Scottish Government

CHAPTER SEVEN: CONCLUSIONS

Summary findings

Introduction

7.1 The Scottish Government's MCN initiative set out to explore different approaches to improving service provision for individuals with multiple and complex needs - the overall aim of the programme evaluation was to draw lessons around what does and does not work in improving service access, the service experience and outcomes for clients with multiple and complex needs.

7.2 The process of selecting the 14 MCN demonstration projects led to significant diversity in target groups, size, rationale and project set-up across the 14 MCN projects. This has presented a particular challenge to the programme evaluation and the nature of evidence available to the evaluation team. Only half of the MCN projects had an element of direct client engagement; the others were change management or service redesign projects which focused their attention on staff - the latter group could not provide evidence of changes in client outcomes; they could however point to changes in staff awareness or behaviour.

7.3 Much MCN learning provides further evidence and case study examples confirming principles of service improvement familiar from elsewhere. This includes for example the importance of proactive outreach to engage harder to reach clients, partnership working and a flexible, client-centred approach. None of this is new - these insights and principles have been championed for some time now. However, practical application of these principles has often proved elusive. The added value of the MCN programme is that it has enabled stakeholders to explore in more detail the challenges to implementation, as well as a number of possible practical solutions to these challenges.

What provokes MCN as an issue within services?

7.4 The 14 MCN projects tended to focus on well-defined and fairly specific service gaps, as follows:

• No or limited provision targeting a particular need or client group;
• No or low take-up of the available service;
• Clients were accessing the service but some needs remained unidentified; or,
• More needed to be done to drive at the root causes of MCN by making service provision better attuned to clients' particular concerns or needs.

7.5 Evidence on the nature and extent of the service gap varied. In some cases projects had a clear understanding of the service gap and the cause(s) for the gap, based on existing evidence or their organisation's past experience. In other instances, projects started from an assumed service gap or assumed cause(s) of this service gap and tested the validity of their assumptions through the MCN pilot project. By and large, the service gaps MCN projects first identified proved to be correct, even when initially based on anecdotal feedback or perceptions rather than hard evidence. Some projects changed their focus but this was not because of a fundamental shift in their understanding of the service gap.

7.6 The majority of projects were 'external' to the service that they were seeking to change and in most cases, had some association to the MCN group they were seeking to support. An involvement with the MCN client group in question provided many organisations with the evidence for (i) the extent of the issue and (ii) how best to respond to address this issue.

7.7 Pilot projects which were 'internal' to the service provider were a minority of MCN projects. In these settings, MCN was provoked through a combination of policy drivers and the presence of a champion: services (at frontline or management level) often knew that there was a problem with delivery; change was first triggered when a champion was prepared to act on this knowledge.

Getting in - engaging with clients

7.8 The key findings from MCN projects on engaging MCN clients are very familiar: no one size fits all and the nature of outreach activities must necessarily be different for different target groups and in different service settings. Many MCN clients were in contact with some (other) service providers. However, potential inward referrals from other providers only came about if:

• These other providers felt comfortable raising additional issues with their clients - for example, housing staff feeling comfortable raising mental health issues or employability with their clients; and,
• They understood and trusted other providers' service offer sufficiently to recommend it to their clients.

7.9 Moreover, relying on referrals or recommendations from other service providers did not work if there was any (perceived) stigma attached to accessing the service or if the service was perceived as 'not for us'. More proactive outreach methods are then required. MCN projects did this through proactive outreach to the target community, for example operating from another provider's premises (a prison, a HIV clinic).

7.10 The above has direct implications for human resource policy: MCN staff were given the space and time to (i) build their knowledge and awareness of wider MCN needs, (ii) establish direct relationships with contacts in other organisations and (iii) where relevant, engage in advocacy or community outreach.

7.11 Although the outreach element (to other providers and the target group) was important, engagement was not wholly external to the service setting. Services also had to accept a degree of change and stretch out to reach MCN clients. MCN projects did this through:

• Reflective delivery with an active policy of recruiting staff from backgrounds similar to the spectrum of clients;
• Dedicated support for the client group introduced through changes in staff induction and Continual Professional Development training or for example through women-only or BME-only provision; and,
• Client advocacy roles within the service. This role tended to be additional to existing provision, but caseloads could be high and the provision was not necessarily full-time: clients dipped in and out of support.

