By Alex Fox, CEO of Mayday Trust. Alex believes that the UK’s charities and public services have one goal: to create ways for people who want support, and people who want to help, to meet as equals. What works best in support services usually feels small, human and personal. Alex is fascinated by how to scale up those strengths-based ways of working to reach many more people, without accidentally rebuilding old institutions and (invisible) asylums. 

No Unplanned Crises 

I’ve started working alongside one of my Mayday colleagues with a group developing a council area’s strategy for people with ‘severe and multiple disadvantage’. It’s an opportunity to help shape how health, care and support agencies respond to people who are seen as having a number of problems or challenges, often including a serious mental health problem, substance misuse issues and being homeless. In any area there is a group of people – probably several hundred in a London borough for instance – who are typically known to lots of services, but are not getting the help they need from any of them. 

‘Severe and multiple disadvantage’ (SMD) is not the strengths-based language we’d choose to identify this issue. But you might ask, is there any strengths-based way you could meaningfully identify a group of people who experience so many challenges? The group I’m part of has started to engage with this question, and it’s got me thinking, What happens if you turn ‘severe  and multiple disadvantage’ on its head?  

The SMD label is intended to be less stigmatising than some other labels (‘frequent flyers’, ‘revolving door customers’, ‘non-engagers’, people who ‘challenge’ services), but it locates the big, multiple problems, and implicitly the roots of those problems, within the individuals. Another way of looking at it, is that what this group of people have in common is that they have been severely and repeatedly let down by services.  

Some of them will have been considered not to be ‘eligible enough’ for one or more services: their mental health wasn’t bad enough to get access to a mental health service, their housing need wasn’t big enough to get access a housing service, their family crisis wasn’t acute enough to be prioritised by social services. But they are just as likely to have too much ‘eligibility’: that same person, once those many issues combine into a crisis, is now eligible for all of those services, except that none of them will now work with that person until their other problems have been fixed.  

Some of those people’s crises will even have been caused by one of those agencies, not necessarily through some a perceived failure of their part: when someone behaves seriously antisocially, or their home becomes used by criminals, the police or council can apply for a closure order, which can make that person homeless. They can be a perpetrator, a victim (of cuckooing, for instance), or both. Either way, they might be judged to be ‘intentionally’ homeless as a result, giving them few options for support and housing. The closure order could be a necessary response to a situation which has been making life dangerous or miserable for their neighbours. But it also undoubtedly causes a crisis which tips that person swiftly into the ‘SMD’ group if they weren’t in it already.  

Gateshead, like all councils, had a problem with unpaid council tax. The standard response is enforcement: court orders and debt collection. But Gateshead Council recognised that that method doesn’t work because the people in debt tend to have lots of other issues going on. The debt collection becomes part of the problem.  

So, Gateshead decided to take a different approach. They set themselves two rules: do no harm and don’t break the law. They gave a small team £10k, and adopted strengths-based principles (which director for public service reform Mark Smith set out recently at a Start with People NHS England event): 

  1. No assessments: understand what matters and build trust
  2. No referrals: pull expertise in rather than passing people on
  3. No standardised care packages: person-led and bespoke are cheaper because they work
  4. Use measures to learn and improve, not to keep the score 
  5. Don’t close cases – if the person knows you’re there for them, they can move on

Gateshead’s approach, one of the Changing Futures demonstrators, worked so well, they’ve extended the approach to numerous other groups seen as ‘challenging’ or ‘complex’. 

This is an example of how different our approach can be if we recognise that, while we all have personal responsibility, some problems stem not from bad luck or bad choices, but from systems which aren’t human, don’t join up, or can’t talk to each other. So perhaps the future for ‘severe and multiple disadvantage’ work is not getting better at finding and tracking people who cause services multiple problems. It is finding the places where services create the most gaps and problems and asking ‘How could this gap be closed?’ ‘What needs to happen elsewhere in our system when one service creates a problem for someone?’   

A key test for such a human, flexible, creative system would be becoming a ‘No Unplanned Crises’ system: one in which no service ever creates a crisis for someone without planning in place to respond to its impact. You can’t make someone homeless without talking to housing services. You can’t pursue debt collection without asking the other services involved what consequences that will have for the debtor. You can’t ask someone to become an unpaid carer without asking them what that will do to the financial sustainability of that household. The principle will be that each service is expected to look at the whole picture, and to pursue a ‘no surprises’ ethos with other local agencies. Agencies having to talk to each other as part of any high-risk intervention will often lead to a less punitive, less problematic response being identified, to avoid the crisis in the first place. Instead of thinking in terms of ‘frequent flyers’ it would be possible to ask which service interventions were frequent crisis creators. And even where a punitive approach is unavoidable, such a system will be one with far fewer SMSFs: severe and multiple system failures.  

More about the author

Alex is CEO of Mayday Trust. Mayday is a partner of the New System Alliance and founder of the Person-led, Transitional and Strength-based (PTS) Response, which offers strengths-based coaching to people going through tough times, such as homelessness. Through the PTS, Mayday, alongside the people it works with, also seeks to challenge and change the process-led systems that surround public services.

Previously, Alex led Shared Lives Plus, the UK network for Shared Lives and Homeshare which offer strengths-based, highly personalised support to around 15,000 people as part of supportive households and communities. Alex sits on the NHS Assembly and was Vice Chair of Think Local, Act Personal, developing the Asset Based Area model. He is a trustee of Alternative Futures Group (& previously of Social Care Institute for Excellence where he is co Director of a strengths-based leadership course), an Honorary Senior Fellow, Birmingham University and a Fellow of the Royal Society of Arts. He chaired the government’s review of health and care charities (2015-18), the Social Care Learning disability & Autism Advisory Group and co-founded the Social Care Innovation Network.

Alex is the author of A new health and care system: escaping the invisible asylum (Policy Press) and Meeting as Equals (RSA/NCVO) on building asset-based charities. He was awarded an OBE in 2017 for services to social care.