Social work with adults experiencing complex needs

This guideline covers the planning, delivery and review of social work interventions for adults who have complex needs. It promotes ways for social work professionals, other care staff and people with complex needs to work together to make decisions about care and support.

# Context
'Adults with complex needs' is not a defined clinical group but encompasses any adult needing a high level of support with many aspects of their daily life who relies on a range of health and social care services. These needs for support may result from illness, disability, broader life circumstances or any combination of these. Complex needs may be present from birth or may develop over the course of a person's life and may fluctuate. The nature of these needs, and the way society is organised to respond to them, means adults with complex needs often face multiple challenges to living as they would wish and accessing support when it is needed. They are consequently vulnerable to preventable secondary conditions and premature mortality.
Social workers are one of the main professional groups who support adults with complex needs. They do this in a range of settings, on a long- or short-term basis. Their responsibilities include facilitating the local authority's duty to conduct needs assessments under the Care Act 2014. They also work with individuals and families to address identified needs, effect change and organise support. Social workers can help people with practical, social and interpersonal difficulties, and promote human rights and wellbeing.
There are about 100,000 social workers registered in England in 2021, according to the Social work in England: emerging themes report by Social Work England. Most commonly they are employed in local authority social care settings, but also in health and voluntary sector services. As well as providing care directly, social workers have a key role in organising support from the wider social care sector and other agencies. They work in a challenging context. The King's Fund Social care 360 report in 2021 describes a rising demand for social care, but a reduction in how many people are receiving care, and that social care funding levels have only just returned to 2010 to 2011 levels, after a decade of lower real-terms investment. The Care Quality Commission State of Care report for 2019/20 reports that the quality of social care received by most people was good overall. However, it noted regional variation in access to and quality of care, the need for better integration and joined-up care between services, and that the COVID-19 pandemic is 'having a disproportionate effect on some groups of people, and is shining a light on existing inequality in the health and social care system'.
In this context, it is vital that the organisation and delivery of social work is informed by the best available evidence about effective ways of working. The Chief Social Worker for Adults' annual report: 2018 to 2019 acknowledges evidence gaps for social work, setting as priorities knowing what works and developing a better evidence base for social work practice.
This guideline was commissioned by the Department of Health and Social Care to meet this need and develop evidence-based recommendations for social work for adults with complex needs. The guideline was developed by a guideline committee following a detailed review of the evidence. It covers assessment and care management or support which is delivered by or led by social workers. It seeks to provide recommendations which are generalisable to the whole population of adults with complex needs. This guideline is for social workers, and organisations which employ social workers or commission social work services. It is also relevant for adults with complex needs and their involved family and informal carers, and for other professionals who work with social workers in supporting adults with complex needs.
Adults with complex needs are defined as people aged 18 or over who need a high level of support with many aspects of their daily life, and relying on a range of health and social care services. This may be because of illness, disability, broader life circumstances or a combination of these. Complex needs may be present from birth or develop over the course of a person's life, and may fluctuate. Unless otherwise specified, when a recommendation refers to 'people' or 'the person', this is the adult with complex needs.
This guideline does not replace statutory duties and good practice as set out in relevant legislation and guidance, including:
Care Act 2014 and associated guidance
Equality Act 2010
Mental Capacity Act 2005
Accessible Information Standard
Human Rights Act 1998
Social Work England's professional standards.
This guideline aims to complement legislation and guidance by providing evidence-based recommendations about how social work interventions including assessment, care management and support for adults with complex needs could be improved. Actions already required by law, or recommended in statutory guidance, are not replicated here unless there was evidence to suggest that these are not implemented consistently in practice, or there was a need to emphasise specific points relevant to social work interventions including assessment, care management and support for adults with complex needs. NICE guidelines cover health and care in England and therefore focus on English legislation. Other UK countries have to follow legislation from the Welsh Government, Scottish Government, and Northern Ireland Executive.# Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

# Principles of social work for adults with complex needs

## For social workers
Treat people with respect and dignity, recognising and supporting their decisions and choices. In particular:
show understanding of people's and their family's circumstances, and be non-judgemental
respect the validity of the person's lived experience
value their first-hand knowledge of their own needs to inform care planning
use professional curiosity and professional judgement
understand the power imbalance between the person and social workers.
