VOICES Legacy Evaluation by VOICES

VOICES OF INDEPENDENCE CHANGE & EMPOWERMENT IN STOKE-ON-TRENT

Legacy Evaluation A final summative report of the implementation of fulfilling lives: supporting people experiencing multiple disadvantage in Stoke-on-Trent MARCH 2022

Authors Christopher Gidlow Centre for Health and Development, Staffordshire University Kostas Spyropoulos Centre for Health and Development, Staffordshire University Fiona McCormack Centre for Health and Development, Staffordshire University Naomi Ellis Centre for Health and Development, Staffordshire University Ros Beddows Research, Innovation and Impact Services, Staffordshire University Sophia Fedorowicz Centre for Health and Development, Staffordshire University Rachele Hine Expert Citizens

Other Contributors Sharon Sharman Director, VOICES Andy Meakin YMCA (former Director of VOICES) Nic Gratton Research, Innovation and Impact Services, Staffordshire University Adam Gratton Research, Innovation and Impact Services, Staffordshire University Ryan Fox Research, Innovation and Impact Services, Staffordshire University Victoria Riley Centre for Health and Development, Staffordshire University

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This research was funded by The National Lottery Community Fund through VOICES. We are grateful to Andy Meakin and Sharon Sharman for their support throughout the process. We would also like to acknowledge Expert Citizens, especially those from the Get Talking group who provided input on Situational Analysis and implications; evaluation Steering Group members; VOICES Partnership Board; and all those who contributed to the discrete projects that feature in this report, including participants and stakeholders.

Contents Executive Summary..................................................................... 4 1. Introduction............................................................................. 7 1.1 - Multiple disadvantage........................................................................... 7 1.2 - VOICES (Voices of Independence Change and Empowerment in Stoke-on-Trent)................................ 8 1.3 - Evaluation aims and objectives............................................................ 9 1.4 - Evaluation outline.................................................................................. 9

2. Key Learning from Discrete Projects...................................11 2.1 - Introduction...........................................................................................11 2.2 - Hard Edges 2021...................................................................................11 2.3 - City centre rough sleeping and street activity (2016).......................12 2.4 - Systems change impact evaluation (2017).........................................13 2.5 - Gatekeepers: Access to primary care for those with multiple needs (2018)..................................................................14 2.6 - Hospital discharge and homelessness (2019)...................................15 2.7 - Personal Budgets in Service Coordination (2019).............................17 2.8 - Citywide Learning Programme Evaluation (2020).............................18 2.9 - Care Act Toolkit (2020)..........................................................................19 2.10 - Annual Stakeholder Survey (2016-2020)..........................................20 2.11 - Specialist Welfare Benefit Advice and Advocacy at VOICES (2018)................................................................22 2.12 - Specialist welfare advisor model – three other settings (2021).........23 2.13 - Housing First in Stoke-on-Trent: Evaluation (2021)........................24 2.14 - Multi-agency Resolution Group (2021).............................................26

3. Get Talking..............................................................................27 3.1 - Aim .........................................................................................................27 3.2 - Introduction to Get Talking..................................................................27 3.3 - Summary of the approach...................................................................28 3.4 - Output....................................................................................................28 3.5 - Outcomes of Get Talking for the VOICES legacy...............................30

4. Overall Evaluation of VOICES through Situational Analysis...31 4.1 - Introduction...........................................................................................31 4.2 - Method...................................................................................................31 4.3 - Data collection and analysis: Situational maps (Stage 1).................32 4.4 - Data collection and analysis: Social worlds/arenas maps (Stage 1)..........32 4.5 - Data collection and analysis: Main findings - Positional maps (Stage 3)..35 4.5.1 - Fair access to local support services of people experiencing multiple disadvantage.........................................................................35 4.5.2 - Housing First.......................................................................................40 4.5.3 - Making Service users leaders in service design and commissioning...........................................................................44 4.6 - Summary of Situation Analysis: VOICES addressing failure demand through promoting equity.......................................46

5. Strengths and limitations of the evaluation......................49 6. Implications............................................................................50 6.1 - Fair access to services..........................................................................50 6.2 - Housing First..........................................................................................52 6.3 - Making service users leaders in service design and commissioning.....52 6.4 - Summary................................................................................................53

7. References..............................................................................54 Appendix 1. Resources for Situational Analysis.....................56 Appendix 2. Situational messy map........................................59 Appendix 3. Situational order maps........................................60 Appendix 4. Situational relational map Fair Access to Services.........................................63 Appendix 5. Situational relational map Housing First.........................................................64 Appendix 6. Situational relational map Expert Citizens......................................................65

Executive Summary Background This report presents a summative evaluation of VOICES, the Stoke-on-Trent implementation of the national Fulfilling Lives: supporting people experiencing multiple disadvantage programme. VOICES was an eight-year partnership project (20142022) that sought to empower people experiencing multiple disadvantage to improve their lives and to influence the services on which they depend. The VOICES programme included a wide range of discrete projects, evaluations, and development work to influence various parts of the system, aligned with three priority areas: Ensuring fair access to services; Housing First; Making service users leaders in service design and commissioning.

Approach This 12-month evaluation (JanDec 2021) drew on learning from the discrete projects/activities and evaluation reports, and used Situational Analysis for a qualitative exploration (with a systems lens) of the wider systems change resulting from VOICES work in each priority area. Expert Citizens were involved as evaluation partners, and also contributed through participation in accredited training (‘Get Talking’) and as a panel of experts with lived experience and knowledge of VOICES.

Main findings Learning from the discrete projects highlighted successes of, and challenges encountered

through VOICES work. The Situational Analysis drew on this learning and summarised the systemic challenges facing VOICES customers and progress made by VOICES in each priority area, with an overarching theme of addressing failure demand (demand caused by a failure to act effectively for the customer) in the system of support for people experiencing multiple disadvantage, through working to promote equity rather than equality.

Fair access to local support services for people experiencing multiple disadvantage Stigma and marginalisation among some personnel in support services were identified as fundamental barriers to people experiencing multiple disadvantage accessing services. This was exemplified through dysfunctional processes for hospital discharge and primary care registration in people experiencing homelessness. VOICES made important moves to challenge this problem through producing legally informed materials and recommendations to raise awareness; co-producing solution-focused products that challenge stigma and marginalisation (e.g., INSIGHT, Care Act, the Mutlple Needs Toolkit, Multiple Exclusion Homelessness Safeguarding); and empowering and training public sector professionals to acknowledge the importance of lived experience through the VOICES Citywide Learning Programme.

Silo working among organisations and the resulting responsibility gaps were observed in a fragmented system of support services. This jeopardises effective coordination between services and can lead to gaps in responsibility and accountability, which can be particularly important when people are exiting crisis services (e.g., hospitals, prison), where a clear understanding of respective legal responsibilities is critical for continuity of care and to avoid a return to crisis situations. VOICES challenged these issues through multiagency approaches and solution-focused interventions that develop knowledge in key organisations and support changes in practice, targeted learning programme opportunities, communities of practice and through the integration of specilist welfare benefit advisors within specific services. A lack of legal literacy appeared to be a common problem that was largely unchallenged before VOICES. There was evidence that frontline personnel in the public and third sector lacked knowledge of important legislation, which acts as a serious barrier to people experiencing multiple disadvantage accessing the services they need and to which they are entitled. VOICES helped to improve legal literacy in the system through developing toolkits (e.g., Multiple Needs Toolkit) and models (e.g., specialist welfare benefit advisor models) to facilitate development of related knowledge and skills in frontline staff. Resistance to change at both organisational and individual levels was evident as a barrier to changing ways of working that could improve access to

services. This was exemplified in the Welfare Benefits Leading and Learning (WBLL) model. Having a specialist welfare benefit advisor embedded in support services elicited resistance at both operational (functional) and organisational (structural) levels. Such resistance to change is a well-known phenomenon in systems thinking and various solutions should be planned and tested to mitigate the problem.

Housing First VOICES has had considerable success through initiating a Housing First programme in Stoke-on-Trent, funding a 12-month extension (until 2022), and commissioning a local evaluation to give an evidence-based rationale for its continuation and suggestions to improve the future delivery model. However, issues regarding the programme remain. Limited availability of suitable properties was the perennial challenge of Housing First Stoke-on-Trent. A general lack of single occupancy properties in Stoke-on-Trent compound the difficulties in securing a consistent supply of such properties from the council and housing associations. The resulting reliance on private landlords, in some cases, created problems with quality and location of properties. The result was that some customers had to choose between accommodation that is unsuitable (based on quality and/or location) or wait for suitable accommodation (perhaps in hostel or on the street), with delays in securing a tenancy being linked with worse outcomes among customers (evidenced by higher demand on criminal justice system and health services). 5

Sustainable Housing First programmes require it being adopted as a key local strategy for tackling chronic homelessness, yet the culture shift among local partners was not evident. Rather than accepting the principles and ethos of Housing First, it appeared more likely that a revised programme that adheres less rigidly to the Housing First principles would be more acceptable. Housing First was still being considered as a housing solution, rather than a holistic health and well-being intervention. Therefore, only the cost of implementation (compared with other housing solutions) was considered, without acknowledgement of the cost of doing nothing, or the wider benefits of effective intervention (e.g., reduced demand on criminal justice system, emergency hospital care, 24/7 social care services).

Making service users leaders in service design and commissioning People with lived experience have been at the heart of VOICES work. With VOICES support, they have become established within the political agenda and can be considered a key requirement of a systems change approach. The most substantial contribution to the VOICES legacy in this area relates to the establishment and evolution of Expert Citizens. This evaluation is focused on the legacy of VOICES and, therefore, as a fundamental part of that legacy, Expert Citizens are discussed in that context, while recognising that they operate as an independent, autonomous group who no longer rely on VOICES funding.

Development of Expert Citizens CIC is a cornerstone achievement of VOICES. It is the pinnacle of co-production between VOICES partnership and local people with lived experience, in addition to subsequent, and no less important co-development and co-production between VOICES and Expert Citizens-CIC methodologies and toolkits. Sustainability of Expert Citizens CIC is a product of VOICES and Expert Citizens own endeavors. First, Expert Citizens are embedded through the Changing Futures plans through which the city will support people experiencing multiple disadvantage over the next 2-3 years. Second, through VOICES commissioned work, Expert Citizens have partnered with academic teams in various projects (e.g., CHAD, Keele), which has developed experience of academia to allow this work and other partnerships to develop, whilst also beginning to apply their lived experience expertise into other settings (i.e. health). Peer Mentoring whereby support is given to the VOICES customers by people with lived experience who joined Expert Citizens and received training, was used primarily for Housing First. Learning from peer mentoring within VOICES (which was discontinued), Expert Citizens deliver and manage Housing First peer mentoring. This has shown value in building informal relationships with customers and providing support around activities of daily life. Whilst acknowledging the complexities of the model and need for adequate support, peer mentoring was included in the recommendations for the future Housing First specification, potentially augmenting the legacy of lived experience.

Conclusion VOICES has had a substantial impact on the system of support for people in Stoke-on-Trent who are experiencing multiple disadvantage. During the eight years of VOICES, there has been progress against all three priority areas for systems change, which should now be built on through the Changing Futures funding (2-3 years funding to deliver improvements for adults experiencing multiple disadvantage at the individual, service, and system level). Learning from VOICES has shaped the Changing Futures approach; successful components are included e.g. Case coordination Multi-Agency Resolution Group (MARG) CRM Welfare Benefits Leading and Learning (WBLL) Centre of Excellence (Citywide Learning Programme) Where VOICES was unable to effect change the learning from VOICES commitment to research and evaluation has informed alternative approaches.

1. 1.1

Introduction Multiple disadvantage

This report presents a summative evaluation of the VOICES programme, which was the Stokeon-Trent implementation of the national Fulfilling Lives: supporting people experiencing multiple disadvantage. Fulfilling Lives was established by the National Lottery Community Fund (formerly Big Lottery), investing £112 million across 12 areas of England that had high concentrations of people experiencing multiple disadvantage. The aim was that each area develop partnerships with local people with lived experiences, service providers and commissioners, to design, test and implement different approaches to improving the lives of people experiencing multiple disadvantage. Despite variation in terms used to describe those who would be target beneficiaries of the programme, including multiple needs and complex needs, we will use the term ‘multiple disadvantage’, which has been defined as: “

Experience of two or more of homelessness, offending, substance misuse and mental ill health” [1,pg 5]

Common to the concept of severe and multiple disadvantage (SMD) offered by Lankelly Chase, we use this to refer to those at the ‘extreme margins of social disadvantage’ [2, p11] who tend to have much worse health and quality of life compared to many other low income and vulnerable people, and can create a substantial cost for the rest of society, particularly with respect to disproportionate use of certain public services (e.g., emergency health care, criminal justice system). Fulfilling Lives aimed to improve the lives of this group by: Providing learning which can be used to create system change Addressing the combination of factors that can affect the person, in a way that is simple and straightforward for individuals to navigate, with a single access point Assuming that people can improve their own circumstances and life chances with the right support Engaging people with lived experience of multiple disadvantage in the design and delivery of services.

1.2

VOICES

(Voices of Independence Change and Empowerment in Stoke-on-Trent) VOICES was an eight-year partnership (2014-2022) project that sought to empower people experiencing multiple disadvantage to change their lives and to influence the services on which they depend [3]. VOICES customers (i.e., those experiencing multiple disadvantage) are people whose lives have been seriously affected by events and conditions over a prolonged period. To improve their lives, health and wellbeing, requires action and support from a system of different sectors and organisations [4].

To affect sustainable changes, VOICES has taken a whole systems change approach A core function of VOICES was casework and service coordination to ensure people experiencing multiple disadvantage are supported. It was delivered by an operational team that coordinated a range of services and stakeholders around people currently experiencing multiple disadvantage. Part of its mission is to change systems through casework and assertive advocacy to help people access appropriate services. Even within the partnership this is not always easy. Work needs to be done to understand the drivers behind these barriers, which may be, for example, skills-based, culturally constructed, or process driven. Central to all the work undertaken are the voices of those with lived experience. The Expert Citizens, supported by VOICES have formed their own Community Interest Company and are central to the progress of change in the city and the legacy of the VOICES project. 8

The VOICES work has included a wide range of discrete projects, evaluations, and development work to influence various parts of the system, aligned with three priority areas: Housing First Ensuring fair access to services Making service users leaders in service design and commissioning Evaluations to date around many aspects of this work have indicated important impact of VOICES work on VOICES customers, partner organisations and how they work together (i.e., some evidence of systems change). However, a sustainable legacy of VOICES beyond the life of the project is contingent on changes that mean people who experience multiple disadvantage are supported through a better functioning and coherent system when the VOICESfunded activity is no longer there. This evaluation employed a systems methodology. The wider system within which VOICES has been operating and trying affect, can be considered as a complex non-centrally controlled system of interdependent, autonomous parts that are expected to (but often do not) function as a coherent whole to improve the circumstances and lives of those experiencing multiple disadvantage[5]. The complexity of understanding the impact of VOICES’ work and its potential legacy means that traditional research methods grounded in linear models of cause and effect, are unsuitable [6]. A shift toward methods that focus on complexity theory and systems change approaches is necessary to evaluate both VOICES impact on promoting health and health equity in the multiple disadvantage population, and for generating knowledge about the processes implemented for building the VOICES legacy [7].

