Nottinghamshire County Council: Support for people experiencing severe multiple disadvantage

In his 2023 annual report, Nottinghamshire’s former Director of Public Health, Jonathan Gribbin, highlighted the challenges faced by people experiencing SMD. These complex issues often originate in deprivation or childhood trauma. As an inclusion health group, people experiencing SMD face some of the worst health and wellbeing outcomes of any population group. 

Across Nottinghamshire, it is estimated that almost 30,000 people experience at least two of four key factors: 

• substance use 
• mental ill-health 
• homelessness 
• domestic abuse. 

The 2023 report was co-produced with people experiencing SMD. It aimed to raise awareness and encourage service providers to think about how they can make a difference. The report complemented the LGA publication ‘Care and support and homelessness: top tips on the role of adult social care’, which was co-authored by Nottinghamshire’s Director of Social Care, Melanie Brooks. 

Alongside this, Nottingham and Nottinghamshire Integrated Care System (ICS) has written SMD into its strategy. This means that the whole system has committed to action, in line with the approach advocated by the NHS inclusion health framework.    

In 2022, Nottinghamshire County Council joined the ‘Making Every Adult Matter’ (MEAM) network. This coalition of the national charities Clinks, Collective Voice, Homeless Link and Mind supports local areas to transform services and systems for people experiencing multiple disadvantage. 

These individuals can fall through the gaps between services and systems, making it harder for them to address their issues and lead healthy, fulfilling lives. They may find themselves shut out of one service (such as mental health support) as a result of another issue (such as alcohol use). 

Catherine O’Byrne, Senior Public Health and Commissioning Manager, said the MEAM approach presses areas to recognise that multiple disadvantage is a systemic, not an individual, issue. “The pathways might work for 99 per cent of people, but for this 1 per cent we need to work differently to get the same outcomes. It’s about services asking: what power do we have to help this person, what are the skills we can bring to make a difference here?”

‘Flex’ is key to this approach. The team cites the story of a man with paralysis being released from prison without his wheelchair because it belonged to the prison. Empowering staff to feel that they can do things differently, when it really matters, can make a big difference. 

Giving people access to the right support, at the right time and alongside the right long-term accommodation offer, are essential for improving people’s health and wellbeing. 

In 2023, Nottinghamshire’s public health team won funding from the Government’s drug strategy housing support grant, which is helping local areas to test targeted interventions and their effect on recovery outcomes. The bid was led by Sarah Quilty, Senior Public Health and Commissioning Manager.

This funding is being used in two main areas of activity. The first is working with people already on the caseload of Change Grow Live (CGL), the voluntary sector provider delivering Nottinghamshire’s substance use treatment service. Specialist housing support workers have been brought in to work alongside CGL’s recovery specialists to reduce eviction rates and ensure that people have stable housing. Within less than a year, they had already prevented more than 50 evictions. 

The second area of activity relates to testing the MEAM approach. A social work team manager and an advanced social work practitioner from Nottinghamshire County Council, and a specialist worker within CGL, are working with an initial cohort of 15 individuals experiencing SMD. Walking alongside them on their journey through the system is providing crucial information on what could be done differently. 

James Bunning, Strategic SMD Lead at CGL, said: “It’s about looking at how the system is treating people experiencing SMD. Focusing on people’s whole journey and experience has given us a really high level of insight into challenges that will affect multiple people. 

“Using our partnership-led steering group we can quickly cascade what we are doing, take that learning and strengthen relationships and understanding at pace across organisations.” 

Other ways in which the housing support funding is being used include: 

• Bringing Citizens Advice on board for income maximisation work. 
• Helping to wipe out housing arrears with private providers (with special agreement from the Office for Health Improvement and Disparities). 
• Purchasing white goods. 
• Temporarily placing people in a specialist care home while they are assessed and during initial wrap-around work. 

It is early days with this work. Nottinghamshire’s public health team are working collaboratively with Nottingham city’s ‘Changing Futures’ programme to share findings and work with partners to use the learning to improve support. The ICS has put a severe multiple disadvantage model in place to drive this work across the two areas. 

Sarah Mackintosh, Social Work Team Manager, said: “Once we started looking, it became apparent that there is lots of systems change to be made. At the moment, it’s about looking at what we could do to make things better for lots of people by seeing what’s going wrong for a few people and noticing the patterns. 

These are often people with high support needs, experiencing high risks to their wellbeing. It can be difficult to talk about pathways because the challenges may be very individual. Building trusted relationships with individuals and having the right professional relationships and the right collaborative spaces to have discussions are key to making progress.

“We started with nothing but some great relationships and the idea that we needed to do something. The rest of the work has happened because as partners we held steadfastly in this view and have used every opportunity that has emerged to try something different in this space.”