What can service providers do to improve access ... - The PATH project

Partnerships for Access to Health (PATH) Project 

What can service providers do to 

improve access to services for people 

with multiple and complex needs? 

A literature review of service providers’ 

views on what works and why

Literature 

review 

findings 

from the 

Path Project: 

voLume 2 

Annette Gallimore 

Laura Hay 

Phil Mackie 


Part of the Multiple & Complex Needs Initiative 

october 2009 

2

aBout Path 

T 

his literature review was undertaken by the 

Partnerships for Access to Health (PATH) Project. 

The aim of PATH is to explore how health, social care, 

community justice and voluntary sector partners in local 

Community Health Partnerships can work together to 

improve access to services for people with multiple and 

complex needs. 

PATH is funded by the Scottish Government’s Multiple 

and Complex Needs Initiative. PATH is hosted by 

Lothian NHS Board and undertaken in partnership with 

NHS Highland. 

for further information please contact: 


Senior Public Health Researcher 


Multiple and Complex Needs Initiative 

Department of Public Health & Health Policy 

Lothian NHS Board 

Deaconess House 

148 Pleasance 

Edinburgh, EH8 9RS 

tel: +44 (0)131-536-9000 

e-mail: annette.gallimore@nhslothian.scot.nhs.uk 

website: www.pathproject.scot.nhs.uk 

The views expressed in this report are those of the authors and do not necessarily reflect those 

of NHS Lothian, NHS Highland or the Scottish Government. 

3

contents 

executive summary ................................................................................................................................................. 5 

1 introduction 

1.1 Multiple and Complex Needs Initiative ........................................................................................................................... 8 

1.2 Aim of literature review ................................................................................................................................................... 8 

1.3 Overview of this report .................................................................................................................................................... 8 

2 methods 

2.1 Rosengard literature review ............................................................................................................................................ 9 

2.2 Defining multiple and complex needs ............................................................................................................................. 9 

2.3 Defining access .............................................................................................................................................................. 9 

2.4 Search strategy .............................................................................................................................................................11 

2.5 Assessing the quality of studies included ......................................................................................................................11 

2.6 Description of included studies ..................................................................................................................................... 12 

3 service providers’ views 

3.1 Introduction ................................................................................................................................................................... 13 

3.2 Presentation of results .................................................................................................................................................. 13 

3.3 Common themes .......................................................................................................................................................... 13 

3.4 Improving access to services – ‘getting in’ ................................................................................................................... 15 

3.5 Improving engagement with services – ‘getting through’ .............................................................................................. 19 

3.6 Improving outcomes from services and aftercare – ‘getting on’ ................................................................................... 23 

4 discussion 

4.1 Gaps in the evidence .................................................................................................................................................... 24 

4.2 Quality of evidence found ............................................................................................................................................. 24 

4.3 Key themes and common issues .................................................................................................................................. 24 

4.4 Consistency of findings ................................................................................................................................................. 25 

4.5 Implementing change ................................................................................................................................................... 25 

4.6 Transferring good practice ............................................................................................................................................ 25 

5 conclusion ........................................................................................................................................................ 26 

6 references .......................................................................................................................................................... 27 

appendix i: Abbreviations ......................................................................................................................................................... 31 

appendix ii: Glossary ................................................................................................................................................................ 32 

appendix iii: Databases and sources searched ....................................................................................................................... 33 

appendix iv: Keywords used in literature search...................................................................................................................... 35 

appendix v: Checklist for appraising a qualitative research paper ........................................................................................... 36 

appendix vi: Summary table of included studies...................................................................................................................... 37 

4

Executive Summary What can service providers do to 



executive summarY 

Introduction 

This literature review explores what 

service providers can do to improve 

access to health, social care and 

voluntary sector services for people 

with multiple and complex needs. 

aim of Literature review 

The aim of the literature review was to explore the question: 

“What can be done from a service provider’s perspective 

to improve access to health, social care & voluntary 

sector services for those with multiple and complex 

needs? What works and why?” 

the Path Project 

The review was undertaken by the Partnerships for Access to 

Health (PATH) Project, which is part of the Scottish Government’s 

Multiple and Complex Needs Initiative (MCNI). The aim of PATH 

is to explore how health, social care, community justice and 

voluntary sector partners in local Community Health Partnerships 

(CHPs) can work together to improve services for a variety of 

users with multiple and complex needs. 

PATH is hosted by Lothian NHS Board and undertaken in 

partnership with NHS Highland. Further information on PATH 

is available from www.pathproject.scot.nhs.uk 

This is the second of two literature reviews undertaken by PATH. 

The first review focused on what service users with multiple and 

complex needs want from services (i.e. service users’ views) 

(Gallimore et al, 2008) and is available from the PATH website. 

defining muLtiPLe and comPLex needs 

For the purpose of PATH ‘multiple and complex needs’ 

is defined as: 

“Multiple interlocking needs that span health and social 

issues that lead to limited participation with society.” 

In practice, this has been limited to those with the 

following health problems and/or exacerbating social 

factors (in any combination): 

health problems: 

● mental health or psychological problems; 

● drug and/or alcohol misuse; 

● limiting long term health problems; 

● learning disability; or 

● physical disability. 

social factors: 

● homelessness; 

● unemployment/history of economic inactivity; 

● lack of skills or qualifications; 

● low literacy, language and numeracy skills; 

● criminal record; 

● ethnicity (ethnic minority groups, including asylum 

seekers, refugees and Gypsy Travellers); 

● a first language other than English; 

● faith/religious background; 

● gender and sexual orientation (e.g. lesbian, gay, 

bisexual and transgender); 

● younger and older people at points of transition e.g. 

leaving home, leaving institutions (e.g. hostels and 

hospitals) or onset of illness and disease; 

● those experiencing violence or abuse/victims of 

crime; 

● those with caring responsibilities; or 

● rurality. 

5




It is recognised that this definition may be different to that used 

by other agencies, organisations or services, but should be seen 

as a working definition for the purpose of this specific project. 

PATH considers a spectrum of need. It considers both those 

with multiple and complex needs who aren’t engaging with 

the services they need and those with multiple and complex 

needs who are already heavy users of services but who may 

be experiencing inappropriate service responses, due to the 

challenging, intense or ‘revolving door’ nature of their needs. 

PATH considers only adults aged over 16 years. 

methods 

Standard literature search techniques were used to undertake 

electronic searches of the primary and secondary research 

literature and the grey literature evidence bases. Manual 

searches of relevant websites were used to identify web 

based grey literature. English language papers from the UK, 

Europe, Australia and New Zealand published in the last 10 

years were included. 

The search focused on identifying papers describing service 

providers’ views on what is good practice and/or evaluations 

of services considered good practice. 

resuLts 

50 studies were included in the review, 49 of which were from 

the UK. A core set of common themes emerged. 

common themes 

Regardless of the particular combination of service user need, 

service providers saw the following key aspects of services as 

good practice: 

getting in: 

● early intervention from services 

(before a client reaches a crisis); 

● immediate help from services and fast referral; 

● a single point of entry into services; 

● flexible access to services e.g. evenings 

and weekends, open door policies; 

● provision of accurate information on 

available services; 

● outreach work; 

● link workers; and 

● initiatives to overcome transport and access 

difficulties in remote and rural areas. 

getting through: 

● taking a holistic approach to a client’s problems; 

● good relationships with staff; 

● providing support, advocacy and follow up e.g. 

by using a link or key worker who will work with an 

individual client across a range of mainstream and 

specialist services; 

● joint working and multi-disciplinary working within 

and across health, social care, community justice 

and voluntary sector services; 

● cultural sensitivity; 

● gender sensitivity; 

● more intensive and flexible support for those with 

the most complex needs, through specialist services 

if required; 

● inreach work; 

● training and support for staff; 

● peer support; 

● support for families; 

● long term funding for services; and 

● removal or alteration of targets for services which 

may act against helping those who require more 

intensive support. 

getting on: 

● providing after care and ongoing support for 

clients who need it; 

● allowing for client relapses; and 

● user empowerment, including the use of 

social care approaches, where appropriate. 

6




discussion 

The amount of evidence around services for people with 

multiple and complex needs varies according to the type of 

need and combination of needs. This review could not be 

comprehensive and we may not have identified all the literature 

in this area. There are also gaps in the evidence available. 

A large proportion of the evidence found in the review 

represented the general views of service providers on what 

constitutes good practice, ie ‘expert opinion’ as opposed 

to evidence from formal evaluations. Also of note, where 

evaluations were undertaken, the length of follow up was 

often limited, most being short term follow up studies. While 

in most instances this was the case because the intervention 

had only been running for a short period (usually around one 

year) there is a need for long term follow up of interventions to 

identify if initial results are sustained. 

Despite the limitations in the evidence base, several key 

themes emerged along with a number of factors that promote 

positive engagement and outcomes. 

concLusion 

Service users need to see services as accessible and find 

them, or be assisted to find them, easy to access. In general, 

good practice in engaging those with multiple and complex 

needs can involve services targeting certain groups and 

supporting them with entry to services, for example through 

outreach work and link workers. The need for services to 

work from the perspective of what the service user wants and 

needs is key. 

Maximising and sustaining the benefits to clients while 

they are engaged with services then involves tailoring the 

level and type of support to a client’s needs and recognising 

how one problem or difficulty may impact on other areas of a 

client’s life. 

For some, aftercare and long term support is a key 

element. Aftercare may involve continued support in some 

aspects of a client’s life or may mean that the client is aware 

that the service will always be available to them should they 

need assistance at a later time. 

Taken alongside the service users’ views identified in the 

first PATH literature review (Gallimore et al, 2008), this review 

hopefully provides a useful starting point for areas of practice 

to consider when designing, commissioning and providing 

services that better meet the needs of those with multiple and 


7

Introduction What can service providers do to 



1 introduction 

This report describes a literature 

review exploring what service 

providers can do to improve access 

to health, social care and voluntary 

sector services for people with 

multiple and 


This chapter describes the aim of the review, the policy 

context and the layout of the report. 

1.1 muLtiPLe and comPLex 

needs initiative 

This literature review was undertaken by the Partnerships for 

Access to Health (PATH) Project which is part of the Scottish 

Government’s Multiple and Complex Needs Initiative. 

The Multiple and Complex Needs Initiative (MCNI) is a 

Scottish Government initiative to improve public services 

for those with multiple and complex needs. The MCNI aims 

to test how changes in service delivery can impact on how 

those with multiple and complex needs are made aware of, 

access, engage with and move through services to achieve 

successful outcomes (referred to as ‘getting in, getting 

through, getting on’). 

The MCNI consists of fourteen projects across Scotland, 

representing a wide range of service settings and client 

groups. The Partnerships for Access to Health (PATH) Project 

is one of these projects. 

The literature review was undertaken to support the work 

of PATH. Further information on PATH is available from 

www.pathproject.scot.nhs.uk 

1.2 aim of Literature review 

The aim of the literature review was to explore the question: 

“What can be done from a service provider’s perspective 

to improve access to health, social care & voluntary 

sector services for those with multiple and complex 

needs? What works and why?” 

This is the second of two literature reviews undertaken by 

PATH. The first review focused on what service users with 

multiple and complex needs want from services (i.e. service 

users’ views) (Gallimore et al, 2008). This, the second, review 

describes the service providers’ perspective of what works 

and why. The two reviews are complementary and should 

ideally be read together. The first review is available from the 

PATH website www.pathproject.scot.nhs.uk 

1.3 overview of this rePort 

This report is divided into a number of chapters: 

● Chapter 2 defines the terms ‘multiple and complex needs’ 

and ‘access’ and describes the literature review methods; 

● Chapter 3 presents the results; and 

● Chapters 4 and 5 discuss the implications of the findings 

for those involved in designing and providing services for 

people with multiple and complex needs. 

In addition there are a number of appendices: 

● Appendix I explains the abbreviations used in the report; 

● Appendix II 

provides a glossary of terms used; 

● Appendix III 

to Appendix V provide detailed information on 

the literature search methods; and 

● Appendix VI provides a summary of all the studies 

included in the review. 

8

Methods What can service providers do to 



2 methods 

This chapter defines the terms 

‘multiple and complex needs’ and 

‘access’ and describes the literature 

review methods. 

2.1 rosengard Literature review 

At the start of the Multiple and Complex Needs Initiative, the 

Scottish Government commissioned a literature review by Ann 

Rosengard Associates (2007). Rosengard assessed research 

from a broad range of settings into how services cater for 

those with multiple and complex needs. The PATH literature 

reviews complement that already undertaken by Rosengard. 

2.2 defining muLtiPLe and 

comPLex needs 

2.2.1 Definitions in the current literature 

There is no consensus in the current literature on the definition 

of the term ‘multiple and complex needs’. The definitions 

used vary depending on the context and user. The following 

definition by Rankin and Regan (2004) is frequently referred 

to in the grey literature on multiple and complex needs. It 

describes multiple and complex needs in relation to both 

breadth (range) and depth (severity) of need. 

“‘Complex needs’ is a framework for understanding 

multiple interlocking needs that span health and social 

issues. People with complex needs may have to 

negotiate a number of different issues in their life, for 

example, 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…..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. 

We do not believe that complex needs should 

function as another service label to determine eligibility, 

but rather as an active and useful description to highlight 

those people who need a more targeted intervention from 

service providers. Peoples’ complex needs can have a 

breadth (range of need) and/or depth (severity of need). 

It is valuable shorthand to describe multiple interlocking 

problems where the total represents more than the sum.” 

rankin and regan (2004) 

2.2.2 PATH definition of multiple and complex needs 

The PATH Project definition of ‘multiple and complex needs’ 

(used in this literature review) is given in Box 2.1. 

The PATH definition uses the concept of breadth of need 

(multiple needs that are interrelated or interconnected) and 

depth of need (profound, severe, serious or intense needs). 

It is recognised that this definition may not be identical to 

that used by other agencies, organisations or services, but 

should be seen as a working definition for the purpose of this 

specific project. 

2.3 defining access 

For the purpose of PATH, “access” is defined as: 

“The ability of clients with multiple and complex needs 

to utilise and benefit from health, social care, community 

justice and voluntary sector services, gaining the 

maximum benefit from these services and moving on 

while sustaining the benefits gained.” 

This definition is in line with the Multiple and Complex Needs 

Initiative’s ethos of ‘getting in, getting through, getting on’. 

9




Box 2.1: Path definition of ‘muLtiPLe and comPLex needs’ 

For the purpose of the PATH Project, ‘multiple and 

complex needs’ is defined as: 

“Multiple interlocking needs that span health and social 

issues that lead to limited participation with society.” 

In practice, this has been limited to those with the following 

health problems and/or exacerbating social factors (in any 

combination): 

a) health problems: 

● mental health or psychological problems; 

● drug and/or alcohol misuse; 

● limiting long term health problems; 

● learning disability; or 

● physical disability. 

b) social factors: 

● homelessness; 

● unemployment/history of economic inactivity; 

● lack of skills or qualifications; 

● low literacy, language and numeracy skills; 

● criminal record; 

● ethnicity (ethnic minority groups, including asylum 

seekers, refugees and Gypsy Travellers); 

● 

● 

● 

● 

● 

● 

● 

a first language other than English; 

faith/religious background; 

gender and sexual orientation 

(e.g. lesbian, gay, bisexual and transgender); 

younger and older people at points of transition 

e.g. leaving home, leaving institutions (e.g. hostels 

or hospitals), onset of illness and disease; 

those experiencing violence or abuse/victims of crime; 

those with caring responsibilities; or 

rurality. 

PATH considers only adults aged over 16 years of age. 

It does not therefore consider the needs of looked after 

children, children with challenging behaviour, children 

under 16 involved with the criminal justice system or other 

children with multiple and complex needs. 

PATH considers a spectrum of need. It considers both 

those with multiple and complex needs who aren’t 

engaging with the services they need and those with 

multiple and complex needs who are already heavy users 

of services but who may be experiencing inappropriate 

service responses, due to the challenging, intense or 

‘revolving door’ nature of their needs. 