This summative evaluation examined what has changed as a result of VOICES work and the potential legacy post-March 2022. It drew on learning from the discrete projects and evaluations, including an overall Hard Edges evaluation, and took a qualitative approach (with systems lens) to examine the wider systems change. Expert Citizens’ lived experience provided ongoing insight and validation of findings.

1.3 Evaluation aims and objectives The overarching aim of this evaluation was to understand the impact of the VOICES partnership and its legacy. This was addressed through a series of objectives: Draw key learning from discrete evaluations Use Situational Analysis to explore the role of VOICES in effecting systems change for each of the VOICES priority areas Embed lived experience in the evaluation through Expert Citizens Get Talking training to add to the legacy through further professional development Consider the VOICES legacy in the context of the city’s ongoing plans around support for people experiencing multiple disadvantage.

1.4 Evaluation outline As summarised in Figure 1, the approach drew on learning from discrete projects, which are summarised to provide a standalone record of the legacy of VOICES projects and the associated learning from research/evaluation.

These reports, a range of other data sources (e.g., project reports, partner organisation websites, minutes from meetings, project proposals), and additional discussions/workshops with key stakeholders, fed into an overarching systems analysis, using Situational Analysis[8].

After considering the strengths and weaknesses of this summative evaluation, we conclude by considering the implications: what is the legacy of VOICES in the context of the city’s plans for supporting people with multiple disadvantage postMarch 2022.

As detailed in Section 4, Situational Analysis was well suited for this purpose because: the situation (i.e. the system of support for people experiencing multiple disadvantage in Stoke-on-Trent) is complex and methods to study linear models of cause and effect were inappropriate; it can use data gathered using various methods; it is iterative and data driven (not for hypothesis testing); it is one of the few complex systems methodologies that places the importance of context at the heart of its investigation[9]. Situational Analysis results in a series of maps that show different positions around key issues or discourses. These offered a useful means of considering the problems that VOICES were trying to address, the previous or current conflicting positions to change, and the progress made by VOICES. Concurrent work using Get Talking training was included to allow members of the research team and Expert Citizens to collaborate and reflect on the contribution of VOICES, whilst providing further professional development and accredited learning to Expert Citizens in the Get Talking approach. Finally, and critically, this provided a panel of individuals with lived experience of multiple disadvantage and VOICES to have input on various parts of this summative evaluation (e.g., Situational Analysis, interpretation of data, implications).

Figure 1. Overview of evaluation approach 10

2. 2.1

Key Learning from Discrete Projects Introduction

This section summarises key learning from many (not all) of the discrete programmes of work and commissioned research/ evaluations within the VOICES programme. Section 2.2 represents the overall findings from Hard Edges, which draws on service use data from across the VOICES programme. The remainder of the section presents projects in approximately chronological order and provides references to reports and outputs for each piece of work.

2.2

Hard Edges 2021

Background Using a framework set up by the national evaluators of the Fulfilling Lives programme, data were collated on VOICES customers’ contact with criminal justice and health services before and during engagement with VOICES. Hard Edges 2021 [10] built on two earlier Hard Edges reports [3, 11] by analysing data from all 116 customers across the total VOICES customer base (2014-2020) for whom at least 12 months of data were available. Analysis explored changes in service use and associated costs, overall, by gender and for those referred to Housing First.

Key Learning Substantial reductions in customers’ service use were observed during year 1 of VOICES support, with the largest reductions in Magistrates’ court appearances and A&E episodes, followed by number of arrests, nights in police custody, and hospital in-patient episodes.

Applying unit cost estimates to each type of service contact showed an overall reduction from one year of VOICES support of £604,060, with an average reduction of £5,207 per customer. In those supported by VOICES for more than one year, we observed a non-linear response and a particularly complex picture for changes in health service use over time. For the 60 customers who were supported by VOICES for at least two years; after year one, there were modest reductions in magistrates court appearances and arrests, a stabilising of reduced levels for nights in custody and A&E episodes and increases for inpatient episodes. Analysis of data for the 27 customers supported for a third year showed that, after year 2, contact with the criminal justice system remained stable, but health service use increased (both planned and emergency). Overall changes in service use appeared to reflect large reductions in a small number of customers who had the highest level of contact, with a disproportionate impact on the observed overall patterns. Reductions in service contact and costs among female customers were smaller than those observed for male customers. From pre-support to year 1, the marked difference in mean cost per customer (women -£475; males -£7,258) was largely attributable to a small increase in planned hospital care in women and a large corresponding decrease in men. Therefore, what appeared to be a costly lack of a reduction in hospital care in women, could show a marked

benefit in terms of better access to planned care in female vs. male VOICES customers, or gender differences in using healthcare when it is available. This requires further investigation. Objective indicators of service use and cost provide useful proxies for impact on customer need and the potential financial benefit of intervention in terms of demand avoided. However, outcomes do not reflect all relevant areas of service use and related behaviours (e.g., mentalhealth inpatient episodes, custodial sentences, use of rough sleeper services, repeated new welfare benefit claims and related administration, evictions from supported housing and other types of accommodation, behaviour that could be regarded as antisocial, e.g., begging and street drinking). Nor do they reflect the wider impact on customers’ quality of life and experience.

An overall reduction from 1 year of support from VOICES

£604,060 which is an average reduction of

£5,207 per customer

60 customers

were supported by

for at least two years the results show that After year 1, there were modest reductions in magistrates court appearances and arrests

Hard Edges (2015) estimated that there were 2,155 people in Stoke-on-Trent who had a similar needs profile to the research cohort (this is now likely to be higher and will continue to rise). If the same reduction in service contact across the five indicators used in this report were realised through better coordination of services for half of this group (1,078), the cost reduction could be over £5.6 million per year of service contact. A more nuanced analysis would be required to consider the increase in cost of support services required to meet this need, in addition to the expansion of service coordinators, and the unmeasured impacts on other services (e.g., prison and mental health inpatient services, reduced re-offending and associated prison time) and the wider societal costs of crime (e.g., impact on victims’ health, economic activity, etc).

2.3 City centre rough sleeping and street activity (2016) Background

MAGISTRATES' COURT APPEARANCES

ARRESTS

REDUCTION

and stabilisation of reduced levels for nights in custody and A&E episodes and increases for in-patient episodes

MAGISTRATES' COURT APPEARANCES

INPATIENT EPISODES

VOICES, Expert Citizens and Staffordshire University collaborated on a research project to help inform the debate locally about perceived city centre homelessness and anti-social behaviour and inform the development of positive city centre solutions which recognise the needs of people engaged in street activity alongside those who live, work and shop in the city centre. This research explored perceptions and experiences with stakeholders and core participants (those perceived to be curently experiencing homelessness), which concluded with nine recommendations and a stakeholder action plan that

was presented in a final report [12], in addition to a peer-reviewed output [13]. As part of this project, Expert Citizens were trained to conduct the data collection to understand the views, experiences, and assets of a wide range of individuals perceived to be curently experiencing homelessness (n=8) and stakeholders (n=10), which was followed by a participatory stakeholder workshop to develop the action plan.

Key Learning Context Perception that the number of ‘rough sleepers’ in the city centre was increasing. Stakeholders acknowledged that street activity can be ‘off-putting’ and contribute to a negative environment in the city centre, impacting upon local businesses, staff, shoppers, and visitors. Frustration from local businesses around issues they felt were not being addressed. Stakeholders highlighted the multiple and complex health needs of individuals perceived to be currently experiencing homelessness and/or engaging in street activity. Mental health, alcohol and drug-related issues were all mentioned. Accessing services was identified as difficult for individuals, with a sense that they may not be receiving or completing treatment and may lack access to a GP. Those engaging in street activity are not necessarily rough sleepers.

Perceived Pull Factors Opportunities for the individual to access money and food (through begging), drugs and alcohol and for shoplifting and crime. City centre was perceived as a safe environment for those perceived to be currently experiencing homelessness.

The presence of others, lighting, and CCTV cameras were all considered to offer a sense of safety and/or protection. There was a perception that the city centre offered a sense of community in comparison to other more isolated areas.

Potential Solutions

Access to support as the first approach, supported where necessary, by anti-social behaviour powers. Further research into services to understand their strengths, limitations, what works well and what does not work so well (e.g., prisons, hostels).

Coordinated partnership working to involve public, private and third sector organisations.

Insight evaluation to be embedded within all commissioned services addressing multiple disadvantage.

Provide opportunities to include somewhere for people to go and meet during the day, enhanced one-to-one support provision (including outreach for individuals at risk of rough sleeping), provision of specialist services (alcohol, drugs and mental health), proactive and accessible services.

Engage other stakeholders with discussions on city centre street activity and rough sleeping (e.g., re-settlement teams and street chaplains).

Accommodation options which improve and expand existing provision (e.g., Housing First) and further research to understand and learn from the challenges with the current model. More visible police presence to both deter street activity and signpost to support services. Education of the public to encourage donations to local homelessness charities instead of individuals.

Implications Nine co-produced recommendations emerged from the findings and stakeholder discussions. Education and awareness raising (including the public, local businesses, public sector, authorities, and rough sleepers). City Centre as its own locality with dedicated City Centre Manager who can support better join up of services. Work towards implementation of ‘day opportunities’, with joined up services, facilities and opportunities to engage in meaningful activity.

Sharing of best practice between providers of various services (e.g., housing, benefits, health). Provide service users with a voice and opportunity to input and engage with the process. Several actions were agreed at the stakeholder event and highlighted stakeholders’ commitment to improving the current situation. These actions fall into three categories – maintain and build upon existing activity; engaging more stakeholders and partnership working; changing perceptions and policy.

2.4 Systems change impact evaluation (2017) Background This 2017 report aimed to provide an overview of systems change progress made in the three VOICES priority areas of Housing First, ensuring fair access to services, and making service users leaders in service design and commissioning. The report drew on the systems change literature, discussion groups and interviews, and analysis of data provided by the VOICES team, and a wider body of evidence gathered during the ongoing evaluation of the VOICES project since December 2014 [14]

Findings and Implications Housing First This report concluded that Housing First was now accepted as part of the pathway for people experiencing homelessness and multiple disadvantage. Opportunities to involve people with lived experience should be explored. Ongoing risks to sustaining Housing First included the identifying/encouraging appropriate landlords to engage, and seeking ways to mitigate potential impact of welfare reform. A specific evaluation for Housing First in Stoke-on-Trent was recommended.

Making service users leaders in service design and commissioning INSIGHT evaluations and conference, specific projects (e.g., ‘Gatekeepers’ report’) and membership of the Partnership Board and other forums have embedded the role of the Expert Citizens within Stoke-on-Trent, which should be expended and continued locally. VOICES and Expert Citizens should continue to seek involvement in commissioning of individual services, testing and building evidence around mechanisms for co-production in commissioning. Strategic priority should be placed on recruitment to and refreshment of the core Expert Citizens group, and efforts to reach out to those who are experiencing multiple disadvantage. Expert Citizens and VOICES should ensure that the Community Interest Company (CIC) adds value for VOICES and Stoke-on-Trent. 14

Fair Access to Services The service coordination team should consider ways to record examples of advocacy for customers’ fair access to services. Assertive advocacy on a casework basis was shown to be a powerful tool for enabling fair access; part of VOICES legacy could be recognition that a small team working flexibly with small caseloads is an ongoing need to sustain and progress fair access systems change.

2.5 Gatekeepers: Access to primary care for those with multiple needs (2018) Background This work responded to issues among those with multiple needs in Stoke-on-Trent when trying to access primary health care. Through gathering data from stakeholders, intelligence and experience, and using a mystery shopper approach, Expert Citizens worked with Healthwatch Stoke-on-Trent and VOICES to understand the exclusion from primary care of people experiencing homelessness [15].

Key Learning General Practice willingness to register a person of no fixed abode (NFA)

26.1% YES

47.8% NO

26.1% MAYBE

Said they would not register an NFA patient (21.7% signposted to Snow Hill Surgery or walk in centres) Said they would need to seek advice from colleagues Said they would accept the patient

Barriers and Gatekeeping Not being registered with a GP prevents people experiencing homelessness accessing other services they need such as a social care, mental health, drug services. Primary care gatekeeping staff (e.g. receptionists) do not understand the needs of this group. Lack of clarity among general practice staff meant that it was unclear how much autonomy gatekeeping staff have in making such decisions. Barriers to care for patients included stigma, distance to travel and substance abuse. Risk of stigma arises through people of NFA status receiving a different type of service offer to those able to provide an address.

Implications All practices should register people experiencing homelessness in accordance with the NHS England guidance. Guidance from the Gatekeeping report (and subsequent toolkit) should be communicated to inform GP Practices of their obligations to register NFA patients. Gatekeeping staff (e.g., receptionists) may need training to understand the needs of people experiencing homelessness and how to build relationships with them. Further work should seek to understand disincentives for practices and staff regarding the registration of people of NFA (e.g., registration fraud, attendance requirements). Training delivered by Expert Citizens could address misconceptions or stereotypes. Systematic monitoring arrangements should ensure that practices adhere to best practice.

2.6 Hospital discharge and homelessness (2019) Background Historically, discharge protocols for homeless individuals have been poor. Research by Homeless Link and St Mungo’s Broadway (2012) reported that over 70% of homeless people had been discharged from hospital back to the streets, without their housing or underlying health problems being addressed [16]. With the implementation of the Homelessness Reduction Act [17] in April 2018, this was a timely exploration of local hospital discharge processes and practices for homeless people. VOICES commissioned a qualitative study of stakeholders’ views about hospital discharge and the wider context for people experiencing homelessness in Stoke-on-Trent. Data were presented from interviews with 27 stakeholders representing the local authority (n=7), third sector (n=12) and NHS (n=8). A stakeholder feedback event in June 2019 (with 20 wider stakeholders) was used to discuss preliminary findings, and coproduce recommendations, which are presented in a final report [18] and peer-reviewed article [19].

Key Learning Stakeholders emphasised the complexity, particularly in the context of limited resources. The overriding sense was that the current mainstream health system does not work for this group. Challenges for hospital discharge and homelessness: Multiple and complex needs of this group can pose a challenge for the mainstream healthcare system, with issues of marginalisation, stigma, and prejudice. Some health professionals were thought to lack the willingness, knowledge, skills, or capacity to work effectively with this group.

Hospital discharge in the context of limited resources: Recent funding cuts had led to decreased capacity across the system, with pressure in hospitals to ‘free up beds’. There were difficulties for people experiencing homelessness in accessing follow up support (including mental health, social services, appropriate after care and accommodation). There were problems around medication and prescribing during hospital stays and/or arising after discharge. Discharge letters were considered ineffective (often sent to GPs, rather than handed to the individual on discharge). Lack of planning and poor communication and coordination between hospital and services (i.e., silo working). Lack of knowledge around the needs of this group was discussed, as was poor communication with homeless individuals by professionals. Perceived lack of understanding of the HRA and its requirements amongst some hospital staff. Questions raised around who has responsibility for ensuring an effective and timely hospital discharge. Sense that the third sector were working above and beyond their remit in providing support and advocacy for people experiencing homelessness, which could mask the extent of the problem which would otherwise be felt by statutory organisations. Difficulties in monitoring and capturing accurate information about the extent of engagement with hospital services for people experiencing homelessness made it difficult to evidence the extent of the issue and raised questions around accountability.

