(COR0072)

Written evidence submitted by Fulfilling Lives South East Partnership (COR0072)

Introduction

1. We are currently experiencing what has been frequently described as an ‘unprecedented situation’ on a local, national, and global scale. Radical measures have been taken in a bid to slow the spread of Coronavirus (COVID-19), resulting in the closing of, or reduction in, local services and organisations who provide support for people with multiple and complex needs.

2. Fulfilling Lives South East (FLSE) Partnership has likewise been impacted. Client-facing work has been significantly restricted, as has face-to-face meeting with our various stakeholders. Our Systems Change projects are being evaluated regarding their feasibility under current conditions. The Fulfilling Lives SE teams have adapted alternative ways of working to ensure our clients continue to receive the best support possible. We can continue our systems change work whilst adhering to Government directives for managing the COVID-19 pandemic.

3. We recognise that COVID-19 will very likely have a disproportionate impact on our client group – people with multiple and complex needs. Our clients already experience health, social, and economic disadvantages, which could easily be exacerbated by the disruption to services and the valuable support they depend upon. We also recognise that for the Frontline Delivery teams, adapting to new and challenging working conditions, in addition to managing the personal anxieties and uncertainties of COVID-19, is especially demanding.

4. Due to the speed at which the Coronavirus pandemic has escalated, and the degree of uncertainty of its ongoing impact, we have had to act quickly to formulate an appropriate response. Part of our response has been to try and capture client and worker experiences ‘on the ground’, and to gain insight into:

• The challenges our clients are facing in this difficult time and how they are adapting and coping.
• The challenges that front-line workers are facing in adapting to new ways of working, often remotely.
• The ways support systems have changed and the gaps and barriers in service provision that appear to have a disproportionate impact on people with multiple and complex needs.
• Examples of successes, creative solutions and good practice, as we seek to understand what good or even best practice looks like, in this highly challenging situation.

5. To begin capturing this data a survey was conducted with all specialist workers and area leads in FL SE (Brighton & Hove, Eastbourne, and Hastings). The initial findings from this survey are summarised in this report and will feed into further research, evaluation, and shared learning.

Summary of Findings

Good Practice: Challenges and Learning

The mental wellbeing of clients and workers

6. Most front-line workers report feeling ‘about the same’ or ‘a little worse than before COVID-19’. Some feel it is too early to tell what the impact might be. The most common source of anxiety for workers is not being able to physically see clients and assess their wellbeing. Workers are having to accept that they cannot meet all their clients’ wants and needs and are having to manage tendencies towards risk-aversion or overly self-sacrificing.

COVID-19 as a ‘re-traumatising’ event

7. Workers report that clients who have experienced multiple disadvantages are struggling with isolation and lack of access to ways of staying connected. Workers are concerned that lack of contact may lead some clients to experience feelings of rejection and abandonment, as well as triggering other behaviours connected to past trauma.

Other services have demonstrated more flexible, trauma-aware approaches

8. Some services, such as a local authorities and local prison services, have been more flexible in how they are supporting clients. More services are being made available online, meaning clients and workers can avoid unnecessary travel. It is felt that some services are giving thought to the mental wellbeing of clients during lockdown.

It has been harder to involve clients in their support

9. It has been difficult contacting clients as workers are unable to find them on outreach, and online communication is not always possible with the client group. Many services are no longer offering face-to-face appointments and new ways of working have led to a lack of joined-up decision making with partner organisations.

We are meeting the challenge of working remotely and in a trauma informed way

10. Workers are being creative in finding new ways to work with clients. Technology has played a critical role in staying connected, and a lot of work has gone into meeting clients’ practical needs as well as providing ongoing support for their emotional wellbeing.

Systems Change Thematic Areas

11. 01 Health Inequalities: COVID-19 response measures have changed the way clients access primary healthcare services, receive prescriptions, and in some instances hospital admissions and discharges have been disrupted.

12. 02 Domestic Abuse: Most workers feel that female clients are now much more at risk of experiencing domestic abuse due to COVID-19 response measures.

13. 03 Criminal Justice System: There are wide-reaching concerns amongst workers that prisons are spaces where COVID-19 could easily spread. For clients living in the community, there appears to be a reduced risk of them breaching licence conditions due to self-isolation and ‘stay at home’ advice.

