It makes financial and moral sense to support people experiencing multiple disadvantage

It makes financial and moral sense to support people experiencing multiple disadvantage by Christopher Gidlow and Andy Meakin.

Chris was the Principal Investigator in the evaluation of VOICES, the Stoke-on-Trent implementation of the Fulfilling Lives programme.

Andy was the Director of VOICES from 2014-2022, and is a Visiting Fellow at Staffordshire University.

A relatively small proportion of the population place a disproportionate demand on emergency health care and the criminal justice system.[1] There are strong moral and financial arguments for systems change to better support them.

Terms such as ‘multiple needs’, ‘complex needs’ or ‘multiple disadvantage’ are often used to describe people who experience a combination homelessness, substance misuse, mental health problems and offending.[2] Such individuals tend to be those most excluded from the services they need. Failure to support them can result in escalation of need, whereby what might start as relatively minor issue (e.g., minor illness, wound requiring treatment, medication need) are not dealt with, and then escalate and accumulate to crisis situations.

The VOICES partnership was Stoke-on-Trent’s implementation of the National Lottery’s Fulfilling Lives programme; one of 12 programmes across the country aiming to improve support for, and lives of people who experience multiple disadvantage. This involved coordination work to improve customers’ access to services, assertive advocacy, influencing the wider support system (e.g., training frontline staff), and ensuring that people with relevant lived experience are involved in the design and management of services.

In 2021, the Centre for Health and Development (CHAD) completed analysis of data for – 116 VOICES customers, to see how their contact with criminal justice and health services, and the associated costs changed with VOICES support.[3] The most striking finding was the substantial reduction in service use during the first year of VOICES support. This was true for Magistrates’ court appearances, A&E episodes, number of arrests, nights in police custody, and hospital in-patient episodes, equating to an overall reduction of £604,060, with an average reduction of £5,207 per customer.

Moreover, these overall changes in service use reflected large reductions in a small number of customers who had the highest level of contact with services. For example, reductions in costs of more than £10,000 were observed in 18 customers, while equivalent increases in costs were observed for nine customers. At the extreme edges, 10 individual customer’s decline in service contact equated to reductions of more than £60,000 each.

However, the picture is not straightforward. There were far smaller reductions among female customers compared with males, which might suggest an improvement in access to engagement with planned care in women. We also saw that, after the first year of support, reductions were less marked, so more work is needed to understand the changing support needs over time.

The findings of the evaluation, including the differences observed between demographic categories, may illuminate debates in public health about the balance between equality and equity of opportunity.[4] Our data suggest that providing services using what Professor Sir Michael Marmot described as proportionate universalism [5] not only serves to promote social justice through fairer access, but could add value by being both more economic and effective overall.  As such, the Fulfilling Lives programme may have found a genuine ‘win-win’ for public health and broader social policy as well as the public finances in this very challenging and complex context.

We also realise that these data tell only part of the story. Objective measures of service use and cost explored here do not reflect all relevant services and related behaviours (e.g., mental-health inpatient episodes, custodial sentences, or use of rough sleeper services), nor the wider impact on customers’ quality of life and experience. Nevertheless, these data do make a compelling economic argument for intensive support for those with the greatest need.

Critically, these data merely provide further justification to support the fundamental moral argument, that supporting people with the most extreme needs is the right thing to do, and requires systemic and cultural shift to prevent the escalation and accumulation of disadvantage and need, and to ensure whose who need it, receive the support to improve their lives.

In Stoke-on-Trent, as VOICES comes to an end (March 2022), the Changing Futures programme gets underway, hopefully continuing the good work in the city and keep this often forgotten about group on the political agenda. Following the release of the government’s Levelling Up White Paper,[6] we need to monitor the extent to which promising rhetoric around ‘whole system’ approaches and ‘cross-government’ programmes leads to long term investment and meaningful change that can address multiple disadvantage.

The full report of Hard Edges can be accessed here.