10




2.4 search strategY 

2.4.1 inclusion criteria 

The literature search included papers from the UK, Europe, 

Australia and New Zealand. Both primary (reports of original 

research) and secondary (collections of primary research) 

sources of evidence were included. Studies from the USA 

were excluded due to differences in the health and social care 

systems and difficulties drawing conclusions relevant to the UK. 

The inclusion criteria were: 

● 

● 

● 

● 

the search was limited to papers published over 

the past 10 years (i.e. 1998 to 2008); 

only English language papers were considered due 

to time constraints; 

titles, abstracts and the full text of all articles were 

read where available. All articles fulfilling the inclusion 

criteria were included; and 

policy documents were considered where they provided 

evidence of the perspective of service providers on 

what works to improve access to health, social care and 

voluntary services for people with multiple and complex 

needs, and why. 

2.4.2 exclusion criteria 

Studies relating to children under 16 years old were excluded. 

Papers which focused on issues around the subject group 

but did not either discuss the views of service providers 

or evaluate projects designed to improve access to and 

engagement with health, social care and voluntary services 

were excluded. 

2.4.3 databases and sources searched 

The literature review included both peer reviewed primary 

and secondary research and grey literature and was 

undertaken by a senior researcher experienced in literature 

searches and reviews. 

The search included searching library databases, 

publishers, journals, government websites and internet sites 

from health, social care and the voluntary sector. Manual 

searches of relevant websites were used to identify web 

based grey literature. 

Due to time and resource constraints, the review could not 

be fully comprehensive. The databases and sources searched 

are listed in Appendix III. 

The review identified a large and varied range of examples 

of ‘good practice’. The decision was taken not to include 

specific examples as there were too many to ensure within the 

timescales for the literature review that information on these 

specific examples was accurate and up to date. 

2.4.4 Keywords 

The health issues/social factors identified in the project 

definition of multiple and complex needs (Box 2.1, section 

2.2.2) were used as keywords. Combinations of keywords 

were adapted to narrow database searches as necessary. 

Overlap between the specific issues and groups was noted. 

The keywords, and combinations of keywords used, are 

given in Appendix IV. Further details of the literature search 

trail are available on request from the PATH Project office. 

2.5 assessing the quaLitY of 

studies incLuded 

2.5.1 Defining ‘good practice’ 

The review aimed to identify not just the evidence on what 

works in increasing access to services, engagement with 

services, and successful outcomes; but also, where possible, 

to identify the underlying elements that impact on success. 

This involved identifying the elements and characteristics of 

‘good practice’ as perceived by service providers and, where 

possible, backed up by evidence from service evaluations. 

There was no strict definition of ‘good practice’ in the 

literature identified for this review. For the purpose of the 

review, ‘good practice’ was perceived as the means of 

improving and maintaining the highest quality of an effective, 

efficient and appropriate service that best serves the interest 

of its clients. 

Evaluations of service interventions and projects were 

included, where available. There is an assumption that 

service providers’ views are based on expert knowledge and 

experience. The authors recognise that such views are subject 

to bias, whether policy, resource or personally influenced. 

2.5.2 use of qualitative data 

Many of the studies included in the review used qualitative 

research methods. Qualitative data is particularly useful for 

answering questions of ‘how’ and ‘why’ something works and 

for exploring complex cultural and social issues. Therefore it 

is not surprising that much of the data found in the review was 

qualitative in nature. 

11




2.5.3 hierarchy of study design 

Traditionally, quantitative studies are assessed according to 

a hierarchy of study design model, based on the perceived 

quality of the study design used. In this hierarchy, systematic 

reviews and meta-analyses are considered to be the highest 

quality, followed by randomised controlled trials, cohort 

studies, case control studies, cross-sectional surveys and 

case reports (subject to the methodological quality of the 

individual study) (Greenhalgh, 2001). This order does not 

apply to qualitative research however and was therefore 

not used in this review. 

2.5.4 critical appraisal criteria 

The quality of qualitative studies was assessed using the 

checklist for appraising qualitative research by Greenhalgh 

(2001). The criteria by Greenhalgh are widely recognised 

as key issues to consider when assessing and appraising 

qualitative research. A copy of the checklist is provided in 

Appendix V. 

2.6 descriPtion of incLuded studies 

2.6.1 summary table 

The studies included in the review are summarised in the table 

in Appendix VI. This details the author(s), source, methods 

used, study population and key issues identified. 

2.6.2 number of studies 

An extensive electronic literature search resulted in the 

identification of 112 potentially relevant citations. Sixty-two 

papers were then excluded because they did not meet the 

inclusion criteria for the review. This reduced the number of 

included papers to 50. 

Fifty documents were included in the review. Eight were 

articles published in peer reviewed journals and 42 were grey 

literature research documents (either primary and/or secondary 

research reports carried out by voluntary organisations, the 

Scottish or UK Government, or NHS research). 

Twenty seven publications were primary research only 

(i.e. reports of original research); eight were secondary 

research (i.e. collections of primary research); seven were 

combined primary and secondary research; and eight were 

guidance, policy or expert opinion. 

2.6.3 cited articles 

There is one cited article included in this review (Langley et al, 

2002 cited by Quilgars & Pearce, 2003). It was not possible to 

access a copy of the original paper. 

2.6.4 geographical setting of studies 

The geographical setting of each study is given in 

Appendix VI. Sixteen of the 50 publications included were 

from Scotland only (not UK wide), of which three were carried 

out in Glasgow, one in Edinburgh, one in Argyll & Clyde and 

11 were studies across Scotland. 

The focus of the search was limited to articles and 

literature from countries where the patient experience could 

be related to the UK i.e. the UK, Europe, Australia and 

New Zealand. However, an exception was made for one 

Canadian paper by Brotman et al (2003) as it focused on 

the experiences of gay and lesbian older people of which 

no literature had been found elsewhere. 

2.6.5 complex needs populations 

For the purpose of this review, it was assumed that the 

homeless, those with substance misuse problems, sex 

workers and asylum seekers and refugees may well have 

multiple and complex needs. Therefore, studies relating 

to these groups were included, even if the paper did not 

specifically state that the participants had multiple and 


2.6.6 sample size 

Sample sizes in qualitative research are often small. This 

may be due to difficulties in recruiting participants or due 

to the particular context of the study which may focus on 

a specific location, ethnic group or health and social care 

need. The study design may also restrict the sample size. For 

example, in-depth interviews may uncover detailed information 

but they are time consuming compared with surveys and 

questionnaires which can be completed by the recipient in 

their own time. 

A number of studies included in the review used a 

combination of questionnaires, surveys and focus groups with 

the selection of a small sample for more in depth research. 

Whilst small sample sizes can affect the extent to which 

findings can be generalised, such studies are still useful for 

identifying issues among the population they relate to and 

for identifying issues that can be explored further in other 

contexts. Small sample sizes are not necessarily a problem, 

providing one is aware of how the results can be generalised 

to other populations. The table in Appendix VI summarises 

the number of participants and methods used for each study 

included in the review. 

12

Service Providers’ Views What can service providers do to 



3 service 

Providers’ views 

This chapter describes the findings 

from the review. 

3.1 introduction 

The purpose of this literature review was to inform the work 

of the PATH Project. To this extent, a pragmatic approach 

was used around the inclusion of evidence and the extent 

to which specific areas were explored. The review was 

intended as a starting point for service providers, rather than 

an extensive exploration and review of all published practice, 

guidelines and evaluations relating to those with multiple and 


The following should be borne in mind when interpreting the 

findings of the review: 

● 

● 

● 

the initial intention of the review was to identify evaluations 

of services and projects that provided evidence of good 

practice. However, only a limited number of evaluations 

were found (eight out of the 50 papers included); 

the majority of the evidence identified was from primary 

research studies reporting service provider views (usually 

sought as part of a research project, rather than the sole 

reason for the research). Much of the evidence presented 

here therefore represents service providers’ views and 

‘expert opinion’, rather than evidence based on robust 

evaluations of specific projects; and 

of the eight evaluations available, the length of follow up 

was limited. All reported on the early stages i.e. six months 

to 3 years after implementation of the project. No long 

term or follow up evaluations were identified. 

3.2 Presentation of resuLts 

The findings from the review are presented below according 

to the key stages of access identified by the MCNI of ‘getting 

in’ (access to services), ‘getting through’ (engagement with 

services and sustaining their use) and ‘getting on’ (the move 

out of services on to aftercare or independence). 

It is recognised that the issues raised often overlap. 

This chapter summarises the common themes and key issues 

found across the studies. Details of individual studies are 

given in Appendix VI. 

3.3 common themes 

A core set of issues emerged from the studies, which are 

summarised in Box 3.1. Many of the themes identified by 

service providers overlap considerably with the views of 

service users identified in the first literature review by 

PATH (Gallimore et al, 2008). 

13




Box 3.1: common themes 

The following were identified by service providers as 

improving access to services for those with multiple and 


Getting in: 

● early intervention from services (before 

a client reaches a crisis); 

● immediate help from services and fast referral; 

● a single point of entry into services, or a single service 

or site, providing help across a broad range of issues; 

● flexible access to services e.g. evenings and 

weekends, open door policies; 

● provision of accurate information on available services; 

● outreach work; 

● link workers; and 

● initiatives to overcome transport and access 

difficulties in remote and rural areas. 

Getting through: 

● taking a holistic approach to a client’s problems; 

● good relationships with staff; 

● providing support, advocacy and follow up e.g. by 

using a link or key worker who will work with an 

individual client across a range of mainstream and 

specialist services; 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

joint working and multi-disciplinary working within 

and across health, social care, community justice 

and voluntary sector services; 

cultural sensitivity; 

gender sensitivity; 

more intensive and flexible support for those with 

the most complex needs, through specialist 

services if required; 

inreach work; 

training and support for staff; 

peer support; 

support for families; 

long term funding for services; and 

removal or alteration of targets for services 

which may act against helping those who require 

more intensive support. 

Getting on: 

● providing after care and ongoing 

support for clients who need it; 

● allowing for client relapses; and 

● user empowerment, including the use of social 

care approaches, where appropriate. 

14




3.4 imProving access to 

services – ‘getting in’ 

Those with multiple and complex needs who wish to access 

services may find the process confusing and complex due to the 

number of services available, lack of information on suitable and 

available services, set opening times and difficulty communicating 

their needs. There is also the question of how to encourage those 

with multiple and complex needs who are ‘hard to reach’ or not 

ready to access services, to do so. The following section focuses 

on service providers’ views of what is good practice in helping 

those with multiple and complex needs access services. 

Key themes of good practice which improve access 

to services – ‘getting in’: 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

early intervention to support and resolve problems 

for people before their problems increase, become 

more complex or they reach a crisis point; 

immediate help from services and fast referral 

when requested; 

a single point of entry into services; 

flexible access to services e.g. appointment 

free systems/open door policies; 

joint working between and across services; 

provision of accurate information on services; 

access to information in other languages/ 

translation services; 

removal of stigma; 


outreach work; 

link workers; 

initiatives to overcome transport and access 

difficulties in remote and rural areas; and 

provision of specialist services targeted at specific 

groups of people with multiple and complex needs 

to help those clients who have difficulty or who 

would not normally access mainstream services 

to do so. 

3.4.1 early intervention 

Early interventions aim to support and resolve problems for 

people with multiple and complex needs before their problems 

increase, become more complex or they reach a point of crisis. 

Examples of early interventions identified include: 

● 

● 

● 

the use of neighbourhood policing models, which build 

relationships with vulnerable people who have mental 

health problems and are in contact with the criminal justice 

system, with the aim of directing them to services before 

they reach a crisis (Kutchinsky, 2007); 

developing effective hospital admission and discharge 

protocols for those who are homeless or in temporary/ 

insecure accommodation, to ensure that people are 

not discharged from hospital onto the streets or into 

inappropriate accommodation (Dept for Communities and 

Local Government and Dept of Health, 2006); and 

link workers who can support a client through a range of 

services, as required, and help the client get the help they 

need before a crisis is reached (see section 3.4.11). 

3.4.2 immediate help from services and fast referral 

Immediate help from services and fast referral to other 

services, if necessary, was raised by service providers as a 

means of encouraging clients to access services. Quick, easy 

access and the knowledge that there will be a quick response 

from services to their difficulties can encourage access. Long 

waiting times for services can be a deterrent, especially if 

it has taken a while for the client to approach a service, the 

client has a health issue that requires immediate help or the 

client is in crisis. This is particularly relevant for substance 

misusers, homeless people and sex workers with substance 

misuse problems when requesting referral to drug treatment 

services (Edwards, 2003; Hodges et al, 2006; Randall & 

Drugscope, 2002; Hunter, May & Drug Strategy Directorate, 

2004; Bindel, 2006). 

3.4.3 single entry into services 

A single point of entry into services, or a single service or site 

providing help with a broad range of issues such as health, 

accommodation, practical and emotional support (e.g. paying 

bills, accessing counselling) was identified as good practice 

by a number of service providers. The single point of entry 

into services is intended to prevent duplication of assessment 

for eligibility or treatment and end the process of an individual 

being passed on from a service which is not willing or able 

to deal with their problems until other issues are resolved 

(Neale & Kennedy, 2002; Hodges et al, 2006; Edwards, 2003; 

Rosengard Associates, 2001; SACDM & SACAM, 2003; 

Social Exclusion Unit, 2005; Rankin & Regan, 2004). 

15




3.4.4 flexible access to services 

The chaotic lives of many people with multiple and complex 

needs can result in difficulties attending appointments 

and accessing services which open at specific times. The 

removal of barriers such as set opening times for services 

and appointments would help to maximise opportunities 

for service users accessing services. An open door policy, 

where possible, is encouraged (Randall & Drugscope, 2002; 

Rosengard et al, 2007). 

3.4.5 joint working 

Joint working between services within and across health, 

social care, community justice and voluntary sectors was 

commonly identified as good practice. Multidisciplinary 

working helps ensure that a single point of entry to services 

works efficiently, improves communication between different 

services and helps provide a holistic approach to the 

individual, focusing on issues such as accommodation and 

emotional support as well as health needs (Neale & Kennedy, 

2002; Audit Commission, 2002; SACDM & SACAM, 2003; 

Croft-White & Parry-Crooke, 2004; NHS Argyll & Clyde, 2002; 

Quilgars & Pearce, 2003). 

“I think it’s really a question of having such a range of 

services you can tap into that are appropriate for their 

needs at that particular time because we know this is a 

group of people whose needs change quite dramatically 

over periods of time, and indeed within 24 hours 

depending on what they’re using. This is an incredible 

opportunity that we must take to shift services for dual 

diagnosis and other people with acute and enduring 

mental health problems to a different way of working, 

different area, different timescales, different times of 

the day.” 

commissioner (Hodges et al, 2006) 

Examples of good practice in relation to joint working included: 

● 

● 

multidisciplinary meetings (e.g. for case reviews) and 

shared responsibility for particularly vulnerable and chaotic 

homeless drug users (Neale and Kennedy, 2002); 

single shared assessment and joint agency assessment 

tools to reduce the number of times a client is assessed 

by different services (Rosengard et al, 2007; Croft-White & 

Parry Crooke, 2004); 

● 

● 

multidisciplinary support for people with mental health and 

multiple needs in contact with the criminal justice system 

to help access primary care (Revolving Doors Agency, 

2001); and 

a multi-agency and multi-strategy approach involving 

health, drug, housing agencies and the police to help 

overcome the chaotic lives and the multitude of mental 

and physical issues experienced by sex workers e.g. 

mental health difficulties, health problems, social problems 

and physical abuse (Bindel, 2006; Hunter, May & Drug 

Strategy Directorate, 2004). 

3.4.6 Provision of accurate information on services 

Better knowledge and provision of information on suitable 

and available services was identified by service providers as 

beneficial to them as well as service users (Neale & Kennedy, 

2002; Hodges et al, 2006; Croft-White & Parry-Crooke, 2004; 

Social Exclusion Unit, 2005a; Bindel, 2006). 