14. 04 Treatment Pathways and Coexisting Conditions: Workers have had to re-prioritise from supporting clients to access and engage with recovery and treatment pathways to instead supporting clients with meeting basic needs. This has included supporting clients to manage a change from daily to two-weekly substitute opioid prescriptions.

15. 05 Temporary Accommodation: Clients in temporary accommodation are felt to be at high risk of contracting and spreading COVID-19. Clients are finding it hard to self-isolate and follow social distancing practices in emergency and temporary accommodation spaces. 

16. 06 Repeat removals of children and the impact on women with multiple complex needs: Support services have been unable to offer face to face support to clients who are in the process of having a child removed to care and/or have had a child removed. This has been challenging to clients and workers; however workers are trying to navigate providing support via phone and online with sensitivity.

Good Practice: Challenges and Learning

17.  FLSE Front-line Workers and Area Leads have had to adapt their working practices to comply with government directives and practice self-care, whilst providing the best possible support to clients. This has inevitably raised the question of what ‘good practice’ looks like under these highly challenging and unprecedented conditions. The survey asked questions about worker and client wellbeing, the challenges and possibilities of working remotely in a ‘trauma informed’ way, and the challenges of involving clients in their own support, i.e. person-centred when contact is restricted.

18. The impact of COVID-19 on the mental wellbeing of clients and workers so far is comparable
19. Most reported feeling about the same or a little worse than before. Some people felt it was too early to tell what the impact might be.

20. Workers are feeling…

• Training to respond to crises has meant specialist workers feel equipped to cope with the current situation.
• The most common source of anxiety is being unable to see clients physically and assess their appearance or observe their adaption to things by reading body language, when responding to questions over the phone.
• As working from home becomes more normal it is less stressful but working online has led to some feeling that online working may be de-skilling.
• Anxiety about maintaining trust and boundaries with clients under the new way of working, and how clients will respond to that.
• Concerned that clients who experience paranoia may be heightened in this time.

21. Clients are feeling…

• Reducing social networks has had benefits for some in that it has helped them to reduce consumption of substances and given some stability.
• There has been anxiety about getting medications and scripts.

22. One third of workers surveyed feel that clients are experiencing ‘re-traumatisation’ as a result of the COVID-19 pandemic
23. All other workers were unsure about the impact because they felt it was too early to tell or have not been able to see their clients in person. Generally, it was felt that clients who had experienced multiple disadvantages struggled to be alone with their thoughts, and often do not have internet, television, or phone data to help them stay connected during social isolation. Temporary accommodation does not supply WIFI. The fear of being alone in the evening or night has led to some clients experiencing flashbacks and nightmares. Other impacts include:

• Workers not being able to meet their clients in person and changing the frequency and ways of contacting them has triggered some clients to feel rejection and abandonment. Workers are concerned that could lead to a loss of trust in them.
• Some workers are concerned that the controlled situation in lockdown is mimicking previous coercive control experiences for certain clients.
• The issues with food supply have triggered eating disorders in some clients.

One client who was rough sleeping with her partner was initially told by the local housing department that she should not put in a joint housing application as they would not be recognised as a "household". She said that COVID-19 meant that she feared becoming ill and not having contact with family. The emerging restrictions around lockdown majorly increased her anxiety about being alone, isolated in emergency accommodation; her and her partner were being offered accommodation in different counties and shared one mobile phone between them.  As a result, over a two-week period she repeatedly turned down offers of emergency accommodation and remained street homeless.

24. Other services are being more flexible with clients as a result of the COVID-19 pandemic. Workers perceive this as being more trauma aware

• Hastings Borough Council took on board a client's anxiety about travelling alone to out of area accommodation and offered to pay for a taxi. This had not been offered previously.
• The food banks now accept an email for vouchers, which removes worry and a need for unnecessary travel by workers.
• HMP Lewes is ensuring mental health and substance misuse plans are in place during lockdown.

25. However, there is a feeling from workers that approaches to client engagement have polarised, with some services avoiding any contact with clients and others over-involving themselves with clients. 