Implications There is a need for a partnership approach that is multi-disciplined and co-ordinated. All services and sectors need to be involved, including people who have experienced or are currently experiencing homelessness. General training to improve understanding around the homeless population and their needs, which could be delivered by experts’ by experience and/or the third sector. Specific training for frontline staff around identifying people who are experiencing homelessness and the requirements of the Homeless Reduction Act (HRA). Develop site-specific pathways to provide standardised approaches to hospital discharge for this group, including agreed procedures that relate to the HRA. Improve identification and recording of housing need on presentation to hospital to allow for better communication and planning ahead of discharge. Disseminate information about existing services and their roles to front line staff (such as posters), which needs to be regularly updated. Reinstate the previous Homeless Matron (which has been discontinued) with a focus on outreach, flexibility, and personcentred approach. Introduce provision. Improve access to primary health care for those experiencing homelessness. Improve the provision of appropriate housing for this population. Review hospital discharge processes and practice in local hospitals, including the use/ provision of discharge letters. Develop a checklist for practice before discharge to ensure measures are in place for accessing following on care and support.

2.7 Personal Budgets in Service Coordination (2019) Background This report presents findings from a small-scale independent evaluation of VOICES innovative model of using personal budgets in service coordination work [20], described as ‘personal budget[s], managed with the Service Coordinator, to ensure that the right help is there for [customers] on their journey’. VOICES customers were allocated annual personal budgets of £1,000 to be used in partnership with the Service Coordinators to support them towards positive outcomes, from securing initial engagement to creating a home or connecting the customer with services. This is based on an aspiration to provide choice and control for VOICES customers. Customers were aware of personal budgets, they are designed to be used flexibly as and when needed, rather than being an amount that a customer is entitled to spend. This is linked to the MaRG (section 2.12), which has some responsibilities to promote effective use of personal budgets for helping people to overcome several barriers reported to MaRG.

Key Learning Implications Level of use: From October 2014 to December 2018, 174 customers used their personal budget allocation. Data from 2018 showed an annual total amount claimed of £164,500, with customers usually claiming between £100 and £500 per year; only 14 (8%) exceeded the £1000 (maximum claim £5,153). Type of use: Highest categories of expenditure were: temporary accommodation, £24,159 (average £153/transaction); clothes, £14,867 (average £33/transaction); permanent accommodation, such as

rent deposits and agents fees, £14,540 (average £255/ transaction). There were many small transactions, usually for a hot drink, snack or bus pass.

Benefits of personal budgets Addressing immediate needs and promoting engagement. One of the first uses of the personal budget for many customers was to meet basic needs such as purchasing food, clothing, and toiletries, often when customers are rough sleeping or sofa-surfing. Such purchases also give Service Coordinators a useful means of creating rapport. Finding and sustaining accommodation, such as securing emergency accommodation (e.g. basic hotel costs), securing access to private rented sector accommodation (e.g. deposits or agents’ fees), making accommodation ‘feel like home’ (e.g. furniture, bedding, utensils and soft furnishings), managing moves and crises (e.g. paying moving costs and cleaning costs). Addressing services. Practical support to ensure that customers were aware of and could attend appointments (e.g., paying for travel, phone/credit), and access to necessary independent expert assessments (e.g., occupational therapy, mental health assessment), or legal advice to advocate for access to health and care services. Independence and Wellbeing. Expenditure to support meaningful use of time to help manage mental health, such as gym memberships, fishing equipment, cycling equipment and clothing, newspapers, art and craft equipment such as sketchbooks and colouring pencils, and veterinary services.

From

Oct 2014 — Dec 2018

174 customers

used their Personal Budget Allocation Data from 2018 shows... Total amount claimed

£164,500 Customers usually claimed between

£100—£500 a year

Only 14 (8%) exceeded the £1000 maximum claim

The 3 Highest categories of expenditure during this time...

TEMPORARY ACCOMODATION

£24,159

CLOTHES

£14,867

PERMANENT ACCOMODATION

£14,540

Implications

From

2016—2019 The Learning Programme delivered

more than 250 learning opportunities

Continued use of personal budgets by VOICES and promotion of this model to other services were recommended, especially as part of the exit plan and legacy post2022, because: Personal budgets help to build trust and connection with customers. Relatively small amounts of money can make a big difference. Personal budgets support service coordination work. Personal budgets promote creativity, positivity and problem-solving. Personal budgets enhance advocacy work.

Over

2,200

participants in masterclasses, accredited and non-accredited courses

This number

grew to over

2,300 in 2019 across all Learning Programme Opportunities

Challenges and risks The flexibility of not having a pre-defined sum can create a lack of clarity for customers, and challenges to ensuring consistency and fairness. There was a perceived risk of people wanting a VOICES worker ‘for the budget’ or potential for unrealistic or unreasonable expectations use of the budget. The VOICES model was seen to depart somewhat from the Fulfilling Lives evaluation report as there was freedom to use budgets for ‘life-enhancing activities’ and to ‘plug the gaps in services’, in addition to basic living costs and managing crises.

2.8 Citywide Learning Programme Evaluation (2020) Background The VOICES Citywide Learning Programme aimed to contribute to systems change by supporting professionals to acknowledge the importance of lived experience as a core component of their own learning process, which could improve local support services

for people experiencing multiple disadvantage. Through consultation with participating organisations, input from Expert Citizens and VOICES’ expertise through service coordination work, a flexible and responsive programme was developed, covering: Legislative change and policy landscape, and how to best navigate systems. Up-to-date expertise on issues currently affecting those experiencing multiple disadvantage, and how to best support these needs. Root causes of multiple disadvantage to inform empathetic and effective practice. Professional development (e.g., wellbeing and resilience) to support customers, volunteers, colleagues, and multi-agency working. The programme was delivered through standalone masterclasses, accredited and non-accredited courses, bespoke workshops, and Communities of Practice (CoP). An evaluation drew on programme monitoring data, and interviews with stakeholders (e.g., specialist learning facilitators, Expert Citizens and learning programme participants) [21].

Key Findings Participation From 2016 to 2019, the Learning Programme delivered more than 250 learning opportunities, with over 2,200 participants of masterclasses, and accredited/ non-accredited courses. In 2019, there were over 2,300 participants across all Learning Programme opportunities (including 700 attendees of masterclasses, and accredited/ non-accredited courses, covering 30 organisations, and 28 bespoke workshops, often delivered in response to specific requests from local organisations).

Impacts and Contribution to Systems Change Individuals who participated reported benefits through increased knowledge, skills and confidence. Sharing lived experiences of people with multiple disadvantage was particularly impactful. Bespoke workshops codelivered by Expert Citizens were particularly impactful for some organisations who subsequently commissioned their own training programmes. Empowering individuals to advocate effectively for customers and strive for accountability. The shared learning environment fostered professional connections and networks. Cross-organisational impact was achieved through improving organisations’ culture and practice, and willingness and ability to work together towards a more flexible and solutions focused approach to service delivery. Embedded a culture of shared learning, so that organisations across Stoke-on-Trent can continue to come together for peer and expert-led learning opportunities. Positive experience and future asset for Expert Citizens CIC, mainly through their central roles in the co-design and delivery of learning opportunities.

Implications Organisations should continue to encourage and enable staff to attend the Citywide Learning Programme. VOICES need to continue seeking greater attendance by health sector colleagues and senior staff. VOICES need to focus remainder of the Learning Programme on shared learning experience, high quality provision and lived experience.

VOICES should promote the Citywide Learning Programme, including to funders at the National Lottery Community Fund (given the unique breadth and scale). Other areas or organisations arranging training on multiple disadvantage should: - Incorporate the three key success factors from the VOICES Citywide Learning Programme. - Undertake ongoing consultation with services and customers to identify bespoke learning needs to influence the design and delivery of a shared learning programme. - Consider how crossorganisational training will impact on internal training to avoid duplication. - Consider from practical issues (e.g., promotion, booking tools, venues, administration).

2.9 Care Act Toolkit (2020) Background VOICES recognised the potential of the 2014 Care Act to facilitate access to help for people facing multiple disadvantage. However, initial referrals to Adult Social Care Services were often unsuccessful, providing narrative accounts of the drama of people’s lives, thus not aligning with Care Act requirements, or the way that social workers understand need. Consequently, referrals were being dismissed as behavioural problems or lifestyle choices. Once the need for a tool was recognised, Head of Services at VOICES undertook research into the legal framework focusing on identifying physical or mental impairments, and their impact on a person’s ability to achieve in different aspects of their life, such as maintaining personal hygiene and relationships. The management team then worked together to develop a toolkit

that was accessible and easy to use by staff, providing guidance alongside the assessment. People with experience of multiple disadvantage also commented on its design and content. To circumvent recognised power imbalances between professionals, carers and customers inherent in some types of needs assessments, the toolkit brings together the views of the customer, the qualified assessor and the support worker. The Multiple Needs Toolkit was presented as a good practice case study, with insight from stakeholders who had experience or knowledge of its application [22].

Key Findings & Implications The toolkit was thought to have increased successful referrals for assessment, and people receiving their legal entitlement to care and support. Assessments were considered to be quicker, more effective and with fewer barriers. This was confirmed by Adult Social Care who believed that assessments had become more focused, contain more robust information and that the right people are being referred. The Toolkit helped VOICES and other partner staff to exercise greater judgement about referrals, make more informed decisions, including when not to refer. It enhanced staff knowledge and confidence helping them to develop their knowledge and understanding of the Care Act. This familiarity ultimately meant that they could move beyond relying on the Toolkit to make effective and appropriate referrals. Staff became recognised as experts and have been approached by Adult Social Care/other services in the city looking for advice.

Staff members found it easier to have conversations with Adult Social Care; the Toolkit meant that they had all the necessary information to guide their conversation. This improved staff confidence and allowed them to better advocate for their clients. The success of the toolkit enhanced staff confidence, empowering them to be more effective advocates. By helping staff to achieve positive results, the toolkit is said to have helped boost staff morale in a role with high risk of burn out (given the frequent challenges of supporting people facing multiple disadvantage), in turn, benefitting those they support.

2.10 Annual Stakeholder Survey (2016-2020) Background VOICES commissioned an independent evaluator to design and administer annual surveys to capture the views and experiences of VOICES customers, key stakeholders (from a range of statutory and third sector organisations), and Expert Citizens. Customer and Expert Citizens surveys were completed as hard copy forms and stakeholder surveys administered online. Table 1 summarises the numbers of respondents per group from which key findings are summarised.

Key Findings Satisfaction. Surveys in all years reflected a high level of satisfaction among VOICES customers. Most stakeholders (7688%) were also satisfied the way VOICES supported their service to work with people experiencing multiple disadvantage.

Table 1. Survey respondent numbers by group Year

VOICES Customers

Stakeholders

Expert Citizens

2016

2017

2018

2019

2020

Perceived strengths. Stakeholders commented on the benefit of having an independent, flexible, intensive, personalised and assertive team, giving a voice and influence to people experiencing multiple disadvantage, with cross-sector working and partnership. In all years, customers most valued their VOICES Service Coordinator, who they trusted and had a genuine connection with. Peer Mentoring. This was perceived positively by the small number of interviewed customers who had Peer Mentors and by Expert Citizens. Awareness. VOICES was thought to have raised awareness of multiple disadvantage among stakeholders from other organisations. Some stakeholders reported that VOICES had led them to change how they worked with people experiencing multiple disadvantage (and had engaged in the Citywide Learning Programme). Systems change. Questions introduced in 2017 identified a perception that VOICES contributed positively to changing and influencing systems in Stokeon-Trent for people experiencing multiple disadvantage. Over 80% of respondents agreed with this impact in all years, although the number of stakeholders answering this question was small (with likely self-selection bias).

Expert Citizens. Surveys from earlier years highlighted perceived benefits among Expert Citizens that VOICES helped them to get appropriate support and training to develop skills through their role as an Expert Citizen. All but one respondent was positive, reflecting satisfaction, enjoyment, generally feeling listened to and supported by VOICES. Expert Citizens as a legacy. Expert Citizens were regarded as a key part of the VOICES legacy post-2022.

Areas of Improvement Customers’ identified areas in which they would have liked more support Housing (support to retain tenancy or find more suitable accommodation) and support to get to appointments with other services (2017, 2019 and 2020 surveys). Support with mental health assessments and getting to appointments (2018, 2019 and 2020 surveys). Accommodation, fitness, personal finances, mobility and mental health (2020 survey). Stakeholders

From 2018 to 2020, further training requests were common but varied, and included training in mental health training, complex disorders, and substance misuse. Expert Citizens’ surveys did not yield comments on areas to improve, although there were suggestions that VOICES should consider how it could support the Expert Citizens to continue to raise the profile of their work locally.

Implications The 2020 survey, was the latest and, therefore, most useful when considering the VOICES legacy identified that: Positive feedback across stakeholder groups should be shared with the staff team and VOICES Partnership Board and be recognised as an indication of the overall success of VOICES. VOICES could consider supporting Expert Citizens in recruiting new people to the organisation and expanding its reach. Data gathered highlights the importance of VOICES in customers lives and the potential gaps when the service ends. Exit planning and seeking suitable support for customers should be a key priority. It should be noted that the above findings are likely to be subject to considerable self-selection bias, whereby responses are more likely from those most engaged with VOICES and in a good enough place to feel able to complete the survey. Nevertheless, the positive ratings were supported through case studies showing impact.

In 2017 there were few comments, but these included interesting suggestions for mental health first aid and health awareness, including access to screening 21

Between

2014

2018

67 customers were advised, with a total financial gain of

£613,860

2.11 Specialist Welfare Benefit Advice and Advocacy at VOICES (2018)

Supervised and mentored Service Coordinators to become skilled welfare benefits advocates, increasing their confidence to recognise and manage customer welfare benefits matters.

Background

Adviser was able to identify where customers need other specialist advice and refer them to CAB.

VOICES recognised a need for expert knowledge of welfare benefits to ensure that its customers and Service Coordinators could manage the often complex processes involved in customers receiving and maintaining the welfare benefits to which they were entitled. From the outset of VOICES in 2014, VOICES commissioned a Citizen’s Advice (CA) Adviser from Citizens Advice Staffordshire North and Stokeon-Trent (CASNS) to work with the team, full-time. They provided advice on debt and welfare benefits, and supervision/support for Service Coordinators. The 2018 evaluation presented data on benefits claimed, customer case studies and interviews with three stakeholders [23].

Key Findings Welfare Benefits Claimed From October 2014 to 2018, 67 customers were advised, with a total ongoing annual financial gain of £613,860.

