Tackling multiple disadvantage requires prioritising reason and evidence over the lure of exciting new approaches and the inertia of established ways of working, argues Beth Watts.
This week’s Making Every Adult Matter national summit brought together 300 delegates – people with experiences of multiple needs, service providers, commissioners, policy makers and researchers. The task was to identify the next steps required to tackle the multiple disadvantage faced by people experiencing combined problems of homelessness, substance misuse, mental ill health, violence, contact with the criminal justice system, domestic abuse and extreme poverty. In the closing panel of the first day, I was asked to consider the role that research can and should play in ‘changing the game’ for people with multiple needs.
Last year, Suzanne Fitzpatrick, Glen Bramley and I conducted a review of international evidence on ‘what works’ in tackling multiple disadvantage – this was part of the Joseph Rowntree Foundation’s anti-poverty strategy and we were seeking to identify the policies and interventions that demonstrably improved the prospects of those with multiple needs.
The exercise clarified some of the gaps in evidence that remain – and we and many others are working to fill those. Perhaps more striking, however, were the very clear messages that emerged on the kinds of approaches that work best, and the distance we have to go in bringing UK policy and practice into line with that evidence-base. To put it another way, there is a massive opportunity and a clear route to ‘change the game’ and make a huge difference to the wellbeing of some of the most marginalised individuals in the UK.
From the wide range of international evidence reviewed, we distilled five core principles that should inform approaches seeking to improve the prospects and wellbeing of those with multiple needs[i]:
- Personalisation: support should wherever possible be individually-tailored, open-ended, persistent, flexible and co-ordinated.
- Deinstitutionalisation: as far as possible, people should have the option of staying in mainstream housing, rather than specific, separate institutions.
- Reintegration: the focus should be on enabling people to socialise in ordinary social settings, and where employment is a realistic prospect, work in ordinary mainstream settings (with support).
- Asset-based: effective interventions identify and nurture people’s strengths and assets, as well as addressing their needs.
- Poverty-informed: the financial and material hardship that people with multiple needs face (and underlie their complex needs) should be directly addressed, and not seen as supplementary to tackling the challenging behaviours sometimes associated with multiple needs.
Standing in front of some of the people most committed to trying to translate these principles into positive real world change, it was easy to feel optimistic. But reflecting on the wider context brings such optimism into check. In my contribution, I wanted to highlight – in the spirit of, hopefully, being constructive – the extent of the challenge ahead.
There are some very clear examples of approaches that accord with these principles, not least the MEAM approach itself, and some the models under discussion in the conference workshop sessions[ii]. Another obvious example of an intervention reflecting these five principles is Housing First, and it’s great to see commitment to this model among an increasingly broad group of stakeholders. But progress has been hard won, and frustratingly slow, and scepticism and resistance surprisingly easy to find given the sheer weight of high quality evidence attesting to the difference Housing First can make to a severely and multiply disadvantaged group.
Moreover, examples that fly in the face of these principles are easy to find. I see two key reasons for this: one being about the durability of ‘old’ ways of doing things and another about the risk that apparently ‘new’ ways of doing things presents.
The durability of old models (or ‘path dependence’) problem reflects that these principles demand a (sometimes quite radical) shift in well-established ways of doing things, a profound culture shift, on the part of provider organisations (trustees, management and operational staff) and commissioners, and thus getting these principles translated into practice requires a battle against both inertia and, sometimes, finding ways through genuine financial and practical challenges. Delegates at the summit were full of examples of the difficulties associated with ambitious change – the risk-averse resistance or understandable caution of a board; the need to convince commissioners to think differently; the challenge of winning long-term staff or volunteers round to new evidence-informed ways of working. A particularly striking example I discussed with one service provider was the tension between their Christian roots – and the impact of this on the values and sensibilities of their volunteers – and what the management team now saw as clear messages about how to most effectively work with those with multiple needs e.g. according to the principles of psychologically-informed environments.
The risks of apparently ‘new’ and ‘exciting’ (but in fact sometimes rather orthodox and old-fashioned methods) is becoming increasingly apparent in the homelessness-field at the moment. In a context where rough sleeping is increasingly visible – local communities, business leaders, churches, students – whoever – perceive crisis, feel compassion and empathy (pity perhaps?) and want to help. But the responses that can emerge from such good intentions – from ‘pop-up’ on street food distribution by faith or community groups, to ‘street pastors’, to plans for specialist accommodation, volunteering or employment that congregate homeless people together and away from ordinary communities and workplaces – can be very far from evidence-informed given that experts and those familiar with the evidence and effective models are often not involved in their genesis. But that doesn’t necessarily stop them drawing large-scale public donations, the media spotlight and (most worrying) attention from political leaders, that at best, is annoying for those working hard behind closed doors on demonstrably effective but less photogenic responses, and at worst, might lead to policy drifting in a direction that is incontrovertibly the wrong one from an evidence-informed perspective.
There’s is a high risk, then, that both existing and emerging responses make the same old mistakes that we should have already learned from.
In discussions on these topics I’ve had elsewhere, people sometimes respond ‘but any response to these issues is positive, is better than doing nothing’, but that’s simply not true. Ill-designed and/or out of date responses have the potential to be genuinely harmful and counterproductive. In any case, I’d argue that if you want to do something or anything to help those with complex needs, there’s a moral obligation to do the things that promise to make the most and the best difference[iii]. This is as much a challenge for public-spirited social entrepreneurs, churches, local communities, student unions and anyone else that wants to get involved as it is for long-established organisations that simply keep doing what they’ve always done.
So, there really is no space to be complacent. But I think there are some clear implications of this diagnosis of the challenge, not just for researchers, but everyone involved in tackling multiple disadvantage.
First, be open minded where appropriate – where we don’t yet know the answers, or where we’re trying to translate evidence-based principles into new and better policies and services. But be robust, stubborn and unbending where we know that we know the right answers. Be vocal when we see the wrong answers gaining profile or money.
Second, never stop examining current ways of doing things. How do they accord with the principles above? Are systems in place to monitor as far as possible short and long-term outcomes, hard and soft outcomes? Are processes in place that translate that monitoring into refinements (or radical changes) to these ways of doing things? Or are we just doing things that way because we always have or because intuition (rather than an impartial application of reason and evidence) tells us so?
Third, collaborate: be vocal, participate in conversations and partnerships – with commissioners, politicians, local communities, business leaders, other organisations, researchers, those with multiple needs who’ve navigated the services/policies we’re talking about – to seek to realise these principles. Researchers, for instance, need to get out there, into charity board rooms, in front of the desks of commissioners, in the inboxes and at the select committee meetings of politicians, but all of those stakeholders need to be prepared to have those conversations too.
And lastly, don’t lose sight of the values that underpin what you do. For me, those values are about wanting to improve the wellbeing of those with multiple needs – those whose wellbeing is constrained in ways that are life-limiting, life-threatening and also, crucially, at least to some extent resolvable. But good intentions really aren’t enough – it’s about translating those good intentions not into pity, or even empathy or sympathy,[iv] or the slight alleviation of subsistence needs or one particular crisis, but into sustainable positive outcomes by using impartial, evidence-informed reason.
Image Credit: Making Every Adult Matter www.meam.org.uk
[ii] For instance, 16-25 Independent People’s Future for Me project, part of the Beyond Youth Custody project; The May Day Trust’s radical organisational transformation to a strengths-based model; and St Basil’s Positive Pathway model for young people. All of these examples are underpinned by ongoing efforts to evaluate progress, monitor outcomes and refine the intervention.
[iv] For a thought-provoking read in this territory see Paul Boom’s book Against Empathy: The Case for Rational Compassionate.