26. It has been harder to involve clients in their support since COVID-19

• Workers have faced difficulty contacting clients to get views heard, as they are unable to find them on outreach and online communication is not always possible with this client group
• Refocusing on meeting client’s basic needs means being less responsive to client ‘wants’ in the current situation. Moreover, some clients have expressed ‘wants’ which may go against national guidance on managing COVID-19. This can lead to clients feeling rejected or unheard.
• It is no longer possible to attend face-to-face meetings with clients and advocate alongside them. This means that whilst their voices can be heard, those who don’t feel comfortable on the phone or talking to services directly are not getting opportunities to self-advocate in a supported way.
• Many services are no longer offering face-to-face appointments, and new ways of working remotely have led to a lack of joined up decision making. There have been instances where services are providing updates directly to clients which have differed from updates front-line workers are receiving.

27. … but there are positive examples of involving clients

      Services asking clients how they would like to be communicated with (WhatsApp, text, phone call, email).

      Workers accessing Universal Credit journals and advocating remotely.

      Continuing with client interviews at Fulfilling Lives SE.

28. Workers are meeting the challenge of supporting clients remotely and in a trauma-informed way
29. Positive approaches include:

• Taking a non-judgemental approach about non-compliance with social distancing - trying to support people to problem-solve themselves.
• Consistency in our approach to advocacy despite new circumstances, demonstrating reliability and trustworthiness despite changing methods of contact.
• Collective debriefing on cases, ensuring psychological models are used to reflect on client and worker reactions.
• Reflecting on the unsettling nature of the current situation, acknowledging and accepting that it may not always be possible for workers to give clients the service that they would like to at this time.

30. Top tips from workers-practical ways of engaging clients during the pandemic include:

      Encouraging creativity, e.g. clients doing artwork and photography and sending finished work via WhatsApp to boost self-esteem and distract from isolation.

      Working in partnership with agencies – coordinating care.

      Practicing social distancing, thus modelling respect for self and others.

      Ensuring clients have phones with credit and data where possible.

      Registering things like mobile phones and bus passes online so everyday tasks can be done remotely.

      Offering meetings on doorsteps for those less able to use phones or technology.

      Setting up referrals to food bank local delivery so less time is spent on logistics and more time on providing emotional support to clients.

      Use of WhatsApp where possible to allow for a wider sharing of media, like voice messages, pictures, video calls and texts.

      Having access to petty cash cards to purchase essential items as and when.

      Encouraging mindfulness through online resources.

      Connecting clients with recovery podcasts, and live NA or AA meetings.

      Daily check-ins by phone or text.

31. One respondent felt that as an organisation we should be reflecting on

1. The way that COVID-19 can be experienced as a traumatic event by staff, clients and services.
2. That individual staff and teams can have a trauma response to this event, e.g. by being too risk averse, or by being overly self-sacrificing.
3. To find a middle ground response that acknowledges the need to say no to physical client contact, whilst recognising that there will be times when workers need to go beyond their typical duties in order to meet client needs. To do this in a reflective and responsive way rather than reactive jumping into crisis situations.

Impact on Thematic Areas

32. Fulfilling Lives South East Partnership not only works at an immediate level – directly with people who are most in need right now, but also on a lasting level – changing systems to enable people experiencing multiple disadvantage to receive the support they need at the right time. In November 2019, we published our Manifesto for Change, which highlights the six key themes that have arisen from the work of the Fulfilling Lives Project since its beginning in 2014 and sets out our commitments under each of these themes.
33. The survey asked questions specific to each of these six key themes in order to better understand the impact of COVID-19 on these areas. This will help us to determine how best to proceed with our ‘systems change’ work in the coming weeks and months.

Theme 01: Health Inequalities

34. The impact of COVID-19 on the healthcare of clients has changed the way they access primary healthcare services, receive prescriptions and some hospital admissions and discharges have been disrupted.

35. The impact on the working practices of services within the healthcare system include:

• GP appointments taking place online or via phone instead of face to face.
• Prescriptions being issued in two-week batches for some clients who may have once been on daily pickups.
• Some pharmacies have reduced their opening hours.
• Some pharmacies are unable to deliver prescriptions as they once did.
• Patient transport has not been available for clients to get to healthcare appointments.
• Early hospital discharge for non-CV19 affected clients.
• Stopping visitors going onto hospital wards.
• Test results seem to be taking a bit longer than usual.
• And one client was held in police custody rather than being admitted to hospital following suicidal behaviour.