35 customers received back payments totalling

£110,857 which is an average of

£3,167 per person

35 customers received back payments totalling £110,857 (average £3,167 per person) and an additional average weekly gain of £176.19, most often through securing Personal Independence Payment or Employment Support Allowance.

Benefits of the WBLL model Enabling VOICES to address issues relating to customers’ welfare benefits more effectively, including challenging benefits decisions. Allowed Service Coordinators to focus on more immediate customer needs such as housing.

CASNS was able to provide direct advice to people often not reached through centre-based advice provision (e.g., rough sleepers). Customers who receive welfare benefits advice via VOICES might also be more likely to access other advice services at CASNS.

Implications Commissioners and service providers should recognise the need for specialist welfare benefits advice for people experiencing multiple disadvantage. Organisations providing specialist support / service coordination for people experiencing multiple disadvantage should consider the embedding of independent expert advisors to provide welfare benefits and employment advice. Commissioners and other funders should ensure appropriate funding and commissioning of specialist welfare advice for people experiencing multiple disadvantage. Specialist welfare benefits advice services should be flexible and facilitate a culture of learning and capacity building as part of the role.

2.12 Specialist welfare advisor model – three other settings (2021) Background Following the success of the model of Specialist Welfare Benefits Advice and Advocacy at VOICES, the Welfare Benefits: Leading and Learning (WBLL) project was introduced in April 2019. WBLL involved embedding a specialist adviser from Citizen’s Advice within different organisations who support people experiencing multiple disadvantage, to support staff in advising their customers in welfare benefit claims. WBLL was implemented in: Brighter Futures (Housing First and 90 Hope Street Hostel); Concrete (Supported Housing Team); and Community Drug and Alcohol Service (CDAS), but the WBLL adviser in CDAS was later moved to Integrated Offender Management (IOM). This evaluation drew on: service data on welfare benefits claimed overall, and by service, from April 2019-March 2021; case studies provided by the services involved; interviews with seven staff and stakeholders from across the settings.

Key Findings Welfare Benefits Claimed Over two years, a total of 56 customers were given welfare advice, resulting in payments totalling £565,629, or £10,101 per customer. This comprised oneoff payments to 44 customers totalling £217,198 (£4,936 per customer), and recurrent monthly or weekly payments that totalled £348,431, or £6,222 per customer (equating to a minimum weekly ongoing income increase of £59.83 per customer).Over two years, a total of 56 customers were given welfare advice, resulting in payments totalling £565,629,

or £10,101 per customer. This comprised one-off payments to 44 customers totalling £217,198 (£4,936 per customer), and recurrent monthly or weekly payments that totalled £348,431, or £6,222 per customer (equating to a minimum weekly ongoing income increase of £59.83 per customer). The most common welfare benefit type that customers were supported to receive were Personal Independence Payment (PIP) and Employment Support Allowance (ESA), which accounted for approximately 80% of total financial gains.

Benefits of the WBLL model Improving the skills, knowledge, legal literacy (regarding welfare benefits) and confidence in frontline staff in supporting welfare benefit claims and when/how to challenge, which is necessary for effective advocacy to ensure that customers receive the welfare benefits to which they are entitled.

56 customers were given welfare advice, resulting in payments totalling

£565,629 which is an average of

£10,101 per person

Increased financial security for customers. Flexible (not appointment-based) approach that is better suited to customers’ needs.

Challenges of the WBLL model COVID-19-related shift to remote working was an impediment to WBLL advisors becoming fully embedded as a team member within the services. Organisations not understanding the adviser role (i.e., to train staff, not take on cases). Lack of organisational buy-in. Time required for WBLL adviser to build relationship/trust with staff, and to demonstrate the value of the model (through successful claims).

The most common benefit type received

Personal Independence Payment (PIP) & Employment Support Allowance (ESA) accounting for

80%

of total payment

Management of claims for large back payments. High staff turnover disrupting relationships between WBLL and partner organisations.

Implications Ensure that organisation staff understand the role of the advisor. Allow time for development work to secure buy-in at both management and frontline staff level. Awareness raising/education to develop recognition in organisations and wider services that welfare benefits are a right and legal entitlement of customers. Need for specialist welfare benefits advice for customers experiencing multiple disadvantage given the complexity and changes in rules over time. All new staff need to be trained and upskilled by specialist advisers (to mitigate issues of staff turnover and lost knowledge). Potential for increased efficiency of a well-planned remote working model could be explored and tested. Investment in WBLL is necessary to ensure customers experiencing multiple disadvantage receive the welfare benefits to which they are entitled.

2.13 Housing First in Stoke-on-Trent: Evaluation (2021) Background

The Housing First model represents a shift from ‘treatment first’ approaches, by placing chronically homeless people into ordinary private accommodation, rather than offering housing as a reward for progress in treatment. Despite some evidence of benefits in terms of housing sustainment, reduced demand for emergency medical services, homeless shelters, police and courts, interarea variation in context and customer groups, means that local delivery models should be informed by local intelligence.

Housing First has been operational in Stoke-on-Trent since April 2018 and completes in March 2022. This evaluation used data on Housing First customer engagement with services (health and criminal justice), customer case studies, interviews with stakeholders and a stakeholder workshop to explore the benefits and potential challenges of the local programme, to inform future programme specification [24].

Key Learning Service Use Housing First customers who were housed had lower use of the criminal justice system and might manage their health better than those who did not start a tenancy following referral to Housing First. This indicates that housing in its own right can reduce criminal behaviour and health-related crises that warrant unplanned emergency care.

Housing Supply A lack of suitable properties was as a key programme challenge. Stakeholders highlighted insufficient properties to support demand, reflecting a citywide housing supply issue. A lack of social rented properties had led to an over-reliance on private landlords which reduced the rapidity with which Housing First could put an end to an individual’s homelessness.

Relationships Qualitative data highlighted the importance of relationships between customers and Housing First, which were primarily dependent on their relationship with Service Coordinators and Peer Mentors. Risks to these relationships (e.g., through staff turnover or COVID-19 related restrictions on contact) were considered a risk to successful engagement.

Working with other services and funding There was an apparent need for a culture shift to among other service and the wider system to promote recognition of what Housing First Stoke-on-Trent does and how Housing First customers are supported, to encourage and foster collaboration with other services. This, in turn, could facilitate better partnership working, commitment to Housing First, and commissioning that could enable long-term funding (i.e., agencies from different parts of the system contributing to support an intervention that has system-wide benefit).

Implications Housing Supply Properties are needed for the programme to exist and to allow rapid housing of those referred.

Services and Potential Funders Services and partner organisations should understand Housing First and the nature of support for Housing First customers.

Property Supply The most critical challenge for a future Housing First model is to resolve challenges in the supply of properties. Without the properties, there is no programme.

THIS REQUIRES Leadership of the housing strategy for Housing First, minimum commitment of properties per annum from local authorities and social landlords.

Relationships Strong, trusting relationships between the customer and Housing First are necessary to allow service coordination and support to function. Developing and maintaining effective relationships with customers is critical: Service coordinators should maintain small caseloads, have periodic reviews to check customer-coordinator relationships, prepare for changes (from staff turnover/ transitions), have frequent informal contacts with customers, and use available training/support for emotional well-being. Peer Mentors have clear value in facilitating informal, supportive relationships between the programme and the customers. The existing model should be reviewed and evolved through further consultation (including protection of mentor-customer boundaries), and sufficient time and resource should be afforded for Peer Mentor management/ coordination and monitoring.

Culture Shift The future of Housing First in the city is likely to require a culture shift; wider appreciation of fundamental Housing First principles: people have a right to housing, no matter what. This requires a move away from a solely economic justification to a nuanced appreciation of the wide-ranging potential benefits to the individual and state, and the guiding principles.

Solving the supply issue would help to increase the rapidity of housing through having a stock of properties that could meet the requirements a range of customers.

2.14 Multi-agency Resolution Group (2021) Background The Multi-agency Resolution Group (MaRG) is hosted by Stoke-on-Trent City Council and comprises a range of statutory and voluntary sector organisations. The professionals involved collaborate to help overcome perceived barriers for people experiencing multiple disadvantage that have become 'stuck' in the system. The MaRG attempts to broker flexible solutions for complex cases, to manage and share risk across relevant agencies by promoting flexibility and a coordinated response. The MaRG evaluation was based on information gathered through case studies provided by members of the MaRG, interviews with five members of the MaRG, conducted between October 2021 and November 2021, and a workshop (in November 2021) with other group members [25].

Key Findings Strengths The MaRG plays a valuable role in the wider system of support for complex cases. Agencies come together to collaborate and identify creative solutions to move cases forward. The professionals involved are sufficiently senior to make decisions then and there, to ‘flex’ processes and procedures. Through the MaRG, agencies work well together, and the opportunity to listen and learn from each other is key. Having sufficient time allocated to hear and discuss each case is also important.

It has led to improved communication between agencies on specific cases, better inter-agency relationships, trust, and a sense of sharing the risk.The MaRG There were also suggestions that it had led to better interagency working outside of the MaRG. The MaRG does not seek to blame or criticise any agency, but to understand barriers and work together to identify solutions. It was considered to have a very positive influence on the professionals involved and ‘breaking down those barriers’.

Challenges The MaRG is operating within a wider system that can be inflexible and rigid. Housing needs were a common barrier in complex cases. Ensuring that the ‘right’ cases are being brought to the MaRG/ whether professionals fully understand the role and remit of the MaRG. It can be difficult for a case to get heard at the MaRG. Difficulties associated with a ‘rotating chair’. If a customer is not engaged or on board, then the MaRG is limited in what it is able to achieve.

Recommendations Collate and review the evidence to date on cases heard to help understand common ‘sticking points’. Develop a multi-agency toolkit which sets out options that professionals could try before escalating a case to the MaRG.

Identify a stable MaRG Chair who will drive the initiative forward. Resource for the administration also needs to be factored in (e.g., minute taking and collating evidence into a database for monitoring activities). Further consultation about changes to the referral form to ensure professionals fully understand the changes to the form and process. The form could also be piloted to help ensure that changes do not unintentionally create a barrier to eligible cases being heard. Identify ways to bring lived experience into the MaRG, to make customers aware their case will be discussed and to capture what they would like the outcomes to be. Consider how the review mechanism of individual cases can be built into the meetings, to review progress against action plans and identify any sticking points. Resolve issues around information governance, confidentiality, record keeping and sharing records, for future models of the MaRG. Continue work to develop ‘robust’ terms of reference and share with the wide range of professionals involved in supporting complex cases locally.

3. 3.1

Get Talking Aim

The aims of the VOICES Legacy Evaluation included working with Expert Citizens to embed lived experience expertise in the project and, through this role, Expert Citizens could complete the Get Talking and their role in this evaluation could be used to obtain a Get Talking qualification. The plan was to work with Expert Citizens as community researchers for the VOICES Legacy evaluation, alongside some of the CHAD research team, and train and support them in their role in the evaluation. Expert Citizens could also choose to receive full training and support throughout the project and complete a short assessment to gain a 15-credit, level 3 Get Talking Community Consultation qualification.

3.2 Introduction to Get Talking Get Talking is an approach to participatory action research developed and delivered by Staffordshire University that works with members of communities as partners in the research process. Get Talking is a form of Participatory Appraisal, which has been described as ‘a family of approaches and methods that values people’s knowledge and experience and their ability to come up with solutions to problems that affect them’ [26]. A Participatory Appraisal is always carried out by a team, who use tools and techniques in place of traditional research methods, to get people talking in a way that enables everyone to share their skills, local knowledge and expertise. Many of the methods used in Participatory Appraisal are visual and make it easier for people to participate in discussions in ways they feel comfortable with. The tools can be used in meetings, with groups or individuals. Sometimes people participate for a few minutes, at other times for longer. The methods can be used wherever people are, at home, at bus stops, in school or clubs. The methods are effective with people of any gender, age or cultural background. 27

3.3 Summary of the approach

3.4

Nine individuals participated, with a mix of males/females and ages (~20-50 years). Most of the group had a long-standing relationship with VOICES and Expert Citizens, two had recently become involved and two were researchers from CHAD who had previously worked with VOICES. The course took place March-June 2021 and was held over 10 sessions (Table 2, to the right). All sessions started with a reminder of the ground rules, a recap of the previous session, an update on enrolment and offer of support, a review of where we were up to with ethics and completion and return of consent forms (where applicable). Each participant was provided with a pack which included a notebook for learning from session, recording what we have done and how we felt as well as any questions. This will be helpful for reflection and completing reflective workbooks.

Three members of Expert Citizens presented an overview of their Get Talking journey with an honest reflection on the challenges of online learning. They also outlined activities that they used to collect the data for their research, including interviews and a timeline. They identified the challenges of some people having a greater understanding of VOICES than others but found ways of dealing with this and ensuring that they managed to engage all members of the group.

The group were introduced to a variety of creative tools and had opportunity to use them by practising with their peers in small groups. (e.g., Timeline, Dot voting, Ranking lines, Solution Tree). To support participants with preparing for and delivering the presentation, and completing their reflective diaries, some faceto-face sessions were added. The Reflective Diaries were submitted (23rd July) by three participants who achieved their level 3 certificates..

Output

Presentations

Their reflection on the value of using creative tools, identified their previous experience of using similar approaches for other areas of work and how helpful it was to have an explanation and framework for this. For example, they had used a ‘mystery shopper’ approach to support work with people with lived experience. Their examples of personal experience demonstrated their commitment to inclusive practice and valuing people’s lived experience in research. Being involved in Get Talking helped them to realise how their existing skills and knowledge were supported by participatory and peer research principles and methodologies. Their discussion about using creative tools in this way was insightful and helped to make them feel more part of the results. Using photos and videos helped the group to evaluate the impact of VOICES. The themes from the photographs provided a foundation to build on for the VOICES dissemination event and included some personal reflections from their own experiences which were very powerful and added to the overall message. They felt that the work of VOICES was supportive, and person centered. One of their findings was that they had previously used craft and art tools, whilst talking to people, as a way of ensuring inclusion and it was useful to have an approach with creative tools.

Table 2. Summary of Get Talking session content

Session

Content

Get to know each other and the tutors Hopes and fears for the course Introduction to the VOICES Legacy Project Understand how you will be involved in the evaluation as community researchers Establish some ground rules for how we want to work together

Introduction to the Get Talking course Find out more about each other Principles of Get Talking, how it works and how you can be involved Think about VOICES Legacy Have a chance to ask questions about the course Work out how we all want to work together Who wants to be a Millionaire?