7.12 The key characteristics of MCN projects where the evidence of improved access was stronger are that they:

• Had a clear focus on a well-evidenced and highly specific access challenge;
• Offered provision that addressed a service need that was seen as a priority for the target group; and,
• Undertook proactive outreach into the target community, providing continued support to the individual client until the point of access.

7.13 The MCN research findings present service managers who are interested in improving their service's client engagement pathway with a checklist (see figure 7.1):

• Do services actually know who they are reaching and not reaching? Are their monitoring systems and needs assessments sufficiently robust and comprehensive to assess the reach of their provision? Are data available about the presence of the target group(s) in the geographical area of the service provision to assess the extent of any gaps?
• Does the service know why some groups are not accessing the service? Have services asked target groups why they are not coming forward?
• Which factors should guide service managers in the prioritisation process? This prioritisation process is important if funds and/or resources are to be found to support the process of improving the client engagement pathway. Do we have enough evidence to convince service managers that service improvements are worthwhile - when set against other service targets, other client groups and other objectives?

Figure 7.1 - Checklist for service managers: client engagement

Getting in - identifying needs

7.14 Improving needs assessment by pursuing difficult issues with clients was a challenge. This took time and often involved additional resources to implement, capture the evidence and keep the signposting knowledge base up-to-date. Staff needed support and encouragement to feel confident in asking questions outwith their existing service role. A number of MCN projects established that sensitive questions troubled providers more than clients - in an appropriate context, clients typically felt that services enquiring across a broader range of issues were more supportive of their circumstances. MCN projects confirmed that staff can be supported to take a more holistic perspective to their needs assessments, but merely including a new issue in the checklist or questionnaire was not sufficient: staff needed to see the relevance and feel confident about asking sensitive questions.

7.15 Those projects which were more successful in introducing changes in their client engagement and needs assessment process, were those that:

• Embedded their awareness-raising sessions and training in a wider process of working with and alongside staff;
• Provided staff the time to discuss the issues with their peers - this encouraged engagement in the issues and may have gone some way to overcoming concerns of (yet) another top-down edict on service standards;
• Made the training practical and included sessions on how to raise sensitive questions with clients; and,
• Included an input from the client target group in the training or wider process.

Getting through and getting on - supporting and empowering clients

7.16 MCN examples throughout the evaluation report have shown how much can be achieved through fairly small steps, by simply enabling staff to step back from their day-to-day practice and by thinking outside the box. However, the experience of some MCN projects - such as RooP - suggested that in some cases there was a need for substantial service enhancement as opposed to light touches and small steps. Figure 7.2 presents the two pathways that are available to service managers who are interested in making their provision more sensitive to the needs of MCN clients:

• Are there any light-touch improvements services can make?
• Are there instances where light-touch improvements alone are not sufficient and the introduction of specialist provision, advocacy support or peer support would be beneficial?

Figure 7.2 - Checklist for service managers: adjusting provision

7.17 The MCN programme shows that undertaking client consultation exercises can significantly facilitate this process for service managers: clients can bring to light new insights and introduce the clients' voice - which is often absent in service redesign processes and is very powerful in overcoming any resistance to the need for service change. This can be useful both in identifying and implementing examples of light-touch changes to the service provision and in wider service redesign.

7.18 A key challenge is knowing when to make light-touch improvements to existing provision and when to opt for the introduction of specialist provision. The MCN initiative provides some guidance in this respect. The MCN pilots seem to suggest that relatively light-touch improvements to existing provision are most effective where communication barriers or culturally determined patterns of behaviour or human interaction are at stake. This does include for example, offering translation support to people whose first language is not English and, using the term 'partner' instead of 'girlfriend' to accommodate people with different sexual orientations or, talking to the person with the learning disability rather than to his or her carer. Staff awareness raising sessions, in particular when delivered by people from the target group, appeared to be especially effective for these types of service adjustments.

7.19 There are arguments for introducing specialist support provision if:

• There is a clear gap in provision - for example, the RCA Trust project offered a service (alcohol counselling in BSL) that was not available previously.
• A pilot project shows that introducing specialist provision achieves more or better client outcomes than existing provision - for example, there were some early indications that the peer support provision offered by RooP and Plan2Change may lead to better client outcomes. More generally, the MCN initiative offers consistent evidence of the value of peer support provision in improving the service experience and empowering clients, in particular where peers have had similar lived experiences to the client, such as mental health issues or a criminal record.
• A pilot project shows that introducing specialist provision is more cost-effective.