36. In response to this, workers are feeling:

• That many pharmacies are being helpful and flexible, trying to operate as ‘normal’.
• Concerned that some clients who have been moved from a daily prescription pick up to a two-weekly prescription are at higher risk of overdose.
• Pleased that scheduled GP appointments are going ahead via phone/online channels.
• Pleased that most prescriptions are still be prescribed and accessible to clients.
• Concerned that clients who may not have phones, internet access or phone credit are unable to engage with the healthcare services in these new ways.
• Lack of face to face support for clients is causing concerns that client relationships may break down.

37. In response to this, clients are:

• Anxious that their prescriptions could stop.
• Having to change their routines and pick up prescriptions in new ways.
• Mostly able to access primary healthcare but without as much support as they might usually get from workers who would usually accompany them to appointments and advocate for them.
• One client was unable to access hospital when she was suicidal and was taken into police custody instead.

38. No clients have been accepted on to the ‘extremely vulnerable person’ register

• Four have applied, with one declined and three pending decision. One worker feels the register criteria is ‘quite limiting and don't necessarily lend themselves to our clients’ complex needs’.

Theme 02: Domestic Abuse

39. Most workers feel that female clients are now at significantly higher risk of experiencing domestic abuse due to COVID-19 response measures

40. The main response measures that are a cause of concern are:

• Self-isolation – leading to victims being forced to stay in spaces with abusive partners.
• Working from home – support services’ workers unable to meet clients face to face.
• Social distancing - support services are unable to facilitate support groups.

41. The impact on the working practices of services within the domestic abuse support system include:

• Some refuges have paused referrals.
• Outreach work to women experiencing domestic abuse has largely stopped.
• Face to face support groups have stopped and online groups are not yet in place to replace the face to face support forums.
• A spike in reports of domestic abuse incidents and/or concerns across England to police services and domestic abuse support services.
• Suspension in local connection / some ‘priority needs’ criteria at local authority housing options teams to enable rapid housing of those who are street homeless.

42. In response to this, workers are:

• Very concerned for the safety and wellbeing of clients.
• Concerned that domestic abuse risks cannot be fully assessed as workers are unable to spot any physical signs of abuse.
• Feeling unable to have in-depth private conversations with clients as they are often in environments with perpetrators who may be listening and monitoring phone calls.
• Concerned that clients feel unsupported and will isolate and withdraw from support.
• Trying to be creative with clients, for example, one worker shared how she is encouraging clients to take a daily walk and call support services during this time. Another shared how they were hoping to facilitate access to accommodation for a client’s partner under the newly relaxed allocation policies in the housing options teams at one local authority.

43. In response to this, clients are:

• Some are implementing their own protective factors and have been able to avoid isolating with partners who have perpetrated domestic abuse.
• Lacking privacy and safe spaces if isolating with abusive partners.
• Engaging with support services a lot less, which for some is leading to feelings of abandonment.
• Some are sex working again to make money.
• Often restricted to engaging with support via online channels as this can be easily accessed and controlled by perpetrators.
• At increased risk of being victims of domestic abuse and violence.

The following content below contains a selection of stories from client and worker experiences during the first few weeks of national and local response measures to slow the spread of Coronavirus (COVID-19) across Brighton & Hove and East Sussex:

44. ‘We have one client who is travelling back to [location], meaning soon she will be isolating with her abusive partner, who is homeless but stays with her. This puts her at extreme risk of physical harm. We are contacting the council to request he is housed due to the covid 19 suspension of requirement for priority need and referring to MARAC to back this up. 
    
    We have clients who are struggling to understand that the shops are closed, that we cannot go near them, that we cannot take them for coffee. Many are seeing this as a personal rejection from services and their support networks.
    
    Many clients are shouting at workers on the phone, struggling with this new boundary, with our flexible frontline workers saying 'sorry I can't come and see you' . This isn't an ending we have built up to and prepared for, but still feels like an ending of sorts. 
    
    Covid 19 has triggered a relapse in eating disorders and body dysphoria for many women we work with. Discussion of stockpiling, food banks and scarcity has caused some of them to begin to starve themselves. For many who experience paranoia, the current situation has confirmed their paranoid thoughts as fact. 
    
    For one person, they are back on their methadone script, because they cannot get income through begging and can no longer pay for the substances they usually use. 
    
