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Clients with Complex Needs:
Interprofessional Practice

J. Keene
Professor of Primary Care
University of Reading

b
Blackwell
Science
Clients with Complex Needs:
Interprofessional Practice
Clients with Complex Needs:
Interprofessional Practice

J. Keene
Professor of Primary Care
University of Reading

b
Blackwell
Science
# 2001 by DISTRIBUTORS
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For Bill
Contents

Acknowledgements viii

Introduction 1

Part I Understanding Complex Needs: a Multidisciplinary

Approach 11
1 Clients with Complex Psychosocial Problems 13
2 Shared Clients: Complex Needs and Multiple Service Use 32
3 Planning Comprehensive Care: Assessed Needs Across
Populations 48

Part II The Limitations of Specialist Perspectives: a Psychosocial

Approach to Multidisciplinary Working 63
4 Understanding Client and Professional Perspectives:
the Need for Psychosocial Care and Maintenance 66
5 Understanding Different Professional Perspectives: the Need
for a Common Comprehensive Psychosocial Approach 95

Part III Comprehensive Practice: a Psychosocial Approach to

Change and Maintenance 125
6 Comprehensive Psychosocial Assessment 132
7 Psychological Change-orientated Methods 146
8 Psychosocial Maintenance Methods 162
9 New Models of Ongoing Psychosocial Care 192

References 196
Index 210

vii
Acknowledgements

With thanks to: Sue Bailey, Darren Howell, Jan Janacek, Deborah Martin,
Mark Owers, Louise Swift, and Margaret Woolgrove for data collection
and statistical advice.
But most thanks go to the public service managers, practitioners,
database workers and clients without whom the research would not have
been possible.

viii
Introduction

This book is concerned with bringing about a major beneficial change in

the way that professionals in health and social care and the criminal justice
system deal with adult clients/patients with complex needs. (For brevity,
both patients and clients will be referred to throughout as `clients'.) The
book is aimed at professional practitioners, but also at those responsible
for managing and planning, as well as providing, services.
The book examines the limitations of service provision for clients with
complex needs and demonstrates that it is not only worthwhile for pro-
fessionals but also cost-effective for agencies to assess psychosocial
problems, prioritise service provision for shared clients and provide
psychosocial maintenance support as well as psychological change pro-
grammes. (For a general review of the psychosocial perspective see Woods
and Hollis 2000 and for a useful discussion of maintenance see Davies
1985.)
The first part of the book outlines the problems of complex needs
clients in a psychosocial context. It builds on a comprehensive literature
search and a collaborative multiagency database and places these in the
context of contemporary policy and planning. The second part is con-
cerned with gaining a greater understanding of the obstacles to compre-
hensive multidisciplinary care through qualitative in-depth interviews
with different professionals and clients. It examines contemporary prac-
tice, highlighting how needs are often assessed in isolation and how
interventions can be limited, not only by narrow assessments but also
by time-limited specialist models of intervention. It then considers
potential ways of multidisciplinary working. The third part examines
the usefulness and limitations of a psychological approach to individual
change and proposes an additional model of psychosocial maintenance.
It then deals with the management of clients with complex needs in this
psychosocial context; it gives clear guidelines for working with these
clients in terms of assessment, psychological change models and psycho-
social maintenance methods.
By combining these three parts, this book presents research findings on
complex needs and psychosocial problems and public service responses. It
considers why traditional professional philosophies and practice models

1
2 Clients with Complex Needs

might be less effective with these clients and considers additional or

alternative approaches.

