental importance. A system such as that adopted in Gloucestershire for
the village agents may be appropriate. The village agents attend regular training
days where they are updated on local services, and receive talks from
organisations who explain their services so that they can pass the details onto
clients. For this to occur it is necessary for the Citizen Advisor service to build
awareness amongst other service providers, and for them to be seen as
providing a professional, credible service.
Furthermore, by training and developing the skills of local community members,
such projects will contribute to building the capacity of the Citizen Advisor
workforce. As has been suggested in Hartlepool for the Connected Care project,
there is also great potential for community members to move into providing
brokerage and assessment services, thus arming them with more skills to take
into their communities. Citizen Advisors should also have the opportunity to
further their own knowledge and capacity by developing skills in case
management, assessment, outreach, referral and co-ordination. This would
position Citizen Advisors as quasi professional members of the community as
well as improving service provision for the majority.
2. Their remit should be designed and developed by local communities to
help meet the specific needs locally.
Communities should be involved in the design as well as the delivery of Citizen
Advisor style services to ensure fit locally. Co-production is an important
element, which is notable in its absence in many of the examples discussed in
this review, and holds great potential for realising the coalition government’s
ambitions for a Big Society.
Engaging local people and identifying the needs of the population from the
perspective of the community can ensure that the service is responsive to local
issues and tackles unmet needs. This approach worked particularly well in
Hartlepool, where the navigator service was developed in response to the
findings emerging from the Connected Care community audit. In this project, not
only did the community have their say with regards to local needs, but local
people were recruited as community researchers to speak to the community and
to become champions for the project and their area.
Several members of this original team of community researchers now work as
navigators in the Connected Care service. In addition, the service retains its
community focus as it has been set up through a community based social
enterprise that operates from a local residents association. Social enterprises
have distinctly social objectives and allow community members to take control
over service provision to build upon their own skills.

Turning Point Connected Care Report 37
Moreover, by working together and drawing upon resources, communities can
pool different kinds of knowledge of needs and skills locally, and build on the
contribution of existing voluntary groups. Giving individuals in the community the
opportunity to shape local services helps to build resilience and empower
people to seek help and support when needed, and to expect better from local
services.
In addition, it is important that a Citizen Advisor service includes space for
ongoing consultation with the community, both at the outset of the project in the
service design stage and throughout its existence. Service users should be able
to review the service to ensure that it is responsive and meeting the needs of
the community, and the project should adapt accordingly. This also helps give
the community local ownership of the service thus encouraging people to trust it
and use it in times of need.
Lastly, there is also a role for Citizen Advisors to identify and highlight unmet
need and to feed this back to staff at statutory and voluntary sector services in
the area. This would provide a mechanism for the Citizen Advisor service to link
into the wider system and to gain credibility amongst other professionals and
front line staff, thus leading to wider system change.
3. Citizen Advisors should focus on supporting individuals who are in
greatest need and/or have not traditionally used local services.
Citizen Advisors should focus upon helping disengaged and marginalised
members of their communities to access services. In some cases this may be
individuals and families who have a range of complex needs such as mental
health problems, substance misuse problems and long term health conditions.
For example, the Link Worker model has illustrated that having a Citizen Advisor
service is particularly important for people with complex needs. It is ‘people’
focused and person centred when addressing peoples’ needs and directing
them to services.
Furthermore, Citizen Advisor services may also involve assisting people to use
services more appropriately, for example, decreasing their reliance on services
such as A&E, and utilising more ongoing, preventative support. The IAPT
service, for example, takes a long term preventative approach to supporting
people with complex needs and mental health problems.
A Citizen Advisor service should also be universally available for people with
more low-level needs. Many of the examples discussed in this report have a set
of eligibility criteria or they are for people of a certain age or with a certain
condition only. For future work, it is recommended that a generic model is
accessible to all, including families, and meets all levels of need. Within this
generic team there could be specialist workers, with expertise in particular fields
or in particular groups of people or conditions. This approach could also assist in
the management of the Citizen Advisors caseloads. Indeed, there is a danger
that with the success of the Citizen Advisor role the size of the caseloads inhibit
the ability of the advisor to be effective in their role.

