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Developing services that can address the needs of people with multiple, complex health and social care needs is a challenge. Very often, people with such needs range from those who are ‘hard to reach’ and do not engage with services, to those who are already heavy users of services but who experience inappropriate service responses due to the challenging, intense or ‘revolving door’ nature of their needs.

Developing services that meet the needs of people with multiple and complex needs is an important issue for all service providers. However, ensuring the sustainability of such services is also important if they are to be effective in promoting health and wellbeing in the longer term.

Evidence suggests that a partnership approach between health, social care, voluntary and other relevant agencies is the best means of providing the type of services needed by people with multiple and complex needs (1, 2). The continuing development of Community Health Partnerships (CHPs) in Scotland is expected to provide greater opportunity for collaboration between the NHS, social care, voluntary sector and other partners to identify and address local need. This should provide good opportunities for the NHS and its partners to develop local services that are responsive to the needs of people with multiple and complex needs. However, what does this mean in practice? This chapter describes the approach being taken by the Partnerships for Access to Health (PATH) project in the Lothian and Highland areas to explore this issue.

What is the PATH project?

The PATH project is part of the Scottish Government’s Multiple and Complex Needs Initiative. PATH is hosted by NHS Lothian and undertaken in partnership with NHS Highland. The aim of PATH is to:

“Explore how health, social care, community justice and voluntary sector partners in local Community Health Partnerships can work together to develop services responsive to a wide variety of users with multiple and complex needs.”

PATH is working with three Community Health Partnerships (CHPs) in Lothian and Highland, chosen to represent a range of urban and rural areas:

  • Urban: Edinburgh CHP
  • Rural but not remote: East Lothian CHP
  • Rural and remote: Mid Highland CHP

PATH focuses on developing existing, sustainable practice, not on developing new services. While PATH is a time-limited project, the learning from PATH will be shared with other CHPs and service providers.

For the purpose of the PATH project, the term ‘multiple and complex needs’ is defined as:

“Multiple interlocking needs that span health and social issues that lead to limited participation with society.”

and ‘access’ is defined as:

“The ability of clients with multiple and complex needs to utilise and benefit from health, social care, community justice and voluntary sector services, gaining the maximum benefit from these services and moving on while sustaining the benefits gained.”

Developing services responsive to local needs

The development of services for those with multiple and complex needs should be based upon an awareness and understanding of what service users want from services and the interventions and approaches which work. PATH has therefore reviewed the literature to answer the following questions:

  • What do people with multiple and complex needs want from services?
  • What can service providers do to improve access to services? What works and why?

We found that people with multiple and complex needs want the following from services: simple, quick access; a single point of access; cultural sensitivity; a flexible approach; information about services; support with the practicalities of everyday life; peer support; involvement in decision making; effective joint working and communication between services; and greater employment of staff from black and minority ethnic communities.

Also identified, was the importance of funding arrangements, training and support for staff and addressing the disadvantages of targets for services. The full findings of the literature reviews are available at www.pathproject.scot.nhs.uk

PATH will be developing toolkits as a resource for CHPs elsewhere who may wish to use the lessons learnt from PATH to develop their own local services. The toolkits will be available on the PATH website from autumn 2008 onwards.

Building on existing good practice

Service development should be sustainable. Part of the PATH process to date has involved undertaking a rapid appraisal in each study CHP area to identify examples of local good practice and explore the elements of services that promote engagement with clients who have multiple and complex needs. The features of services that improve engagement are summarised in Box 1.

The CHPs taking part in PATH are developing their practice in response to locally identified needs. Box 2 describes the approach being taken by Edinburgh CHP to improve access to services for those people with multiple and complex needs who are leaving prison or are on community disposals. These are early days for the project, but already links are being made which, if nothing else, have improved inter-agency communication and understanding.

Projects to develop sustainable practice in East Lothan and Highland will come on-stream during 2008.


key points

  • Addressing the needs of people with multiple, complex health and social care needs is a challenge for many services. To do so in a sustainable way requires focus on developing existing practice rather than simply creating new services.
  • The development of Community Health Partnerships in Scotland provides a good opportunity for the NHS to work with local partners to develop sustainable practice within existing services that are responsive to the needs of this client group.
  • The Partnerships for Access to Health project is exploring how health, social care, community justice and voluntary sector partners in local CHPs can work together to develop services that are responsive to a wide variety of users with multiple and complex needs. The lessons learnt will be shared with CHPs and service providers elsewhere.
Box 1: Features of services that promote engagement
with people who have multiple and complex needs
  • A single point of access with very flexible self referral systems and the ability to access services without an appointment.
  • Case management or key worker systems which signpost people to other services.
  • Provision of a wide range of services.
  • Comprehensive and holistic assessments, with services focusing on identifying, tackling and improving the life circumstances underlying clients’ presenting problems.
  • Optimism and goodwill towards the client group with celebration of success, often through ‘small wins’.
  • A non-judgemental culture that ensures clients are consistently treated with respect and courtesy.
  • Staff are given support and tools to deal with difficult behaviours.
  • Building trust with clients.
  • Staff work with clients to re-establish (or establish for the first time) structured daily routines, access to mainstream services and an ability in the client to accept help from the statutory sector where this may have previously been rejected.
  • An ethos of helping clients to help themselves and to take responsibility for their own safety, health, learning, etc.
  • Working in partnership, communication between services and integration of teams across different agencies.
  • Multi-skilling and flexibility of staff and tasks across disciplines and organisations.
  • Long-term support, structured exit strategies and on-going follow up for as long as clients need it after the programme/service has finished, in order to support people as they move on.
  • Service user involvement in the management and running of programmes.
  • People are allowed to fail and come back again as often as it takes..
Box 2: Edinburgh CHP Prison Leavers project As part of PATH, Edinburgh CHP are working with local health, social care, community justice and voluntary sector agencies to improve access to services for people with multiple and complex needs leaving prison or on community disposals. The Prison Leavers project involves:
  • Working with Sacro (Safeguarding communites, reducing offending), the Scottish Prison Service, HM Prison Edinburgh, HM Young Offenders Institution Polmont, HM Prison & Young Offenders Institution Corton Vale and other local partners to develop the links between community justice and mainstream primary care and health improvement services;
  • Integrating NHS primary care services into the through care and aftercare services provided by Sacro, in order to create seamless pathways of care for those with multiple and complex needs leaving prison; and
  • Supporting local primary care services in becoming part of an effective network of agencies that support clients within mainstream services.
Key to the process are:
  • Understanding the needs of those leaving prison and their families (this is being explored via discussions with service providers and focus groups and case studies with prisoners and their families);
  • Understanding the current services available and identifying barriers to access/engagement;
  • Identifying opportunities for improving access/ engagement; and
  • Developing partnership working between agencies