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Cambridge - How we deliver

How we deliver

The Chronically Excluded Adult service (CEA) offers a co-ordination of existing services for clients who typically have complex and multiple needs, face exclusions from one or more services, and have a history of rough sleeping or homelessness. The CEA service offers an assertive and flexible approach based on the needs and wishes (both short and long term) of clients. It supports local services to adopt the same approach with this group, which is small in number but high in social and service expense. It is governed by a multi-agency group of relevant agencies.

Partnership and Audit

The right people at the table and a shared understanding of the problem

An Operational Group of service managers and a Governance group of commissioners oversees the CEA service. The partnership initially came together to consider the escalating problems of one individual in Cambridge City. By working together a solution was found that made a significant difference to the life of this individual and their physical health, mental health, housing, ASB, alcoholism, drug abuse and vulnerability to exploitation. At the same time, an analysis of premature death at the GP service for homeless clients was included in a specific ‘homelessness’ section of the Cambridgeshire JSNA. The resulting strategy committed Cambridgeshire to exploring coordinated approaches and the City Council, County Council, Police and NHS each put in a relatively small amount to fund a Manager to co-ordinate work for complex needs clients.

Consistency in Client Identification

Being consistent about identification, referral processes and caseloads

Clients are referred to the service using the New Directions Team Assessment. This is a simple tool to assess behaviours and is completed by the referring agency. The CEA service contacts the referrer to validate the assessment scores and get further background information. The multi-agency Operational Group then considers and prioritises each referral. As well as the NDTA score, consideration is given to the effectiveness of previous service responses, repeat returners, the individual’s previous journey through services and their level of engagement. Broadly speaking the caseload is 12 – 15 clients per CEA worker; however capacity is measured on a time needs basis. Case co-ordination is maintained until the support network and client can maintain progress without CEA intervention. This can be a short period to engage clients with services and remove barriers, but may also involve support over a number of years.

Coordination for Clients and Services

The practical resource to link individuals to existing services and to broker engagement from local agencies

The CEA service employs two coordinators to engage with clients and support local services to re-engage. The coordinators have no remit other than to the client and have the authority to explore innovative approaches for individuals. They work to the client’s wishes within the boundaries of law, individual safety and social expectation, using a truly person centred approach that is not constrained by service remits. By doing this and achieving small gains, they earn trust to get things done, but never promise anything they cannot deliver. The coordinators also follow the client’s journey irrespective of where it takes them. Local agencies see the positive benefit to clients of this coordination and the opportunity to effect change in areas where they lack influence.

Flexible Responses From Services

Ensuring flexible responses from all statutory and voluntary agencies

Flexibility from services is vital for the work of the coordinators. The CEA service received senior level strategic buy-in from the start. This has been built on by ensuring that the Governance Group contains sufficiently senior commissioners who have the authority to request service flexibility. Ultimately all involved want the best outcome for that client and having a co-ordinator with a direct link between client and commissioner can help ensure positive outcomes. A broad knowledge base of experience and expertise within the Operational Group ensures that responses are targeted and effective. In addition, the service holds a fund to assist flexible approaches. This is used where no other resource is available and may enable travel to appointments or mobile phone credit to enable clients to stay in contact.

Service Improvement and Gap Filling

Filling any gaps in services and seeking continuous improvement

The CEA service plays a consultative role in the tendering process for services in Cambridgeshire, identifying where gaps exist so that better provision can be made. There have also been discussions around building a requirement for service flexibility into the commissioning process. The CEA service has also involved clients in service development and re-design, using the ‘Working Together for Change’ process. This identified a number of gaps which has resulted in work towards improving these, including new service provision. The CEA service has also been able to ensure that clients who have successfully made changes to their lives are able to inform services and commissioners about why change was possible this time after years of falling through the gaps.

Measurement of Success

A commitment to measuring social and economic outcomes

The CEA service has used several evaluation tools with the support of MEAM. An economic evaluation to measure change in costs associated with Housing, Health, Substance Misuse and Criminal Justice was undertaken. In the first year this showed that significant reductions in costs to the criminal justice system could be made, however there were increases to costs associated with the other areas as client accessed treatment and support which they had not been using previously. Assessments made using the Homelessness Outcomes Star and NDTA at the start and end of the first year showed significant positive change. We have monitored both economic and social outcomes for original clients for a second year with support from MEAM. We are looking to develop a simple tool to measure economic outcomes for new clients so that economic monitoring can be an ongoing process.

Sustainability and Systems Change

Making sure your intervention is sustainable through systemic change

The CEA service is seeking to sustain both the practical coordination it offers and the flexibility from local services. The economic and social evaluation, along with case studies, has demonstrated to all within the original partnership the value of this work. It has also brought new bodies to the partnership and strengthened the Governance Group. Initially, a number of services put in small amounts of money to fund the coordination service and this worked well to ensure buy-in. However, we are now looking at the possibility of mainstreaming within one service whilst continuing to seek smaller contributions from other services to reinforce the strategic significance of the work. Regarding flexibility, the Governance Group continues to make this a strategic priority and early discussions have been held about around building a requirement for service flexibility into the commissioning process.

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