Plan how you will be involved in the evaluation as community researchers Introduced to Toolkit of creative tools – Acrostic poem Digital approaches and recording findings Try out some creative tools Small groups to look at lockdown activities One per group and discuss how being involved with VOICES is like their activity

Plan how you will be involved in the evaluation as community researchers What makes a good consultation? Think about stakeholders for this project Agree next steps

Continue work on Stakeholders – Power and Influence Think about the best ways of getting people involved in Community consultation Themes for podcasts Creative tools – Timeline and ‘On the one hand…on the other hand’ Stakeholder board game

Timeline – VOICES and individual Plan for more research Skills and assets activity

Timeline – VOICES and individual Skills and assets activity Identify emerging themes and plan for more research

Go through ethics and information and consent forms Practice interviews Research questions Plan for deep research - questions and dates/methods

Prepare for analysis and collation by sharing photographs and information from last time - For people that don’t know, describe VOICES in a few sentences - Five words on post-its/speech bubble - If VOICES were an image or picture – what would it be? - Additional question of own choice Review words and photos – collate and analyse

Prepare for analysis and collation by sharing photographs and information from last time Share PowerPoint of images and words - Discuss main findings, themes emerging, any gaps Solution Tree Action planning Evaluation including review of tools and techniques Next steps

Podcasts The podcasts were recorded between November-December 2021. Seven people produced three episodes of the VOICES podcast which covered Expert Citizens’ views of the impact that the VOICES programme has had on them over the eight years that it has ran. The interviewees discuss Support, Unity/Community, Growth, Opportunity, and the future after VOICES concludes.

The purpose of the podcast was to reflect and provide an additional output to the overall VOICES evaluation and the Get Talking programme. Reflections included the journey and impact of VOICES on Expert Citizens and their role in making it a success, while showing the benefits of lived experience and peer support in working with people facing multiple disadvantage.

Photographs Images and photographs were taken, from which 13 were selected to include in an exhibition at the Legacy Event (March 2022).

3.5 Outcomes of Get Talking for the VOICES legacy The following summarise the contribution of this Get Talking activity towards the VOICES legacy. Expert Citizens involvement in the presentation consolidated their relationships through working effectively as a team. They reflected on their learning from the course, including how they valued the approach of not ‘being done to’. The group produced some top tips of how to make a consultation as effective as possible which included using a timeline as a reflection positives and learning, provide a welcoming environment and ensure that everyone feels listened to. They explored the partnership between VOICES and Expert Citizens. Their continued involvement with Expert Citizens has allowed them to develop, “it’s been massive… it really helps to guide you and nurture you... Creates a lot of interest, keeps me good and keeps me busy”.

Despite the limitations of online delivery some research was undertaken including interviews, small focus groups, use of photos and a timeline.

They valued using different reflective tools which helped them to explore different aspects of their collective and individual experiences with VOICES. They had a tool bag of creative tools for future use and confidence and experience to use them. This will enable them to bring different methods to their work to help represent how they are feeling, what it means, how important issues are and seeing things from different perspectives. When people reflected on their chosen images and words they felt that it was a positive experience and they had enjoyed working creatively. The training and experience of being involved in the project had increased their confidence as well as their willingness and ability to be involved in similar projects in the future. Most preferred working faceto-face where possible, where having breaks and sharing stories helped them to ask questions and get feedback from other members of the group. They particularly valued getting together, working collaboratively with other colleagues as well as establishing and maintaining these connections. Three people achieved a level three certificate. All participants, Expert Citizens, CHAD researchers and colleagues from Staffordshire University Research, Innovation and Impact Services valued the opportunity to get to know each better and collaborate. This relationship development has increased the potential for future collaboration in this area, further adding to the VOICES.

4. 4.1

Overall Evaluation of VOICES through Situational Analysis Introduction

The study of multi-faceted interventions like VOICES, that aim to intervene on various aspects of already complex systems, such as the provision of health and social care for people experiencing multiple disadvantage, requires advanced methodologies to understand the potential impact on the target population’s health, well-being, and on health equity [8]. Situational Analysis is a methodology designed to unpick the knowledge from complex inquiries, where methodologies grounded in linear models of cause and effect are inappropriate [6]. It is well-suited to this purpose for several reasons. First, data can be gathered using various methods, such as reports, interviews, field notes and minutes [7]. Second, emerged from Grounded Theory, it is an iterative and data driven methodology, where data collection in each phase depends on the findings from the previous phase. This is appropriate as we are not testing predefined hypotheses but are being guided by the data [9]. Third, Situational Analysis is one of the few complex systems methodologies that places the importance of context at the heart of its investigation [9].

4.2

Method

Specifically, Situational Analysis involves a three-stage methodology of conceptual maps, which aims to provide a detailed picture of non-linear interlinkage of complex systems structures and processes that shape the experiences of those within a specific environment [7]. The three stages are: Micro level analysis on situational maps is implemented where all important human, nonhuman, elements of the situation under concern unfold (reported in section 4.3). Meso level analysis involves the production of social worlds/arenas maps, where all collective actors (humans) and actants (non-humans) are analysed in relation to the arena in which they are engaged and negotiated the related to situation discourses (reported in section 4.4). Macro level analysis uses positional maps to unpack all positions that have emerged from data around key discourses or issues. These positions are presented on a Cartesian map in which axes present the issues of concern or controversy [8, 27] (reported in section 4.5).

Through this bottom-up, data driven methodology, Situational Analysis produces a higher and abstract level of explanation of non-linear relationships within the context (or situation) of interest. The Situational Analysis process is iterative. There are no fixed boundaries between the three analytical stages. Data collection of each phase depends on the findings of the previous one, but there is a constant recursive analytical loop (where earlier stages can be amended based findings from subsequent stages) until the saturation of evidence is achieved. For the overall exploration of VOICES’ impact and legacy, Situational Analysis was chosen as linearity, universality and generalisability are not relevant. Rather, post-modern ideas that embrace fragmentation, instability, diversity, context, and positionalities (all accepted by Situational Analysis) are necessary. When taking this approach, nothing was taken for granted; especially on issues that seem ‘normal’ within the situation and, therefore, have become invisible. Minor discourses or issues are given equal consideration as those that appear to be major or more prominent, because they may be indicative of power imbalances. Similarly, deviations from the norm are not treated as exceptions but as the boundaries 31

of the situation. Finally, a thorough investigation is used to identify all relevant actors/ actants (including those that are usually hidden, silenced, or only discursively/tangentially present) as they might help to improve our understanding of the situation. For this project, Situational Analysis focused on the three priority areas through which VOICES aimed to affect systems change: Ensuring fair access to services. Housing First Stoke-on-Trent. Making service users leaders in service design and commissioning. Data sources were primarily from existing material, including completed and on-going VOICES discrete reports (including those summarised in Section 2), previous interviews and case studies, field notes, and minutes of meetings (see Appendix 1 for list of data sources).

4.3 Data collection and analysis: Situational maps (Stage 1) Following processes set out by Clarke [27], after thoroughly reading all written materials, the first stage of analysis was to create situational maps. The analytic focus of the situational map is the situation. In this case, the situation was the wider system of support for people in Stoke-on-Trent who experience multiple disadvantage. Initially, various ‘messy’ situational maps were produced and included all human (i.e., key people, groups, networks, organisations) and non-human elements of the situation (i.e.,

physical infrastructure, resources, policies, discourses). To produce a readable map different colours have been used to indicate different categories of elements (Appendix 2). The messy map was then used to create an ordered map, which arranged all elements into categories (Appendix 3). This helped to identify ‘major issues/ debates’ and ‘related discourses’ that were most relevant to situation (e.g., “coproduction”, “stigma and marginalization”, “equity and healthcare provision”) and were later used to focus the Situational Analysis. Subsequently, three situational relational maps were created, one for each of the three VOICES priorities (Appendices 4-6). These maps are used to show relationships between the elements of interest and other elements in the situation, in a systematic and coherent way. These maps were used to generate questions that were explored in three workshops (one for each priority area). These workshops helped to further understand the relationships between key elements and significant discourses/issues, leading to the next phase of Situational Analysis.

4.4 Data collection and analysis: Social worlds/arenas maps (Stage 2) The meso level of analysis began with the creation of the social worlds/arenas map (Figure 2). This map represents the key social active players (social worlds), and the field (arena) in which they interact; for example, how the social worlds of local voluntary and public sector organisations interact within the arena of the

local support system for people in Stoke-on-Trent who experience multiple disadvantage. In this sense, social worlds are comprised by various social entities and institutions, all with their own perspective and collective identity at the present time, within the situation of inquiry, and are dynamic, potentially changing over time[8]. Through Situational Analysis, we attempted to understand the boundaries of the social worlds, as well as their collective actions and interactions with each other (i.e., their negotiations, collaborations, conflicts, seeking of power). The final product is a map of “relational ecological form of organizational analysis dealing with how meaning making, and commitments are organized and reorganized again and again over time” [27, p150]. In the map, social worlds that are similar are positioned adjacent to each other, and those with conflicting or opposing relationships are positioned opposite. The depth of intersections indicates the extent of their single or cooperative involvement with the situation. Finally, the actor(s) or actant(s) identified as important from the data, but which are not part of a collective action, are shown in the social worlds/arena maps without a surrounding circle [27]. In the social worlds/arena map for this evaluation, people from Stoke-on-Trent who currently experience multiple disadvantage were defined as the arena in which all the actions, negotiations, conflicts, debates and so on, took place. Within this arena, 10 different social worlds were identified, five of which comprised the VOICES partnership (and, therefore, intersect the large green square that represents the VOICES organisation):

5 social worlds identified and comprising the VOICES organisation

1) Third sector housing associations that support housing needs 2) Voluntary sector champions who support those who need and use health care services 3) Local public sector agencies, mostly derived from the City Council (e.g., Housing, MaRG) and the NHS 4) Legal advisers’ social world, which is dominated by the third sector welfare advisers 5) Expert Citizens social world, acting as ambassadors of local people with lived experience on multiple disadvantage.

In the map, social worlds that are similar are positioned adjacent to each other, and those with conflicting or have opposing relationships are positioned opposite. The depth of intersections indicates the extent of their single or cooperative involvement with the situation. Finally, the actor(s) or actant(s) identified as important from the data, but which are not part of a collective action, are shown in the social worlds/arena maps without a surrounding circle. The other five social worlds aligned closely with VOICES objectives (while not being part of the VOICES partnership) such as legislation, criminal justice system, healthcare sector, Department for Work and Pensions and Academia. Nine out of 10 social worlds actively, collaborated, competed and/or conflicted with one another, while one was identified only discursively.

The visual representation of the VOICES partnership in Figure 2 shows the complexity of the situation, but also illustrates how VOICES provided the common ground for many organisations to work towards widely accepted targets regarding the tackling of multiple disadvantage. This helped to overcome competitive attitudes and practices from partnerships of voluntary and public sectors. 33

Figure 2. Social worlds / Arenas map The positional maps in section 4.5 present the main findings. However, there are several aspects of the social world/ arenas map to note, as they are important it the development of the analysis. First, a pinnacle of the VOICES legacy captured in the social worlds/arena is the evolution of 34

Expert Citizens. Expert Citizens have transformed from a group of people with lived experience of multiple disadvantage without collective action, to a Community Interest Company (CIC) that is independent of VOICES and holds equal positioning among the other social worlds within the arena (of supporting people experiencing multiple

disadvantage in Stoke-on-Trent). This power-seeking relationship of Expert Citizen’s relative to the other VOICES partnership organisations (as identified from narratives and workshops with Expert Citizens) was presented by positioning Expert Citizen’s social world opposite to voluntary and public sector.

The map also illustrates the emergence of Expert Citizens as a new social world that started to interact autonomously with the other social worlds and the situation, with potential for sustainable impact through affecting the wider system of support for people experiencing multiple disadvantage. The Expert’s Citizens social world is positioned slightly opposite the public sector healthcare social world, mainly due to Expert Citizens’ involvement in the primary care report and the identification of the gatekeeping role of local GP practices to people experiencing multiple disadvantage when trying to access them. However, Expert Citizen’s social world is adjacent to voluntary sector champions and Academia as where both social worlds collaborated with Expert Citizen’s for various VOICES reports/evaluations. Expert Citizens’ social world takes the largest part of the VOICES partnership organisation to indicate the extent of support that they have received from VOICES, to: Develop as an autonomous organisational entity. Emerge as co-designers, codeliverers and co-evaluators of various methodologies and tools that have been developed with VOICES (e.g., INSIGHT service evaluation, Care Act toolkit). Second, legal advisors’ social world is positioned opposite public sector social worlds (specifically in relation to welfare benefit claims), but adjacent to Legislation social world, to reflect their role in promoting legal literacy. This is because the lack of legal literacy in the public sector emerged as a main barrier to people experiencing multiple disadvantage having fair access to benefits and welfare (to which they were entitled), and legal advisors offered a solution.

Third, the criminal justice system, which includes organisations like the probation service and police, did not oppose any other social worlds. Despite the issues regarding inappropriate prison release plans or the initial resistance to incorporate specialist welfare benefits adviser within the probation service, there were positive changes throughout the period of VOICES. Indeed, this was true for all social worlds, especially Expert Citizens, except for the healthcare sector where a lack of engagement was observed. Fourth, academia played a part, albeit a lesser one, mostly in trying to apply rigorous independent research and evaluation to study specific activities, projects or areas relevant to VOICES (as indicated in Section 2). An independent consultant who also supported VOICES evaluation process, though not part of Academia social world, also appeared adjacent to it. Finally, several ‘implicated actors’ (human) and ‘actants’ (non-human) were identified; elements that play an indirect role in the situation, but critically, did not appear to have done so before VOICES (i.e., their indirect involvement is part of the VOICES legacy). For example, private landlords and letting agents benefited through Housing First (through renting properties), but in some cases created problems (e.g., failing to maintain property quality standards). They are not presented as a social world because they did not act collectively. General Practitioners have often been reluctant to intervene (as reflected in Section 2.5), either through lack of understanding of their legal obligations, a belief that people experiencing multiple disadvantage are primarily a social care phenomenon, or because they are able to

remain disengaged (which increases pressure on crisis healthcare services through failure to identify and treat health problems before they escalate). The implicated actants relating to the Legislation social world included legislation that governs how the public sector must support people facing multiple disadvantage (e.g., Care Act 2014, Homelessness Reduction Act 2017, National Framework for Continuing Health Care, Equality & inclusion strategy 201-2017). The important point here is that the public sector can lack knowledge regarding the legal rights of people experiencing multiple disadvantage, follow them reluctantly or partially/ not in the spirit of the law (e.g., as observed through primary care gatekeeping and hospital discharge reports).

4.5 Data collection and analysis: Main findings - Positional maps (Stage 3) Drawing on the wealth of material considered, the final macro analysis reflects our best effort to elucidate and represent the various positions taken with respect to the major discourses/ issues. Again, where possible, we avoid naming specific individuals, groups, or organisations. The outcome is a number of positional maps, some generic and some specifically relating to the three priorities under investigation

4.5.1 Fair access to local support services of people experiencing multiple disadvantage Within this priority area, five positional maps are presented to highlight the key discourses/ issues that create barriers to fair access and that VOICES’ work has attempted to address.

