Evaluation of the Brighton & Hove Multiple Compound Needs Programme - Executive Summary

This evaluation was commissioned by the city’s Health & Care Partnership as part of its Multiple & Compound Needs (MCNs) Transformation Programme. This programme originated from the 2020 MCN Joint Strategic Needs Assessment to deliver on the recommendations. The MCN Transformation Programme is a partnership with the Sussex Changing Futures programme and the local Changing Futures Team pilot service. The city’s MCN programme is also a frontrunner for the new Sussex Integrated Care Strategy. The findings from the evaluation will support the Integrated Care Strategy’s long-term transformation aims through the development of 13 new Integrated Community Teams across Sussex. 

Changing Futures (CF) Brighton & Hove is a multi-disciplinary team (MDT) based within Brighton & Hove’s City Council (BHCC) Adult Social Care Directorate. It is funded through MHCLG’s Changing Futures Sussex grant and by BHCC. The MDT aims to provide a holistic ‘wrap around’ service for people with MCN to reduce health inequalities and improve life expectancy. The CF MDT launched in December 2022 and was fully operational by Summer of 2023.  

This independent evaluation ran from February 2024 to January 2025, and activities included: MDT staff interviews and observations; development of a Theory of Change; document review; analysis of administrative and monitoring data and case studies; and group and/or individual interviews with 28 professionals working outside of the MDT, focusing on the themes of housing, MARAC, co-occurring conditions, urgent care and safeguarding. The MDT peer support team collected ‘stories of most significant change’ told by 4 clients and 7 workers, reviewed by Common Ambition (lived experience partner). 

The evaluation is structured around the six key outcomes identified within the Theory of Change, i.e., Trust & Engagement, Safety, Health (mental & physical), Meeting basic needs, Housing, and Self, connection & recovery.

Description of the MDT pilot

Key features of the MDT way of working include: 

• Team hosted by Adult Social Care (ASC), with ASC and drug & alcohol services being the most frequent referrers. 
• Allocated keyworker(s) – most clients have a mini-team of 2-4 MDT keyworkers.
• Small caseloads – typically 4-7: the MDT’s total caseload is around 60. 
• Co-location, with restricted working from home.
• Assertive outreach. 
• Peer support team. 
• Personalisation budget.
• Structures to promote learning, development and communication – regular team meetings, supervision, duty system, and an extensive training offer. 

There is strong evidence to suggest the team work well together and are highly supported in their roles. The ability to share information and resolve issues by being in the same room and learning from each other’s professional and/or lived experience as a wider team drawn from different parts of the system is highly effective. There is strong emphasis on relationship building to enable holistic wraparound support by drawing on specialisms within the team, whilst minimising the risk of retraumatising service users. Excellent resources have been developed to promote staff wellbeing (e.g. lone worker policy, risk assessments) but some planned development work has been delayed due to lack of capacity in the face of operational demands.  

Recommendation

The plans to develop a new MCN Integrated Community Team model in Brighton & Hove should build on, incorporate and further develop the trauma-informed/ Team around Me model and staff management resources developed by the CF MDT pilot. Approval of the compact agreement between participating agencies should be prioritised so that respective roles and responsibilities are clear, especially in relation to line management and support arrangements for the MDT. 

Trust and engagement

The MDT has successfully built relationships with people who have a deep mistrust of services. This takes time, resource, creativity and persistence; the personalisation budget and input from the peer support team have been enablers. Having built this relationship, MDT workers can support clients to engage with health, substance use services, DWP, etc. There is evidence that this eases some of the pressure on professionals outside of the MDT by reducing missed appointments, and providing assertive outreach as an intermediary, or - better still - a member of their own agency. 

Co-production has been a key feature of the MDT model and its evaluation – for example, the peer support team has influenced the trauma-informed model of practice and interviewed clients and colleagues for this evaluation, whilst Common Ambition co-produced the design of lived experience research and the evaluation findings. Common Ambition reflected that this helps to build trust in the system at many levels: they have been struck by the fact that they had recommended holistic case coordination several years ago and have been pleased to see it implemented.  

Recommendation: The design, delivery and ongoing monitoring and evaluation of the Integrated Community Team should be co-produced with lived experience, building on the capacity and skills of both Common Ambition and the MDT peer support team.  

