Michelle Cornes, King’s College, London
New research published by Lankelly Chase Foundation raises important questions about workforce development in the context of supporting individuals facing severe and multiple disadvantage. The research quantifies the ‘huge overlap between the recorded offender, drug misuse and homeless populations’, people among whom ‘poverty [is] an almost universal and, mental ill-health [and childhood trauma] a very common, complicating factor’ (p3).
The National Lottery’s ‘Fullfilling Lives’ Programme has recently invested £112 million in 12 areas across England in order to showcase and evidence the most effective and efficient ways of delivering support services to people who ‘rotate’ through various health, welfare and justice systems. New types of service design and different workforce configurations (ways of organizing jobs and teams) are being tested. The goal is the targeting of ‘multiple and complex needs’ rather than any single issue such as homelessness. It is planned that these new ‘multiple and complex needs’ services will be evaluated and that the learning will be shared widely.
Asked to predict what this learning might be I would guess with some confidence that it will confirm the value of well-resourced, good quality ‘support work’ that is delivered compassionately, flexibly and unconditionally over the longish term. Complex problems do not always require complex solutions. What emerges from the literature on ‘system transformation’ however, is the importance of context.
In the UK, it is acknowledged that care and support services are underfunded relative to need. Support is an increasingly scarse commodity which is strictly rationed by over-stretched public or voluntary services. Despite the best efforts of ‘personalisation’ (changes to give greater control and choices to people eligible for publicly funded social care), resources are still channeled mostly into meeting ‘personal care’ needs often at the expense of social inclusion. Indeed, a significant finding of the ‘Hard Edges’ report concerns the loneliness and social isolation that is experienced by people ‘at the extreme margins of society’.
With moves to ‘personal budgets’ (individualised commissioning) providers are increasingly paid only for the time they actually deliver support. This means that some employers take on staff working on zero hours contracts with all the uncertainties and challenges that these bring, most notably the ‘stripping out’ of capacity for things like supervision, collaborative working and team development. These are the building blocks of the ‘Psychologically Informed Environments’ (PIEs) that are known to protect against staff ‘burn out’ and the recruitment and retention problems which make continuity of support and trusting relationships difficult. Already, it has been reported that increased pressure on staffing has led to the ratcheting-up of the inverse care law – whereby those people with greatest needs get less:
‘If you are homeless, with a drug and alcohol problem and a criminal past, your chances of finding help are becoming much slimmer. As services continue to experience savage funding cuts they are increasingly being forced to turn away the most vulnerable.’ (Inside Housing, March 14th 2014)
If we start to (re)consider the workforce implications of ‘Hard Edges’ against this context then the priority for the ‘21st Century Public Servant’ is to find ways of supporting organisations to continue to deliver some form of meaningful activity in the face of considerable adversity. The debates following of the publication of the Francis Inquiry into the abuse and neglect at the Mid-Staffordshire NHS Foundation Trust are particularly informative with regard to the need for helpful and supportive commissioning environments. They caution strongly against resorting to highly contractual or bureaucratised approaches in which complex problems get reduced to ‘tick box’ compliance, arguing instead for more authentic and relational commissioning which creates trust and space for contention and creativity.
Neil Perkins and David Hunter’s work on the apparently disappointing performance of ‘Joint Strategic Needs Assessments’ (JSNAs) and high level strategic partnerships is also insightful. He makes the point that Health and Well-being Boards will need to understand the value and scale of local community and voluntary organisations and how to work with them to address health inequalities. In particular, ‘Hard Edges’ draws attention to the potential for more community development workers who can bridge the gap between initiatives addressing local poverty and economic decline with those focused on the individual needs of vulnerable or at risk groups (p7).
Overall, Perkins and Hunter argue that achieving these changes will require a new type of leadership which operates horizontally and vertically across organisations and encompasses the skill sets to bring key people and organisations together in a nurturing and constructive manner. In their view ‘boundary spanning’ leaders remain the exception (p223).
To make a reality of co-ordination and integration in grass roots practice, Helen Dickenson calls for less science, and more ‘craft and graft’. A craft and graft perspective is less interested in specific mechanisms that make integration work and more on the working practices of those charged with delivering integration. Communities of practice are for example, one mechanism through which this approach might be nurtured.
One of the ‘Fullfilling Lives’ sites is about to start working with a new community of practice which will explore how people experiencing severe and multiple disadvantage can be armed with a ‘Golden Ticket’ to open-up access to ‘hard to reach’ services. The first case study to be considered concerns the case of Elizabeth (not her real name) who was discharged from hospital with nowhere to go. Her support worker describes how they went straight from the hospital to the local housing options office where they spent four and half hours negotiating access to temporary Bed and Breakfast accommodation. The hope is that by encouraging workers to join a community of practice this will allow for the development of more collegiate working relationships and will enable participants to be more ‘in-tune’ with each others’ roles, regulations and responsibilities. Ultimately, that this approach will be the catalyst to help reduce the kinds of capacity draining and energy sapping encounters experienced by Elizabeth’s worker. Importantly, communities of practice also open-up space for frontline workers to hear about and discuss research findings such as those contained in the ‘Hard Edges’ report. Although research is often undervalued because it can seem distant from practice, it is often the infusion of this kind of evidence which has the potential to challenge what is tacit or taken for granted in street level practices (for example, who is in ‘priority need’). Research can also sometimes shine a light on the ‘elephant in the room’ in this case that the problem may sit with more with troubled systems rather than troubled lives.
Dr Michelle Cornes is a Senior Research Fellow at the Social Care Workforce Research Unit, King’s College London, Michelle.firstname.lastname@example.org
 Lankelly Chase Foundation (2014) Hard Edges: Mapping Severe and Multiple Disadvantage. England. Lankelly Chase: London http://www.lankellychase.org.uk/assets/0000/2858/Hard_Edges_Mapping_SMD_FINAL_VERSION_Web.pdf
 Perkins, N and Hunter, D. (2014) Health and Well-being Boards: a new dawn for public health partnerships? Journal of Integrated Care, 22(5/6) 220-229
 Dickinson, H. (2014) Making a reality of integration: less science, more craft and graft. Journal of Integrated Care, 22(5/6) 220-229
 Cornes, M., Manthorpe, J., Hennessy, C. and Anderson, S. (2013) Little Miracles: Using communities of practice to improve frontline collaborative responses to multiple needs and exclusions. London: King’s College London and Revolving Doors Agency. Download at: http://www.revolving-doors.org.uk/documents/little-miracles/