Stigma & Marginalisation Figure 3 illustrates a fundamental barrier to people experiencing multiple disadvantage accessing services: stigma and marginalisation among some personnel in public sector support services. This is the first position (Position A) on the positional map that was identified in the data, and specifically in two different VOICES reports: a) Hospital discharge and homelessness and b) Primary care gatekeeper projects. It was also widely acknowledged during the workshops with stakeholders and Expert Citizens. “

I think probably the elephant in the room is a little bit the stigma which gets attached to our customer group at times” McCormack, Parry and Gidlow [18]

Workshop discussions highlighted (Position B) that stigma can vary with the needs/situation of the individual presenting (e.g., different stigma attached to people with substance misuse issues vs. homeless vs. past offenders). This is not only problematic for the individuals seeking care/support, but also for staff who lack the knowledge and experience to deal effectively with potentially challenging behaviour or situations (as a result of their inexperience). This position found strong support among participating stakeholders. 36

VOICES has made important moves to challenge this problem (Position C) through: Producing legally informed materials and recommendations to raise awareness (e.g., Gatekeeper report on Primary care where through mystery shopping methodology raise awareness on the subject matter on national level). Co-producing solution-focused products that challenge stigma and marginalisation, such as VOICES and Expert Citizen’s coproduced methodologies (e.g., INSIGHT) and tool kits (e.g., Care Act tool kits, MEH safeguarding). These examined understanding among local organisations who work with people experiencing multiple disadvantage, and empowered VOICES to challenge any incorrect or unjust decisions. Empowering and training public sector professionals to acknowledge the importance of lived experience as basic component of their own learning process.

Silo Working Figure 4 illustrates the common issue of silo working by organisations within a fragmented system of support services. Critically, the gaps between services/ organisations are experienced by people experiencing multiple disadvantage as exclusion. Silo working jeopardises effective coordination between services, which has the potential to avoid the “revolving door” phenomenon. To challenge this, VOICES developed a multi-agency approach and solution-focused interventions that have helped to develop knowledge in key organisations and supported changes in practice, such as codevelopment and co-production together with Expert Citizens of targeted Learning programmes and Community Of Practice workshops, and the incorporation of the specialist welfare benefits adviser within the frontline teams.

Figure 3. Positional map for stigma and marginalisation as a barrier to accessing services

Figure 4. Positional map for silo working as a barrier to accessing services

Responsibility and accountability gaps Figure 5 illustrates the issue of gaps in responsibility and accountability for supporting people experiencing multiple disadvantage, a likely consequence of a system fragmented by silo working. This is particularly important in the context of people exiting crisis services, such as hospitals, where there needs to be a clear understanding of each organisations’ legal responsibilities to ensure that the individuals transition between settings and who is responsible for each stage (e.g., Accident and Emergency, to local authority). As the Former Chair of the Faculty for Homeless and Inclusion Health acknowledged “long-term dispossession is fundamentally an issue of health” [28, p8] and, as such, requires a change in position from the health sector where it is generally considered to be the concern of housing and social care. VOICES reports have shown the large gaps in provision, in particular, between health and other services (as illustrated in Figure 5). The positional map highlights two strong positions found in the data: the notion that this is the responsibility of social care (position A); the other position that the third sector work beyond their remit to cover this gap, to the benefit of the individuals, but serving to mask a shortcoming in the system (position C). No position was found regarding the “taking of responsibility”, but one stakeholder identified potential for misunderstanding regarding the meaning of “multiple disadvantage” in different settings, and the need for better clarification (e.g., in healthcare settings this implies a need for multiple medical services vs. social care, where the meaning is more aligned with VOICES customers and their needs)

Legal Literacy Figure 6 shows the positional map relating to a lack of legal literacy, another common phenomenon that was largely unchallenged before VOICES. Position A shows the public sector apparently lacking knowledge of some important legislation, which acts as a serious barrier to people experiencing multiple disadvantage accessing the services they need and to which they are entitled. Often, frontline personnel are working with insufficient knowledge and or misunderstandings around policies, which are perpetuated as the policy. This can be considered a ‘negative feedback loop’, whereby organisations lack the incentive to address legal literacy problems in their staff. Doing so could mean having to dealing more situations, and potentially complex cases, perceived to be high demand with low chances of reward/positive outcomes. Therefore, managers pass on ‘myths’ and misunderstandings to frontline workers that, in turn, are enacted as policy. VOICES helped to address this problem through developing toolkits (e.g., Care Act toolkit) and models (e.g., WBLL) to facilitate development of related knowledge and skill in frontline staff (Position B).

Figure 5. Positional map for responsibility and accountability gaps as a barrier to accessing services

Figure 6. Positional map for legal literacy as a barrier to accessing services

Figure 7. Positional map for resistance to change as a barrier to accessing services

Resistance to change Figure 7 is the final Fair Access to Services positional map and relates to resistance to change, at both organisational and individual levels. Evidence, such as that presented in WBLL report and workshops undertaken for this analysis, highlighted a perception that key organisations can be reluctant to internal change their processes and ways of working. This issue was exemplified by the WBLL model (see 2.12). Having a specialist welfare advisor embedded in support services was a key proposal from VOICES, taking a multi-agency approach to provide free welfare/ benefit expertise to key partners (first within VOICES, then other services) to allow organisations to provide effective and legally informed financial advice and support to people experiencing multiple disadvantage. As Position A indicates, resistance to change was observed at personal/functional and structural (organisational) level. No position was found on how VOICES had systematically responded to such challenges. Some examples were given during the workshops, but these seemed more as a response to a given problem rather than well-planned solution focus approach. Resistance to change is a wellknown phenomenon in systems thinking and various solutions should be planned and tested at future similar attempts.

4.5.2 Housing First Within this priority area, three positional maps are presented that illustrate the main discourses that emerged.

Availability of suitable housing Figure 8 outlines the major discourse/issue and perennial challenge with Housing First in Stoke-on-Trent: limited availability of suitable housing. Positions A suggested that the biggest problem is the difficulty to secure both the social and council properties, and those of private landlords. Similarly, Position B indicates the general challenge of housing demand exceeding supply, leading to delays in securing appropriate tenancies for those referred to Housing First. “

Housing First ... it is what it says on the tin, you have got appropriate accommodation for somebody first and then you wrap support around them. Now if you haven’t got enough properties to begin with, that’s clearly an issue, isn’t it?” Gidlow et al [24]

Another barrier shown through Position C was that the lack of social and council housing availability leading to a reliance on private landlords and letting agents, one of the biggest concerns. This position verified the importance given to these roles at the social worlds/arenas as implicated actors (as they could not be engaged, despite best efforts, through the Housing First evaluation).

Finally, Position D suggested that customer expectations were another type of barrier, with examples of customer who had refused two or three different accommodation offers. This neither violates Housing First principles nor suggests a mainstream behaviour of Housing First customers. Rather, it may indicate another issue that emerged from the Housing First evaluation regarding unsuitable accommodation (e.g., sub-standard, or unsuitable location). Unrealistic customer expectations were a position among some stakeholders and reported as such. However, the solution does not necessarily lie in addressing those expectations, but in addressing perceptions among the stakeholders regarding the Housing First model. This links back to the demand for appropriate properties (primarily single occupancy) leading to compromise, where customers might have to choose between accommodation that is not suitable (based on quality or location) or wait for suitable accommodation (perhaps in hostel or on the street).

Figure 8. Positional map for availability of suitable housing as a barrier to Housing First

Staff turnover Figure 9 is the positional map relating to staff turnover. The frequency and negative implication of staff turnover in Housing First were a key issue. Three main positions were identified through the Housing First evaluation and related workshops. Position A notes the negative effects of high turnover through interrupting the continuity and stability of customers’ relationship with the service and, in turn, their engagement with other support services. Opposing this, Position B indicates the response to problems of staff turnover, which is inevitable and needs to be managed (rather than prevented). This stresses the need to encourage customers to develop good relationship with the program itself – rather than only their service coordinator or peer mentor (who might leave). Although this was recognised as a challenge, it is in keeping with Housing First principles and necessary for people experiencing homelessness who are likely to feel disengaged from and let down by services. Position C illustrates the position that high staff turnover is a sector-wide challenge and is not specific to Housing First. Two reasons identified were the high demands of the role and the development/ progression of workforce who might see frontline Housing First work as pathway in developing their own career.

Sustainability of Housing First in Stoke-on-Trent Figure 10 illustrates the final and most critical discourse regarding local systems change needed for a sustainable Housing First programme as a local strategy for tackling chronic homelessness, or a revised programme that adheres less rigidly to the Housing First principles but might be more readily accepted by key stakeholders. Three positions were verified from the data and workshops. Position A shows the wellknown argument that focuses on the cost of implementation. This view considers Housing First as a costly approach with a relatively small number of beneficiaries. It advocates for a less intense, housing-led intervention, which deviates from Housing First principles (e.g., finite support, greater for selection of customers, tenancy conditional on engagement with support services). In opposition, Position B expresses the need to maintain Housing First as the key strategy for people experiencing multiple disadvantage, especially after being acknowledged as the best possible option for this population and its approval by the VOICES Partnership Board (which includes a range of public/ third sector partners) to extend the programme for 12 months. This position acknowledges the high cost of running a Housing First programme but provides a counter argument that numerous other support services that are even more expensive. Position C uses the comparative principle, arguing that doing nothing costs more than doing something, and that effective intervention (even costly options) has wider benefits through avoiding the costs of dealing with the consequences of inaction (e.g., incarceration, emergency hospital care, 24/7 social care services).

Figure 9. Positional map for staff turnover as a barrier to Housing First

Figure 10. Positional map for programme sustainability as a barrier to Housing First

4.5.3 Making Service users leaders in service design and commissioning The third VOICES priority area concerned the greater role for people with lived experience, who have: “

Tasted at first-hand how the system can progressively miss chances to help them or even actively exclude them” Project Plan, Fulfilling Lives Stoke p.7

These are the people with lived experience who, through VOICES, have become established within the political agenda and can be considered a key requirement for a systems change approach. Two positional maps are presented to illustrate key discourses/issues for this theme.

Development of Expert Citizens CIC In Figure 11, which relates to the development of Expert Citizens CIC, Position A identified this as a cornerstone achievement of VOICES. It is the pinnacle of co-production between VOICES partnership and local people with lived experience, in addition to subsequent, and no less important co-development and co-production between VOICES and EC-CIC methodologies (e.g., INSIGHT) and tool kits (e.g., Care Act tool kits, MEH safeguarding). Position B stresses that, despite Expert Citizens have managed to improve the things in Stokeon-Trent, not all their ideas have been taken under serious consideration or actioned by VOICES, questioning the extent of true co-production.

Peer Mentoring Figure 12 relates to peer mentoring, whereby support is given to the VOICES beneficiaries by people with lived experience who joined Expert Citizens and received training. This is used primarily for Housing First. Learning from Peer Mentoring within VOICES (which was discontinued), Expert Citizens deliver and manage Housing First Peer Mentoring. Peer mentors help to build informal relationships with Housing First customers and provide support around activities of daily life, which can be of great value to the customer. Position A stresses the positive impact of peer mentoring, while acknowledging the complexities and that such support is not a requirement of Housing First principles (i.e., a feature not common to other Housing First programmes). Position B valued the notion of peer mentoring but showed concern regarding potential negative impact on peer mentors. These included difficult situations for peer mentors who, because of pressure on themselves or from the customers, might feel obliged to act beyond the remit of their role, or feel overburdened. This poses risks to peer mentors’ mental health and jeopardises both customer’s and their own recovery process. Caution and regular monitoring have been proposed as one feasible solution.

Figure 11. Positional map for the development of Expert Citizens CIC

Figure 12. Positional map for use of Peer Mentoring

4.6 Summary of Situation Analysis: VOICES addressing failure demand through promoting equity This section provides a summary, reflecting on the learning from sections 2 and 4, to consider VOICES efforts to address the failure demand of the support systems for local people experiencing multiple disadvantage. The last positional map (Figure 13) summarises the identified positions taken by VOICES in relation to pre-existing positions within the situation (the system of support for people experiencing multiple disadvantage) at the time of inquiry. This map also proposes a higher level explanation of how the local system’s failure demand (“demand caused by a failure to do something or do something right for the customer” [29, p26]) negatively impacted the situation as VOICES applied solutionbased responses. VOICES made considerable efforts to free local people experiencing multiple disadvantage from a system that often shifts blame to the individual for non-engagement/ non-compliance with typical processes. Figure 13 shows the differential positions of the public sector and VOICES, in relation to equality and equity.

In general, equality approaches fairness as the provision of the same treatment/ support opportunities to all, whereas equity acknowledges the potentially different needs and abilities to access services provided, thus allocating treatment/ support proportionately. This seemingly small conceptual difference can have substantial

implications for the support that people experiencing multiple disadvantage receive. Moreover, this provides an appropriate basis to consider differences in this system and resulting support before and during VOICES (i.e. what difference VOICES has made). According to the evidence considered in Situational Analysis, support services more aligned with equality were mostly those of the public sector. This is perhaps not surprising as the common delivery focus is citywide and based on population needs, rather than being targeted or tailored to those with the most extreme disadvantage and needs. However, this appears to have led to the observed failure demand that exacerbates social and health inequalities between the local general population and those experiencing multiple disadvantage. A series of examples have been presented in VOICES reports that show how people experiencing multiple disadvantage have been excluded from services for which they were eligible, and entitled to. Some of these are illustrated in Position A of Figure 13. Legal literacy and misinterpretation of the legislation’s inclination toward equity affects many services, excluding the VOICES customer group from social, health and financial services. In turn, the observed lack of responsibilitytaking in the public sector for those experiencing multiple disadvantage, alongside reactive and untargeted nature of some provision (e.g., prison release plans, hospital discharge), were illustrations of the causes of the revolving door issue, whereby those with the greatest needs are continually in/out of the same local support services (often in crisis). Finally, Position A also notes the perpetuation of the traditional treatment first or temporary hostel accommodation policy that had failed to address local chronic homelessness.