7.20 Evidencing better client outcomes can be tricky. In some instances it should be possible to compare and contrast provision: for example, over time, it should be possible to compare recidivism between RooP-supported ex-offenders and others. In other cases, the improvements may relate to soft indicators such as a better service experience or a sense of empowerment - which cannot be quantified but can be assessed through qualitative research and/or anecdotal client feedback or client surveys.

7.21 If specialist provision is being introduced, a separate question is how to best deliver this support, in-house or commissioned externally. For example, if a service wants to introduce advocacy support, it can shift existing resources to free-up staff time to offer this support, recruit new staff or commission another organisation to act as advocates. For example, the Greater Glasgow and Clyde Health Board saw value in the advocacy support offered through the African Health Project and decided to offer funding to continue the peer support worker's post. It considered recruiting the African Health Project worker as NHS staff and commissioning Waverley Care to continue delivery. At the time of the final evaluation fieldwork, it was unclear which the preferred option was.

7.22 Economies of scale and comparative advantages (in effectiveness and cost-effectiveness of delivery) may be guiding principles in choosing between different options. Economies of scale play where the target group is relatively small in any particular geographical area, such as deaf Asian children or deaf people with alcohol misuse problems. Effectiveness of delivery may again be difficult to assess, as it can include hard or soft indicators.

Mainstreaming lessons

7.23 An important aspect of the MCN service improvement agenda is facilitating and managing the process of change, in particular the way that frontline staff and their supervisors and managers operate. MCN evidence suggests that influencing staff appeared to work significantly better when there was:

• A dedicated staff resource to support the learning process (the 'change manager'), ideally able to operate and be seen to operate independently but with direct links with the organisation they are trying to influence and strong line management support.
• Sufficient face-to-face time between staff and the change manager, finding the right balance between allowing sufficient time for the staff engagement process and at one point creating a sense of urgency. The process also tended to benefit from direct interaction between frontline staff and the client group or between frontline staff from different organisations.
• Direct alignment with organisational priorities: introducing change worked better if the organisation had already identified that there was an issue and/or was already trying to address the issue.
• A champion for the change within the organisation - getting senior staff involved can be facilitated by aligning the change offer with existing organisational priorities or by offering support to help the organisation fulfil any existing (legal) obligations or minimise risk.
• A positive staff engagement process, working alongside staff and offering them support rather than criticising them for failing the target group and creating some space for staff to discuss these issues together.

7.24 The last point is particularly important. The MCN programme suggests that the service improvement agenda needs increased attention for the 'staff empowerment' process. MCN projects have shown what can be achieved when ownership and decision-making are returned to the frontline level and staff are given flexibility (away from performance targets) to follow their clients' agenda and invest time in developing and nurturing partnership links.

Recommendations

Introduction

7.25 The Scottish Government invested £4.8 million in testing what 'works' and what does not in improving service provision for people with multiple and complex needs. If this investment is to pay off, lessons from the programme need to be learnt and shared. A clear dissemination strategy needs to be developed, drawing out the lessons for different service sectors, in particular health given the important health component in the MCN programme, and criminal justice - because of the significant investment in the RooP project. That being said, the conclusions and recommendations apply widely: a whole range of agencies encounter clients with MCN characteristics and the dissemination strategy should make the MCN findings accessible to a wide audience, including local community planning partnerships. The dissemination strategy also needs to differentiate between key stakeholders and what their role in the MCN agenda can be.

7.26 This final section sets out a preliminary route map for the dissemination strategy, identifying key MCN messages for different stakeholders.

Service managers

7.27 Service managers are the key players in the MCN service improvement agenda. Key tasks for this group are:

• To identify where their service is currently deficient in relation to MCN clients. This includes a review of who is currently not accessing provision and why (as specified in figure 7.1 above);
• To identify the scope and nature of possible changes to service delivery, including both possible light-touch adjustments to improve communication and interaction with individuals and the introduction of specialist provision where provision is currently lacking or ineffective (following the checklist suggested in figure 7.2 above);
• To establish the necessary evidence base to facilitate this process of identifying deficiencies and possible solutions - including the introduction of a mechanism for talking to individuals from key MCN groups to get their views on all aspects of the service;
• To create the space to allow changes to service delivery to come about - this will include:
• • Investment in staff development to raise their awareness of MCN client issues and increase their confidence in raising sensitive questions - this may or may not involve formal training sessions; it may well be more important to create time for staff to meet each other and discuss practice and scope for improvements;
  • Reviewing overall staff resources and individual staff workloads to create opportunities for more active outreach towards the target community or for building direct links with external partner organisations;
  • Sourcing or shifting resources to fund the specialist support provision that is being proposed;
  • Finally, the MCN evidence suggests that the MCN service improvement agenda will in most cases require the introduction of a change manager role to take the agenda forward.

