Running from 2014 to 2022, the Fulfilling Lives projects are coming to an end this summer. This blog will explore the some of the solutions that the Fulfilling Lives programme in Stoke-on-Trent[1] developed, consider some of the evidence of their effectiveness, and look ahead at what long-term systems change is possible as a result.
Fulfilling Lives is a strategic investment programme from the National Lottery Community Fund. £112m was allocated to twelve areas across the England aimed at delivering systems change for people experiencing combinations of homelessness, mental ill-health, addiction, and offending behaviour – or multiple disadvantage for short. People in this situation tend to access crisis services frequently, such as accident and emergency, hospitals, or homeless hostels, as well as coming to the regular attention of the criminal justices system through arrests, court appearances, and prison sentences.
Twelve areas received funding to understand why people experiencing multiple disadvantage were tending to become estranged from the services designed to aid their recovery. Fulfilling Lives also attempted to identify effective approaches to reengagement in services, using a test and learn approach, and then change the system in their locality to reflect learning.
Service Coordination
All of the Fulfilling Lives projects delivered a frontline service directly to people experiencing multiple disadvantage. There were several similar models offering people a Coordinator or Navigator to help them access the services that they needed. In Stoke-on-Trent, these staff were called Service Coordinators. Typically, a Service Coordinator would have a caseload of between 7 and 10 customers that they worked with at any one time. The ratio is low to provide the necessary time to build trust and rapport with individuals. Tools at the disposal of Services Coordinators included:
· A personal budget (notionally £1000 per person per year) which could be used for a wide range of interventions from the small, such as facilitating engagement by buying lunch or clothing, through to the large, such as a rent deposit and basic furniture pack. Personal budgets were also used to accelerate interventions that may have otherwise taken a long time. For example, an occupational or speech therapy assessment to inform referrals to social care and legal advice. The idea behind the personal budget was to provide a flexible solution focused resource capable of yielding rapid and tangible results for customers.[2]
· Access to high quality independent welfare benefits and housing rights advice via embedded Citizens Advice Bureau specialists. The role of the benefits specialist was to help people access the welfare benefits to which they were entitled and to challenge decisions where necessary through the appeals processes all the way to tribunal. In the case of the Housing Rights specialist their function was to promote and protect people’s access to accommodation. A key element of the model was that the specialists’ primarily helped the Service Coordinator through the relevant processes and provided ‘on-the-job’ coaching to upskill the frontline workforce.[3]
· Access to a tool kit that promoted legal literacy in the context of the Care Act and its application for people experiencing multiple disadvantage. The Care Act Toolkit helps frontline workers to articulate people’s situation to assist social care colleagues firstly to understand whether there is an appearance of need sufficient to trigger an assessment and then to provide information to inform that assessment. Primarily, the Care Act Toolkit is intended to focus on the ability of the individual to maintain their wellbeing and overcome a tendency to overlook hidden disabilities or to focus on behaviours or lifestyle.[4]
A service coordination plan would detail the organisations and systems that the person needed and the Service Coordinator would use their skills to involve and sequence the necessary services and interventions. Service Coordinators became skilled and assertive advocates who worked with some of the most excluded people in the community.
A longitudinal evaluation of the impact for customers measured the frequency of their interaction with crisis services – such as A&E presentations, in-patient stays, arrests, nights in custody, and court appearances – from 12-months before accessing the help of a Service Coordinator and then subsequently. The evidence shows a significant reduction in the frequency of people needing to access crisis services, particularly in the first year see Figure 1 (where period A is the 12-months before VOICES and period B is the subsequent 12-months). [5] This quantitative evidence of effectiveness is supported by case-based qualitative evidence from customers reporting improvements in their quality of life and experience of services.
Service Coordination was a key success of the Fulfilling Lives programme in Stoke-on-Trent and elsewhere but requires a great deal of effort in implementation and wraparound support.
If we consider that the work of Service Coordination concerned itself with tackling the demand side pressures of multiple disadvantage, the next section looks at the approach to supply side pressures and prevention.
Workforce Development
Stoke-on-Trent’s implementation of Fulfilling Lives includes a large multi-agency workforce development programme. This provided a shared learning environment that brought together managers, staff, and volunteers from the local voluntary and statutory sector to learn about effective approaches to multiple disadvantage together. This enabled people to meet in a neutral setting and to discuss solutions to the common problems they face in a shared learning context.