Turning Point Connected Care Report 38
4. The role of Citizen Advisors should not be limited to signposting to
existing services but encompass wider support across early intervention,
self care and building community capacity.
This report has indicated that building social capital and increasing informal
connections in the community, as well as more formal links to mainstream
services, can help people to be more independent and supported in their local
area. Providing and signposting people to social activities and community
networks and services is an effective way of preventing the need for more costly
statutory services in the future, particularly amongst older people. Indeed,
prevention and early intervention are at the heart of the personalisation/localism
agenda, and Citizen Advisors are an appropriate and efficient way in which this
message can be spread to service users with individuals encouraged to access
the appropriate level of support to address their needs. This has been illustrated
in the Partnerships for Older People Projects which has had great success in
decreasing reliance on statutory services and reducing the associated costs.
The Local Area Coordinators, for example, have made efforts to support
individuals to get more involved with their local communities. Similarly, an
important aspect of the village agents’ role is the organising of and linking of
people into social activities with the aim of maintaining their independence. This
is particularly important in rural areas, where there is likely to be fewer services
and people need more support to access and travel to community projects.
Citizen Advisors should, therefore, seek to motivate and mentor individuals to
build their aspirations for change and to take responsibility for their well-being, to
help connect them with existing community networks, and ultimately remove
their reliance on statutory services. Encouraging individuals to manage their
own health and well-being and to get more involved in the community helps to
build local resilience as well as leading to the more appropriate and effective
use of services and resources.
Furthermore, through working amongst the community, Citizen Advisors may
have the knowledge of local need and the expertise to support or to lead the
coordination of timebanking activities in their local area. Timebanks are
frameworks that allow people who would not normally meet to come together
and help one another by sharing their skills, experiences and time. Time
banking values everyone's time as equal, 1 hour equals 1 hour, or 1 credit. For
every hour you spend helping someone in your community you are entitled to an
hour of help in return. Time Bank members can give and receive support such
as lifts to the Doctors or the Hospital, accompanying people to the shops,
befriending and companionship, gardening help etc. All of which are services
and types of support that enable people to be more independent and engaged in
their local communities.

Turning Point Connected Care Report 39
5. Citizen Advisors must provide a holistic, flexible and responsive service
that is built around the needs of the client and able to meet people’s
inter-connected needs.
Citizen Advisors should take a holistic approach to improving health and wellbeing
by focusing on employment skills, social capital, and alleviating housing
and debt problems.
Citizen Advisors should act as a single point of access to services to help
communities get the support that they need and help them to interact with
services. They should be able to provide an immediate assessment across
health and wellbeing, meaning that Citizen Advisors take on an encompassing
role that is not limited to health and social care, but is flexible and can support
people with employment, financial, housing or community issues, for example.
Citizen Advisors should provide an integrated health and social care service.
Integration in health and social care can improve the efficiency, quality and
continuity of service delivery, thus leading to improved service user experiences
and outcomes. In addition, the provision of integrated services addresses the
changing and increasing demand for care that comes alongside the growing
older population, and it is also recognised to provide significant financial
benefits. A Citizen Advisor is also well placed to work across the boundaries of
health and social care, providing flexible support that responds to peoples’
individual needs. This would lead to the development of a more encompassing
Citizen Advisor role that promotes general health and well-being through
addressing the issues that are affecting the client.
In addition, this may involve working with partners across sectors. Citizen
Advisors should be supported by a strong team of professionals who are
connected to different organisations and agencies. This joint working can help
Citizen Advisors provide support across health, housing, social care,
employment and so on. The RightSteps model developed by Turning Point to
support people with low level mental health needs is an example of a service
that seeks to wrap support around the needs of the individual through sustaining
good relationships with other agencies. There is potential for elements of this
model to be adopted when developing and delivering a Citizen Advisor service.
Moreover, it is crucial that there is clarity over the Citizen Advisor role as it is
developed in different areas. This is important not only for service users, but for
the other agencies in the local area as it gives credibility to the role amongst
professionals. Since the networks and connections between other organisations
and services are so fundamental to the Citizen Advisor role, it is important that
the advisors establish good working relationships, and central to this is clarity
over the role itself. It is important that other stakeholders champion the service
and understand how it fits into the work that they are doing.
However, there is also a risk that by adopting this approach that the Citizen
Advisor service can add another layer of complexity onto an already complex
service landscape. This needs to be taken into consideration through service

Turning Point Connected Care Report 40
design, and efforts need to be made to inform all agencies of the service so as
to avoid this.
7.2 Future work
The recommendations above set out a vision for community-led Citizen Advisor
services and they capture a new approach to service delivery that is not ‘service’
focused but ‘people’ focused. The recommendations propose that Citizen
Advisors are recruited from and based in the heart of their local communities.
They should operate at the interface between primary care and the community,
with a remit to provide a joined up approach to multiple challenges and remove
layers of bureaucracy, not add to it.
Whilst there are a number of examples across the UK of initiatives that have
included some form of Citizen Advisor, the evidence base to support their
effectiveness and their future implementation needs to be strengthened. Few of
the examples discussed in this review have been fully evaluated, and of those
that have, several adopted a qualitative methodology which suggests the main
benefits include; improved quality of life, the provision of practical support
leading to greater independence, a sense of empowerment and the
development of trusting relationships with the workers themselves. However, as
Hudson (2010) comments in his review of Local Area Coordination, “the
evaluators were unable to be sure that these positive changes had come about
because of LAC per se, as opposed to the commitment and support of the
dedicated workers.”
There is therefore a clear need to develop a robust evaluation tool in order to
assess and appraise the process and outcomes of delivering service navigation.
Outcomes need to be agreed, understood and supported at every level and
evaluation should be put in place at the start so that learning can be shared. In
turn, this will help contribute to the development of an evidence base
surrounding the benefits of the Citizen Advisor model.