Safety and safeguarding

A key objective of the Changing Futures MDT has been to better coordinate the management of risk for people with MCN, and ultimately to reduce avoidable deaths (including from drug-related overdose, as highlighted in the recent drug deaths audit) and improve people’s sense of safety.  

The evaluation has identified examples of individuals’ risks being reduced, for example in relation to substance use, self-harm, domestic abuse, or accommodation. There is a slight overall improvement for the MDT caseload in average scores for intentional/ unintentional self-harm and risks to and from others, though these have remained volatile for some.  

The MDT provides effective care coordination within statutory safeguarding structures; its location within Adult Social Care, strong leadership from senior management and the Safeguarding Adults Board have been key enablers for this.  

This is evidenced by increases in the number of cases progressing to a S42 enquiry, the number of Safeguarding Plans and the number of Safeguarding Reviews for those on the MDT caseload. Meanwhile, there has been a 70% reduction in processing and decision-making for the central team for this cohort, since activity is now handled by the MDT. This approach addresses many issues raised in recent local Safeguarding Adults Reviews for people with MCN. The MDT acts as an anchor between the person and other agencies, modelling trauma-informed practice and highlighting barriers faced by this group, e.g. in relation to having their views represented at the MARAC. The MDT (operationally) and the SAB (strategically) have been able to provide mutual support in relation to system change, working together to establish the Multi-Agency Risk Management (MARM) group. There has been engagement with the Police operationally through safeguarding planning and the MARAC, however community safety partners are still missing from the current model.

Recommendations: To increase the supply of safe and suitable emergency accommodation for people with MCN who are particularly vulnerable to abuse and exploitation, including domestic abuse. In developing the Integrated Community Team, consider how gender-specific services for women with MCN might also be better integrated within the city and barriers reduced. Further development needed to engage criminal justice agencies in the model, perhaps via the Community Safety Partnership 

Health (mental and physical) 

The evaluation confirms the high rate of physical health conditions amongst the caseload, with 58% reporting health problems at or above ‘moderate’ levels and 43% describing themselves as in physical pain. The most reported physical issues were joint aches/ problems with bones, chest pains/ breathing issues, and mobility problems. 

86% of clients reported not being able to manage their mental health difficulties at the outset; ‘stress and anxiety’ levels show the clearest trend of improvement out of the New Directions Team Assessment Collection (NDTA) indicators.  

There are many examples of people being supported by the MDT to access health services in a more timely, planned and effective way, thereby reducing use of crisis services. The proportion of people saying they could access a GP or dentist when they needed one showed a marked increase following MDT involvement.  

Access to primary care (via ARCH) and drug and alcohol services (via CGL worker on the MDT) were reported to work reasonably well; however, challenges remain at the interface with secondary health services, (including issues getting information about a person’s needs to travel with them through hospital), and mental health services. The level of specialist mental health provision within the CF MDT (originally 1 x Band 6 (increased to Band 7) mental health nurse, and no direct access to psychiatry or psychology) has proven insufficient; case formulation by a clinical psychologist should be built into future models as a minimum; ideally psychiatry and psychology would be integrated into the team to respond to co-occurring conditions holistically. The CF MDT also reports a lack of specialist services for people with MCN with Acquired Brain Injury and/or personality disorder in Brighton & Hove, including access to detoxification. 

Recommendations: At system level, the CF MDT pilot has highlighted the need for an integrated response to co-occurring mental health, substance use, and underpinning trauma, and for additional specialist social worker input for people with MCN at the hospital. The new MCN Integrated Community Team provides further opportunities to develop the role of health care partners in the care and support of people with MCNs: build in dedicated time from a clinical psychologist for case formulation as a minimum, ideally also include psychiatry in the future ICT and implement Plexus Care Record to facilitate information sharing as a priority.  

Meeting basic needs

There is evidence of the MDT helping to reduce destitution for its clients, by enabling people to access food banks, other community resources, benefits and bank accounts. The MDT’s personalisation budget allows immediate needs to be met e.g., for food, drink, bedding, clothing, transport, personal and household items. Individual clients have received intensive practical support, e.g. with moving into a new home.  

