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).

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.