1. BLF Fulfilling Lives : Supporting People with Multiple and Complex Needs Project South East Partnership

2. Brighton, Eastbourne and Hastings has been identified as one of 12 areas nationally, in which the BLF has invested. To make what already exists work better for people with Multiple and Complex Needs – through systems change and innovative short term interventions To bring about lasting change in how existing services work with people with multiple and complex needs Funding

3. BLF Fulfilling Lives Our project will work on two levels: an immediate level - working directly with the people who are most in need of help right now, and on a lasting level - changing systems to enable people with multiple and complex needs to receive the right support, at the right time. We will work with: Those who are most invisible to services: unable to access existing services – whether because they need thorough preparation and planning work to do so, including specialist interventions, or because services are unable to meet their needs (for example, having access criteria which exclude them) Those who are most visible: clients who are accessing numerous services, numerous times, but insufficient co-ordination and inappropriate and erratic interventions are leaving needs unaddressed and recovery unachieved

4. Core Group Members Statutory sector reps: Hastings Borough Council Eastbourne Borough Council Brighton and Hove City Council East Sussex County Council Voluntary sector reps: BHT Sussex CRI Sanctuary Supported Living Southdown Housing Association Sussex Central YMCA Sussex Oakleaf Equalities and Diversity rep: Brighton Women’s Centre Other: Homeless Link

5. Partner Agencies Involved

6. The Project Model To address the priority issues of people with multiple and complex needs (MCN), as identified by service users and services, we have developed the following delivery model: A team in each area, made up of: – An Area Lead – A Service Improvement Officer focusing on systems change – 2 Specialist Workers focusing on specific, identified priority issues : 1 Specialist Worker (Women) & 1 Specialist Worker Dual Diagnosis – Project Consultants assisting with project development and delivery – Peer mentors and buddies to support service users in their recovery journey eg: support attending appointments, training and activities

7. The Project Model Each of the 3 teams will undertake new interventions/pilots/ways of working with the client group 6 specialist posts (2 in each geographical location) will work with service users on a targeted one-to-one basis, all of whom will be those with the most complex needs The team of workers will co-ordinate all services involved with each individual client and work pro-actively and creatively to ensure clients are able to navigate and access the services they need, and can remain engaged.

8. The Project Model: Specialists Specialist Workers will work directly with clients. For the first two years of the Project our consultation with service users has led us to prioritise the following issues: – Dual diagnosis work with people with multiple and complex needs – Work with vulnerable women with multiple and complex needs, including women with multiple children in care, women involved in repeat violent/abusive relationships Caseloads will remain small and manageable and completely targeted to those who are the hardest to reach, living highly chaotic lives with the most complex and entrenched problems. Posts may change during the programme, as will post holders, and the employing agency.

9. The Project Model: Service and Role Reviews Services/roles will undergo a process of review and evaluation each year, leading to changes in design and delivery to better meet the needs of this client group. Changes may include opening times, access criteria, exclusion decisions, locations, co-ordinated referral processes etc.. We will link these reviews to the work of the Specialist Posts In each of the 3 geographical areas 2 posts will lead on this work; the Area Lead and the Service Improvement Officer (Systems Change) Service users and ex-service users will be centrally involved in this process, particularly through the work of the Project Consultants and the Service User Panels

10. Our Outcomes People with multiple and complex needs, previously not engaging well with services, self- report that changes in delivery have had a positive impact on them managing their lives, as a result of them being accessible, targeted and better coordinated Service users will directly influence commissioning processes, priorities and decisions

11. Our Outcomes Services and roles will undergo a process of review and evaluation each year, leading to lasting change in design and delivery, to better meet the needs of service users The project will achieve long term improvements in systems, commissioning and policy through improved outcomes measurement, evaluation and shared learning

12. Systems Change From the outset of the Fulfilling Lives: Supporting People with Multiple and Complex Needs Programme being introduced, systems change was integral to achieve the long term outcomes the programme is aiming to achieve. We are aiming to bring about a system that can achieve lasting positive impact on the lives of people with multiple and complex needs. This will require fundamental changes, many of which will be discovered over the lifetime of the project. There are also, however, changes needed that are already apparent, and well evidenced by service users, which this project will explore, research and find ways to implement, and these include the following principles:

13. Systems Change One shared data system One shared referral and assessment process. Service users and panels included in all policy and commissioning decisions. Peer support embedded in all provision Shared training and skills standards across all sectors Service user assured Quality Mark Flexible access criteria, service thresholds, operating hours and location

14. Systems Change Outreach and assertive engagement No service user to be left without appropriate support Personalised, individualised interventions Immediate crisis response and fast tracking Alignment of commissioning cycles Shared outcomes system Culture of continuous improvement and learning Implementation of evidenced national recommendations, e.g. No Wrong Door, No Second Night Out