When first contacting someone, and throughout provision of support, the social worker should establish with the person or with their family, carers or people important to them whether there are any advocacy, sensory or communication needs or impairments, in line with recommendation 1.1.5 in the NICE guideline on people's experience in adult social care services (see also the NICE guideline on advocacy services for adults with health and social care needs).
For any social work activity or process, the social worker should ensure that the person understands:
the reasons for the activity or process (for example, an assessment, or care management and support)
the aims of the activity or process, and how this relates to them
the key processes that will be followed, ensuring the person knows these at the planning stage for the process or activity
what will happen at each new stage in the process (for example, by giving the person information about any upcoming review meetings).
Social workers should provide people with the support they need to be fully and actively involved in discussion and decision making, taking into account:
whether the person has any familiarity or previous experience with statutory processes and support agencies
whether the person might be reluctant to ask for help or raise issues because of personal, societal or other factors, such as stigma or mistrust of services
the person's expectations and emotional state
the person's wishes and needs for both family support, and for culturally specific support services.
Social workers should ensure that they discuss and actively listen to the person's:
history and life story
family and community networks
experience of disadvantage, discrimination or abuse
wishes and aspirations
past experiences of services.
Social workers should discuss with the person how their experiences may impact on their care needs and preferences, and how any difficulties may be mitigated. In these discussions:
avoid making assumptions about the individual's circumstances
recognise that some people's prior positive or negative views and experiences of social work may impact on the relationship with the social worker and services.
Social workers should explore with the person:
their experiences of society and accessing services and
the potential impact of intersectionality.Take these into account when planning care (for example, by liaising with appropriate support organisations).
When planning support, social workers:
must consider whether reasonable adjustments can be made to protect against, or help the person deal with, discrimination arising from a person's protected characteristics as defined by the Equality Act 2010, or from other life circumstances and experiences (see box 1) and
record the rationale for the decision made.
Protected characteristics of the Equality Act 2010
age
disability
gender reassignment
marriage and civil partnership
pregnancy and maternity
race
religion or belief
sex
sexual orientation.
Life circumstances and experiences that could lead to discrimination or inequalities, including:
modern slavery
coercive control
domestic abuse
trafficking
refugee status
asylum seeking
being a migrant
being from a traveller community
being a prisoner
being an offender
homelessness
poor literacy
learning difficulties
learning disabilities
cognitive impairment
acquired brain injury
autism
communication impairment
leaving care
transitioning from children's to adults' care services
sensory impairment
substance misuse
living in rural and isolated areas
long-term conditions
English not being a first language
socio-economic status
addictions.
The social worker must inform the person, in accordance with the UK General Data Protection Regulation (GDPR) and the Data Protection Act 2018, about the extent and content of information sharing across agencies and within multidisciplinary teams, and their rights in relation to this.
The social worker should be aware of NICE guidance about relevant conditions that could affect the person they work with and how they work with them. For example, the NICE guidelines on:
autism spectrum disorder in adults
challenging behaviour and learning disabilities
cystic fibrosis
depression in adults
multiple sclerosis in adults
psychosis and schizophrenia in adults.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on principles of social work for adults with complex needs (for social workers) .
Full details of the evidence and the committee's discussion are in:
evidence review A: needs assessment
evidence review B: risk assessment
evidence review C: supporting changing needs
evidence review E: integrated working.
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## For organisations
What is an 'organisation'?
In the context of this guideline, organisations are bodies that employ social workers in a professional capacity. This can include local authority social care departments, health services, the criminal justice system, higher and further education and voluntary and community services.
Organisations (see box 2) should consider making time allowances for social workers in caseloads so they can build relationships with people with complex needs. Recognise that building relationships may take longer with people who may have had negative experiences with services, or people concerned about stigma from being in contact with services.
Organisations should provide continuous professional development for social workers that specifically covers equality and diversity, so they are competent and confident in:
asking all people they support about their personal and social identity as well as circumstances or experiences that may lead to inequalities or discrimination (for example, related to characteristics listed in box 1) and
understanding how their personal and social identity as well as circumstances or experiences may affect their lives, care needs and preferences.
