A city's system approach to complex needs provision

Abstract

Like most health and social care services, the system for service users with complex needs is massively fragmented. This group struggle to navigate the system and often fail to receive or access the care they require., Due to the lack of dedicated pathways we see high rates of admissions and readmissions for a population living with complex needs, often related to drugs and alcohol use and managing >2 Long term conditions. 2- A substantial amount of time has been spent on engagement across the city's organisations: Including Integrated Delivery Units, mainstream health services, and workshops with voluntary and 3rd sector. The whole system was mapped in its current state and a future vision articulated. Work has since begun to develop a linked dataset for the group across health services to improve the data on health and homelessness. 3- The focus of this work was to connect the CCG with the Local Authority, Voluntary and 3rd Sector Providers for Liverpool's Complex needs groups in order to co-design a 'health offer'. By making the system visible to itself, new opportunities for person centred improvement are created. 4- Individuals with experience of severe and multiple disadvantage SMD as laid out by Lankelly Chase Foundation research below. SMD 1 - Experiencing 1 disadvantage domain only i.e. homelessness only, substance misuse only offending only SMD 2 - Experiencing 2 out of 3 disadvantage domains in SMD1 SMD 3 - Experiencing all disadvantage domains in SMD 1 5- AQuA have spent 6 months focusing on the 'current state' of the system across Liverpool. The Design phase of the programme' 4 Months involves the whole system and service users. Impact will be measured within 12 months. 6- A Homeless Hub model creates an integrated response to homelessness and rough sleeping and proactive approach to providing care. EMIS homeless template for primary care recording enables a better understanding of the population. The 'test and learn' Community Alcohol Related Brain Injury service via Waves of Hope Project is exploring Brain Injury in the homeless population 7- The relationships built within the city providing the services are not just sustaining but developing. 8- The core concepts of AQuA's model are very flexible. We have tools and techniques that we use to help understand a system and then improve it, each of which can be made bespoke. The learning from our existing projects will ultimately allow us to be more proactive in understanding the needs of other systems earlier. 9- The process of engaging and sharing skills, knowledge and experience across the city has had positive impact 10- Identification of gaps in provision, knowledge and skills are used to enable the system to work effectively across historical boundaries. 11- The services that meet the needs of this population are incredibly varied. A whole system approach will not be easy - with a new approach potentially required to deliver sustainable change.