3.4.7 Provision of information in other languages and 

ease of access to translation services 

The provision of information on services in languages 

other than English and the availability and ease of access 

to translation services were noted by service providers as 

necessary for easy access to services for those who do 

not have English as a first language (Orchard, Symanski & 

Vlahova, 2007). Good practice examples identified included: 

● 

● 

translation and interpreting services to help identify trauma 

and related mental health difficulties among foreign 

prisoners (Sainsbury Centre for Mental Health, 2006); and 

multilingual staff and increased access to translation 

and interpretation services at key housing and homeless 

services (Orchard, Symanski & Vlahova, 2007). 

3.4.8 removal of stigma 

Stigma and discrimination from service staff and society 

relating to a range of health and social issues (e.g. substance 

misuse, HIV, sexuality, sex work and mental health) have been 

highlighted as potential barriers to using services. Work to 

remove these is seen by some service providers as a means 

of encouraging a range of people (e.g. prisoners, gay and 

lesbian older people, black and minority ethnic people with 

multiple and complex needs, sex workers, asylum seekers 

and refugees) to access services (Rosengard 2007; Hodges 

et al, 2006; Revolving Doors Agency, 2000; Brotman et al, 

2003; Green and Smith, 2004; Bindel, 2006; Hunter, May & 

Drug Strategy Directorate, 2004; Roshan, 2005). 

16




3.4.9 training and support for staff 

Specific areas of training for staff to support good practice 

were raised by service providers working with a range of 

people with multiple and complex needs across sectors. 

Examples included: 

● 

● 

● 

● 

● 

● 

● 

education and training of GPs in remote and rural areas 

on the support and treatment of patients on methadone to 

help improve access to methadone prescription in these 

areas (EIU, 2004); 

training for prison staff on recognition of mental health 

problems at the time of a prisoner’s assessment at 

reception into prison (Revolving Doors Agency, 2000 

and 2001; Sainsbury Centre for Mental Health, 2006); 

training primary care staff (e.g. reception staff in GP 

practices) to recognise when behaviour is a result of 

complex needs or mental health issues (Revolving 

Doors Agency, 2000 and 2001; Sainsbury Centre 

for Mental Health, 2006); 

training in sign language for bilingual staff working with 

disabled people (Stalker et al, 2006); 

training or recruitment of staff with knowledge of 

equality issues for black, disabled people, where 

applicable (Singh, 2005); 

staff training in the Worker Registration Scheme, 

benefit entitlement and cultural awareness for those 

working with homeless EU8 migrants (Orchard, 

Symanski & Vlahova, 2007); and 

specialist training on issues relating to sex workers for 

drug action teams and other health focused projects 

working with sex workers (Bindel, 2006). 

3.4.10 outreach work 

Outreach work involves actively taking a service to the client 

as opposed to the client coming to the service. It is seen 

as good practice by service providers across a range of 

services in helping to engage the most ‘hard to reach’ client 

and ‘hidden’ populations, such as drug users, the homeless, 

rough sleepers, those in rural areas, sex workers, black and 

minority ethnic people with multiple and complex needs and 

older gay and lesbian people. Outreach workers often take 

on an advocacy role, assisting clients to access mainstream 

or specialist health services (EIU, 2004; Hodges et al, 2006; 

Randall & Drugscope, 2002; Croft-White & Parry-Crooke, 

2004; Quilgars & Pearce, 2003; Hunter, May & Drug Strategy 

Directorate, 2004; Bindel, 2006; Brotman et al, 2004). 

Examples of outreach work included: 

● 

● 

an assertive outreach project for the homeless in 

Edinburgh providing interventions for alcohol misuse 

and assessment and quick referral to drug services e.g. 

counselling, detoxification services and life skills (Langley 

et al, 2002 cited by Quilgars & Pearce, 2003); and 

link worker scheme which helped people with mental health 

and multiple needs in contact with the criminal justice system 

engage with services (Revolving Doors Agency, 2001). 

3.4.11 Link workers 

Link workers support a client through a range of services across 

sectors with the level of support tailored to the client’s needs. 

This can take the form of advocacy, making appointments, 

accompanying the client to appointments and helping the client 

with applications for benefits, housing and GP registration. Link 

workers are identified by service providers as one of the key 

interventions in working with clients with multiple and complex 

needs (Finn et al, 2000; Revolving Doors Agency, 2001; O’Shea, 

Moran & Bergin, 2003; Ramon, 2003; Graham Jones et al, 2004; 

Revolving Doors Agency, 2001; Social Exclusion Unit, 2005a). 

Evidence indicates that the benefits of link worker 

schemes include: 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

helping clients to access and engage with services 

(Revolving Doors Agency, 2001); 

helping resolve communication difficulties with health 

professionals and staff (Revolving Doors Agency, 2001); 

helping reduce clients’ chaotic lives and resolve behaviour 

that is often a result of complex needs and mental health 

issues (Revolving Doors Agency, 2001); 

an increase in provision of stable accommodation, improved 

housing and housing assessments for vulnerably housed 

clients (Revolving Doors Agency, 2001; Finn et al, 2002); 

a reduction in visits to A&E in crisis (Finn et al, 2000); 

a reduction in client anxiety (as a result of being 

accompanied and supported with appointments) 

(O’Shea, Moran & Bergin, 2003); 

helping clients move on from illness related services 

to more general services (Ramon, 2003); 

success at engaging clients from ethnic backgrounds 

(O’Shea, Moran & Bergin, 2003); 

continuing to engage or support clients who do not want 

drug or alcohol rehabilitation, for example helping a client 

to register with a GP (O’Shea, Moran & Bergin, 2003); and 

a positive effect on the health and wellbeing of clients 

(Revolving Doors Agency, 2001). 

17




Examples of link worker schemes included: 

● 

● 

● 

a link worker scheme aiming to establish relationships 

with people with mental health and complex needs in 

contact with the police (Finn et al, 2000); 

a link worker scheme to: provide support and advice 

to those with multiple and complex needs at police 

stations, courts and prisons; link individuals back into 

mainstream services; and to work in the longer term with 

those with multiple and complex needs (Revolving 

Doors Agency, 2001); and 

health advocates supporting homeless people in 

temporary housing to access health and social care, 

providing information, involving the client in decision 

making and promoting well-being (Graham Jones 

et al, 2004). 

3.4.12 transport and access 

Service users in remote and rural areas may have to travel 

long distances to access services with the additional barriers 

of cost and potential reliance on the availability of public 

transport. While research suggests that drug users in remote 

and rural areas of Scotland who want treatment are prepared 

to travel, it appears that transport difficulties can deter others 

(EIU, 2004). 

Initiatives suggested to overcome transport and access 

difficulties in remote and rural areas included: 

● 

● 

● 

● 

● 

● 

● 

subsidising clients’ travel; 

community transport initiatives; 

provision of transport by services; 

establishment of local planning groups to provide 

services more responsive to local needs; 

outreach (health or social care staff going out to the 

community and clients rather than waiting for the 

client to come to the service); 

shared location of services; and 

home visits to clients (EIU, 2004). 

3.4.13 specialist services targeted 

at specific groups or problems 

Specialist services targeted at specific groups of people with 

multiple and complex needs were seen by many service 

providers as a means of helping those clients who have 

difficulty or who would not normally access mainstream 

services to do so. Reasons for clients not accessing 

mainstream services include: the stigma of their problems 

(whether true or perceived as true by the client); their 

behaviour or communication difficulties (which may be as a 

result of their problems); because they don’t recognise that 

they need help; or the range and complexity of their difficulties 

and lives (Edwards, 2003; Rankin & Regan, 2004; Bindel, 

2006; Croft-White & Parry-Crooke, 2004). 

Individuals with complex needs can fall between gaps in 

mainstream services or find that a service can only help one 

of their needs, not other interdependent issues e.g. health and 

housing (Rankin & Regan, 2004). Mainstream services can also 

suffer from a lack of expertise and knowledge on how to work 

with those with multiple and complex needs (Edwards, 2003). 

However, increasing access to mainstream services is also 

seen as important by many service providers. By acting as a 

point of entry, for example, specialist services can provide a link 

for people into mainstream services and help ensure that clients 

benefit from these services. Specialist services can then help 

those who can to support themselves without specialist help 

(Rankin & Regan, 2004; Hodges et al, 2006). 

Examples of specialist services included: 

● drug treatment services, including detoxification and 

rehabilitation, hostel places and day centres offering 

screening, advice and information for the homeless 

(Fountain & Howes 2002; Randall & Drugscope 2002); 

● a dedicated physiotherapy service for the homeless in 

Glasgow based in established drop in centres for the 

homeless (Dawes et al, 2003); 

● specialist expertise in a prison setting e.g. specialist 

learning disability nurses, speech and language therapists, 

one-to-one work, multidisciplinary case conferences, links 

with community learning disability support, peer support 

with education and innovative approaches to education for 

offenders with learning disabilities (Loucks & Talbot, 2007); 

● Dept of Health guidance for healthcare professionals on 

the commissioning of specialist learning disability services 

for adults (including offenders) (Dept of Health, 2007); and 

● while the treatment and support within mainstream 

services of people with profound and multiple impairment 

is welcomed, specialist expertise should be available as 

required (Stalker et al, 2006; PMLD Network, 2002). 

18




3.5 imProving engagement with 

services – ‘getting through’ 

Ensuring that people with multiple and complex needs sustain 

engagement with services is key to meeting their needs and 

helping them to gain the maximum benefit from services. 

Service providers highlight the following key issues around 

sustaining engagement with services for people with multiple 

and complex needs: 

● 

● 

● 

those with multiple and complex needs may experience 

inappropriate service responses due to the challenging, 

intense or ‘revolving door’ nature of their difficulties which 

leads to withdrawal from services (Rosengard, 2007); 

they may drop out due to their personal problems or the 

chaotic nature of their lives (Rosengard, 2007; Rankin & 

Regan, 2004; Edwards, 2003); and 

in the case of the most chaotic and difficult to work with 

clients, just remaining in contact is progress (O’Shea, 

Moran & Bergin, 2003; Rosengard, 2007). 

The following section looks at what service providers’ state 

improves engagement with services for those with multiple 

and complex needs. 

Key themes of good practice in improving engagement 

with services - ‘getting through’: 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

link workers; 

using a holistic approach to clients’ needs; 

developing good relationships between clients 

and staff; 

cultural sensitivity; 

gender sensitivity; 

joint working across services; 

prison inreach work; 

specialist services targeted at specific groups 

or problems; 


peer support; 

support for families; 

long term funding for services; and 

removal or alteration of targets for services which 

may act against helping those who require more 

intensive support. 

3.5.1 Link workers 

Using a link worker to support a client through a range of cross 

sector services, with the level of support tailored to the client’s 

needs, is reported as a key intervention by service providers. 

This is discussed in more detail above in section 3.4.11. 

3.5.2 holistic approach 

A holistic approach to people with multiple and complex needs 

involves services treating the client as a whole person and 

taking into account all of their issues and difficulties rather 

than just a single health or social problem. A holistic approach 

recognises that a client’s problems may be inter-related and 

may not be resolved independently. It also recognises that 

some clients require support in other areas of their life, as 

well as with the immediate presenting problems (Edwards, 

2003; Hodges et al, 2006; Barclay et al, 2003; Croft-White & 

Parry-Crooke, 2004; Mansell, 2007). 

“We try to provide a holistic social and psychological 

model of care to try and achieve optimum functioning 

in all areas. We have to think broadly from providing 

clothes to drawing a route map. Awareness of social 

factors that impact on everyday life.” 

service provider working with asylum seekers, 

scotland (Barclay et al, 2003) 

Examples of the use of a holistic approach included: 

● 

● 

● 

● 

● 

services for sex workers that address mental health, general 

health and safe accommodation issues and provide drug 

treatment, counselling, long term after care and follow up for 

sex workers who have dropped out of projects (Hunter, May 

& Drug Strategy Directorate, 2004; Bindel, 2006); 

emotional and practical support for the homeless, including 

accommodation (and potentially long term support with 

accommodation), food, clothing, storage facilities, crèche 

facilities, the rebuilding of a client’s confidence and self 

esteem, outreach and aftercare services (Neale and 

Kennedy, 2002; Quilgars & Pearce, 2003); 

the ability of a project or agency to cater for clients who 

fail and return to the service to seek help when working 

with the homeless with substance misuse problems 

(Fountain & Howes, 2002); 

healthy living centres and similar specialist projects for 

homeless young people (Quilgars & Pearce, 2003); and 

interventions supporting sex workers with drug problems 

in contact with the criminal justice system to support 

them to leave prostitution (Hunter, May & Drug Strategy 

Directorate, 2004). 

19




3.5.3 relationships with health professionals 

Respect from non-judgemental, committed and 

understanding staff who have a positive attitude about their 

clients’ circumstances and see clients as individuals was 

consistently identified by service providers as important 

in working with those who are homeless, drug users and 

those with learning disabilities and mental health problems 

(Quilgars & Pearce, 2003; O’Shea, Moran & Bergin, 2003; 

Ramon, 2003; Neale and Kennedy, 2002; Croft-White and 

Parry-Crooke, 2004; Social Exclusion Unit, 2005b; EIU, 

2004; Hardy et al, 2006). 

The benefits of building a good relationship with health 

professionals include building trust (which can be difficult 

to do for some people with multiple and complex needs), 

helping to keep the client engaged with services and meeting 

their needs, and building confidence and self-esteem 

(Ramon, 2003; Neale & Kennedy, 2002; Social Exclusion 

Unit, 2005b). Key elements of the relationship between 

service users and health professionals are stated as: 

● 

● 

● 

● 

identification of the client’s needs with and by the 

client (O’Shea, Moran & Bergin, 2003; Ramon, 2003); 

willingness of staff to work with any client (Neale 

and Kennedy, 2002); 

client involvement and ensuring consent is given by a 

client before a service is approached (Croft-White and 

Parry-Crooke, 2004; Neale and Kennedy, 2002; Social 

Exclusion Unit, 2005b); and 

respect for an individual’s privacy (Hardy et al, 2006). 

3.5.4 cultural sensitivity of services 

Cultural sensitivity involves recognising that services may not 

be appropriate for the needs of those from black and minority 

ethnic communities due to cultural differences and ethical 

and attitude issues (Singh, 2005; Green & Smith, 2004). 

Cultural sensitivity and adaption of services to meet the 

needs of those from different cultures are highlighted as good 

practice by service providers in working with people with 

complex needs from black and minority ethnic communities 

and asylum seekers and refugees (Barclay et al, 2003; 

Roshan, 2005; Singh, 2005; Ahmad et al, 1998; Green & 

Smith, 2004; Evans & Banton, 2001; Stalker et al, 2006; 

Sainsbury Centre for Mental Health, 2006). 

Service providers note that it should not be assumed that 

services targeted at black and minority ethnic communities will 

be appropriate for all black and minority ethnic communities, 

and that it is also necessary to recognise that individuals 

may not fit into simple classifications due to the complexity of 

identity (Singh, 2005). 

Key elements of good practice were highlighted as: 

● 

● 

● 

● 

● 

● 

● 

● 

employment of black and minority ethnic workers to help 

increase engagement with black and ethnic minority 

clients (O’Shea, Moran & Bergin, 2003); 

extra resources for services for minority ethnic deaf people 

and their families (Ahmad et al, 1998); 

training or recruitment of staff with skills such as equality 

issues for the disabled and link working if necessary (Singh, 

2005; Green & Smith, 2004; Evans & Banton, 2001); 

consultation with black disabled people on their 

needs (Evans & Banton, 2001); 

the need to challenge staff and service assumptions 

about black disabled people and what they might want 

from services (Singh, 2005); 

customising information (both translated and in English) 

produced for black and minority ethnic disabled people 

so that it is relevant to both disability and ethnicity 

(Stalker et al, 2006); 

community development work to address racism 

(Barclay et al, 2003; Roshan, 2005); and 

culturally sensitive services for dealing with issues such as 

drugs or HIV e.g. awareness of potential stigma relating to 

cultural awareness and attitudes to drugs or people who 

are HIV positive (Ross, 2004; Green & Smith, 2004). 