BACKGROUND

The provision of care for clients with complex needs is undertaken by a

large and varied number of statutory and voluntary agencies; public order
and safety are the responsibility of the criminal justice system. The wide
experience of these agencies and their considerable resources are
employed to deal with millions of men and women each year. It is,
however, common knowledge that many individuals fail to receive the
comprehensive help and support that they need and that many do not
benefit from what is provided, despite making repeated demands of a wide
range of agencies. These people are often the most vulnerable and socially
excluded members of our society (Woogh 1990; Brach et al. 1995).
Service provision for clients with multiple problems can be fragmented
and uncoordinated, handicapped by philosophical differences, incom-
patible treatment methods, categorical funding and inadequate staff
training (Sommerville 1985; Woogh 1990). The combination of frequent
service use and non-compliance by clients (Brach et al. 1995) is perhaps
the greatest challenge to both treating the problem and monitoring it,
rendering epidemiological information sparse and services ineffective
(Woogh 1990). Treatment is confined often to services for discrete dis-
orders, and conventional methods of monitoring have been largely limited
to treatment samples in specialist agencies (Barbee et al. 1989). As a
consequence, purchasers and providers lack information about the true
extent and characteristics of this group among wider social and health
care populations, making it extremely difficult to construct a compre-
hensive profile of needs.
Problems in multidisciplinary and multiagency working have been
attributed to a variety of causes, for example from social workers ignoring
health problems (Corney 1985) to health workers ignoring social and
other non-health problems (Sommerville 1985). However, one of the main
obstacles to multidisciplinary agency working is the lack of information
about overlapping populations and shared patients. Whilst each agency
had some evidence of particularly problematic patient groups which
repeatedly attended their own agency and did not appear to benefit (Brach
et al. 1995), they remained unaware of the extent to which these prob-
lematic patients were shared with other agencies.
Recent changes in policy and practice have placed greater emphasis on
multiagency development of policy, planning and collaborative working
(see, for example, in the UK, DoH 1998a, b). Issues of anti-discriminatory
and anti-oppressive practice need to be confronted (see, for example,
 Introduction 3

Collins and Keene 2000). The development of joint primary health and
social care systems depends increasingly on information concerning the
needs of social and health care populations and services provided by each
agency. In addition, the increasingly close collaboration with the criminal
justice system in Britain in the context of the Crime and Disorder Act 1998
relies on understanding of the social and health care needs of criminal
populations. However, distinct individual agendas determine both prac-
tice and research policies within each agency.
The author strongly believes that professionals can overcome obstacles
to multidisciplinary and interprofessional working if these constraints are
clearly identified and there is accurate information about the clients they
are sharing (or could be sharing). One of the major problems has been the
lack of comprehensive and accurate quantitative data about the shared
clientele of agencies and understanding of the theories, beliefs and roles of
professional groups. While there is growing awareness, based on anec-
dotal evidence, that professionals have clients or patients in common, the
organisational and professional boundaries between agencies have
inhibited the development of common systems of information. It was to
remedy this major gap in the delivery of services that the Tracking Project
database was established and this book written.
The book emphasises the needs of clients with multiple problems. It
establishes the principles of shared data and shared practice methods
when working with shared clients. It provides a base of information
designed to bring different professionals and agencies together in order to
identify and define common problems and to plan their solutions.
Each agency is accustomed to a particular model of working and defines
its role in specific terms and from a professionally established perspective.
For example, a man or woman experiencing a serious drug dependency
will be treated by a GP as a medical problem, by a drug agency as needing
treatment or a harm minimisation programme and by the police as a
possible threat to public order. Each agency will assess every patient/client
in terms of its perceived remit and allocate them an appropriate priority (a
`tariff'), depending on the agency's conception of the severity of the
problems in their specific area. Little, if any, account is taken of problems
presented by the same people to other agencies. As a consequence, men
and women with multiple problems, who make the greatest demands on
resources, may often receive a package of support that is inadequate and
not cost-effective.
This book is concerned with identifying these problems, both in face-to-
face contact with individual clients and within agency populations as a
whole. Once we have information about this group of shared clients and a
clearer understanding of the psychosocial context of complex problems, it
becomes possible to consider realistic practical solutions.
The book is divided into three parts, as outlined here.
4 Clients with Complex Needs

PART I UNDERSTANDING COMPLEX NEEDS:

A PSYCHOSOCIAL APPROACH

Part I examines what we know about adult clients with complex needs and
then analyses their service use and contact with a range of professionals
responsible for psychological and social interventions. It explores the type
of characteristics and problems of this group and the kind of professional
help they receive.
Researchers have identified a significant group of vulnerable men and
women with complex health, psychological and social problems who
move more or less continually through social, mental health and health
care agencies, homeless hostels, drug and alcohol agencies and the
criminal justice system. They constitute a disproportionate part of the
caseloads of health, social care and criminal justice professionals. Many of
them are vulnerable, deprived and often labelled as `revolving door'
clients. It is clear that this group is shared by a range of different pro-
fessions each of which may have multiple contacts with each client.
Part I examines assessed needs and service use within total populations
(across a range of agencies) in order to identify obstacles to effective ser-
vice provision, and opportunities for developing better services for this
group and improving cost-effectiveness. Whilst there are, of course, clients
with psychosocial needs who only contact one service or none, this work
focuses more closely on shared populations of clients.
Finally, the implications for planning and policy are considered.