The MDT’s location within Adult Social Care, and the investment which Adult Social Care has made to the programme have enabled the MDT to improve access to care and support for its clients via Care Act Assessments. Twice as many Care Act assessments were carried out for the caseload since joining the CF MDT than in the equivalent period before, and these were more likely to result in services being put in place, ranging from one-off deep cleans, to specialist care home or supported housing placements. There is some emerging evidence of ripple effects from the MDT to wider social work teams and other agencies in relation to the application of the Care Act and Mental Capacity Act to people with MCN. 

Recommendations: Build a flexible personalisation fund into the budget for the MCN Integrated Community Team. Ongoing work is required to support, educate and challenge locality and hospital social work teams on the use of the Care Act and Mental Capacity Act with people with MCN.  

Housing 

Housing is a major issue for almost everyone on the caseload and clients often mentioned housing outcomes as being the most significant change for them due to MDT support. There is evidence that the MDT has helped many of its clients to move out of rough sleeping (in one case after decades), sustain settled tenancies and supported housing placements, move to more suitable temporary accommodation or longer-term supported housing, though housing journeys remain volatile for a significant minority. 

Statutory homelessness assessments can be carried out by Homelessness Prevention Officers (HPOs) on the team. It has taken a year to evolve this role and embed the necessary partnerships between the MDT and Housing Services, but HPOs are now well-placed to help clients access housing entitlements and better understand their rights within these processes. The flip side of this is that the MDT hosts social work input for the Rough Sleeping Initiative (RSI)-funded Navigator service.  

Accessing suitable accommodation for its clients has been a significant challenge for the CF MDT. Unlike the RSI funded services, the MDT does not have direct access to emergency beds for those sleeping rough. Access has been improved via the development of an ‘informal pilot’ in which the MDT works closely to support some of its clients in New Steine Mews hostel; and through successfully advocating for the development of new specialist supported housing in Brighton & Hove which can work with people with MCN. There is evidence of stronger relationships between Housing and the MDT (facilitated also by the recent merger of Housing and Adult Social Care), with improved mutual awareness of roles and legal duties.  

Recommendations: At a strategic level, the pilot has highlighted the need to better join up existing resources (e.g. the RSI Navigator and CF MDT services); develop clear housing, care and support pathways for people with MCN in the city (including formalising the New Steine Mews pilot and properly embedding it in pathways), and consider how the city’s Housing First offer might be scaled up as part of the next phase of Integrated Community Team development. The Homelessness Review and Strategy provides an opportunity for this.  

Self, connection and recovery

The CF MDT has worked with people to promote recovery outcomes: self-management, relapse resiliency, self- awareness, motivation, and hope. The Peer Support team has been instrumental in this, actively working with 9 people in October 2024 to provide recovery support at their own pace, linking them in with existing resources in the city, and providing lived experience training and development for the rest of the MDT.  

Loneliness and isolation are common experiences for people; however, recurring themes in client stories about the impact of CF include people feeling less alone, growing in confidence, independence and self-sufficiency, feeling better able to make choices, reduced stress, managing things better. Clients describe feeling ‘content’, ‘happy’, ‘excited for the future’. Flexible and consistent support which is relational, non-judgemental and person-led is the key factor in these outcomes; accommodation in which people feel sufficiently safe is also a necessary foundation.  

Recommendations: Ensure the sustainment of the current ‘wealth’ of community recovery activities in the city and continue to develop the ‘recovery pack’ and training offer being developed by the MDT’s peer support work team.  

Effectiveness has been monitored by CF for individual clients using cost and cost offset data, measures of ‘system pressure’, and NDTA outcome scoring. Analysis of this data shows that positive outcomes for individuals do not always lead to straightforward reductions in cost and pressures, though there are many examples of these shifting away from emergency service usage to planned community-based treatment, support and care. Supporting the stabilisation of diverse individuals with inter-related support needs and trauma can take years not months, and patterns of service usage can vary considerably during this time. 

Recommendations: There are positive signs of progress, however, longer-term monitoring of outcomes and patterns of wider service usage across more of the caseload is required.  

Assessment of progress against the JSNA findings 

The 2020 (published in 2023) JSNA on Multiple & Complex Needs made recommendations in relation to service development and system change for people with MCN. The CF MDT has been able to progress, test and generate learning in relation to many of these. The following table summarises this and identifies remaining gaps and suggested next steps.  