3.5.5 gender sensitive services 

The need for gender sensitive services has been highlighted as 

good practice when working with specific groups e.g. homeless 

women, sex workers and women with learning disabilities 

and mental health needs (Kohen, 2004; Bindel, 2006; Neale 

& Kennedy, 2002). Gender sensitive services are seen as 

creating safe and secure environments for women who are 

vulnerable and may have suffered abuse and who may be 

deterred from using a male dominated service (Bindel, 2006). 

Examples of gender sensitive services included: 

● 

● 

● 

provision of women only spaces and services or sessions 

in mixed sex services for homeless women to provide a 

safe and secure environment as homeless women are 

frequently deterred from male dominated environments and 

mixed sex accommodation (Neale and Kennedy, 2002); 

women only drop in and therapy sessions for sex workers 

(Bindel, 2006); and 

while there is a lack of research around lesbian, gay, 

bisexual and transgender people with complex needs, there 

are issues of good practice in general that can be noted 

as likely to apply to those with complex needs e.g. the use 

of language that does not assume heterosexuality and 

recognition and inclusion in monitoring forms of registered 

same sex partnerships, sexual orientation and transgender 

(NHS Inclusion Project, 2003; Stalker et al, 2006). 

20




3.5.6 joint working 

Joint working and networking between services are generally 

seen as good practice by service providers from a range 

of services as this allows information to be shared and 

reduces duplication of assessment and the need for clients to 

repeatedly explain their difficulties to services (Stalker et al, 

2006; Croft-White & Parry Crooke, 2004; Neale & Kennedy, 

2002; Rosengard et al, 2007; O’Shea, Moran & Bergin, 2003; 

Myers, 2004; Kohen, 2004). See also section 3.4.5. 

In addition, joint working can help to keep clients engaged 

with services through: improved coherence and continuity 

of care and treatment; shared responsibility for particularly 

vulnerable and chaotic service users; ensuring appropriate 

referrals; and improved continuity during the transition 

between child and adult services (O’Shea, Moran & Bergin, 

2003; Revolving Doors Agency, 2000; Stalker et al, 2006; 

Neale and Kennedy, 2002; Croft-White & Parry Crooke, 2004). 

Examples given of good practice in joint working include: 

● 

● 

● 

● 

staff from one agency keeping other agencies up-to-date 

with information on their services (Croft-White and 

Parry-Crooke, 2004); 

the sharing of information between the medical profession 

and probation service on people on remand or short 

services (O’Shea, Moran & Bergin, 2003); 

establishing links with community based agencies for 

prisoners with mental health issues so that there is 

support for prisoners on release (O’Shea, Moran 

& Bergin, 2003); and 

joint working in areas such as information and 

assessment, and integration with specialists in learning 

disabilities for services for young people and adults with 

learning disabilities and/or autistic spectrum disorders 

(ASD) in secure, forensic and other specialist settings 

in Scotland (Myers, 2004). 

3.5.7 inreach work 

Inreach involves the service going to the client (or potential 

client) rather than the service waiting for the client to access 

it. Prison inreach teams focusing on inmates with severe 

and enduring mental health problems have been noted as 

important in prison mental health care policy in England and 

Wales. Inreach work can help identify those offenders with 

mental health needs and help direct them to appropriate care 

(Sainsbury Centre for Mental Health, 2006). 

3.5.8 Specialist services targeted at specific 

groups or problems 

As discussed in section 3.4.13, while it is seen as good 

practice to support and treat those with multiple and complex 

needs within mainstream services, specialist services may 

be required for specific needs and health problems, or for 

those with chaotic lives, in order for service users to remain 

engaged with services. Benefits of specialist services to 

clients with substance misuse problems include harm 

reduction, detoxification and rehabilitation, and stabilising 

accommodation (Randall & Drugscope, 2002). 

Examples of specialist services are: 

● 

● 

● 

● 

● 

● 

● 

● 

dedicated specialists in substance misuse and mental 

health based within mainstream mental health and/or 

substance misuse services; 

the development of different strategies for supporting 

different groups of homeless people e.g. single homeless 

people and families with children (NHS Argyll & Clyde, 2002); 

the Rough Sleepers Initiative (RSI) in Scotland which 

provided funding for a range of services and projects 

designed to end rough sleeping (Fitzpatrick, Pleace 

and Bevan, 2005); 

specialist dental services within homeless services 

(Quilgars & Pearce, 2003); 

provision of local services based in the community as 

opposed to residential care for people with learning 

disabilities and challenging behaviour (Mansell, 2007); 

services for individuals involved in prostitution e.g: 

interventions specifically for crack cocaine users; 

substance misuse clinics; workers to accompany 

clients to drug appointments; and residential drug 

treatment (Hunter, May & Drug Strategy Directorate, 

2004; Bindel, 2006); 

‘ugly mug’ schemes which inform women of dangerous 

customers who may pose a threat in some way 

(Bindel, 2006); and 

exit support for sex workers which includes outreach, safe 

accommodation, single sex rehabilitation and counselling, 

risk assessment, mental health services, education 

programmes and long term aftercare (Bindel, 2006). 

“The availability of good quality, immediately available, 

emergency accommodation will make a crucial 

difference to those women wishing to leave prostitution.” 

organisation supporting sex workers (Bindel, 2006) 

21




3.5.9 training and support for staff 

As stated in section 3.4.9, service providers state that staff 

training and support are good practice for services for 

those with multiple and complex needs, to help keep clients 

engaged with services. In addition to the examples given in 

section 3.4.9, examples of training and support for staff that 

help promote engagement with services include: 

● 

● 

● 

● 

financial incentives to recruit and retain staff in remote 

and rural areas, where there are often lower rates of pay 

and less opportunity for career progression than urban 

areas (EIU, 2004); 

training and support for people working with drug users 

e.g. staff in homeless services (Neale and Kennedy, 2002; 

Randall & Drugscope, 2002; Hodges et al, 2006; Audit 

Commission, 2002); 

training for staff working with sex workers on the effects of 

sexual abuse and trauma; training in sensitive interviewing 

skills; and staffing that reflects, where possible, the 

demographics of service users (Hunter, May & Drug 

Strategy Directorate, 2004; Bindel, 2006); and 

specialist training for all staff working in services that 

support people with learning disabilities and challenging 

behaviour or mental health needs (Mansell, 2007; 

Kohen, 2004). 

3.5.10 Peer support 

Peer support may be useful for some clients in that support 

is provided by someone who has directly experienced and 

overcome the same difficulties as experienced by the client 

(Bindel, 2006; Loucks & Talbot, 2007). 

Examples included: 

● 

● 

peer support in prison education departments to 

encourage prisoners with learning disabilities to 

become involved in improving their education (Loucks 

& Talbot, 2007); and 

peer support for sex workers exiting prostitution 

(Bindel, 2006). 

3.5.11 support for families 

Respite for families and carers of people with learning 

disabilities and challenging behaviour or mental health needs 

was seen by service providers as a valuable means of support. 

Examples of good practice included: 

● 

● 

individualised short breaks for families and carers 

(Mansell, 2007); and 

services to support the families of prostitutes including 

day care services and drug treatment for partners (Hunter, 

May & Drug Strategy Directorate, 2004). 

3.5.12 Long term funding for services 

Long term funding was welcomed by many service providers 

and agencies who frequently have to apply for funding which 

can be time consuming and competitive and can have a 

negative effect on projects. In addition, voluntary services feel 

they are sometimes not taken seriously by the statutory sector 

and that this can impact on the success of applications for 

mainstream funding (Social Exclusion Unit, 2005b). Long term 

funding is seen as beneficial for the recruitment and retention 

of staff, the ability to expand an intervention and the ability to 

offer long term support to those who need it (Social Exclusion 

Unit, 2005b; Rankin & Regan, 2004). 

3.5.13 removal of targets for services 

Some service providers would welcome government 

consideration of alternatives to targets based on throughput 

to measure the success of an agency or intervention. The 

use of targets and their relationship with funding is an area 

of concern as it can result in services focusing on clients who 

need less support as opposed to those with more complex 

needs who require greater and more sustained support (Social 

Exclusion Unit, 2005b; McSweeney and Hough, 2006). 

An alternative means of measuring success proposes 

focusing on improving worst outcomes or decreasing the gap 

between worst and average, or the use of measures to assess 

progress and achievement. These methods are already used 

by some providers (Social Exclusion Unit, 2005b). 

Removal of targets would help enable service providers 

to focus on the most difficult or hard to reach clients (Social 

Exclusion Unit, 2005b). 

“With the pressure of targets and funding tied to targets 

it becomes difficult to remain committed to meeting 

clients’ needs when you have to get numbers ‘through 

the doors’ or ‘onto seats’.” 

seu consultation response (Social Exclusion Unit, 2005b) 

22




3.6 imProving outcomes from services 

and aftercare – ‘getting on’ 

Services for those with multiple and complex needs should 

also aim to help clients gain the maximum benefit from 

services and move on, while sustaining the benefits achieved. 

The manner in which a client moves on depends on the 

nature of the client’s needs. For example, it may involve the 

client moving onto independence, or a service offering less 

or different support, or in the case of some clients, long term 

assistance with specific issues to ensure their problems do not 

arise again. Ongoing support and user empowerment were 

identified by service providers as key. 

Key themes of improving outcomes from services and 

aftercare – ‘getting on’: 

● 

● 

provision of ongoing support, where needed; and 

user empowerment, including the use of social 

care approaches. 

3.6.1 ongoing support 

It may be necessary for services to recognise that some 

clients will require long term support and advocacy to sustain 

the benefits gained from services and to help prevent their 

former health and social issues from becoming problems 

again (Edwards, 2003). 

For example: 

● 

● 

● 

the need to keep client cases open and the service 

accessible even after a client has moved on (O’Shea, 

Moran & Bergin, 2003; Neale & Kennedy, 2002); 

the provision of drug treatment services which have 

the flexibility to allow for clients to relapse and try again 

(Randall & Drugscope, 2002); and 

personal life plans for young people and adults with 

learning disabilities and/or autistic spectrum disorder 

in secure settings e.g. prison. Such plans would help 

ensure on-going responsibility for those who enter secure 

environments (Myers, 2004). 

3.6.2 user empowerment 

Empowering those with multiple and complex needs to 

take responsibility for aspects of their life where possible 

was seen as good practice by some service providers. 

User empowerment is perceived as helping to contribute to 

confidence and self-esteem through clients taking control of 

decisions, as well as helping some clients to move on from 

receiving support from services (Rosengard, 2007). 

Examples cited included: 

● 

● 

staff helping the homeless take responsibility for their own 

healthcare e.g. taking medication appropriately (Croft- 

White and Parry-Crooke, 2004); and 

the use of social care approaches such as individual 

budgets, social prescribing and direct payments (IBSEN, 

2007; SDC, 2007; NICE, 2004; SCIE, 2007). 

23

Discussion What can service providers do to 



4 discussion 

This chapter describes the 

limitations of the evidence 

base informing the review and 

summarises the key themes 

emerging from the review. 

4.1 gaPs in the evidence 

The amount of evidence around services for people with 

multiple and complex needs varies according to the type of 

need/combination of needs considered. The authors recognise 

that this review could not be comprehensive and there may 

well be literature that wasn’t identified during the review. 

While there is a considerable amount of evidence around 

good practice with groups of people such as the homeless, 

offenders and substance misusers, there appear to be gaps in 

the evidence for specific groups and combinations of needs. 

For example, there was limited or no evidence relating to 

specific areas such as: older people with complex needs; 

lesbian, gay, bisexual and transgender people with complex 

needs; recent immigrants with complex needs; those with 

literacy difficulties among their complex needs; victims of 

domestic abuse with multiple needs; and people in rural areas 

with multiple needs. 

4.2 quaLitY of evidence found 

As discussed in section 3.1, a large proportion of the evidence 

found in the review represented the general views of service 

providers on what constitutes good practice, as opposed to 

evidence from formal evaluations. Much of what is described 

in this review, therefore, represents ‘expert opinion’. Also of 

note, where evaluations were undertaken, the length of follow 

up was often limited. The timing of the evaluations was an 

issue with the majority being short term follow up studies. 

While in most instances this was because the intervention 

had only been running for a short period (usually around one 

year), there is a need for long term follow up of interventions 

to identify if initial results are sustained. 

4.3 KeY themes and common issues 

Despite the limitations in the evidence base, several key 

themes emerged and a number of factors that promote 

positive engagement and outcomes were highlighted as 

good practice across the different groups of people and 

combinations of needs. 

A large number of issues underpinning successful practice 

involve treating the client as an individual. Whether this is a 

holistic approach from services to the client’s needs; helping 

them with practical and emotional as well as health problems; 

providing support to the level required by the client; and/or 

recognition of the need to build self esteem and confidence 

in the move to independence from services. Link workers 

providing individual support to clients to the level required by 

the client has been a successful intervention across a range 

of multiple needs. 

The nature of those with the most complex problems 

creates the need to recognise that some people are more 

difficult to help and require a high level of support, sometimes 

long term support. For some, merely maintaining engagement 

with a service may be considered a success. For those 

with complex needs who are not ready to get involved with 

services, support with other issues can be offered until they 

are ready. 

24

Discussion What can service providers do to 



4.4 consistencY of findings 

The issues raised by service providers in this review overlap 

considerably with those identified in the PATH review of 

service users’ views (Gallimore et al, 2008) and by local 

work undertaken by PATH in three CHP areas in Lothian 

and Highland (PATH Project, 2008). The fact that a large 

proportion of the issues identified by service providers are 

shared with service users is encouraging. Where the views 

of service providers differed from those of users tended to be 

in the practical aspects of service delivery (e.g. training and 

support for staff, funding arrangements for services and target 

setting for services). 

4.5 imPLementing change 

It is useful to note that while the evaluations identified showed 

evidence of successful interventions and practices, they also 

indicate that implementing elements of good practice is not 

always straightforward. For example, changes in work practice 

may be resisted by some staff who may be concerned over 

whether they have the appropriate skills for the new change 

or through fear of loss of responsibility. Another example is the 

move to joint funding where previously a single agency had 

held the funding. 

4.6 transferring good Practice 

Identification of the factor(s) that make a practice successful 

is important if the success is to be repeated elsewhere i.e. is 

the key factor(s) transferrable to another setting? The success 

of an intervention may be due to a dynamic leader or team, 

or to outreach work. However, these factors are not always 

identified in research evidence. 

25

Conclusion What can service providers do to 



5 concLusion 

This chapter summarises the 

conclusions from the review. 

Service users need to see services as accessible and find 

them, or be assisted to find them, easy to access. In general, 

good practice in engaging those with multiple and complex 

needs can involve services targeting certain groups and 

supporting them with entry to services, for example through 

outreach work and link workers. The need for services to 

work from the perspective of what the service user wants and 

needs is key. 

Maximising and sustaining the benefits to clients while 

they are engaged with services then involves tailoring the level 

and type of support to a client’s needs and recognising how 

one problem or difficulty may impact on other areas of 

a client’s life. 

For some, aftercare and long term support is a key 

element. Aftercare may involve continued support in some 

aspects of a client’s life or may mean that the client is aware 

that the service will always be available to them should they 

need assistance at a later time. 