    Some women are sex working again, as they cannot shoplift or beg. This is often controlled through coercion by a partner. 
    
    For some women who already sex work, it may mean a change in clients. This brings new risks (which are unknown). 
    
    Women are unable to speak privately to workers on the phone. We encourage them to take a walk once a day and call us then. 
    
    We are choosing to focus on responding to people's immediate and basic needs, which to me feels like it goes against work we have done so far to enable and encourage people to build Independence and efficacy in their own world. 
    
    We do not want people to be reliant on us, but this current situation requires dependency as we ask people to stay at home and isolate. 
    
    For many people we work with, self -isolation has been an unhealthy coping strategy that we work with them to move outside of. To build trust with others. Currently we cannot do this, and are instead forgoing any recovery-focused work to meet people's basic needs (for them not with them), and I think this will have a lasting impact on our relationships with clients, but also the relationships between individuals and services more widely.’

45. ‘main concern is for people we are unable to make contact with and restrictions on movement mean we won't be able go out to look for them. However I am aware that current restrictions on movement mean that people not having face to face contact with workers, so physical indications of abuse can't be spotted and it is currently not possible to go out to look for clients who we are unable to make contact with by phone. Where people are constantly with a partner in a shared living space, this means lack of privacy / safe space to have discussions about relationships - not being able to meet people out in the community means that we are restricted at times in not being able to have open discussions about any emerging relationship issues or properly assess risk’

46. ‘Increased due to the possibility that they may have large amounts of medication including Opiate substitutes at home which can result in controlling or withholding medication.’

47. ‘Clients are also more socially isolated so professionals are not able to see clients body language when talking on the phone & partner could also be present in the room, meaning client is not able to talk freely. Partner may also control access to phone.’

Theme 03: Criminal Justice System

48. There are wide-reaching concerns that prisons are spaces where COVID-19 could easily spread. However, for those clients in the community, it is felt that there is a reduced risk of clients breaching their license conditions due to self-isolation and ‘stay at home’ advice.

49. The impact of COVID-19 response measures on clients' resettlement and release plans is felt to be:

• Risk of Spreading C-19 if clients are not tested before release to supported accommodation.
• No visits allowed from specialist worker, family or internal prison teams for a client due for release in June. If this continues to be the case closer to the release date, the specialist worker hopes to do a video call for a pre-release housing meeting.
• One client was released before just lockdown and attended temporary accommodation as planned.
• Government guidance on early release of prison residents with less than 2 months sentence means we need to liaise closely with our prison and probation partners to plan accordingly.

50. The impact of COVID-19 response measures on clients' support from probation/CRC teams is felt to be:

• Reduced risk of License Breach:
• Probation are seeing clients on doorstep. Client abiding by their licence agreement, though a change to phone call appointments from doorstep visits may impact this.
• Improved engagement with probation via telephone contact for one client due to underlying physical health risk. This client was previously engaging poorly and is likely to be happy not to travel to probation.
• Concern for our partners in offender management due to new ways of working
• Seen by Probation in separate room by probation at their offices and contacted via phone

Theme 04: Treatment Pathways & Coexisting Conditions

51. The impact of COVID-19 on access and engagement with treatment pathways for clients has largely seen a re-focus on supporting clients with basic needs rather than recovery and mental health support, and a move towards two-weekly instead of daily pickups of substitute opioid prescriptions.

52. The impact on the working practices of services within treatment pathway systems include:

• Pharmacists giving clients methadone to take away rather than daily supervised methadone consumption.
• Prescriptions being issued in two-week batches for some clients who may have once been on daily pick ups
• Staffing levels at some rehabs have led to early client discharges.
• Face to face appointments and support from mental health and substance misuse services being replaced with phone calls and online contact.

53. In response to this, workers are feeling:

• Concerned that some clients who have been moved from a daily prescription to a two-weekly prescription are at higher risk of overdose.
• Concerned that a reduction in daily prescription pickups reduces the amount of contact time between clients and support services, thus limiting workers’ ability to fully assess the risks and needs of their clients.
• Services have been quite easy to contact via phone, email, online.
• That substance misuse services are adapting well and that they are wanting to work in partnership with other agencies.

