Commissioning the way forward – driving change for people facing multiple disadvantage during a crisis and into the future

November 09, 2020

Commissioning the way forward – driving change for people facing multiple disadvantage during a crisis and into the future

A wide range of commissioners are responsible for ensuring the provision of services for people facing multiple disadvantage. This includes local authorities, police and crime commissioners, clinical commissioning groups, and government departments to name a few.

Through the way they choose to work, commissioners have a big impact on how local services and systems operate, including the flexibility that services have to meet individuals’ needs and the working practices, cultures and attitudes of staff.

Throughout the Covid-19 crisis, we have seen commissioners going above and beyond to ensure that services could respond effectively and continue supporting individuals experiencing multiple disadvantage. We captured this learning in our recent paper Learning from the Crisis, which we hope you find the time to read in full. Below we summarise five principles from within this paper that are particularly relevant for commissioners seeking to improve their response for people facing multiple disadvantage.

1. Ensuring coproduction of services

People with lived experience should be involved in all stages of the commissioning process. If support services are going to reach and provide appropriate support to people facing multiple disadvantage, then services need to be heavily informed and directed by their views and opinions. If support is going to be designed effectively it’s vital to involve those who require it directly.

The response to the virus has reinforced the importance of this. Changes and flexibilities have been made to services that experts by experience have long been calling for. If their concerns and thoughts had been given greater focus in the past, it is possible that problems could have been pre-empted and solutions identified ahead of time.

People with lived experience should be involved at the beginning of commissioning, continue to service design and be embedded in monitoring and review processes. They should be seen as equal partners throughout. Systems for involvement should be designed to involve people at all different stages of their journey, ideally including those not yet engaged with services. Treating their views as equal to professionals’ views when commissioning demonstrates to local providers the importance of asset-based environments in which strengths and skills of individuals are prioritised and integral to the support offered.

2. Developing system-wide leadership and shared purpose

People experiencing multiple disadvantage live complex lives, with unique and diverse circumstances, confronting numerous issues and vulnerabilities simultaneously. As a result, positive changes in their lives are the result of a multitude of different direct and indirect interventions and interactions. It can be extremely difficult to attribute any transformation to one specific service or relationship.

There is a growing appreciation that the outcomes commissioners and services aim to achieve are produced by whole systems rather than individual organisations or programmes. This is particularly the case for individuals facing multiple disadvantage, who can be failed by services and commissioning systems that focus on singular issues and outcomes.

The crisis brought services together quicker than ever before. Having a clear ‘shared purpose’ to focus on, to maintain support and protect clients from the virus, was galvanising. There was an appreciation that no one service could achieve this by itself, that entire systems had to come together. Staff felt they could therefore operate and work ‘beyond their remit’, to do what they could to help colleagues in other agencies in order to protect the welfare of this group.

In the future, commissioners should work together to take a ‘systems leadership’ role in their local area, developing a clear sense of shared purpose across local services and a culture of learning, limiting target-based cultures and environments. Incentivising and encouraging collaboration and local partnership working will help improve communication and an increased sense of community.

3. Taking a trauma-informed approach

Trauma is often at the heart of the issues experienced by individuals facing multiple disadvantage. It is frequently the cause of their substance misuse or mental ill health and indirectly what has led them to become involved with the criminal justice system. Trauma-informed services allow staff to pause and consider the role trauma and lingering traumatic stress plays in the lives of their clients. As a result, commissioning services that are trauma informed is vital for individuals experiencing multiple disadvantage.

Services can play a part in perpetuating trauma, inadvertently causing further harm to some of the most vulnerable people they work with. Ensuring that all providers understand the impact of trauma on individuals is therefore fundamental to providing effective support in a local area. The process of commissioning, contract management and policy making should be trauma informed itself, with coproduction being one part in the process of achieving this.

The virus has caused considerable disruption and anxiety to the lives of most individuals experiencing multiple disadvantage, potentially renewing traumatic feelings and memories. Many were suddenly housed in new temporary accommodation in areas they may not know, for an uncertain and indefinite length of time. They were prevented from seeing their peers and social contacts upon whom they may have relied in the past. The support they may have been receiving will have changed dramatically almost overnight.

The manner in which services adapted to continue supporting them and how they reacted towards their behaviour will have had a significant impact in determining their general safety and wellbeing. Services that had a sound understanding of trauma informed care prior to Covid were in a far better position to respond effectively to the needs and circumstances of individuals as lockdown came into place and any challenging behaviour they may have presented, such as substance use.

4. Promoting staff autonomy and personalised support

Services want to improve the lives and wellbeing of those they are supporting. We know that one of the best ways of achieving that improvement for people facing multiple disadvantage is the provision of personalised support by someone they trust.

Through the pandemic we have seen services go to great lengths to increase their flexibility in order to continue supporting individuals’. Many of these flexible responses were often the result of increased staff autonomy. The need to adapt quickly meant that frontline staff were provided greater control over individual decisions. This has in places led to more personalised offers of support to individuals facing multiple disadvantage and in some places improved clients’ trust in services.

Commissioners should aim to develop contracts that provide staff in services with the independence and resources to work in a bespoke manner with each individual depending on their issues, circumstances and the changes they wish to make. Allowing them to concentrate on building relationships and generating trust, often most valued by people experiencing multiple disadvantage, will improve how services can meet the needs and circumstances of individuals. It will help develop learning cultures and allow staff to respond quickly to what is and isn’t working immediately in their day to day work with clients.

5. Addressing equality of access

Ensuring equal access to appropriate support should be a priority for all commissioners. Unfortunately, we know that certain groups of people experiencing multiple disadvantage have fared worse during the crisis period than others. The virus has had a disproportionate impact on Black, Asian and Minority Ethnic communities which has intersected with existing barriers and discrimination that they face in accessing appropriate services. Women have also been significantly impacted, at times forced to stay in inappropriate accommodation during the lockdown period.

Commissioners should prioritise significantly improving access to appropriate services for different demographic groups, particularly focusing on race, ethnicity and gender. In addition, commissioners must also ensure equity of support. Services therefore must be sensitive to individuals’ own backgrounds and circumstances. Developing a local understanding of the challenges and the issues affecting these individuals and the barriers in how they access, experience and engage with services is vital, requiring the involvement of local specialist voluntary sector organisations.