Taken alongside the service users’ views identified in the 

first PATH literature review (Gallimore et al, 2008), this review 

hopefully provides a useful starting point for areas of practice 

to consider when designing, commissioning and providing 

services that better meet the needs of those with multiple and 


26

References What can service providers do to 



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gaLLimore a, haY L & macKie P (2008) 

What do people with multiple and complex needs want 

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30

Appendix I What can service providers do to 



aPPendix i: aBBreviations 

a&e Accident and Emergency 

BsL British Sign Language 

chP Community Health Partnership 

cPn Community Psychiatric Nurse 

d2w Dependency to Work Programme 

eiu Effective Interventions Unit (Scottish Government) 

eu8 

Eight of the 10 countries which joined the European Union in 2004 (Slovenia, 

Latvia, Lithuania, Slovakia, Estonia, Czech Republic, Poland, Hungary) 

gP General Practitioner 

hiv Human Immunodeficiency Virus 

hmP Her Majesty’s Prison 

iBsen Individual Budgets Evaluation Network 

mcni Multiple and Complex Needs Initiative 

nhs National Health Service 

nice National Institute for Health and Clinical Excellence 

Path Project Partnerships for Access to Health Project 

PmLd Profound and Multiple Learning Disabilities 

rsi Rough Sleepers Initiative 

sacam Scottish Advisory Committee on Alcohol Misuse 

sacdm Scottish Advisory Committee on Drug Misuse 

scie Social Care Institute for Excellence 

sdc Scottish Development Centre for Mental Health 

sedd Scottish Executive Development Department 

sesr Scottish Executive Social Research 

seu Social Exclusion Unit 

udset User Defined Service Evaluation Toolkit 

uK United Kingdom 

31

Appendix II What can service providers do to 



aPPendix ii: gLossarY 

Term Explanation 

Community Health Partnerships (CHPs) Community Health Partnerships (CHPs) are primary care 

organisations that operate within the Health Boards in 

Scotland. CHPs typically represent a district or area within 

a Health Board area with a population in the region of 

100,000 people. Their role includes: 

● 

● 

● 

● 

Delivery of primary care services, including community 

mental health and sexual health services; 

Delivery of joint community care and childrens and 

family services in collaboration with social and 

educational services; 

Promotion of health improvement and reduction in 

health inequalities; and 

To facilitate strategic planning and commissioning, 

including at the primary-secondary care interface. 

Grey literature Non-conventional literature, such as conference papers, 

internal reports, government documents, newsletters, 

factsheets and theses. Grey literature does not include 

scientific journals. Grey literature can be more difficult 

to search and access than traditional scientific literature 

(although access to grey literature is improving with the 

growth of the internet). 

Peer reviewed Peer review (known as refereeing in some academic 

journals) is the process of subjecting an author’s work to 

the scrutiny of others who are experts in the field. The peer 

review process aims to make authors meet the standards 

of their discipline, and of science in general. 

Primary literature Reports of original research. 

Qualitative research Qualitative research is one of the two major approaches 

to research methodology in health and social sciences. 

Qualitative research involves an in-depth understanding 

of human behaviour and the reasons that govern human 

behaviour. Qualitative research investigates the ‘why’ and 

‘how’ of decision making, as opposed to the ‘what, where 

and when’ of quantitative research. 

Secondary literature Collections of primary research. 

32

Appendix III What can service providers do to 



aPPendix iii: dataBases and sources searched for the Literature review 

The following databases and sources were searched during the literature review: 

dataBases: 

● e-library: 

Journals@Ovid Full Text 

All EBM Reviews - Cochrane DSR, ACP Journal Club, 

DARE and CCTR 

AMED (Allied and Complementary Medicine) 

British Nursing Index (BNI) 

CINAHL 

EMBASE 

HMIC (Health Management Information Consortium) 

OvidMEDLINE 

PsycINFO 

SPORTDiscus 

Social Work abstracts 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

ASSIA (Applied Social Science Index and Abstracts) 

Campbell Collaboration 

Centre for Reviews and Dissemination, University of York 

Community Care Works – University of Glasgow 

Current Controlled Trials 

Evidence Bank (children and families) 

IDOX/PLANEX 

Ingenta Connect 

National Research Register 

Pubmed 

Science Direct 

Social Care Online (Social Care Institute for Excellence) 

Web of Knowledge 

journaLs: 

● Advanced Nursing 

● British Journal of Social Work 

● British Medical Journal 

● Community Care Journal 

● Criminology and Criminal Justice 

● Drugs: Education, prevention and policy 

● European Journal on Criminal Policy and Research 

● Health and Social Care in the Community 

● HIV Medicine 

● International Journal of STD and AIDS 

● Journal of Forensic Psychiatry and Psychology 

● Journal of Integrated Care 

● Physiotherapy 

● The Briefing 

● The Gerontologist 

● Tizard Learning Review 

government weBsites: 

● Department of Health (including the Social Exclusion 

Unit and the Social Policy Unit) 

● Home Office 

● Modernisation Agency/NHS Institute for Innovation 

and Improvement 

● Office of the Deputy Prime Minister 

● Scottish Government 

● Scottish Government Central Research Unit 

33

Appendix III What can service providers do to 



other weBsites: 

● Action on Elder Abuse 

● Age Concern 

● Alcohol Concern 

● Audit Commission 

● AVERT 

● Breathing Space Scotland 

● Capability Scotland 

● Centre for Rural Health Research and Policy 

● CRISIS 

● DEMOS 

● Disabilities Trust 

● Foundation for People with Learning Disabilities 

● Glasgow LGBT Centre 

● Health and Safety Executive 

● Health and Social Care awards 

● HIT 

● Institute of Alcohol Studies 

● Institute for Criminal Policy Research 

● Institute for Public Policy Research 

● Joseph Rowntree Foundation 

● King’s Fund 

● Learning Disabilities Collaborative Action Network 

● Leonard Cheshire 

● Literacy Trust 

● London Lesbian and Gay Switchboard 

● MacIntyre Charity 

● Medical Research Council Social and Public Health 

Sciences Unit 

● MENCAP 

● Mens Advice Line 

● Mental Health Care 

● Mental Health Foundation 

● Migrant Worker 

● MIND 

● MORI 

● National Primary Care Research and Development Centre 

● National Institute for Health and Clinical Excellence (NICE) 

● NHS National Library for Health 

● Northumberland Strategic Partnership 

● Picker Institute 

● Primary Care Collaborative 

● Quality Improvement Scotland (QIS) 

● Refuge 

● Refugee Council 

● Release 

● Re-Solv 

● Revolving Door Agency 

● Royal College of General Practitioners 

● Royal College of Psychiatrists 

● Royal National Institute for the Blind (RNIB) 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

● 

Royal National Institute for the Deaf (RNID) 

Scottish Disability Equality Forum 

Sainsbury Centre for Mental Health 

Sandyford 

SANE 

Scottish Association for Mental Health 

Scottish Consumer Council 

Scottish Drugs Forum 

Scottish Intercollegiate Guidelines Network (SIGN) 

Shakti Edinburgh 

Shelter 

Social Policy Research Unit 

Steve Retson Project 

Terrence Higgins Trust 

Turning Point 

Victim Support 

Women’s Aid 

PuBLic heaLth oBservatories: 

● Scottish Public Health Observatory 

● North East Public Health Observatory 

● North West Public Health Observatory 

● Yorkshire and Humber Public Health Observatory 

● East Midlands Public Health Observatory 

● West Midlands Public Health Observatory 

● Eastern Region Public Health Observatory 

● South West Public Health Observatory 

● South East Public Health Observatory 

● London Health Observatory Public Health Observatory 

● Wales Centre for Health Public Health Observatory 

● Ireland and Northern Ireland’s Population Health 

Observatory 

PuBLishers: 

● BMJ Books 

● Jessica Kingsley 

● Pavilion Press 

● 

Policy Press 

34

Appendix IV 

aPPendix iv: KeYwords used in Literature search 

The following keywords, and combination of keywords, were used during the literature search: 

Keywords: 

Complex needs 

Multiple needs 

Multiple and complex needs 

Multiple disability 

Multiple impairment 

Multiple disadvantage 

Dual diagnosis 

the above keywords were combined individually with: 

Service provider 

Service 

Access 

Awareness 

the keywords ‘needs’, ‘complex needs’ and ‘multiple needs’ were 

combined with each of the following individually: 

Mental health 

English as a second language 

Learning disability 

Employment 

Learning difficulties 

Literacy 

Physical disability 

Lesbian 

Crime/criminal 

Gay 

Drug misuse 

Gypsy Travellers 

Long term health 

Carers 

Ethnic 

Rural 

Asylum 

Religion 

Refugee 

Faith 

Homeless 

What can service providers do to 



35

Appendix V What can service providers do to 



aPPendix v: checKList for aPPraising a quaLitative research PaPer 

The quality of qualitative studies was assessed using the following checklist for appraising 

qualitative research by Greenhalgh (2001): 

1. Did the article describe an important clinical problem 

addressed via a clearly formulated question? 

2. Was a qualitative approach appropriate? 

3. How were a) the setting and b) the subjects selected? 

4. What was the researcher’s perspective and has this been 

taken into account? 

5. What methods did the researcher use for collecting data 

and are these described in enough detail? 

6. What methods did the researcher use to analyse the data 

and what quality control measures were implemented? 

7. Are the results credible and, if so, are they clinically 

important? 

8. What conclusions were drawn and are they justified by 

the results? 

9. Are the findings of the study transferable to other 

clinical settings? 

Adapted from GREENHALGH, T (2001) How to read a paper. 

The basics of evidence based medicine. BMJ Books. 2nd 

edition. 

36

37 

Appendix VI What can service providers do to improve access to 

services for people with multiple and complex needs? 

APPENDIX VI: summAry tAblE of INcluDED stuDIEs 

PEEr rEVIEwED jourNAls 

Author(s) PublIcAtIoN 

Brotman et al, 

2003 

Dawes et al, 

2003 

Graham-Jones 

et al, 2004 

The 

Gerontologist 

comPlEX NEEDs 

PoPulAtIoN/sAmPlE 

Gay and lesbian older 

people. 

Canada. 

Physiotherapy Homeless people. 

Health and 

Social Care in 

the Community 

Glasgow, Scotland. 

Homeless people in a 

primary care setting. 

Liverpool, England. 

tyPE of EVIDENcE mEthoDology objEctIVE/focus 

Primary research 

Qualitative evidence. 

Views include those of gay 

and lesbian activists working 

in the community; health 

care providers and policy 

makers from public health; 

and representatives from 

mainstream senior groups 

including carers. 



Evaluation focused on the 

model of service required for 

future physiotherapy clinics 

for the homeless. 


Qualitative evidence 

Evaluation. 

Qualitative exploratory 

research based on focus 

group interviews with 32 

people (21 were gay or 

lesbian). 4 focus groups in 3 

locations. 

Description and evaluation 

of a dedicated physiotherapy 

service for homeless people. 

Evaluation involved clinical 

data analysis and qualitative 

methodologies (not 

specified). 

Quasi-experimental, three 

armed controlled trial. 

Homeless people allocated 

in alternating periods of 1 to 

3 months to health centre 

advocacy group, outreach 

advocacy group or usual 

care. 

Assessment of health related 

quality of life outcomes 

by self completed, health 

related questionnaires. 

326 questionnaires given 

out at registration. 222 

completed and returned. 117 

questionnaires completed 

and returned at 3 month 

follow up. 

To gather information on the 

experiences of gay and lesbian 

older people and their families. 

To describe and evaluate a 

dedicated physiotherapy service 

for homeless people. 

Evaluation of effectiveness of a 

health advocate’s casework with 

homeless people in a primary care 

setting. 

sErVIcE ProVIDEr VIEws oN 

ImProVINg AccEss to sErVIcEs 

Good practice: 

● need for awareness in health system of ways gay and lesbian 

people may be discriminated against 

● outreach needed to build trust with gay and lesbian elders 


● physiotherapy clinics housed in established drop in centres which 

already offered support 

● a domiciliary service was available for those who could not, or would 

not attend clinics. Accepted referrals from health and social care 

workers 

● service was only for homeless people who were not able to attend 

outpatients 

● service should be patient centred, with self referral and drop in 

Note: 

● most interventions were assessment, advice and exercise 

● interventions were limited and there was little continuity of care due 

to the transient nature of people treated 

● evaluation identified that treatment helped client symptoms and 

service was easy to access 


● support by health advocate early in stay in temporary housing 

Note: 

● improvements in health related quality of life were greatest in people 

given support by a health advocate early in stay in temporary 

housing, compared with those in control group receiving usual care 

● while health advocate gave valuable support and helped liaison 

with health services and other agencies, the main reasons for client 

stress remained e.g. reasons why client became homeless 

● quality of life scores still lower than for general working class 

population

38 




Green and 

Smith, 2004 

Kohen, 2004 Tizard Learning 

Disability 

Review 

McSweeney and 

Hough, 2006 

comPlEX NEEDs 


HIV Medicine HIV population in 

UK since 1996 and 

introduction of HAART. 

Journal of 

Criminology and 

Criminal Justice 

Women with learning 

disabilities and mental 

health issues. 

Offenders with multiple 

needs including drugs, 

unemployment, illiteracy, 

mental health issues and 

housing. 

D2W project rolled out 

over 12 Inner London 

boroughs over 4 years 

(2000-4). 

London, England. 


Secondary research: - 

including policy papers, 

primary research published in 

journals and reports by AIDS 

service organisations and 

research institutes. 

It is not always specified 

whether views are of 

providers, users or expert 

opinion. 

Qualitative and quantitative 

evidence. 

Secondary research and 

author opinion 

Primary research. 

Evaluation 


Literature review post 1996 

from UK and N Ireland 

and Republic of Ireland. 

HIV positive people only. 

Review of databases, 

conference abstracts and 

research obtained through 

direct contact with relevant 

organisations. 

Literature review. 

No methodology given. 

Article on evaluation of ‘From 

Dependency to Work’ (D2W) 

programme (to support 

offenders with a range of 

multiple needs). 

To identify the changes that 

HAART has had on experiences 

and psychosocial needs of HIV 

positive people in UK. 

Review of research on mental 

health needs for women with 

learning disabilities including how 

current services can be improved. 

To look at what was learnt from 

5 year evaluation of programme 

targeting offenders with multiple 

needs who required help to find 

work or to get to a position to look 

for work. 

The D2W programme aimed 

to co-ordinate statutory and 

voluntary agencies work to ensure 

quicker access to services and 

promote multi-agency working by 

designing an integrated sequence 

of interventions for those with 

multiple and complex needs. 




● addressing barriers for asylum seekers and refugees in accessing 

services related to law and their rights as asylum seekers e.g. 

individuals with HIV not to be placed in detention centres for 

immigration purposes if appropriate medical care cannot be 

provided 

● pregnant asylum seekers with HIV should only be dispersed to 

areas with adequate support services 

● addressing stigma and concerns over confidentiality for a range of 

people with HIV, e.g. black and minority ethnic groups, and older 

people, to encourage them to access services 

● flexible access to food, water and medication for prisoners with HIV 

so they can adhere to drug regimes 

● multidisciplinary teams including medical staff, social workers, 

health advisers, psychologists, counsellors, dentists, dieticians, 

pharmacists and allied health professionals 

● flexible opening hours and provision of childcare will improve access 

to services for those who work and/or have children 

● training for staff to provide awareness and understanding of cultural 

issues affecting black and minority ethnic people with HIV 

● employment of trained and experienced link workers from black and 

minority ethnic communities or with long term experience working 

with black and minority ethnic communities, in services supporting 

black and minority ethnic people with HIV 


● assessment of women with learning difficulties and mental health 

problems by primary care with referral when necessary to specialist 

psychiatric learning disability teams 

● gender sensitive services and well trained staff 

Note: the general conclusion was that those who engaged in D2W 

benefited. While the D2W programme was only partly successful, 

there are areas which can be highlighted as good practice: 

● multi-disciplinary assessment of clients. However, generic 

assessment and sequencing of support proved difficult in practice. 

Best approach is unclear 

● generic assessment carried out on one multi-agency site 

● awareness by service providers that most chaotic clients are most 

likely to be unable to engage with even one service without support 

● programmes and intervention should have realistic aims 

(evaluation found that D2W too ambitious in trying to get this 

client group into employment) 

● assessment tools designed around the needs of clients, 

not professionals

39 




Neale and 

Kennedy, 2002 

Health & Social 

Care in the 

Community 

Ross, 2004 Drugs: 

Education, 

prevention and 

policy 

grEy lItErAturE 


Ahmad et al, 

1998 

Audit 

Commission, 

2002 

Joseph 

Rowntree 

Foundation 

Audit 

Commission 

comPlEX NEEDs 


Homeless drug users. 

Scotland. 

Young people from 

minority ethnic groups, 

agency staff and police. 

Not all young people 

consulted were drug users. 

Greater Glasgow, 

Scotland. 

comPlEX NEEDs 


Deaf and minority ethnic 

people. 

UK. 

Dual diagnosis. 

Assumption made by 

authors of literature review 

that those with drug 

misuse problems will have 

other health need(s). 

UK. 




Service provider and service 

user views. 



Service provider views were 

only a small part of this study 

48 semi-structured interviews 

(12 staff, 36 clients). 