Organisations should provide continuous professional development to ensure that social workers have up-to-date relevant legal literacy and sufficient knowledge of, for example, the:
Mental Capacity Act 2005
Mental Health Act 2007
Human Rights Act 1998
Equality Act 2010
Care Act 2014
Children Act 1989
relevant case law
inherent jurisdiction of the High Court.
Organisations, commissioners and social workers should:
recognise that people with complex needs may experience the impact of intersectionality, resulting in increased inequalities in access to and outcomes of health and social care and
take this into account when planning and delivering services so they are accessible and responsive to the whole range of people's needs (for example, if a person has multiple health and social care needs this could be addressed by multidisciplinary working between health and social care services  see the section on social workers and multidisciplinary teams: communication, support and collaboration).
Organisations should develop a framework, in line with the Social Work England professional standards, to support social workers in contributing to an open and creative learning culture in which they can:
discuss and share best practice to promote the rights, strength and wellbeing of people, families and communities
reflect on their own practice and that of their colleagues
share experiences and learn from each other about how to balance the rights of the individual with the risks to self and others.
For other principles of improving people's experience in adult health and social care services, including the principles of care and communication, see the NICE guidelines on people's experience in adult social care services, patient experience in adult NHS services and service user experience in adult mental health. For guidance on how to make information accessible, see the NHS Accessible Information Standard.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on principles of social work for adults with complex needs (for organisations) .
Full details of the evidence and the committee's discussion are in:
evidence review B: risk assessment
evidence review F: individual or family casework
evidence review G: helping people connect with local communities.
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# Assessment

## Needs assessment
The social worker should give the person information about their upcoming needs assessment in a format that is in line with their needs and preferences, and is accessible to them. Ensure they have enough notice and time to review documents, and prepare for the assessment.
In line with regulation 10 of the Care Act 2014, the social worker must inform carers of people with complex needs about their right to a carer's assessment (for more information, see the NICE guideline on supporting adult carers).
The social worker should inform the person being assessed about where and how they can access information about their rights under relevant legislation, such as the Care Act 2014, the Human Rights Act 1998 or the Mental Capacity Act 2005 (for example, providing written or oral information or signposting to relevant online resources or agencies  see also the section on principles of social work for adults with complex needs for relevant links related to meeting communication needs).
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on assessment  needs assessment (providing information) .
Full details of the evidence and the committee's discussion are in evidence review A: needs assessment.
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The social worker should be aware that a needs assessment can be stressful for the person being assessed, and their families and carers. Ensure that assessment practices are designed to minimise stress whenever possible, including:
using a flexible approach to tailor the assessment to the person's needs (for example, by amending the order of assessment questions)
helping the person to understand assessment documentation when appropriate (for example, explaining complex concepts in a simple, clear way).
Social workers should consider arranging a preparatory initial contact before the assessment itself if it will help the person with complex needs to participate fully in their assessment (in line with statutory guidance for a proportionate assessment in the Care Act 2014), taking into account:
the urgency of the person's support need
whether the person wants a preparatory initial contact, and if so whether they would prefer this as a home visit, virtual contact or a phone call
whether the person would have substantial difficulty in being involved in the assessment and if so, whether an independent advocate should be provided for the assessment.
The social worker should ask the person about their preferences for the practical arrangements of the assessment, such as:
the time and place of the assessment
remote or in-person assessment
whether they would like a supported self-assessment
whether they would like anyone to be present to support them, for example a family member, carer or an independent advocate.
The social worker should take into account that when there is a concern about potential safeguarding issues, an in-person assessment is likely to be needed.
If the person chooses supported self-assessment, the social worker should discuss the advantages and disadvantages of this option with them, taking into account the complexities of their needs.
The social worker should offer people with complex needs individualised support to complete a self-assessment, such as:
ensuring that they have complete information about what it involves, including the list of areas and questions which it covers
involving advocacy services
providing details of who to contact if they want to clarify or discuss any areas of the assessment
giving reassurance that they can ask for an in-person assessment if their preference changes.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on assessment  needs assessment (planning the assessment) .
Full details of the evidence and the committee's discussion are in evidence review A: needs assessment.