Figure 13. Equality vs. equity and the system's failure demand

It is also clear that ‘equality’ was the common target within the diverse local system’s support services. In systems thinking, this could be explained by ‘system’s perpetuation’. Specifically, this mean that various sub-systems in this situation (e.g., prison release, hospital discharge) aim to treat everyone equally (i.e., towards a target of equality), which is reflected in the whole system’s behavior. However, for those experiencing multiple disadvantage who need additional, specific support, the result is exclusion and marginalisation. Furthermore, the equality principle and policies favour those in better social, health and mental position, rather than people experiencing multiple disadvantage resulting in the ‘competitive exclusion principle’; a ‘gravitational force’ that keeps people experiencing multiple disadvantage in the same vulnerable position [30]. Eventually, when the problematic situation becomes unmanageable and overburdens the system (in what is called a ‘feedback delay’), the need to turn to more systems thinking solutions is acknowledged; in this case, such solutions were attempted through Fulfilling Lives and VOICES. VOICES acknowledged the need to focus on equity as the target. The aim was to approach this through implementing changes on every level at the situation, as illustrated in Position B (fig 13). Initially, the emergence of Expert Citizens as ambassadors for people experiencing multiple disadvantage redirects the focus of the local support system. According to system thinking, changing one element cannot be expected to drastically transform the system as a whole. However, it could cause a redirection of priorities if the change is 48

accompanied by analogous changes in nested systemic relationships. For example, it was achieved in this case through supporting Expert Citizens not only to become an independent CIC, but by acknowledging the need for skilful personnel who are accredited and trained to particate equally as co-designers (i.e., Care Act toolkit), coresearchers (i.e., interviewing and collecting data at various VOICES reports) and co-evaluators (i.e., INSIGHT), with VOICES and partner organisations. This is expected to provide gradual and long-lasting change that will steadily help to transform the face of the local support system. VOICES acknowledged the need for great systemic changes. That was mainly achieved by: a) Transforming VOICES to a totally co-produced project (of constantly adapted, innovative, diverse but autonomous partnership. b) Adopting an “evolutionary learning” approach, which acknowledged the complexity of the support system for people experiencing multiple disadvantage (i.e., the situation); e.g., the Learning Programme for workforce development around working with this population; WBLL to improve legal literacy; commissioning research and evaluation around VOICES activities to inform practice. c) Overcoming professionals’ assumptions of who knows best, acknowledging the importance of lived experience as basic component of their own learning process and being open to constructive criticism as opportunities to learn and adapt

Finally, by trying to move the system’s purpose (towards equity, not equality), VOICES aimed to effect profound changes in local systems for people experiencing multiple disadvantage. This was attempted through the efforts to:

a) Reinstate legislation’s inclination toward equity, either by raising awareness through legally-informed documentation (i.e., Gatekeeping report; Care Act toolkit) or by intervening in the internal structure of organisations via the model(s) of specialist welfare Benefits Adviser and WBLL model to the frontline teams. b) Implement a pilot Housing First programme for immediate, permanent and unconditional tenancies for people experiencing multiple disadvantage, regardless of compliance with services[31].

Strengths and limitations of the evaluation The strengths of this summative evaluation include

We were able to draw on a wealth of information in reports from discrete projects, activities, evaluations, and research projects undertaken throughout the VOICES period (many of which are summarised in Section 2). Situational Analysis offered a methodology that could draw on information from these discrete projects, but also a range of other sources (Appendix 1). The evaluation team included Expert Citizens, who provided an invaluable contribution of both lived experience and first-hand knowledge and experience of VOICES. Moreover, the inclusion of the Get Talking training for Expert Citizens and CHAD researchers helped to develop this relation and facilitate feedback on the evaluation.

Through undertaking numerous research and evaluation projects for VOICES, having representation on the Partnership Board and Housing First Steering Groups, the research team have engaged with many of the key stakeholders considered in this work, and had good oversight of work and challenges in this area. To some extent, this ongoing engagement with the situation under investigation (since 2016) helped to mitigate some of the limitations of relying primarily on secondary data sources.

The weaknesses of this summative evaluation include We were unable to engage with some key partner organisations, such as those from the health care sector. Although symptomatic of VOICES’ experience, including the voices of a wider range of health care representatives in the Situational Analysis would have strengthened the work.

A reliance on retrospective and secondary data. With more time, further primary data gathering would have helped to explore key discourses that were identified.

Implications

This final section summarises the main implications from the VOICES legacy, in particular taking in to account the Changing Futures programme. Briefly, Stoke-onTrent was one of 15 areas in England to be awarded funds from central government and the National Lottery Community Fund to deliver improvements for adults experiencing multiple disadvantage at the individual, service, and system level: stabilise and then improve the life situation of adults who face multiple disadvantage transform local services to provide a person-centred approach and to reduce crisis demand to test a different approach to funding, accountability and engagement between local commissioners and services, and between central government and local areas The Stoke-on-Trent Changing Futures approach builds on the approach and learning from VOICES, intervening system, service and individual levels, which interact as described in the Changing Futures proposal:

“

At the system level, we will reconnect systems design and commissioning to the lived experience of practitioners and beneficiaries through a CRM with access to live quantitative and qualitative data. Learning will be captured and disseminated at the service level through a community of practice and workforce development function informed by lived experience. This will equip practitioners at the individual level across the whole system with the up-to-date knowledge and skills required to work more effectively and empathise with people experiencing multiple disadvantage, promoting a person-centred and trauma-informed culture. A Case Coordination Team and Multi-agency Resolution Group will triage and escalate the most problematic frontline situations for analysis, resource allocation, information and risk sharing, and to act as a bridge to connect the frontline, management, strategic oversight, and commissioning functions”

The legacy of VOICES in this proposal is clear. Changing Futures has effectively provided resource to build on VOICES’ work, and the VOICES Director played a central role in the successful bid (which can be considered an additional, considerable part of the VOICES legacy beyond March 2022). We suggest some main implications, in the context of Changing Futures, listed under each of the VOICES priority areas.

6.1 Fair access to services CRM, MARG, silo working and system fragmentation Changing Futures is a multi-agency partnership (as was VOICES), will use a multi-agency CRM (like VOICES) and includes the MARG (which VOICES has helped to develop/shape after it was initiated by the Local Authority). These factors aim to address issues of silo working and system fragmentation observed through VOICES work and which VOICES tried to address. The legacy of VOICES in these parts of the Changing Futures model are clear. First, the multi-agency partnership of VOICES was clearly important for raising awareness and engaging organisations from the public and third sector in efforts to support the customer group. The Changing Futures partnership will build on this at the system level, with an even broader partnership.

Second, VOICES CRM provided a powerful data source that, through Hard Edges reports (Section 2.2), demonstrated benefits of intensive support to reduce demand on crisis services by the customer group. Again, at the system level, the ‘Shared Multiple Disadvantage CRM’ in Changing Futures will be a shared data resource to help ‘resolve the disconnect and inertia between the system, service, and individual levels by rapidly generating management information based on live data’. Through giving partners this access and feedback, the various agencies and sectors should be able to observe the benefits of effectively supporting those experiencing extreme disadvantage, thus work more cooperatively towards a common goal (thus mitigating silo working and fragmentation). Third, at the service level MARG will continue with resources for an independent chair, to deal with exceptional cases. The prominent role of VOICES staff in helping to chair, organise and shape the development of this group, in addition to the value of the MARG among stakeholders evident from the VOICES-commissioned evaluation (Section 2.14), again demonstrates that this can be considered part of a legacy. Fourth, at the individual level, Changing Futures includes Case Coordinators who, much like the VOICES Service Coordinators will be the key workers for individuals. The difference to VOICES, and based on learning regarding parts of the system where continuity of care fails and individuals can be lost, is that these posts will be employed by key services at these ‘pinch-points’ in the system, e.g., hospital discharge teams, primary care outreach, substance misuse, women’s services, or prison release.

Engagement with health care As a direct response to failure of VOICES to consistently engage with, and be heard by, the local health care system, the Changing Futures Project Board will report to the Health & Wellbeing Board. This could prove to be a fundamental system-level shift towards recognition that the needs of this population group are a health concern, not only a social concern.

Ongoing development of legal literacy for benefit claims Funds have been allocated to support the ongoing implementation of WBLL as part of the Changing Futures approach. Through the specialist advisor and WBLL approaches (see Sections 2.11 and 2.12), VOICES started to improve the local system through developing legal literacy among frontline staff in key organisations. However, the challenges of changing practice within these partner organisations were apparent. Given the substantial impact on individuals experiencing multiple disadvantage and need of receiving the benefits to which they are entitled, the continuation and evolution of WBLL is another important part of VOICES’ legacy.

VOICES also developed a range of materials and toolkits as a legacy that can be used beyond the VOICES period.

Hospital Discharge and Homelessness A specific legacy with potential that has not yet been realised relates to proposed changes to hospital discharge processes for people experiencing homelessness. Recommendations from this work (see Section 2.6) were used to develop and plan to improve the discharge process, but due to changes in personnel in the hospital, were not implemented at the time. Through Changing Futures, efforts to progress this have reinitiated and, if successful, would make an important difference to continuity of care and re-admission risk for the city’s homeless.

Prison Release Changing Futures also includes programme review, design and prototyping of prison release plans to mitigate the shortcomings of the present processes that VOICES highlighted. Although these were not addressed during the lifetime of VOICES, the legacy of this work is through its inclusion in the Changing Futures workstream.

Workforce development and resources The Learning Programme in VOICES reached many local staff from a range of organisations to develop knowledge and skills around supporting those experiencing multiple disadvantage. In addition to this observed benefits of this work (see Section 2.8), Changing Futures will build on this through the Centre of Excellence, a ‘workforce development group to develop a learning programme for frontline workers, volunteers, and people with lived experience’.

6.2 Housing First Housing First Extension The clear legacy of VOICES is the establishment and extension of Housing First in Stoke-on-Trent (funded by VOICES). Without this investment, Housing First would not have outlasted the VOICES period.

Housing First Sustainability The longer-term sustainability of Housing First is less certain. Changing Futures does not include a specific Housing First funding allocation. Therefore, the questions around the programme’s future discussed in the context of the positions discussed in 4.5.2 remain. Through VOICES, there is legacy of an evidence base to support the programme (see Section 2.13) and recommendations for the future service specification that have been presented to the local authority (by the programme managers). Ultimately, at the present time, the culture shift needed to accept the principles and ethos of Housing First and to mainstream the programme, was not evident (although the 2022-2027 Housing Strategy had not been released at the time of writing). According to the evidence considered in Situational Analysis, support services more aligned with equality were mostly those of the public sector. This is perhaps not surprising as the common delivery focus is citywide and based on population needs,

6.3 Making service users leaders in service design and commissioning Expert Citizens CIC independence The primary VOICES legacy under this priority is establishment of VOICES as an independent CIC, who at the time of writing, have set up in new offices and will continue to function autonomously post-VOICES. This evaluation is focused on the legacy of VOICES. Expert Citizens are discussed in that context, while recognising that they operate as an independent, autonomous group who no longer rely on VOICES funding. Their establishment as a CIC and growing prominence is a considerable achievement in changing how the city perceives and works to support those experiencing multiple disadvantage. Expert Citizens have also gained national recognition for their work and innovation around lived experience.

Expert Citizens CIC as key partner in Changing Futures Expert Citizens are embedded through the Changing Futures plan at each level: - system level, to ‘involve people with lived experience in all aspects of Changing Futures systems change activity as cocreators and producers including recommendations for commissioning’ - service level, for ‘Development and maintenance of a network of people with lived experience to participate in Communities of Practice and the co-design / codelivery of learning opportunities through the Centre of Excellence’. - individual level, the ‘Project Board will commission periodic evaluations of services by people with lived experience using

the INSIGHT Service Standards developed by Expert Citizens, to test and report on the nature of the beneficiary experience’. This cements Expert Citizens’ position in the city’s plans to improve the lives of those experiencing multiple disadvantage.

Expert Citizens CIC growth in other areas Expert Citizens have partnered with academic teams for various projects. For example, they have partnered with CHAD on projects including City Centre Rough Sleeping and Street Activity [12, 13], Housing First evaluation [24], an exploration of local women’s support services [32] and this summative VOICES legacy evaluation. They have partnered with Keele University on work around primary care gatekeeping (see Section 2.5) and applying INSIGHT evaluation to health care settings. This demonstrates two important additional features of Expert Citizens as a legacy: they have developed experience of academia to allow this work and other partnerships to develop; their lived experience expertise is now being applied beyond the context of multiple disadvantage into other settings (i.e., health). Such efforts will increase sustainability post-March 2022.

6.4 Summary In summary, VOICES has made a substantial impact on the system of support for people in Stokeon-Trent experiencing multiple disadvantage. During the eight years of VOICES, there has been progress against all three priority areas for systems change. Where shortcomings or failures to make lasting impact have been observed, the commitment to learning and evaluation throughout VOICES has allowed the Changing Futures plans to include measures that should address the problems encountered.

References

1. Lamb H, Moreton R, Welford DJ, Leonardi S, O’Donnell J, Howe P. What makes a difference. Evaluation of Fulfilling Lives: Supporting people with multiple needs. London: The National Lottery; 2019. 2. Bramley G, Fitzpatrick S, Edwards J, Ford D, Johnsen S, Sosenko F, et al. Hard Edges, Mapping Severe and Multiple Disadvantage. London: Lankelly Chase; 2015. https://lankellychase.org.uk/wp-content/ uploads/2015/07/Hard-Edges-Mapping-SMD-2015.pdf. 3. Rice B. Hard Edges Stoke-on-Trent. Stoke-on-Trent: VOICES; 2016. 4. Nichols N, Doberstein C. Exploring effective systems responses to homelessness. Toronto, Canada: Toronto Press; 2016. 5. Fowler PJ, Hovmand PS, Marcal KE, Das S. Solving Homelessness from a Complex Systems Perspective: Insights for Prevention Responses. Annu Rev Public Health. 2019;40:465–86. doi:10.1146/annurevpublhealth-040617-013553. 6. Rutter H, Savona N, Glonti K, Bibby J, Cummins S, Finegood DT, et al. The need for a complex systems model of evidence for public health. Lancet. 2017;390:2602–4. doi:10.1016/S0140-6736(17)31267-9. 7. Martin W, Pauly B, MacDonald M. Situational Analysis for Complex Systems: Methodological Development in Public Health Research. AIMS public Heal. 2016;3:94–109. doi:10.3934/ publichealth.2016.1.94. 8. Clarke A. Situational Analysis: Grounded Theory After the Postmodern Turn. Thousand Oaks: Sage; 2005. 9. Meadows DA. Thinking in Systems: A Primer. London: Earthscan; 2008. 10. Gidlow CJ, Spyropoulos K, McCormack F, Hine R. Hard Edges Stoke-on-Trent. Reducing the costs of multiple needs to people and services: the third financial analysis of VOICES. Stoke-on-Trent: VOICES; 2021. 11. Rice B. Hard Edges Stoke-on-Trent. Stoke-on-Trent: VOICES; 2018. 12. McCormack F, Massie R, Machin R, Vincent P, Kurth J, Morton J, et al. City Centre Rough Sleeping and Street Activity Project Report. Stoke on Trent: Centre for Health and Development, Staffordshire University; 2016. 13. Massie R, Machin R, McCormack F, Kurth J. Having a voice: A collaborative research project exploring the challenges and assets of people experiencing homelessness. J Integr Care. 2018;26:342–52. doi:10.1108/JICA-02-2018-0017. 14. Rice. Independent evaluation of VOICES: systems change report. Stoke on Trent; 2017. https://issuu. com/voicesofstoke/docs/evaluationsystemschangereport_draft. 15. Wilson B, Astley P, Cutts J, Hine R, McCall K, Perry S. Gatekeepers: Access to primary care for those with multiple needs. Stoke-on-Trent; 2016. https://issuu.com/voicesofstoke/docs/gatekeepers_voices_ and_hw_stoke_rep. 16. Homeless Link, St Mungo’s Broadway. Improving hospital admission and discharge for people who are homeless. 2012. https://www.homeless.org.uk/sites/default/files/site-attachments/ HOSPITAL_ ADMISSION_AND_DISCHARGE._REPORTdoc.pdf. 17. UK Parliament. Homelessness Reduction Act 2017. London: HMSO; 2017. 18. McCormack F, Parry S, Gidlow CJ. Hospital Discharge and Homelessness: Local stakeholder perspectives. Stoke-on-Trent: Centre for Health and Development, Staffordshire University; 2019. 19. McCormack F, Parry S, Gidlow CJ, Meakin A, Cornes M. Homelessness and hospital discharge: a qualitative study of stakeholders’ views on how to improve support for this marginalised group. under Rev. 2021.