Interviews with staff and 

clients from six agencies 

(three homeless and three 

drug agencies) 

Questionnaires; focus 

groups; interviews 

(predominantly with service 

users, n=174). 

To further understanding of how 

best to support homeless drug 

users by examining good practice 

from the perspectives of service 

providers and users. 

To describe research on drug 

issues affecting Chinese, Indian 

and Pakistani people living in 

Greater Glasgow. 





only part of this study. 

National overview of initiatives 

and services. 

Service provider and service 

user views. 



Service user and service 

provider views. Service 

provider views focused on GP 

views on treating illicit drug 

users and identification of 

funding available for services. 

National study: postal survey 

of range of statutory and 

voluntary organisations; 

telephone interviews. Face 

to face interviews with 85 

people (service users). Use 

of deaf interviewer using 

BSL, hearing interviewer 

with BSL interpreter, hearing 

interviewer using sign 

supported English, spoken 

English or other languages. 

Hearing respondents 

interviewed in relevant 

language. 

Report: resource mapping; 

case file analysis; GP survey: 

user research – one to one 

interviews and focus groups. 

To examine range of initiatives 

and services addressing needs of 

deaf people and their families. 

Sets out recommendations to 

enable a review of specialist 

services and joint commissioning 

arrangements. 




● non-judgemental, respectful, understanding and committed staff 

● staff well trained in issues relating to both drugs and homelessness 

and with knowledge of available services 

● interagency working 

● shared responsibility for very vulnerable and chaotic clients 

● practical support, outreach and aftercare 

● rebuilding client’s self esteem 

● safe and secure agency environment 


● drug and alcohol services and information needs to be sensitive to 

and meet needs of black and minority ethnic groups 




● improved information and training for voluntary sector workers to 

enable them to compete for funding 

● Extra resources and flexibility are required for workers delivering 

sensitive services to minority ethnic deaf people and families 

● Work to end racism towards black and minority workers in statutory 

sector who report experience of hostility from white colleagues and 

service users 


● to promote effective treatment local agencies need to focus on: 

strengthening joint working; reviewing quality and range of treatment 

services, including seeking views of service providers and users; 

strengthening partnership working and commissioning, including 

allowing services more flexibility in developing initiatives and 

promoting long term planning and funding; and improving support 

to primary care, taking into account health professional views when 

developing shared care schemes 

● case studies outlining good practice are given in the Audit 

Commission paper

40 




Barclay et al, 

2003 

Scottish 

Executive Social 

Research 

Bindel, 2006 Eaves, POPPY 

project 

comPlEX NEEDs 


Asylum seekers. 

Scotland. 

Assumption is made by 


that asylum seekers 

and refugees are very 

likely to have multiple 

and complex needs due 

to the reasons for and 

experience of being an 

asylum seeker or refugee 

Women involved in sex 

industry 

Assumption made that 

women involved in sex 

industry are more than 


needs. 

London, England 




Service provider views 



Service provider views 

Qualitative research. 32 

interviews with range of 

organisations which provide 

services to asylum seekers, 

plus three interviews with 

councils; 63 interviews 

with asylum seekers; nine 

interviews with community 

organisations; monitoring 

of newspaper coverage 

during period of fieldwork; 

stakeholders seminar. 

Survey of more than 200 

projects to identify existing 

services for women in sex 

industry in London. 

Multi methodological strategy 

including literature review, 

desk based research, 

questionnaire for service 

providers(28 completed), 

four interviews with workers 

from agencies. 

Overall aim was to assess 

effect of implementation of the 

Immigration and Asylum Act 1999 

on asylum seekers and devolved 

services. 

To identify gaps in service 

provision and address needs of 

women involved in commercial 

sex industry. 



Good practice 

● Multi agency working 

● Cultural sensitivity and holistic approach 

● Community development work to address issues such as racism 

● Dissemination of good practice 


● outreach (on and off street) 

● safe temporary and long term accommodation 

● single sex rehabilitation programmes 

● counselling and mental health services 

● community safety strategies 

● exit programmes addressing and providing support for a wide range 

of needs e.g. safe housing, drug and alcohol rehabilitation, mental 

health, educational needs 

● dedicated training for workers in exit programmes as the work is 

highly complex and resource intensive 

● initiatives tackling demand need to be accompanied by an increase 

in exit support 

● joint working 

● staff training in sensitive interviewing skills and effects of sexual 

abuse 

● support for women with young children 

● clear policy and guidelines for staff working with women in 

prostitution 

● increased knowledge for service providers on existing specialist and 

generic services 

● enhanced access to outreach mental health and general health 

support 

● ‘ugly mug’ schemes that identify dangerous customers to women 

● provision of direct services to young people (and children) 

● government funded primary prevention programmes aimed at 

customers as well as women 

● availability of housing or links to housing organisations that provide 

accommodation for vulnerable women 

● comprehensive gynaecological and sexual healthcare 

● advocacy 

● outreach support and referral service where there is off street 

prostitution 

● service users should never be placed in mixed accommodation 

e.g. hostels as this may make them more vulnerable to returning to 

prostitution 

● female counsellors, women only drop in and therapy sessions and 

telephone lines staffed by women

41 




Cook, Miller & 

Whoriskey, 

2007 

Croft-White & 

Parry-Crooke, 

2004 

Department for 

Communities 

and Local 

Government & 

Department of 

Health, 2006 

Joint Improvement 

Team (JIT) 

comPlEX NEEDs 


Service users of 

community care, including 

older people, people with 

learning disability and 

people with mental health 

difficulties. 

Scotland. 

CRISIS Single homeless people 

and service providers in 4 

geographical study areas: 

Aberdeen, Scotland; 

Wrexham, Wales; 

Birmingham, England; 

and Islington, London, 

England. 

Department of 

Health 

UK. 

Homeless people 

and those living in 

temporary or insecure 

accommodation who are 

admitted to or discharged 

from hospital. 

UK. 


Toolkit is based on primary 

research. 

Guidance document 

developed by JIT for use by 

service providers. 



Service provider views not 

always differentiated from 

service user views. 

Guidance document. 

Expert opinion. 

Based on evidence and 

research tools developed 

through a research 

programme. Initially piloted 

in Scotland in Orkney, 

Fife and East Renfrew. 

Implementation underway at 

eight pilot sites in 2007. 

Qualitative research – review 

of relevant documents; 

questionnaire to service 

providers; 49 interviews with 

key agencies; consultation 

with 24 homeless people with 

multiple health needs. 

Guidance document to 

support hospitals, primary 

care trusts, local authorities 

and the voluntary sector 

drawn up by expert steering 

group with representatives 

from Homeless Link, the 

London Network for Nurses 

and Midwives and the Health 

Inclusion Project Advisory 

Group. 

User Defined Service Evaluation 

Toolkit (UDSET) developed 

to improve practice through 

application of user and carer 

defined outcome tools. 

To identify the experience of 

single homeless people (without 

dependent children) with multiple 

health needs in their quest for 

accessible and acceptable 

health services. 

To provide guidance on 

development of hospital 

admission and discharge 

protocol for homeless and 

those in temporary or insecure 

accommodation, to ensure that 

people are not discharged from 

hospital onto the streets or 

inappropriate accommodation. 




● involvement of service users and carers in decisions around their 

care and support. UDSET is designed for health and social care 

partnerships to collect data to determine whether they are providing 

a good service to users and carers, based on what service users 

and carers define as necessary. 


● easily accessed and available services i.e. provision of information 

about available services, cultural sensitivity of services, removal 

of appointments system and removal of professional boundaries 

● positive and non-prejudicial attitudes from staff to help reduce fear 

of stigma for clients 

● one stop shop with range of services, including primary care services 

● availability for sex workers of non-identifiable dedicated drug 

treatment, no-appointment, no-questions GUM clinic, HIV testing, 

Hep C vaccination, counselling and family planning advice 

● advocacy and support of a professional to help clients with chaotic 

lives access health services 

● provision of information for staff on health difficulties for homeless 

so that they can help clients take responsibility for own health, e.g. 

taking medication 

● consent to be sought from client before approaching another service 

on their behalf. This helps build a relationship of honesty and trust 

● proactive working e.g. seeking to attend staff meetings of other 

agencies or projects to inform new staff about their service 

● joint working e.g. joint outreach sessions 

● specialist homeless mental health team providing training for staff 

in dual diagnosis and personality disorder 

● training on health, alcohol and drugs for hostel staff and residents 

● training courses for health professionals to raise awareness of 

issues around health and homelessness 


● development of a protocol which should: 

be developed in partnership across agencies 

involve a steering group with representation from relevant 

agencies 

review existing systems 

include steps such as establishing housing status and procedures 

for consent to sharing information 

ensure that existing accommodation is sustained for individuals 

identify key agencies to be notified about an individual’s admission 

and involve key agencies throughout discharge planning 

identify training and resource requirements for staff 

build on existing systems 

be piloted, monitored, audited and reviewed and kept up to date

42 




Department of 

Health, 2007 

Department of 

Health 

Edwards, 2003 Institute for 

Public Policy 

Research 

comPlEX NEEDs 


Adults with learning 

disabilities. 

England, Wales and N 

Ireland. 

Note: learning disabilities 

may range from mild 

to severe disabilities 

and may not always be 

defined as complex. 

People with complex 

needs (‘complex needs’ 

was not specifically 

defined but the research 

focused on a range 

of issues including 

homelessness, substance 

misuse, mental health, 

learning disabilities, selfharm, 

eating disorders 

and offenders). 

UK. 


Guidance document. 




Service provider views and 

user views (not separated 

in report). 

No details of methodology 

given for this updated 

version of guidance. States 

that is formed from best 

practice. First version of 

this guidance was based 

on the experiences of 

four exemplary specialist 


Visits to six services; 

interviews with 15 service 

users and with 5 service 

providers; informal 

discussion with 3 service 

users and an unspecified 

number of staff; discussion 

groups with three service 

users; observational work. 

To provide good practice guidance 

in the commissioning of specialist 

learning disability services for 

adults. 

To explore how services should 

change to better support people 

with complex social care needs. 




● specialist community health staff 

joint working and links with criminal justice, housing, employment 

agencies, learning disability boards, specialist learning disability 

and mental health services 

specialist community health staff with appropriate skills to provide 

support to individuals and their families who need more than 

mainstream services; to provide longer term support; and to 

provide emergency support in partnership with mental health 

services 

specialist support to be provided as part of community learning 

disability teams and community mental health teams 

specialist teams providing support including early intervention, 

crisis resolution and assertive outreach 

● general health needs 

support from specialist services to mainstream services to ensure 

they can provide good quality general healthcare to people with 

learning disabilities 

● inpatient services 

inpatient services should have a defined place and purpose within 

the whole system of service delivery for people with learning 

disability 

individuals should be in community rather than institutional 

settings, with no greater security than necessary, and near to 

family if appropriate 

● forensic settings 

forensic settings should maximise rehabilitation and future 

independence 

consideration to be given to links between forensic settings 

specialist learning disability and mental health services 

health screening programmes on entry to prison to identify 

learning disability, physical and mental health issues in order to 

offer appropriate support to people with learning disability 

● continuing healthcare 

NHS commissioned beds should not be used for continuing care 

unless the patient has a highly complicated or unpredictable health 

need or rapidly deteriorating or terminal condition requiring regular 

medical supervision 

services should be individually designed to achieve best outcomes 

for those with challenging behaviour 


● person centred approaches with a focus on the whole person 

e.g. outreach and day centre service work 

● have more than one option to offer 

● long term strategies e.g. follow up support and aftercare 

● a quick response to the client i.e. no waiting times 

● practical support with everyday aspects of life e.g. budgeting 

● advocacy 

● 

breaking down professional barriers, reducing stigma

43 




Effective 

Interventions 

Unit, 2004 

Evans and 

Banton, 2001 

Scottish 

Executive 

Joseph 

Rowntree 

Foundation 

Finn et al, 2000 Revolving Doors 

Agency 

comPlEX NEEDs 


Drug users in rural areas 

of Scotland. 

Scotland, UK. 

Black disabled people 

involved with the 

Warwickshire Council 

of Disabled People (a 

community group run by 

and for disabled people in 

Warwickshire) 

Warwickshire, England. 

People with mental health 

and multiple needs in 

contact with police – High 

Wycombe, Bethnal Green 

and Islington. 

England, UK. 


Primary and secondary 

research. 


Service provider views. 




Evaluation. 


Literature review examining 

the issues that affect remote 

and rural areas and those 

who live there. 

Reference group including 

representatives from Drug 

and Alcohol Action Teams 

(DAAT), organisations 

working with drug misusers, 

drug services, EIU and 

Scottish Executive. 

Two consultation workshops 

with a total of 64 participants 

who were individuals with 

experience of working with 

drug users in remote and 

rural areas. 

Semi-structured interviews 

and focus groups with 35 

people involved in work of 

Council of Disabled People 

Warwickshire. 63% of 

participants were black and 

disabled. 

The number of professionals 

interviewed was not specified. 

Various analysis of data from 

four main sources: 

● an electronic database 

of information about the 

referrals to the scheme 

kept by link workers in all 

three sites (data available 

for 461 of 639 referrals) 

● set of standardised 

questionnaires given to 

new referrals over an 18 

month period 

● review of case notes of all 

clients seen by link workers 

over same 18 months 

● case material and verbal 

feedback from link workers 

To provide information, evidence 

and examples to support future 

development of service provision 

for drug users in rural and remote 

areas. 

Exploration of one organisation’s 

experiences in developing 

involvement of black disabled 

people in development of 

appropriate and responsive 


To evaluate a Link Worker 

scheme to provide link workers 

in police stations to establish 

relationships with people with 

mental health and multiple 

problems in order to improve the 

ways in which the full range of 

their needs can be understood 

or met. 




● recognition that remote and rural areas do not have identical issues 

and experiences to urban areas 

● strategies to recruit and retain skilled staff e.g. financial incentives 

● services that are accessible without client having to travel long 

distances e.g. outreach or co-location of services 

● building on existing relationships with other services combining 

resources, sharing protocols, sharing staff and premises 

● subsidising client travel 

● community transport initiatives 

● consultation with service users and community over services 

● education and training for general practitioners for support and 

treatment of methadone users 

● improved access to methadone dispensing 


● consultation with black disabled people on their service needs 

● employment of black and bilingual workers 

● joint working with other organisations to combine skills and 

knowledge on race and disability 

● training staff on race and disability 

● undertaking direct work with black disabled people and families (if 

desired by them) 


● link worker focuses on continuing and assertive support to client 

after they have left the police station in order to improve continued 

engagement with services e.g. health, local authority 

● link worker scheme can have positive results with little or no impact 

on overall cost to services. Interventions shift cost of services away 

from expensive crisis services such as police, A&E, temporary 

housing, towards primary care and community mental health 


For example 1) a decrease in A&E attendance by clients was linked 

to an increase in GP registration by clients. A&E attendance by 

non-clients and control group increased during the same period, 

while fewer of control group registered with GPs compared with 

clients. 2) a decrease by half in the number of clients living in hostel 

accommodation was seen one year after referral in comparison 

to a 67% increase in the number of clients in local authority 

accommodation. 

● real improvement requires changes to the policy imperatives of 

major players with cross boundary work at heart of agenda. 

● Note: long term effects were not clear at this time as follow up was 

only for 1 year.

44 




Fitzpatrick, 

Pleace & Bevan, 

2005 

Fountain and 

Howes, 2002 

Hardy et al, 

2006 

Scottish 


Research 

comPlEX NEEDs 


Homeless people who 

sleep rough. 

Scotland. 

CRISIS People who are homeless 

and have substance 

misuse difficulties. 

Turning Point & 

the Estia Centre 

London, England 

People with a learning 

disability and mental 

health needs. 

UK. 

Location of research was 

not specified. 




evidence. 

Evaluation. 






Qualitative evidence informing 

production of guidance paper. 


collected during the initial 

stages of the work in order to 

inform the development of the 

guidance. 