At the centre of the learning programme were people with lived experience. The project supported people who had been through multiple disadvantage to co-create and co-deliver the learning opportunities to create a rich learning environment informed by lived experience. The programme included brief masterclasses, longer accredited and non-accredited courses, workshops, seminars, a week long theatrical production based on local case-based evidence, and Communities of Practice.
In 2019, the workforce development programme provided free places for more than 2,300 attendees focusing on the knowledge and skills to help people experiencing multiple disadvantage.[6] 98% of participants that completed the satisfaction questionnaire reported that their knowledge grew. Similarly, 97% of participants that completed a satisfaction questionnaire reported that their confidence of working with people experiencing multiple disadvantage grew. [7] Interviewees as part of the independent evaluation reported that the learning programme promoted ‘ground up’ systems change by providing a better understanding of people’s lived experience, promoting interagency problem solving, enhancing skills and expertise, and encouraging peer and expert-led learning. [8]
By the time the Fulfilling Lives programme in Stoke-on-Trent closes at the end of March 2022, the learning programme will have provided more than 6000 places for people to learn and network with colleagues while focusing on multiple disadvantage. The learning programme was very popular and successful in driving ‘ground up’ change with observable impacts on custom and practice.
Embedding for the long-term
As a result of learning from the Fulfilling Lives project in Stoke-on-Trent, the City was successful in its bid to secure nearly £4m in additional funding to embed the findings and local systems change.
Central to the approach is a tiered escalation and de-escalation system overseen by a multi-agency risk management group who allocate coordination resources to help people experiencing multiple disadvantage. This is in keeping with the concept of ‘Proportionate Universalism’, i.e. scaling the level and intensity of support commensurate to the level of need or disadvantage experienced, from Professor Sir Michael Marmot.
“Focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. We call this proportionate universalism.” [10]
Figure 2 provides a schematic representation of how some of the learning from the Fulfilling Lives programme is being embedded as long term systems change through the Changing Futures programme.
Figure 2: A risk managed approach to proportionate universalism in the context of people experiencing multiple disadvantage
As Stoke-on-Trent is implementing the Changing Futures programme, there is a great deal of optimism that permanent and effective change can be achieved. In particular, for the first time in the City, adult social care is taking the lead for this customer group and embedding a specialist social worker in the system to work with third sector colleagues. There is also a genuine push to embed lived experience as a key asset in the system of workforce development and through the use of peer mentors in direct delivery alongside other more traditional types of support.
In my next blog, we will consider how Fulfilling Lives has harnessed lived experience as an asset to drive better outcomes for people experiencing multiple disadvantage.
[1] The project was called VOICES which is an acronym of Voices of Independence, Change and Empowerment in Stoke-on-Trent
[2] Becky Rice (2019), “The VOICES model of using Personal Budgets in Service Coordination.”
[3] Naomi Pollard & Becky Rice (2018), “A Model of Specialist Welfare Advice and Advocacy at VOICES.”
[4] Michelle Cornes, et al. (2018), “Increasing access to Care Act 2014 assessments and personal budgets among people with experiences of homelessness and multiple exclusion: a theoretically informed case study.”, Housing, Care and Support, Vol. 21 Issue: 1, pp. 1-12.
[5] Professor Chris Gidlow, et al. (December 2021), “Hard Edges Stoke-on-Trent. Reducing the costs of multiple needs to people and services: The third financial analysis of VOICES”, The Centre for Health and Development, Staffordshire University, page 11.
[6] Naomi Pollard and Beck Rice (June 2020), “The VOICES Citywide Learning Programme: Share learning opportunities to improve support for people experiencing multiple needs. Independent Evaluation Report.”
[7] Ibid. page 4.
[8] Ibid. page 5.
[9] See: https://www.stokesentinel.co.uk/news/stoke-on-trent-news/stoke-trent-awarded-39m-govt-5661019
[10] Professor Sir Michael Marmot (2010), “Fair Society, Healthy Lives. The Marmot Review.”, https://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report-pdf.pdf, page 16.