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The social workers must ensure that the information provided by supported self-assessment is an accurate reflection of the person's circumstances (in accordance with section 6.44 of the Care and support statutory guidance, 2021). This can be done by cross referencing it with information from other sources (this should typically include involved family and carers or the multidisciplinary team).
The social worker must conduct the needs assessment for adults with complex needs in compliance with statutory guidance (see regulation 2(1) of the Care Act 2014), and taking account of the following:
whether the person's needs arise from or are related to a physical or mental impairment or illness
whether the person would have difficulties in achieving 2 or more of the 10 listed outcomes; see regulation 2(2) of the Care Act 2014
whether there is a significant impact on wellbeing
whether there are any unmet needs that may relate to a condition or difficulty that may need input from other specialist services, for example from speech and language services or mental health services.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on assessment  needs assessment (conducting the assessment) .
Full details of the evidence and the committee's discussion are in evidence review A: needs assessment.
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The social worker should give the person a draft copy of their assessment and reviews, and the opportunity to identify any inaccuracies, omissions or differences of perspective, before the assessment is finalised.
The social worker should acknowledge and record in formal case notes and the care and support plan any differences of opinion about the needs assessment.
The social worker should give people with complex needs, their families and carers and other people important to them information about the complaints procedure, including how to access it and how to lodge a complaint if they wish to about the process or the outcome of the assessment.
If the person chooses a self-assessment, the organisation must provide them with relevant information that they hold about them and their carer's assessment if applicable, taking into account legal requirements related to consent (in line with sections 2 and 2 of the Care and Support  Regulations 2014).
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on needs assessment (recording and reviewing the assessment) .
Full details of the evidence and the committee's discussion are in:
evidence review A: needs assessment
evidence review B: risk assessment.
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## Risk assessment
Social workers should assess risks as part of a holistic process of assessing the person's strengths, needs and wishes.
The social worker should discuss and record the person's views on involving family, carers, and other people important to them in the risk assessment in the formal case file. Let the person know that it has been recorded and share this information across relevant agencies and with other social workers when appropriate and necessary (in line with the UK GDPR and the Data Protection Act 2018).
The social worker should consider conducting the risk assessment over several contacts, so that:
there is an opportunity for rapport to develop between the social worker and person being assessed
the person's perspective on risks, their strengths, needs and wishes, and their health, environment and support networks are understood.
When planning a risk assessment, take into account the urgency of any situation that may need a risk assessment within a short timeframe (for example, in a single visit; see also the section on responding to an escalation of need, including urgent support).
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on risk assessment (planning the risk assessment) .
Full details of the evidence and the committee's discussion are in evidence review B: risk assessment.
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The social worker should support the person to engage in advance care planning, including:
planning to cover their wishes in the event of any future loss of capacity (see the section on advance care planning in the NICE guideline on decision making and mental capacity)
developing a risk management plan.
Where a social worker has reasonable cause to suspect a person has experienced, is experiencing or is at risk of abuse or neglect, they must follow local safeguarding policies. If a need for action is established, the social worker must follow statutory safeguarding processes as set out in regulation 42 of the Care Act 2014.
For people with complex needs, social workers should tailor risk assessments to the person's strengths and needs and take into account beneficial and harmful outcomes, and their likelihood of occurring, including:
risks to the person from their own behaviour (including accidents, self-neglect and suicide or self-harm)
risks from others (including physical or sexual violence, psychological harm, neglect or exploitation)
risks of harm to others
risks of loss of independence or breakdown of caring arrangements.
When assessing mental capacity, social workers must take account of section 1(4) of the Mental Capacity Act 2005, and not assume that the person lacks capacity because they have made a decision that the practitioner perceives as risky or unwise. See also the section on assessment of mental capacity in the NICE guideline on decision making and mental capacity, including recommendation 1.4.19 on the difficulty in assessing capacity in people with executive dysfunction.
If a person lacks the mental capacity to make decisions related to risk, the social worker must seek and take into consideration their current wishes (and any relevant past wishes expressed at a time when they were believed to have capacity) about any decisions, in line with section 4(6) of the Mental Capacity Act 2005. For further details, see the NICE guideline on decision making and mental capacity.
