Multiple and complex needs

The Revolving Doors Agency is publishing a very valuable range of briefings around working with people with complex needs. The latest, written with the Centre for Mental Health, is titled: “Comprehensive Services for Complex Needs” and reviews the evidence for three models:

  1. Multisystemic therapy (MST)
  2. Wraparound
  3. Link Worker

This table from the report, summarises the three approaches:

3 revdoor models

The Models

The briefing looks at these three models in some detail and helpfully identifies that they share a number of core principles: a strengths based approach, which operates over a sustained period, and which is tailored to meet individual needs. Again this is helpfully summarised in a graphic:

rev doors 3 models shared principles

Summarising the evidence

The quality of the evidence base for each of these three approaches varies markedly.

MST has the most extensive evidence base which shows very promising findings on reconviction rates, family relationships and mental health symptoms. Most of the evidence is from the US but there are an increasing number of UK studies.

Wraparound research is generally promising, despite a smaller number of robust evaluations than for MST.  The evidence, which is largely limited to the US, suggests that wraparound keeps young people in their homes and out of custody, foster care or psychiatric units.

The link worker model has a smaller body of evidence, and there is no finalised definition making it difficult to assess whether a particular project is using a complete model. A number of evaluations have shown promising results in terms of improving housing situations, health, and coping skills. The model can stabilise clients and prevent crisis situations such as rough sleeping and A&E attendance.


Cost Benefit Analysis

Because clients with complex needs make such a heavy demand on a wide range of public services (health, criminal justice, housing/homelessness etc.), it is assumed that any effective model will generate substantial savings in the medium-long term.

As always, the quality of evidence available for rigorous cost benefit analyses of these approaches is variable.

Generally, MST is regarded as expensive to set up (mainly because of training costs) but has been found to generate cost savings – a 2013 Social Research Unit report calculated that it returns £2 in savings for every £1 invested.

The link worker model is inexpensive to set up and two recent UK studies (all research is fully referenced in the Revolving Doors briefing) suggest monthly savings per client of between £347 and £958.

There is not yet a reliable evidence base to assess the cost effectiveness of wraparound.



Revolving Doors makes four key recommendations for commissioners looking to develop more effective services for people with complex needs; urging them to consider:

  • Key features of effective approaches to tackling multiple and complex needs
  • Joint commissioning for multiple and complex needs
  • Implementing models in the right way
  • Building the evidence base.

The briefing concludes with a final, helpful graphic as a key prompt to commissioners or providers looking to implement a new model for this client group:

rev doors csf complex needs

If you’ve worked with people with complex needs using any of these models, please share your experiences in the comments section below.

2 Responses

  1. Our evaluation of the Cabinet Office’s Adults Facing Chronic Exclusion Programme came to a similar conclusion on the linked worker model. Our evaluation recognised the value of a ‘consistent trusted adult’ who came from the non-profit sector, and were able to make public services work for those who had been excluded from statutory services to which they were entitled.

Leave a Reply

Your email address will not be published.