Recommendation

Information sharing: building trust; establishing processes, developing shared system(s).

Progress/ learning from CF MDT

The MDT has provided an opportunity to test information sharing within existing systems and understand the practical opportunities and limitations of working across multiple systems.

Gaps and next steps

Implementing Plexus care record should be a priority for the next phase. Early Information Governance discussions are essential in Integrated Team development.

Recommendation

Including people with lived experience in service design and delivery.

Progress/ learning from CF MDT

CF MDT has generated significant learning, resource and skill in relation to the delivery and management of peer support work with people with MCN. Co-production with Common Ambition through this evaluation has generated further lived experience insights and capacity-building in relation to evaluation.  

Gaps and next steps

Ensure properly resourced peer support is built into the ICT, using models and resources developed in the CF MDT pilot. 

Draw on the significant knowledge and expertise of Common Ambition in the design and ongoing evaluation of the ICT model. 

Recommendation

Care coordinator for individuals with MCN.

Progress/ learning from CF MDT

CF MDT pilot has tested the implementation of this principle, proposing a small but consistent, multi-disciplinary team around the person, ideally hosted by ASC, as being effective and sustainable.

Gaps and next steps

Finding ways to roll out this small ‘team around me’ model of care coordination to include more people with MCN in Brighton & Hove, e.g. through the combining of resources in the Integrated Team/ proposed merger of RSI and CF teams.

Recommendation

An integrated approach to co-occurring substance use and mental health.

Progress/ learning from CF MDT

The CF team has highlighted ongoing system barriers and gaps for those with co-occurring conditions and been able to generate further learning about what resources are needed in practice to effectively support them.

Gaps and next steps

Ensure both clinical psychology case formulation to support staff and access to psychiatry and specialist mental health services for people with MCN are built into the design of the ICT. Resources within the HMHT will not stretch wider than their existing caseload. Feed CF learning into ongoing CDP -led system change project on co-occurring conditions.

Recommendation

Trauma-informed practice.

Progress/ learning from CF MDT

The MDT has developed and demonstrated the value of trauma-informed ways of working with people with MCN, rooted in social work models of anti-oppressive practice. The pilot has tested what is required to sustain these: lived experience input, training, supervision, regular meetings/ team working, reflective practice, changing language and case recording.

Gaps and next steps

Lasting culture change in wider teams/ services requires ongoing leadership and resource. Roll out training, learning and resources tested and developed by the CF MDT across the wider system, prioritising hospitals/ hospital social work teams, locality social work teams, statutory homelessness teams and the MARAC. 

Recommendation

Suitable housing, care and support for people with MCN,

Progress/ learning from CF MDT

Lack of suitable housing has limited the effectiveness of the CF MDT, though progress has been made in the partnerships with New Steine Mews, Filey Care and Support, Housing Options and care providers. The value and lack of gender-specific provision has been confirmed by the evaluation.

Gaps and next steps

Follow evaluation recommendations to formalise, streamline and diversify housing, care and support pathways for people with MCN in B&H, considering how further housing supply combined with Integrated Team support might enable the scale up of Housing First. Ensure the overlap between MCN and homelessness is recognised within the current Homelessness Review and Strategy development.

Recommendation

Gender-informed approach

Progress/ learning from CF MDT

The evaluation has highlighted the importance of the domestic abuse specialist resource within the MDT and the barriers facing women with MCN in accessing gender-specific/ domestic abuse services.

Gaps and next steps

Importance of designing sufficient specialist gender-informed resource within the Integrated Team, in relation to domestic abuse/ coercive control and child protection/ separation. Ongoing partnerships and development with MARAC, Oasis, Equinox, Women’s Centre, etc. towards gender specific integration.

Recommendation

Addressing physical health needs of people with MCN 

Progress/ learning from CF MDT

The evaluation has confirmed the high level of physical health needs amongst people with MCN. Access to primary care has been facilitated by CF MDT working in partnership with ARCH; however, challenges remain ensuring information about MCN follows people into hospital.

Gaps and next steps

Further integration between ARCH and the MDT should be explored, e.g. via proposed homeless health hubs. Further conversations with urgent care/ hospital social work teams, ideally with a view to locating a specialist MCN social worker role in hospital .