Chapter 1 Clients with complex psychosocial problems

Chapter 1 reviews the literature on psychosocial problems and complex
needs. It demonstrates how clients attending more than one agency often
have both psychological and social problems in conjunction with those
problems for which they present.
For example, research indicates that significant proportions of men-
tally disordered individuals have a substance misuse problem (up to
75%) and that this is associated with poor prognosis, higher relapse,
more non-compliance; service costs are greater and clinical and social
outcomes are less favourable. In addition to mental health and sub-
stance abuse problems, complex needs clients have been shown to have
a range of social problems. Studies suggest that these people may also
have unstable accommodation, a history of criminal offences, hostile
behaviour and recent aggression, particularly among young single
males.
 Introduction 5

Chapter 2 Shared clients: complex needs and multiple service use

Adult clients with complex needs cross professional boundaries including
health, social care and low threshold self-referral agencies, together with
the criminal justice system. This chapter examines the patterns of service
use of clients with complex needs. It reports the findings of the `Tracking'
research multiagency database, providing evidence of the extent to which
different professionals share clients with complex needs and the char-
acteristics of this group of clients.
The Tracking Project was established in 1996. It was designed to pro-
vide an innovative method of collating and analysing data within over-
lapping agency populations. The amalgamated database contains the total
county populations (over 800 000 anonymised subjects) of the following
23 partner agencies: social services, health authority, county hospital
health trust, community health trust, community mental health trust,
ambulance trust, GPs, housing, hostels, night shelter, county police, pro-
bation and prison services, together with a range of non-statutory agencies
including all drug and alcohol services in one county.
In this way it has been possible to identify and characterise complex
needs or `revolving door' clients who consistently reused different ser-
vices and were in contact with the criminal justice system. Data for
three years reveal significant overlaps in services, together with identify-
ing and characterising a group of men and women with psychosocial
problems who repeatedly use a wide range of agencies. This is the first
time in the UK that such a database has been created, providing a foun-
dation for interagency working with clients who have multiple prob-
lems. It demonstrates not only that there is a need to examine shared
clients more closely, but also that it is feasible for planners and pro-
fessionals to do so.

Chapter 3 Planning comprehensive care: assessed needs across

populations
This chapter considers the policy and planning perspective, largely
devoted to assessing needs and managing services for single specialist
agency populations. It analyses the underlying assumptions and con-
straints in specialist agency policy and planning which limit comprehen-
sive service delivery for populations of complex needs clients.
It examines how needs assessments for specific agency populations are
constructed for needs-led planning. It demonstrates how a multiagency
approach to policy and planning can be based on assessed health and
psychosocial needs across populations. It considers the limitations of
assessing needs in one agency population only, rather than examining
assessed needs of total or shared populations. The values and priorities of
6 Clients with Complex Needs

planners in different agencies are analysed to show how their approaches

(and therefore also their data collection) may reflect their attitudes to
prioritising services.

Using the `Tracking' method to examine assessed need and service

provision across overlapping agency populations
Having identified the existence of a group of shared clients with complex
psychosocial needs across total social and health care populations and
considered the implications for monitoring assessed needs and planning
services for them, this chapter will demonstrate how the `Tracking'
method can be used to monitor assessed need and service provision in any
area. The method can be used for combining any number of agency
populations for any area, whether this includes all health, social and
criminal justice populations or simply overlapping social and health care
populations.
The chapter then examines how agencies and professionals can work
together more effectively to prioritise services for clients with complex
needs, through the development of multiple agency needs assessments for
interagency service planning and interagency tariffs.

PART II THE LIMITATIONS OF SPECIALIST

PERSPECTIVES: A PSYCHOSOCIAL APPROACH TO
MULTIDISCIPLINARY WORKING

The research findings outlined in Part I raise a series of questions and

highlight a need for greater understanding of different professional
responses to this group. Part II goes some way towards answering these
questions. It will provide a qualitative picture of the different perspec-
tives of clients and professionals and between different professional
groups, in order to give insight and understanding into the problems
and needs of this group and the obstacles and opportunities for pro-
fessional practice.
It examines professional and client perspectives in order to provide
greater understanding of the usefulness and limitations of different pro-
fessional models for this group. It becomes clear that professionals
within each type of agency define the problems within the context of the
academic base and priorities of their profession and that they use
methods derived from this base. Each agency has its own professional
perspective, ideology, methods of working, plans and priorities. Indivi-
dual agency agendas and priorities are often in conflict with other
agencies. So, for example, the probation service might see problems in
terms of criminal behaviour and successful outcome in terms of re-
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