If a person makes a decision that is likely to put them at significant risk, the social worker should consider assessing their capacity to understand, retain and weigh up the relevant information about safety, taking into account:
previous decisions and choices and
the perspectives of involved family members, carers and multidisciplinary team members.
Social workers should use plain language and terminology that is understandable and acceptable to the person. For example, talking about 'safety' or 'being careful', rather than 'risk' or 'self-neglect'.
In discussions between the person and the social worker about risk, consider the use of a structured risk checklist.
The risk assessment should:
include discussion of what has caused previous problems and unplanned escalation of needs
identify what interventions have worked previously to manage and reduce risks.
When assessing risk, in accordance with Social Work England's professional standards, social workers should:
think about how any assumptions or personal biases may have influenced their assessment (for example, assuming that frail people would not want to participate in physical activities)
be reflective about their own values, and challenge the impact they have on their practice (for example, how they personally feel about tidiness when working with a person who is hoarding).
Social workers should respect people's rights to make decisions that they (the social worker) perceive as risky or unwise when the person has capacity to do so. Do not use such decisions as a reason to refuse care.
If a person with capacity declines an intervention aimed at reducing risk (see recommendation 1.2.22 for the types of risk that may need to be reduced), social workers should continue to work with them to find ways to minimise risks.
If a person has been assessed as lacking capacity, then in accordance with the Mental Capacity Act 2005, social workers must:
ascertain the person's best interests (using the best interests checklist in line with section 4 of the Mental Capacity Act 2005), including identifying whether there is a Lasting Power of Attorney or court-appointed deputy with appropriate decision-making powers to make best interests decisions
ensure any restrictions or supervision in their care are proportionate to the risk of harm to the person
take into account any less restrictive ways of meeting the person's needs and managing risks and use these where appropriate.
Social workers should avoid over-reliance on risk prediction (such as 'high' or 'low' risk) during assessments and when recording risks, and instead specify strategies on how to respond to factors contributing to increased risk and reduce potential harms.
When deciding whether to share information in circumstances where the person does not give consent, the social worker:
must balance the rights of the person with complex needs under the Human Rights Act 1998, Article 8 (right to respect for private and family life) against the effect on children or individuals at risk if they do not share the information and
should record all information-sharing decisions, and the reasons for those decisions, in line with the organisation's procedures and requirements.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on risk assessment (conducting the risk assessment) .
Full details of the evidence and the committee's discussion are in:
evidence review B: risk assessment
evidence review C: supporting changing needs.
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In complex risk management situations involving potential risks of serious harm, the social worker should initiate and participate in a case conference involving all relevant agencies to:
share information (in line with the UK GDPR and the Data Protection Act 2018) and
develop a coordinated risk management plan.
The social worker should include the person (and the person's advocate, family and carers, if they wish them to be present) in case conferences for complex risk management situations involving potential risks of serious harm, unless doing so:
would present a risk to (or cause an escalation of risk for) the person or
would present a risk to any of the other parties involved (social workers, other care staff, or the person's advocate, family or carers).
The social worker should ensure that relevant information on significant concerns about risks is shared and discussed with all necessary agencies (taking into account the legal requirements under the UK GDPR and the Data Protection Act 2018).
The social worker should:
give the person a draft copy of their risk assessment, and the opportunity to identify any inaccuracies, omissions or differences of perspectives, before the risk assessment is finalised
acknowledge and record any differences of opinion about the assessment of risk in the risk assessment document and formal case notes.
Social workers should review risk assessments:
at least annually and
if needed, in response to an identified change in the person's circumstances or change in risks.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on risk assessment (recording and reviewing the risk assessment) .
Full details of the evidence and the committee's discussion are in:
evidence review A: needs assessment
evidence review B: risk assessment.
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Organisations should:
provide de-escalation training to staff to support their safety
have systems for formally recording incidents of aggression, threats or abuse against staff.
Organisations should support staff when they experience any safety-related incidents, for example by:
debriefing them
providing peer support
providing counselling following serious incidents.
Organisations should provide access to advice for social workers whenever they are working, including outside normal office hours, about immediate concerns related to the risk to the person with complex needs or others.