Evaluation: critical 

assessment of statistical 

research and monitoring 

information; critical 

assessment of research and 

monitoring information (desk 

based); national telephone 

survey interviewing 26 local 

authority officers from 23 

local authorities; eight in 

depth case studies involving 


providers and 32 service 

users (focus groups). 

Interviews with 389 homeless 

people (who had slept rough 

for at least 6 nights in past 6 

months). 

In depth, themed interviews 

with service providers (drug 

and homelessness services). 

Re-visited service providers 

for meetings one year later. 

Interviews with people with a 

learning disability, and care 

and support staff working 

with people with a learning 

disability and mental health 

problem. 

No information was 

provided on the number of 

interviewees. 

To assess extent to which 

Rough Sleeper Initiative 

(RSI) funding has been used 

effectively; to examine extent 

and effectiveness of the 

mainstreaming of RSI services; 

and to assess effectiveness of 

monitoring systems and produce 

recommendations on future 

practice. 

Aimed to provide evidence 

base on relationship between 

substance misuse and 

homelessness for use in 

developing and improving service 

provision. 

Guidance on supporting people 

with a learning disability who have 

mental health problems, to staff 

who provide day to day support to 

adults with a learning disability. 



The Rough Sleeper Initiative (RSI) provided funding for a range of 

services and projects designed to end rough sleeping. Evaluation 

found: 

● service providers were positive about RSI seeing it as effective 

in developing service responses and acting as a catalyst for joint 

working across homelessness services 

● the number of people sleeping rough presenting to services declined 

by more than one third between 2001 and 2003 (identified by 

George Street Research) 

● there were a number of factors seen as influencing success. These 

include the level of support required by an individual i.e. the less 

support needed, the more likely they are to successfully engage with 

services; those with complex needs (including those who repeatedly 

make contact with services) are slower and less likely to engage 

with services; the availability of local housing and whether there is a 

range of types of accommodation; availability of and easy access to 

drug and alcohol services including counselling and detoxification, or 

mental health services 

● the RSI itself provided funds for new services or for developing 

existing services; allowed innovative approaches; and allowed 

existing services to extend and target support better 

Good practice 

● a number of service providers cited their agency’s strength as being 

able to cater for clients who fail to change, i.e. keep them engaged 

in the service and being flexible in approaches to help them 

● increase in provision of drug treatment services and reduction in 

waiting times for treatment so that clients can have quick access 

● increase accessibility and information on hostel places for drug 

users 

● increase cooperation between agencies 

● more preventative initiatives to address the issues that result in 

homelessness e.g. family mediation 


● proactive approach to mental health e.g. care plan development 

● awareness of changes in behaviour that may indicate a mental 

health problem 

● care over transitions between services and involvement of the 

individual concerned 

● care plans and guidelines to be consistently implemented 

● supporting people to make own decisions 

● consideration of social and psychological interventions as well as 

medication 

● multi-agency approach 

● support for individuals through mental health assessment, including 

help with communication 

● monitoring and reporting of side effects by staff of medication 

● 

respect for an individual’s privacy

45 




Hodges et al, 

2006 

Hunter, May & 

Drug Strategy 

Directorate, 

2004 

Scottish 

Executive 

IBSEN, 2007 Individual 

Budgets 

Evaluation 

Network 

(IBSEN) 

comPlEX NEEDs 


Mental health and 

substance misuse. 

Scotland. 

Home Office Street sex workers with 

drug problems. 

England and Wales. 

Adults receiving social 

care support services in 

England. 

Note: although the 

approach discussed in 

this publication does not 

specifically refer to those 

with complex needs, in 

practice, there may be 

instances when individual 

budgets are used by this 

group of people 




Service provider views: 

commissioners and service 

providers directly delivering 

interventions to service users 

e.g. addiction services, mental 

health services or housing 

agencies. 

Secondary research – details 

are not given. Document 

states that it summarises 

research evidence from 

the UK and the views and 

experiences of ground level 

service providers, police and 

other professionals. 



Evaluation. 


In depth semi structured 


commissioners and 38 

service users; focus groups 

with 90 service providers. 

Data analysed using 

Framework Analysis 

(thematic analysis). 

Most interviews were in 

English although there was 

some interpretation. 

Guidance document (no 

methodology). Steering 

group membership included 

representatives from the 

Department of Health, the 

Violence against Women 

Section, Home Office, drug 

agencies, police, sex worker 

agencies, Barnados, young 

peoples’ agencies and 

others. 

Interviews with project 

managers and other 

professionals: and 14 

recipients (at early stage of 

pilot) of individual budgets. 

Details of methodology not 

given. Evaluation undertaken 

by Personal Social Services 

Research Unit, the Social 

Policy Research Unit and the 

Social Care Workforce 

Research Unit. 

To identify the nature, scope 

and impact of existing service 

provision in Scotland for people 

with co-existing mental health and 

substance misuse problems. 

Guidance document from 

Home Office for partnerships 

and providers of services for 

prostitutes with drug problems. 

To evaluate pilot schemes of 

individual budgets – between 

2006 and 2008. Individual budgets 

aim to bring a range of funding to 

buy social care services under a 

simple, user controlled budget. 




● immediate help for service users when requested 

● holistic care 

● dedicated co-morbidity specialists (substance misuse and 

mental health) 

● specific training and support for providers working with this group of 

clients. Access to workers who have knowledge and experience in 

this area a minimum requirement 

● service user opinions should be taken seriously in formal meetings 

about their care 

● specialist staff should be based within mainstream mental health 

and/or substance misuse services, not in separate teams 

● assertive outreach teams made up from across sectors (but with 

secure support systems when working in community) 


● harm reduction for those not ready to exit prostitution or undergo 

drug treatment 

● criminal justice interventions which provide access to treatment for 

drug problems and other support 

● immediate access to exit services for those who wish to leave 

prostitution 

● easily accessed gateway services linked to outreach and other 


● follow up schemes targeting those who have dropped out of 

programmes 

● drug clinics linked to services for prostitutes or workers to 

accompany women to appointments 

● multi-agency approach which involves health agencies, drug 

services, housing, children’s services (if applicable) and police 

● outreach i.e. workers going out onto the streets to make contact with 

sex workers 

● provision of stable accommodation for those involved in prostitution 

● holistic service addressing multiple needs 

● strategies to reduce prostitution must be in a way as to reduce 

damage without harming those in prostitution and must also meet 

the needs of the community in general 

● early intervention and prevention must be part of any strategy 


● wide and flexible range of approaches to suit client 

The report stated that further evaluation of the development and 

impact of individual budgets is necessary

46 




Kutchinsky, 

2007 

Loucks & Talbot, 

2007 


Agency 

Prison Reform 

Trust 

Mansell, 2007 Department of 

Health 

comPlEX NEEDs 



problems who come to 

attention of criminal justice 

system. 


Prisoners with learning 

disabilities. 

Scotland. 

People with learning 

disabilities and 

challenging behaviour or 

mental health needs. 

England, Wales and 

N Ireland. 



research. 






Seminar involving key 

professions e.g. Home 

Office, Police, Social 

Services. Literature review 

of legislation, guidance 

and protocols on early 

interventions for people 

with mental health issues in 

criminal justice system. 

Input from Revolving Door 

Agency frontline staff and 

service users (number not 

specified). 

Meetings and interviews 

with range of stakeholders, 

including custody officers, 

mental health liaison 

officers, healthcare staff, 

voluntary sector (number not 

specified). 

Questionnaire completed 

by: prison service staff 

responsible for education; 

heads of prison health 

care; heads of psychology; 

heads of prison residence or 

regimes; staff responsible for 

prisoners with disabilities. 

Guidance on best practice. Based on evidence from 

research and discussions 

with families, carers, 

commissioners and others. 

No other details given. 

To explore early interventions 

for people with mental health 

problems who have come to 

attention of criminal justice 

system, to evaluate their impact 

and offer practical solutions. 

Report focuses on emerging 

neighbourhood policing models 

and access to healthcare and 

related services in police custody. 

To identify how prison staff in 

Scotland believed prisoners with 

learning difficulties or learning 

disability were identified and 

supported, focusing on good 

practice and identifying gaps 

in provision. 

To provide guidance on the 

development of adult services for 

those with learning disabilities and 

challenging behaviour or mental 

health needs. 




● link workers building relationships with vulnerable people, directing 

them to appropriate services 

● promotion of interventions for people with mental health problems 

before they hit a crisis 

● very close working with police, the critical agency through which 

there is potential to intervene positively with this client group 

● healthcare models where nurses available 24 hrs/7 days a week in 

policy custody to identify and address presenting needs of those 

with mental health issues 

● assessment of need (carried out in police custody) could form basis 

of healthcare record which could be used in court 

● court liaison schemes (linked to mainstream health provision) to 

identify and assess an offender’s mental health problems 


● use of specific expertise e.g. specialist learning disability nurses 

and speech and language therapists 

● one-to-one work with clients, multi-disciplinary case conferences, 

specialist training for staff and dedicated staff for prisoners with 

learning disabilities 

● strong links with community learning disability support 

● innovative approaches to education e.g. computer programmes 

● peer tutors in education department to encourage prisoners with 

learning disabilities to engage with education 


● development of local services for people with learning disabilities 

and challenging behaviour to understand and respond to challenging 

behaviour 

● local specialist services which support mainstream practice while 

directly helping those who are most challenging 

● individualised short breaks should be available for families with a 

member with learning disabilities and challenging behaviour 

● provision of specialist multi-disciplinary support teams focusing on 

challenging behaviour, providing the intensity and complexity of 

support when the level of support required is more than community 

learning disabilities services can provide 

● availability of emergency support at all times for this client group 

● services developed by committed professionals and staff with 

appropriate knowledge and skills 

● individualised services with person centred planning 

● staff assumptions and understanding of an individuals’ behaviour are 

clear and addressed and managed in a multi-disciplinary context

47 




Myers, 2004 Scottish 


Research 

NHS Argyll & 

Clyde, 2002 

Orchard, 

Symanski & 

Vlahova, 2007 

Argyll & Clyde 

Health Board 

Scottish 


Research 

comPlEX NEEDs 


Children, young people 

and adults with learning 

disabilities and/or autistic 

spectrum disorders (ASD) 

in secure, forensic and 

other specialist settings. 

Scotland, UK 

Homeless people in Argyll 

& Clyde. 

Scotland. 

EU8 migrants in 

Edinburgh. 

(EU8 refers to the eight 

new states who joined the 

European Union in 2004) . 

Edinburgh, Scotland, UK. 





Evidence on children has not 

been included in this literature 

review. 






research. 


Scoping exercise to identify 

the number of people with 

learning disabilities and or 

autistic spectrum disorders 

(ASD) in each of 57 secure 

settings, and the services 

available. 

Unit level profile, unit level 

recording form and individual 

level case recording forms 

completed (90% response 

rate); review of Social 

Enquiry Reports in two local 

authority areas. 

In-depth interviews with 

service managers and staff 

and, where possible, people 

with learning disabilities 

and/or ASD (number not 

specified) in seven secure 

settings. 

Needs assessment involving: 

service mapping in Argyll & 

Clyde; questionnaire survey 

of 119 homeless service 

users; and three focus 

groups each of six service 

providers. 

Official statistical information 

including National Insurance 

Number registrations 

and Home Office data on 

registrations with Worker 

Registration Scheme 

(available for Scotland as 

region only). 

Survey of 67 EU8 migrants 

in Edinburgh. Case study of 

Edinburgh Cowgate Centre 

for the homeless: in depth 

interviews with 17 EU8 

service users at Centre and 

other homeless agencies. 

Survey of services: 

qualitative interviews 

with services within City 

of Edinburgh Children 

& Families Department 

and agencies who work 

specifically with women 

(unspecified number). 

To explore the number of people 

in secure settings known to have 

a learning disability and/or autistic 

spectrum disorders (ASD); and to 

explore the means used to assess 

need and provide services for this 

client group. 

Needs assessment to: map 

current services for the 

homelessness; assess their health 

and healthcare needs; improve 

the understanding of issues faced 

by healthcare providers. 

To assess the demography of 

EU8 migrants in Edinburgh and 

their access to health, housing 

and other social care services. 




● raising awareness about people with learning disabilities and/or 

ASD (e.g. with regard to possible behaviour) across health and 

non-healthcare settings e.g. social work and care, and education 

● development of screening tool for identification of learning disabilities 

and/or ASD for non-healthcare settings 

● increased co-ordination of information and assessment on this client 

group 

● personal life plans 

● identification of a key person with responsibility for issues relating to 

learning disability and / or ASD in each unit 

● perception of prison-based professionals interviewed for review was 

that prisons were not an appropriate environment for this group 


● a focal point or person where homeless people can access services 

● a dedicated multi-disciplinary multi-agency team to facilitate joint 

working 

● a single tool for joint agency assessment 

● different strategies should be developed for different groups 

of homeless people 


● more information on services in EU8 languages 

● multilingual staff available at key services, and increased access to 

interpretation and translation 

● staff training in working with interpreters, benefit entitlement, Worker 

Registration Scheme and cultural awareness

48 




O’Shea, Moran 

& Bergin, 2003 

PMLD Network, 

2008 


Agency 

comPlEX NEEDs 



problems and multiple 

needs. 

South East England, UK. 

MENCAP People with profound 

and multiple learning 

difficulties. 





data. 

Evaluation. 


Policy. 


Evaluation of Revolving 

Doors Link Worker Scheme. 

Interviews with unspecified 

number of link workers. 

Four case studies illustrating 

individual clients stories. 

Data from scheme regarding 

its clients (1,156 clients) e.g. 

numbers undergoing drug 

or alcohol rehabilitation, 

re-offending and registering 

with a GP. 

Policy paper from Profound 

and Multiple Learning 

Difficulties (PMLD) Network 

responding to Government 

White Paper ‘Valuing 

People’. 

PMLD Network membership 

includes representatives 

from Mencap, Royal Institute 

for the Blind, Foundation 

for People with Learning 

Disabilities, Parkside NHS 

Trust, Scope, those working 

with learning disability, and 

a parent representative. 

To examine the experience of 

those referred to the link worker 

scheme by the police, courts 

and prisons between October 

2000 and January 2003. The 

study focuses on client needs, 

the barriers to resolving their 

problems, the difference made by 

link workers and the measurable 

outcomes of the link worker 

scheme. 

To set out what the Profound 

and Multiple Learning Difficulties 

(PMLD) Network sees as critical 

issues for those with PMLD. 




● assertive engagement with focus on building trust although the 

choice to engage is left to the client 

● all members of link worker team work with a client so that if one 

member of staff leaves there is less anxiety for client over being 

abandoned and having to build a new relationship. It is also less 

demanding for link workers as they can share responsibility for 

clients 

● awareness that some clients will try to reject help and that effort 

must be made to keep in contact with them and to help them 

re-engage with services 

● client cases never closed 

● link workers accompany client to appointments, communicate with 

providers, ensure client keeps appointment and reduce anxiety of 

client over attendance 

● employment of ethnic minority link workers (this resulted in 

significant increase in engagement with black and minority 

ethnic clients) 

● strong links with police stations, courts and prisons and regular 

referrals from criminal justice agencies 

● still engage with and give support to those who don’t want to go into 

drug or alcohol rehabilitation e.g. help them register with a GP 


● advocacy and support for people with PMLD to make own decisions 

● key worker for young people with PMLD who supports them and 

co-ordinates service provision 

● family carers should have access to services which give them a 

break from their caring role 

● people with PMLD should have regular health screening 

● health professionals should have training in the skills needed for 

working and communicating with people with PMLD.

49 




Quilgars & 

Pearce, 2003 

Centre for 

Housing Policy, 

University of 

York 

comPlEX NEEDs 


Homeless people. 

Scotland and UK. 

Ramon, 2003 Turning Point Turning Point clients 

with mental illness and 

associated complex needs 

(e.g. substance misuse, 

forensic or offending 

history) in services on four 

sites in Cambridgeshire 

and Hertfordshire. 

Randall & 

Drugscope, 

2002 

Office of the 

Deputy Prime 

Minister 

England, UK. 

Homeless drug users. 

UK. 


Secondary research. 

Qualitative evidence from 

1980 to 2003. 

Views of service providers. 



Evaluation. 