Role of the Scottish Government

7.28 The role of the Scottish Government will essentially be one of enabling and facilitating service managers to implement the MCN service improvement agenda. This can include:

• Developing the evidence base - a number of MCN projects indicated that it was difficult to collect data, evidence and benchmarks relating to their client groups. The Scottish Government, together with local partners, can decide to invest in developing the evidence base, for example on the national and local presence of different MCN target group(s) and benchmarks of effective and cost-effective delivery, and encouraging learning and sharing of good practice between services.
• Working with each of the major service providers (including the NHS, SPS and others) to develop MCN Service Improvement Action Plans - which would identify deficiencies in MCN delivery, practical suggestions for improving delivery and information on how to implement, resource and enable the service improvement agenda, including the change management process. The Action Plans would build on the understanding generated by the evaluation, other research studies and where relevant direct consultation with the MCN target group(s). What is needed are action plans (as opposed to strategy documents) with specific actions, a timescale and information on who will undertake these actions, and how they will be funded.
• Facilitating a dialogue between different (local) service commissioners and (national) service providers to secure potential economies of scale.

7.29 In the health sector, the Scottish Government is currently exploring the possibility of introducing independent advocacy and patient rights officers, similar to the English Patient Advocacy and Liaison Service ( PALS). The advocacy support offered by several of the MCN projects is different to the suggested scheme in that the MCN advocates:

• Tended to be peer support workers;
• Focused their attention on one specific target group, as opposed to being universally available to all users; and,
• Focused their attention in particular on individuals with multiple and complex needs.

7.30 Despite these differences, the proposed Scottish patient advocacy scheme may be able to draw on the MCN findings.

7.31 The success of the MCN advocate role stemmed from its flexibility and the fact that advocates were able to take the client's agenda as their starting point, addressing issues and needs as and when they arose. The suggested patient advocacy scheme may understandably wish to focus on healthcare provision. Still, it may be worthwhile to avoid too rigid role boundaries and allow sufficient time and line management support for the patient advocates to (i) present a flexible support offer to patients and (ii) invest in establishing a wider network of named contacts in organisations outside the health sector who can provide additional support to the patient.

7.32 Secondly, MCN advocates invested heavily in proactive outreach to their client groups, in particular in the early phases of the project life cycle, before word-of-mouth had started operating. It is not sufficient to put in place an advocacy support service; potential users must still be made aware that the service exists and make the decision to use the service. In an MCN context, this often meant that the engagement process had to be made as simple and direct as possible: advocacy support workers had to be at the right place at the right time to be able to introduce themselves face-to-face to potential clients. A universal service such as the suggested Scottish patient advocacy scheme may not require quite the same investment in client engagement. Still, the key message about the importance of awareness-raising and facilitating the engagement process still stands: for the suggested patient advocacy scheme to be truly universal it should also reach patients with multiple and complex needs.

Financing the MCN service improvement agenda

7.33 The current economic climate means that financing the MCN service improvement agenda - the introduction of advocacy support roles or change management roles, a reduction in staff workloads or investment in staff development - will be challenging. There are no easy answers here but the MCN programme can again provide some guidance. In particular, it is important to note that:

• Redesign of existing provision should not be seen as cost-free alternative to introducing specialist support provision: creating space to allow changes to service delivery to come about requires funding for staff development and freeing up staff time to invest in provision. It does, however, stress the importance of evidencing proactive outreach, more intensive provision or building relationships with other providers;
• Funding the MCN improvement agenda is ultimately a matter of organisational priority. The MCN pilots showed that, if service providers recognised the value of the proposed changes or the new support offer, they would often be able to shift or find resources for a continuation. For example, NDCS decided to continue to fund the BME support worker from its core budget; the Greater Glasgow and Clyde Health Board decided to take over funding for the African support worker from the African Health Project; NHS Borders was considering a continuation of the homelessness outreach nurse from its core budget. This is not to underestimate the challenge of resource constraints: it is difficult to generalise on the basis of a limited number of MCN pilots which were successful in generating funding for a continuation of staff posts or support the value of provision.