Turning Point Connected Care Report 41
Appendices
Appendix 1 - Bibliography
Anderson, J and Larke, S (2009) The Sooke Navigator project: using community
resources and research to improve local service for mental health and
addictions. Mental Health in Family Medicine. Vol 6: 21-28
Bartnik, E and Psaila-Savona, S (2003) Review of the Local Area Coordination
Program: Western Australia
Callaghan, G and Duggan, S (2008) Report on the Evaluation of the Connected
Care Audit. Durham University
Chenoweth, L and Stehlik, D (2002) Building the capacity of individuals, families
and communities: Evaluation of the Local Area Coordination program.
Conservative party (2010) Building a Big Society.
Department of Health (2006) Our Health, Our Care, Our Say: A new direction for
community services.
Department of Health (2009) Your Health, Your Way: A guide to long term
conditions and self care.
Department of Health (2010) Improving Care and Saving Money: Learning the
lessons on prevention and early intervention for older people.
HM Government (2010) Building the National Care Service. London: The
Stationery Office
Hudson, B (2010) Local Area Coordination and Neighbourhood Development: A
review of the evidence base.
Klee, D, Robertson, G and Archibald, A (2007) Promoting independence and
well-being: Learning the lessons from the pilots. Care Services Improvement
Partnership
Matrix (2009) ACE Evaluation Interim Report. Care Services Improvement
Partnership
nef and NESTA (2010) Right Here, Right Now: Taking co-production into the
mainstream. London: NESTA
Rankin, J and Regan, S (2004) Meeting Complex Needs: The future of social
care. London: Ippr/Turning Point
Scottish Human Services Trust (2005) South Ayrshire Local Area Coordination
Evaluation.

Turning Point Connected Care Report 42
Social Care Institute for Excellence (2010) Personalisation: A rough guide.
Stalker, K, Malloch, M, Barry, M and Watson, J (2008) Local area coordination:
Strengthening support for people with learning disabilities in Scotland. British
Journal of Learning Disabilities. Vol 36 (4): 215-219
Tamar Consultancy (2007) Local Area Coordination in the Australian Capital
Territory: External Evaluation Summary Report.
Turning Point (2010) Benefits Realisation: Assessing the evidence base for the
cost benefit and cost effectives of integrated health and social care.
Tyson, A (2009) Self Directed Support in Hartlepool 2006-2009. In Control
Partnerships and Hartlepool Borough Council
Wistow, G, Waddington, E and Godfrey, M (2003) Living Well in Later Life: From
prevention to promotion. Nuffield Institute for Health, University of Leeds
Appendix 2 - Search History
Google/navigators (321,000) (pp.1-10)
Google/service navigators (237,000) (pp.1-10)
Google/link workers (885,000) (pp.1-10)
Google/Milton Keynes link workers (86,800) (pp.1-5)
Google/Care navigators (222,000) (pp.1-10)
Google/link worker and navigator (19,300) (pp.1-5)
Google/Milton Keynes link worker scheme (23,400) (pp.1-5)
Google/Navigator AND health and social care (85,300) (pp.1-5)
Google/Village agents (1,320,000) (pp. 1-5)
Google/Local area coordination Australia AND evaluation (77,700) (pp. 1-5)
Google/Local area coordination Scotland AND evaluation (24,300) (pp.1-5)
The Kings Fund/Navigator (1190) (pp. 1-5)
The Kings Fund/Link worker (12)
Ripfa/Local area coordination (19)
Ripfa/service navigator (4)
Ripfa/link worker (24)

Turning Point Connected Care Report 43
We turn lives around every day, by putting the individual at the heart of what we do.
Inspired by those we work with, together we help people build a better life.
Turning Point is the UK’s leading social care organisation. We provide services for people with complex needs, including those
affected by drug and alcohol misuse, mental health problems and those with a learning disability.
Turning Point
Standon House
21 Mansell Street
London E1 8AA
Tel: 020 7481 7600
Fax: 020 7702 1456
For more information please call Richard Kramer, Director, Turning Point
Tel: 020 7481 7651
Email: Richard.kramer@turning-point.co.uk
Or visit our web site at www.turning-point.co.uk
Turning Point is a registered charity, no. 234887, a registered social landlord and a company limited by guarantee no. 793558
(England & Wales).
Registered Office: Standon House, 21 Mansell Street, London E1 8AA.