Literature review, focus 

groups and interviews with 

health professionals and 

homelessness workers. 

Interviews with project users 

(33), workers (16) and 

professional colleagues (32). 

Interviews were face to face 

or by phone. 

Expert opinion. Good practice handbook 

produced by a multidepartmental 

group including 

the Office of the Deputy 

Prime Minister, Home Office, 

National Treatment Agency 

for Substance Misuse and 

Department of Health. No 

methodology given. 

To review evidence on the 

provision of effective health 

services for homeless people. 

To evaluate Turning Point services 

(consisting of range of activities) 

aimed at supporting users to lead 

an ordinary life in community. 

To assist commissioners of drug 

treatment and services e.g. Drug 

Action Teams, to plan services for 

homeless drug users and those at 

risk of becoming homeless. 




● multi service response 

● assertive outreach to help meet needs of hard to reach people 

● specialist dental services, including outreach 

● tolerant and flexible services as opposed to services with set rules 

● open access services preferable although more vulnerable people 

may be better served by appointments (no queues) 

● the relationship between health professional and homeless person 

appears to be key to successful delivery of healthcare 

● holistic services 

● practical, social and emotional support 

● specialist projects for young people (e.g. Rock Trust in Edinburgh) 

which focus on general wellbeing including health and counselling 

i.e. holistic approach 


● personalised, informal, flexible service to high risk clients 

● client needs defined by client rather than service provider 

● sharing of clients between workers to help ensure that client does 

not become too dependent on a key worker 

● joint working between health and criminal justice 

● assisting a client to move away from illness related services to more 

inclusive life areas 

● services and staff should be non judgemental of their clients and 

their problems 

● a safety and support system for staff to ensure staff not exposed 

to risk when visiting clients 


● multi-agency working 

● rapid access to substance misuse services 

● street based harm reduction services which provide positive help 

to improve health and not just support the client’s lifestyle 

● support to stabilise drug use and move into accommodation 

and treatment 

● specialist drug treatment residential services including street 

outreach services; day centres offering advice, screening and 

information; hostels and shelters; and specialist comprehensive 

drug services for homeless people 

● removal of barriers in mainstream services e.g. need for an address, 

restricted opening hours, appointment system, so as to improve 

access for the homeless 

● peripatetic services in rural areas for those with no transport 

● reduced waiting times for treatment and services 

● services that recognise that clients may relapse following drug 

treatment and, therefore, continue to support the client to resolve 

their drug problem 

● support for psychological and emotional needs 

● awareness by services of the possibility that homeless families may 

have drug using parents 

● detoxification and rehabilitation available 

● 

staff with appropriate skills for working with this client group

50 




Rankin & Regan 

2004 


Agency, 2000 


Agency, 2001 

Turning Point 

& Institute for 

Public Policy 

Research 


Agency 


Agency 

comPlEX NEEDs 



problems, substance 

misuse problems, and/or 

learning difficulties. 

England. 

Mentally vulnerable men 

and women leaving prison 

after short sentence or 

remand. 

Pentonville and Holloway 

prisons, London. 

England, UK. 


and multiple needs in 

contact with criminal 

justice system. 


UK. 


Policy paper. 

Secondary qualitative 

research. 

Views of service providers 

and service users, and 

authors’ opinion. 


research. 


evidence. 





In depth interviews and 

discussion groups with 

Turning Point clients. 

Users of Turning Point aged 

16 to 60 years. 

Thirty nine participants, 

26 from community based 

organisations in Islington and 

Tower Hamlets with contact 

with this client group, and 13 

from criminal justice settings. 

Two-thirds of participants 

were front line practitioners. 

Semi structured phone 

interviews were carried out 

with 19 participants. 

Two focus groups each with 

five frontline professionals 

from prison, housing and 

probation services. 

Data from research from a 

study on mentally disordered 

prisoners by the Institute of 

Psychiatry. 

Data from a survey by the 

Office of National Statistics 

(details of methodology not 

provided). 

Data collected for 339 new 

receptions at Pentonville 

during study period. Included 

use of Revolving Doors 

screening questionnaire 

(mental health). 

Interviews with three 

doctors, two nurses, practice 

manager and four clients. 

Focus groups with link 

workers. 

To present strategy for reform to 

meet complex needs. 

To focus on the extent to which 

information regarding mental 

health needs follows individuals 

into criminal justice system 

enabling appropriate treatment 

and support. 

To explore the experiences of 

clients and service providers in 

access and engagement with 

primary care services. 




● accommodation suitable for client needs 

● inclusion of voluntary sector providers from early stages of service 

planning and development 

● integrated training between services is a priority 

● ‘service navigator’ with knowledge of all mainstream and specialist 

services to work with service user and have advocacy remit 


● local agencies need to recognise the needs of people on remand 

or short sentence with mental health needs and make appropriate 

plans to provide treatment and support 

● the benefits to offenders of self disclosure of mental illness need 

to be maximised and communicated well 

● improved liaison between community based agencies and prison 

so that agencies are made aware of the release of prisoners with 

mental illness problems 

● training for prison staff in working with those with mental 

health problems 


● multidisciplinary support to clients to help them to access 

primary care 

● staff training in recognising behaviour that is a likely result of 

complex needs and/or mental health issues 

● range of approaches used by support workers to help overcome 

communication difficulties between clients and services 

● risk assessments and risk awareness procedures to address staff 

fear of violence from clients and help relationships with clients 

● link workers to help clients engage with services and reduce 

chaotic nature of their lives

51 




Rosengard et al, 

2007 

Scottish 


Research 

Roshan, 2005 NHS Greater 

Glasgow 

SACDM & 

SACAM, 2003 

Scottish 

Executive 

comPlEX NEEDs 


People with multiple and 

complex needs 

UK 

Asylum seekers and 

refugees in North 

Glasgow. 

Scotland. 

Assumption is made by 


that asylum seekers 

and refugees are very 


and complex needs due 

to the reasons for and 

experience of being an 

asylum seeker or refugee 


and substance misuse 

problems. 

Scotland, UK 




Service provider and policy 

makers’ views. 

Evidence listed here comes 

from chapters focusing on 

good practice using the views 

of all of the above. 


research. 




research. 


evidence. 

Literature review. To review the evidence from 

research literature on service 

provision for people with multiple 

and complex needs. 

Literature review on health 

needs of asylum seekers and 

refugees. 

Qualitative interviews with 

113 asylum seekers and 

refugees (26 nationalities). 

73% female, 27% male. 

Focus group with 

professionals from 

organisations working closely 

with asylum seekers and 

refugees. 

Report collating evidence 

from a range of sources 

including national datasets, 

general population surveys 

and research studies. 

To identify the health needs of 

asylum seekers and refugees 

in North Glasgow; to explore 

addiction issues; to identify 

barriers to accessing current 

services; to enable development 

of services sensitive to need. 

To address the shortcomings 

and gaps in the help available 

for those with mental health and 

substance misuse problems. 




● holistic and person centred approach 

● joint working 

● pro-active, responsive and flexible services 

● easy access points and/or integrated front line services 

● user empowerment e.g. direct payments 

● advocacy 

● removal of stigma 

● good information on services and what they provide 

● appropriate referrals at times of transition between services 

● access to services when user is ready to engage 

● improved access to translation and interpreting 

● services with flexible access times e.g. weekends and evenings 

● single shared assessments 

● more intensive support for more complex needs 

● link workers to help people through services e.g. key workers, 

service navigators, case managers 

● culturally, linguistically and gender appropriate services 

● active outreach and follow up of clients at risk of disengaging 

from services 

● aftercare i.e. moving on from a service, to be a part of services 


● need for resources or capacity to overcome some of the barriers 

faced by asylum seekers and refugees e.g. fear of stigma, fear of 

discrimination, government legislation 

● need for professionals in addiction services to have the cultural 

understanding and language skills to work with refugee community 


● early intervention with this client group 

● holistic and person centred interventions 

● advocacy i.e. clients supported through treatment and services by 

key worker 

● 

positive expectations by service providers

52 




Sainsbury 

Centre for 

Mental Health, 

2006 

Sainsbury 

Centre for 

Mental Health 

SCIE, 2007 Social Care 

Institute for 

Excellence 

comPlEX NEEDs 


Offenders with mental 

health problems. 

London, England. 

UK. 

Adults receiving social 

care support services in 

England. 

Note: although the 

approach discussed in 

this publication does not 

specifically refer to those 

with complex needs, in 

practice, there will be 

instances when individual 

budgets are used by this 

group of people 



research. 


evidence. 

Service providers views. 



Review of policy documents 

and literature on prison 

mental health care. 

Statistics on prison mental 

health collected from Home 

Office, Prison Health, 

and University of Durham 

National Service Framework 

Service Mapping website. 

Visited prisons and met 

with service providers and 

agencies. 40 stakeholders 

participated in review 

including inreach leads and 

workers, commissioners, 

non-statutory sector 

providers, health and mental 

health professionals, general 

practitioners, researchers, 

prison health representatives 

and one ex-prisoner. 

Research briefing 

summarising current 

knowledge in this area 

intended to lead into more 

in-depth investigation, 

rather than be a definitive 

statement. No other details 

of methodology given. 

To provide an overview of mental 

health provision in London’s 

prisons. 

To provide up to date information 

on the emerging themes relating 

to the development of individual 

budgets for adults currently 

receiving services in England. 

Individual budgets involve 

assessment across agencies 

responsible for a range of funding, 

resulting in the allocation of 

resources to the individual who 

decides how to spend them. 




● prison inreach teams focusing on prisoners with severe and 

enduring mental health problems, providing liaison and support 

to health care and primary care practitioners in prison and prison 

officer staff, using evidence based interventions and providing a 

multi-disciplinary service 

● joint working for clients with dual diagnosis 

● many participants suggest that people with severe mental health 

problems should not be in prison but in a more appropriate 

environment e.g. a high dependency unit 

● prisoners with learning disability and mental health issues may 

require different interventions than those with no learning disabilities 

● translation and interpretation in prison to identify trauma and related 

mental health difficulties in foreign prisoners 

● specialist provision for young offenders with mental health problems 

● prison staff trained in assessment of mental health issues 


● individual budgets add choice and empower service users 

Other issues: 

● there is a lack of evidence on the cost effectiveness of individual 

budgets 

● practical problems have hindered take-up and implementation 

of innovative schemes 

● poor representation in specific groups in those who take up 

individual budgets e.g. carers, people with mental health problems, 

older people and there is mixed evidence relating to take up from 

the black and minority ethnic community

53 




SDC, 2007 Scottish 

Development 

Centre for 

Mental Health 

(SDC) 

Singh, 2005 Joseph 

Rowntree 

Foundation 

Social Exclusion 

Unit, 2005a 

Office of the 

Deputy Prime 

Minister 

comPlEX NEEDs 



problems. 

Scotland. 

Note: although this paper 

does not specifically refer 

to people with complex 

needs, it refers to an 

intervention and approach 

that in practice will 

sometimes cover those 

with multiple and complex 

needs. 

Black disabled people 

involved in projects 

in Rotherham, 

Leeds, Hackney and 

Walthamstow. 

UK. 

Young adults with complex 

needs. 

England, Wales and 

N Ireland. 



research. 





Evaluation. 





Overview of literature on 

social prescribing (no 

methodology given). 

Questionnaire survey of 35 

social prescribing projects in 

Scotland. 

Evaluation methods involved: 

observation; semi structured 

interviews with service 

providers e.g. managers, 

project workers; group 

discussions with service 

users; and service user 

interviews. Numbers not 

specified. 

Detailed case studies from 

two projects. 

Evidence gathering visits to 

projects working with young 

adults with complex needs; 

practitioner questionnaire 

(129); 16 focus groups with 

over 150 young adults; 

stakeholder road shows; 

consultation on interim report 

(100 responses). 

Three steering groups: 

practitioners working with 

young adults; government 

officials with interest in these 

issues; and government 

ministers from other 

departments as part of wider 

Social Exclusion Unit Work 

Programme Steering Group. 

To identify information to inform 

development, commissioning and 

design of social prescribing or 

community referral programmes 

in Scotland. 

These are non medical 

interventions which provide a 

socio-economic support linking 

people, in this instance with 

mental health problems, to non 

medical support in the community 

e.g. arts, physical activity, or help 

with benefits, housing etc. 

Report on ‘Making Change 

Happen’ programme which 

provided one year’s funding 

to four development projects 

providing support to black 

disabled people. 

To gather evidence on problems 

(including health) faced by young 

adults with complex needs. 




● high quality partnerships, joint working and co-operation between 

primary care, voluntary and community agencies and local 

authorities 

● increasing evidence in support of social support for protecting mental 

and physical health 


● building projects on existing strengths of the organisation 

● joint working to learn from other organisations and to share work 

according to skills 

● funding should be appropriate for the organisational need e.g. short 

term funding not always appropriate 

● acknowledgement of multiple discrimination in that both disability 

and racial equality as well as other inequalities need to be 

addressed 

● additional staff training e.g. disability equality, or recruiting those with 

these skills may be required 

● networking nationally and locally 

● take advantage of local opportunities e.g. Learning Disability 

Partnership Boards 


● managing the transition to adult services 

● taking young people’s thinking and behaviour into account and 

building on it 

● involving young adults in service design and delivery 

● providing information on services and sharing information between 


● 

offering a ‘trusted adult’ to support and encourage young people

54 




Social Exclusion 

Unit, 2005b 

Stalker et al, 

2006 

Office of Deputy 

Prime Minister 

Scottish 


Research 

comPlEX NEEDs 


People with low literacy; 

disabled people and 

those with long term 

health conditions; people 

from certain minority 

ethnic groups including 

Pakistanis, Bangladeshis, 

Black Caribbean and 

Black Africans. 

UK. 

Disabled people (16 to 

64 years) including early 

onset dementia. 

Scotland. 

While disability alone 

is not included in PATH 

definition of multiple 

and complex needs, this 

paper includes evidence 

on needs of disabled 

people with other needs, 

e.g. multiple impairment 

and therefore has been 

included in the PATH 

review. 




evidence. 

Service provider views, expert 

opinion. 




Range of evidence, 

predominantly from one 

specific project, which 

involved a public consultation 

with service users and 

providers (340 responses); 

nine focus groups with 

service users; 40 visits 

to service providers; 15 

workshops with service 

providers; meetings and 

seminars with range of key 

stakeholders; desk research. 

Scoping study over a 10 

year period up to December 

2004 with focus on Scottish 

publications. Consultation 

with the Scottish Disability 

Equality Forum. 

Report on range of evidence 

looking at how people with low 

literacy; disabled people; those 

with long term health conditions; 

and people from certain minority 

ethnic groups experience key 

public services. 

To review research and related 

evidence about needs of and 

services for disabled people aged 

16 to 64 years. 




● helping people gain confidence and self esteem to feel able to 

access services 

● joint working with other providers helps to provide a holistic service 

to users, avoiding duplication, sharing skills and ensuring better use 

of resources 

● recruitment of health link workers from disadvantaged areas to act 

as a bridge between health services and communities e.g. providing 

information on appropriate services 

● advocacy welcomed for disadvantaged groups 

● sustained funding to overcome problems arising from short term 

funding and instability of some funding 

● removal of targets or change to system where providers have 

funding attached to targets 


● good quality provision of translation and interpretation for black 

and minority ethnic disabled people, and training of bilingual staff in 

signing 

● supported referrals 

● access to information and advocacy 

Good practice in planning for transition between child and adult 

services for disabled includes: 

● multi-disciplinary and holistic services which ensure some continuity; 

training for staff in transition planning; involving and supporting 

young people (and families and carers, if relevant) in planning for the 

move to adult services 

● specialist expertise as well as mainstream services for those 

working with people with multiple and profound impairment

for further information please contact: 


Senior Public Health Researcher 


Multiple and Complex Needs Initiative 

Department of Public Health & Health Policy 

Lothian NHS Board 

Deaconess House 

148 Pleasance 

Edinburgh, EH8 9RS 

tel: +44 (0)131-536-9000 

e-mail: annette.gallimore@nhslothian.scot.nhs.uk 

www.pathproject.scot.nhs.uk

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