54. In response to this, clients are:

• Some are happy that they are no longer under daily supervised methadone consumption as they feel less stigmatised and less controlled.
• Experiencing a shift in worker focus towards helping with basic needs.
• Seeing support workers less to support their recovery and are having to engage with appointments with the likes of Assessment and Treatment Services, Sussex Partnership NHS Foundation Trust in new ways, e.g. over the phone and online.

Theme 05: Temporary Accommodation

55. Clients in temporary accommodation (TA) at this time are felt to be at high risk of contracting and spreading COVID-19. Clients are finding it hard to self-isolate and follow social distancing practices in emergency and temporary accommodation spaces. 

56. The impact on the working practices of services within housing systems include:

• No visitors allowed into emergency or temporary accommodation buildings.
• TA staffing levels are felt to have reduced.
• Reduced flexibility around accommodation placements for clients by local authority housing departments as options are very limited and the demand is very high.
• Eviction policies in some areas have been relaxed.

57. In the last four weeks, 12 housing placements have taken place for clients. Of these, 8 were in area, 4 out of area and 7 were in temporary accommodation, 3 in hotels, and 2 ‘other’ forms of housing.

58. In response to this, workers are feeling:

• Concerned that clients in TA are at high risk of contracting coronavirus and that these environments are at high risk of being spaces where the virus could take hold, especially if residents share bathroom and kitchen facilities.
• Concerned that isolating and social distancing are made even more difficult for our clients if they are in TA without televisions and/or internet access.
• That some local authorities are giving little guidance or support to TA providers to help them manage the COVID-19 measures.
• Concerned that lower TA staffing levels can lead to less vigilance and reporting of incidents and concerns, thus leaving clients vulnerable to exploitation and abuse.

59. In response to this, clients are:

• Feeling bored and restless in TA and are finding it difficult to isolate in these spaces.
• Finding themselves placed in environments where they are uncomfortable living in close proximity to other residents.
• Venturing out to purchase drugs and alcohol.
• Trying to reduce their contact with others.
• Not being evicted when they might have been before the pandemic.

Theme 06: Repeat Removals of Children

60. Support services have been unable to offer face to face support to clients who are in the process of having a child removed in to care and/or have had a child removed. It is recognised that this is very challenging, and workers are trying to navigate providing support via phone and online with sensitivity.
61. The impact of COVID-19 response measures on these proceedings and the support offered to client has been:

• No face to face therapy or contact offered for one client.
• One client had to be supported via telephone at court hearing for her child’s adoption. This was very challenging for the client and those involved in her support, but everyone was sensitive to her needs. Supporting her afterwards to ensure she understood everything was also very challenging.

Next Steps

Shaping good practice

62. We will be reflecting on how the insights gathered in this survey can best shape and inform our ongoing delivery of front-line support work to clients with multiple and complex needs. Issues that have arisen include, but are not limited to, thinking about ways to promote worker wellbeing and self-care; exploring more ways to engage clients creatively with the aid of technology such as phones and internet; finding new ways to work in a joined up way with partner agencies who are also experiencing similar disruption.

63. Ongoing data collection

64. We will continue to collect data on the impact of COVID-19 on the clients and workers. As the situation is changing rapidly, findings may be quite different in the weeks and months ahead, and we will be closely monitoring these changes.

65. We are currently developing a similar COVID-19 impact survey for the Fulfilling Lives Project Consultants and Volunteers. These individuals have lived experience of multiple and complex need, and their work and insight are invaluable to the project.

Adapting systems change work

66. We have already begun the process of re-evaluating our existing systems change projects. Some pieces of work have been re-prioritised in view of the changes to resources, ability to meet, and the availability of our stakeholders. The learning from this survey will further inform these decisions and may also highlight new areas of work within the six key themes that we feel it is important to concentrate our resources on at this critical time.

Share learning with local and national stakeholders

67. We will be sharing this report with many of our local and national stakeholders, with a view to contributing to discussions and learning around challenges, barriers, and good practice when working with people with multiple and complex needs. We hope also to learn from our partners and welcome feedback, questions, and the opportunity for further dialogue as we seek to navigate this challenging situation together.

Contact us

68. If you would like to know more about this report and Fulfilling Lives South East Partnership, please visit our website, https://www.bht.org.uk/fulfilling-lives/ where you will find full contact details and an overview of the project. You will also find links to our blog, social media, and Manifesto for Change.

April 2020