20. Rice B. The VOICES Model of using Personal Budgets in Service Coordination. Stoke on Trent: VOICES; 2019. 21. Pollard N, Rice B. The VOICES Citywide Learning Programme: Shared learning opportunities to improve support for people experiencing multiple needs. Stoke on Trent; 2020. https://issuu.com/ voicesofstoke/docs/voices_learning_programme_evaluation_2020_final. 22. CFE Research, University of Sheffield, Network SCA. VOICES’ Care Act Toolkit: Improving access to mental health support for people experiencing multiple disadvantage. Sheffield: CFE Research; 2020. 23. Pollard N, Rice B. A Model of Specialist Welfare Advice and Advocacy at VOICES. Stoke-on-Trent: VOICES; 2018. https://issuu.com/voicesofstoke/docs/a_model_of_specialist_welfare_advic. 24. Gidlow C, McCormack F, Spyropoulos K, Fedorowicz S, Hine R. Investigation of Housing First in Stokeon-Trent: Evaluation report. 2021. https://www.chadresearch.co.uk/wp-content/uploads/2021/09/HFreport-FINAL.pdf. 25. McCormack F, Gidlow CJ, Spyropoulos K. Multi-agency Resolution Group (MaRG): Evaluation report. Stoke-on-Trent: Centre for Health and Development, Staffordshire University; 2021. https://www. chadresearch.co.uk/wp-content/uploads/2022/01/MarG-report-final-version.pdf. 26. Gant K, Rowley J. Participatory Appraisal: Practitioner Pack produced by Creative Communities Unit, Staffordshire University Participatory and Practitioners for Change. Stoke-on-Trent: Staffordshire University; 2013. 27. Clarke E, Friese C, Washburn S. Situational Analysis Grounded Theory After the Interpretive Turn: Second Edition. Thousands Oaks: Sage; 2018. 28. McIntyre S, Hewett N, Medcalf P. Inclusion Health Clinical Audit 2015-16. London; 2015. https://www. pathway.org.uk/wp-content/uploads/2015/12/ED-Audit-2015-patient-report.pdf. 29. Seddon J. Freedom from Command and Control. New York: Vanguard Press; 2003. 30. Chapman J. System failure Why governments must learn to think differently learn to think differently. 2nd Edition. London: Demos; 2004. 31. Bretherton J, Pleace N. Housing First in England An Evaluation of Nine Services. York: University of York Centre for Housing Policy,. 32. McCormack F, Fedorowicz S, Gidlow CJ. The provision of support services for women in Stoke-onTrent: Project Report. Stoke-on-Trent; 2019.

Appendix 1. Resources for Situational Analysis Reports (for reports produced by CHAD, some raw data were revisited) Lisa O’Conor (2019) The Wayfarer and other journeys http://www.issuu.com/voicesofstoke VOICES & Expert Citizens (2017) Stoke-on Trent: Call for Evidence on Social Action http://www.issuu.com/ voicesofstoke VOICES (2020) CASE STUDY#1: VOICES’ Care Act Toolkit : Improving access to mental health support for people experiencing multiple disadvantage http://www.issuu.com/voicesofstoke VOICES & Expert Citizens (2020) Stoke-on-Trent Community of Practice Guide: How coffee, cake and conversation can promote preferred futures with positive practice. http://www.issuu.com/voicesofstoke VOICES (2016) Prison Release Support : Stoke-on-Trent Community of Practice @SotCoP http://www. issuu.com/voicesofstoke Fulfilling Lives in Stoke-on-Trent: Project Plan 2014-2022 Rice B. (2016) Hard Edges Stoke-on-Trent: Reducing the costs of multiple needs to people and services: Financial analysis of VOICES http://www.issuu.com/voicesofstoke Rice B, (2018) Hard Edges Stoke-on-Trent: Reducing the costs of multiple needs to people and services: Financial analysis of VOICES http://www.issuu.com/voicesofstoke Gidlow C., Spyropoulos K., McCormack, F., Hine R. (2021) Hard Edges Stoke-on-Trent: Reducing the costs of multiple needs to people and services: Financial analysis of VOICES http://www.issuu.com/ voicesofstoke Gidlow C., Spyropoulos K., McCormack F., Fedorowicz S., Hine R. (2021) Investigation of Housing First in Stoke-on-Trent http://www.issuu.com/voicesofstoke Rice B. (2020) The VOICES Citywide Learning Programme: Share learning opportunities t improve support for people experiencing multiple needs. Independent Evaluation Report http://www.issuu.com/ voicesofstoke Stoke-on-Trent Safe City partnership (2021) Multi-agency Resolution Group Stoke-on-Trent: Working Together for Your Community McCormack F., Gidlow C., Spyropoulos K (2021) Multi-agency Resolution Group (MaRG): Evaluation report https://www.chadresearch.co.uk/wp-content/uploads/2022/01/MarG-report-final-version.pdf CFE Research, University of Sheffield, Systems Change Action Network (2020) Improving access to mental health support for people experiencing multiple disadvantage Evaluation of Fulfilling Lives: Supporting people with multiple needs http://www.issuu.com/voicesofstoke Rice B. (2019) The VOICES Model of using Personal Budgets in Service Coordination http://www.issuu. com/voicesofstoke Wilson B., Astley P. (2016) Gatekeepers: Access to Primary Care for those with Multiple Needs http://www. issuu.com/voicesofstoke McCormack Fiona, Perry Sian and Gidlow Chris (2019) Hospital Discharge and Homelessness: Local stakeholder perspectives http://www.issuu.com/voicesofstoke Sharman Sharon (2020) An Improbable Journey: Exploring a prison release plan - Case Study http://www. issuu.com/voicesofstoke McCormack F., Massie R., Machin R., Vincent P., Kurth J., Morton J., Gidlow C. (2016) City Centre Rough Sleeping and Street Activity: Project Report Fiona http://www.issuu.com/voicesofstoke Ornelas, B., Bateman, F., Meakin, A., Cornes, M., Pritchard-Jones, L. (2020). Multiple Exclusion Homelessness: A safeguarding toolkit for practitioners. Stoke-on-Trent: VOICES http://www.issuu.com/ voicesofstoke Rice, B. (2016) VOICES – Voices of Independence Change and Empowerment in Stoke-on-Trent Stakeholder survey report http://www.issuu.com/voicesofstoke 56

Rice, B. (2017) VOICES – Voices of Independence Change and Empowerment in Stoke-on-Trent Stakeholder survey report Rice, B. (2018) VOICES – Voices of Independence Change and Empowerment in Stoke-on-Trent Stakeholder survey report Rice, B. (2019) VOICES – Voices of Independence Change and Empowerment in Stoke-on-Trent Stakeholder survey report Rice, B. (2020) VOICES – Voices of Independence Change and Empowerment in Stoke-on-Trent Stakeholder survey report Rice B (2017) Independent evaluation of VOICES: systems change reporthttp://www.issuu.com/ voicesofstoke Meakin A. (2020) VOICES: Legacy Projects: Initiation document and plan Meakin A., Murinas D. (2015) Right Time Right Place: A Multiple Needs Charter for Stoke-on-Trent 20162022 Fulfilling Lives (2019) Changing systems for people facing multiple disadvantage Rice B. (2018) A Model of Specialist Welfare Advice and Advocacy at VOICES: How VOICES and Citizens Advice Staffordshire North and Stoke-on-Trent have worked together to provide welfare rights support to people with multiple needs VOICES, Citizens Advice Staffordshire North & Stoke-on-Trent, Brighter Futures, cdas Stoke-on-Trent, CONCRETE (2020) Welfare Benefits Leading & Learning Engaging, Learning and Making Progress Together: Year 1 Report 2019-2020 Gidlow, C., McCormack, F., Riley, V., Spyropoulos, K. (2021) Welfare Benefits: Leading and Learning (WBLL) model in Stoke-on-Trent Evaluation report: Embedding a specialist Citizens Advice adviser in partner organisations, to work with staff and customers on benefits advice for people with multiple needs Mason, K., Cornes, M., Dobson, R., Meakin, a., Ornelas, B., and Whiteford M. (2017) Multiple Exclusion Homelessness and adult social care in England: Exploring the challenges through a researcherpractitioner partnership. Research, Policy and Planning 33(1), 3-14 VOICES, Expert Citizens 92016) The Care Act Multiple Needs Toolkit Cornes, M., Ornelas, B., Bennett, B., Meakin, A., Mason, K., Fuller, J., Manthorpe, J. (2018) Increasing access to Care Act 2014 assessments and personal budgets among people with experiences of homelessness and multiple exclusion: a theoretically informed case study", Housing, Care and Support, Vol. 21 Issue: 1, pp.1-12, https://doi.org/10.1108/HCS-09-2017-0022 Expert Citizens, Keele University (2018) Access to Primary Care Services for Patients with “No Fixed Abode”: A follow-up of he Gatekeeper’s Report NHS Midlands & Lancashire (CSU) (2019) Guidance for considering the needs of people experiencing homelessness in commissioning health services Expert Citizens (2019) Portfolio of Positive Practice Supporting People Experiencing Multiple Disadvantage A showcase of outstanding practice that provide insight to new ways of working and ideas for systems change Expert Citizens (2019) GP Registration Evaluation Toolkit Accessing Primary Health Care For People with “No Fixed Abode” CFE Research, University of Sheffield, Systems Change Action network (2020) Improving access to mental health support for people experiencing multiple disadvantage Evaluation of Fulfilling Lives: Supporting people with multiple needs Murinas D., Meakin, A. (2020) Insight through experience: How Expert Citizens are celebrating the nicest people. People, Place and Policy 14/1 pp. 24-34 CFE Research (2020) The role of lived experience in creating systems change Evaluation of Fulfilling Lives: Supporting people with multiple needs

Websites https://www.voicesofstoke.org.uk/ https://www.brighter-futures.org.uk/ https://www.fulfillinglivesevaluation.org/about/the-partnerships/voices-stoke-on-trent/ https://www.citizensadvice.org.uk/benefits/sick-or-disabled-people-and-carers/pip/appeals/mandatoryreconsideration/ https://www.healthwatchstokeontrent.co.uk/about-us/ https://www.keele.ac.uk/socialinclusion/ourpartnerships/ https://www.expertcitizens.org.uk/ https://www.chadresearch.co.uk/

Minutes and papers from meetings of VOICES Legacy Steering Group Housing First Steering Group

Appendix 2. Situational messy map

Appendix 3. Situational order maps Situational Map: Ordered Version Individual Human Elements/Actors

Nonhuman Elements/Actants

e.g., key individuals and significant (unorganized people in situation, including the researcher(s)

e.g. technologies; material infrastructures; specialized information and/or knowledges; material “things”

Andy Meakin Darren Murinas Rachel Hine Bruno Ornelas Jane Turner Karen Dunn Joanne Cutts Sharon Sharman Alex Smith Alice Evans Nigel Sparrow Jane Morton Sarah Wilshaw

INSIGHT tool Welfare model Housing First Community Of Practice Personal Budget Care Act tool SMD safeguarding Toolkit Golden Ticket Learning programs @SoTCoP Fb page/website International conference BBC radio Newspapers Housing Strategic Needs Assessment GPs Care Act 2014

Implicated/Silent Actors/Actant As found in the situation General Practice Practitioners and Private sector Landlords & Agents National Framework for continuing Healthcare Homelessness reductions Act 2017 Advance Nurse Practitioner

Collective Human/Actors e.g., particular groups; specific organizations Expert Citizens CIC Probation Police Brighter futures Concrete Lottery Stoke-on-Trent Housing First England GPs CHAD Homelessness Link Clinical Commissioning Group Arch North Staffs North Staffs Mind Sallbox Cab CDAS Healthwatch Hospitals Fulfilling Lives Big National Lottery IOM 90 Hope Street Lankely Case SMD people Volunteers Peer mentors Service coordinators Doctors Nurses Blue service personnel Rough sleepers

Discursive Constructions of Individual and/or Collective Human Actors As found in situation Co-production Social Action Helping relationships Reactive vs proactive support Stigma & marginalization Self-neglect Chaotic lives & behaviours

Political / Economic Elements e.g., the state, particular industry/ies; local/regional/global orders; political parties; NGOs; politicized issues Homelessness Reduction Act 2017 Healthcare in Staffordshire Equality & inclusion strategy 2015-2017 Housing availability and deliverance Hospital discharge National Health Cevic Act2006 amended in Health & Social Care Act 2012 Care Act 2014 Homeless Link

Temporal Elements e.g., historical, seasonal, crisis, and/or trajectory aspects Historical deprivation and poverty in Stoke-on-Trent

Discursive Constructions of Nonhuman Actants As found in the situation fair access Raise awareness on people with Multiple needs Effectiveness and sustainability of Housing First housing support service Equity and Healthcare provision

Sociocultural / Symbolic Elements e.g., religion; race; sexuality; gender; ethnicity; nationality; logos; icons; other visual and/or aural symbols @SoTCoP COVID

Spatial Elements e.g., space in the situation, geographical aspects, local, regional, national. Global spatial issues expensive transportation City layout makes travel and access to services difficult Lack of appropriate housing/ quality of housing

Major Issues /Debates (Usually Contested) As found in the situation; and see positional map Fragmented health care Social gradient Invisible minority Accountability Whose responsibility Professional normative authority Prejudice Resistance to change Gatekeeping Ontological security Social integration Self-rated status Fair access to services Services not fit for purpose label people ‘difficult to reach’ or as not engaging with service Co-occurring addiction and ill mental Proportionate universalism Ontological security Equity in healthcare provision Other Kinds of Elements As found in the situation Community of Practice (Learning) Homeless Link

Peer mentor training Volunteering – to support recovery (peer mentors, EC) – To support the workforce of stretched services without adequate support

Related Discourses (Historical, Narrative, and/or Visual) e.g., normative expectations of actors, actant, and/or other specified elements; moral/ethical elements; mass media and other popular cultural discourses; situation-specific discourses Discourse around social disadvantage Discourse around ‘fairness’ and ‘deservedness’ – the idea that some people deserve help and others do not Normative needs Professionals’ Normative authority Enforced normative Dehumanization of the problem Care duality

Appendix 4. Situational relational map Fair Access to Services

Appendix 5. Situational relational map Housing First

Appendix 6. Situational relational map Expert Citizens

VOICES OF INDEPENDENCE CHANGE & EMPOWERMENT IN STOKE-ON-TRENT

www.voicesofstoke.org.uk

facebook.com/voicesofstoke voicesofstoke.org.uk

issuu.com/voicesofstoke

youtube.com/user/voicesofstoke

@voicesofstoke

VOICES Legacy Evaluation

Articles inside

Appendix 1. Resources for Situational Analysis

4. Overall Evaluation of VOICES through Situational Analysis

5. Strengths and limitations of the evaluation

7. References

Executive Summary

6. Implications

1. Introduction