Organisations should ensure the following are in place:
training, including multi-agency training, to support staff in assessing risks thoroughly
supervision structures to support staff and encourage reflective and inclusive practice (for example, a multidisciplinary team discussion about individual situations).
Organisations should have a written strategy promoting a culture that supports staff in helping people with complex needs balance the benefits and harms relating to risk taking. This could include, for example, training and governance systems to support social workers with assessing complex and high-risk situations.
For further principles of decision making in situations where people may lack capacity, see the NICE guideline on decision making and mental capacity.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on risk assessment (organisational support) .
Full details of the evidence and the committee's discussion are in evidence review B: risk assessment.
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# Individual or family casework
Social workers should take account of the principles of social work for adults with complex needs when conducting individual or family casework.
Social workers should help people with complex needs to identify personal goals and desired outcomes (for example, through task-focused approaches).
Social workers must understand the options available through legal frameworks so they can effectively support the rights of the person and the rights (and limits of the rights) of family members, including in situations of conflict and challenge. For example:
Care Act 2014's requirement for advocacy
Mental Capacity Act 2005 requirements on deprivation of liberty safeguards and the Mental Capacity (Amendment) Act 2019 requirements on liberty protection safeguards
Human Rights Act 1998
Safeguarding Vulnerable Groups Act 2006
Protection of Freedoms Act 2012.
Organisations should consider training and support for social workers to promote the rights, strength and wellbeing of people and families (in line with Social Work England's professional standards) to gain specialised and advanced skills in family interventions (for example, behavioural family interventions, family group conferences and restorative approaches).
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on individual or family casework .
Full details of the evidence and the committee's discussion are in evidence review F: individual or family casework.
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# Helping people to connect with local communities and reduce isolation
To help people with complex needs develop social connections, social workers should talk to them about their social networks, strengths (using strengths and asset-based approaches), and preferences for activities and social contact.
Social workers should help people to access a range of groups, social activities and social networks to meet their needs and preferences, looking across the community in addition to what is provided by health and social care services. This could be done by:
identifying local community groups and networks, and resources (for example, social clubs, community gardens, faith and cultural groups, user-led social groups)
finding out about these resources and whether they may meet the person's needs and preferences
helping the person make contact with these groups and activities (for example, by arranging IT and digital training, using familiar and accessible places).
Social workers should think creatively about the types of community resources and networks that they can put in place or support people to develop (for example, by active involvement in commissioning discussions and flexible use of personal budgets, including direct payments).
The social worker should check with the person whether any new community connection is meaningful, beneficial to wellbeing and enjoyable, and if not support the person to find a more suitable alternative.
Organisations and social workers should keep up to date with information on currently available community assets, and pass this information on to adults with complex needs and their families. For example by:
creating lists of resources and updating them regularly
allocating workers to identify resources
liaising with community groups
commissioning voluntary organisations to keep up-to-date resource lists.
Organisations should make information available about their services, and other community resources to people with complex needs (for example, disabled people's user-led organisations and other community groups). This information should cover:
catchment area, and people's right to access services outside of their catchment area
eligibility criteria
referral processes.
For information on community engagement approaches that seek to improve health and wellbeing and reduce health inequalities, see the NICE guideline on community engagement: improving health and wellbeing and reducing health inequalities. For information aimed at engaging people over 65 years in activities to improve mental wellbeing, see the NICE guideline on mental wellbeing in over 65s: occupational therapy and physical activity interventions.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on helping people to connect with local communities and reduce isolation .
Full details of the evidence and the committee's discussion are in:
evidence review F: individual or family casework
evidence review G: helping people connect with local communities.
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# Supporting people to plan for the future, including considering changing needs, wishes and capabilities
The social worker should provide information to support the health and wellbeing of carers in their caring role, and on how the carer can help support the person with complex needs. See also the recommendations on providing information and support to carers in the NICE guideline on supporting adult carers.
Social workers should ensure that care planning meetings take place in the person's preferred location whenever possible and practical.
Social workers should implement a rights-based approach to case management and care planning. This should reflect the following principles:
promoting people's dignity and wellbeing
respecting people's right to self-determination
promoting and supporting participation
taking a holistic approach
focusing on people's strengths and not solely on their needs.
Social workers should, when appropriate and wanted, include input from key support networks in the person's care plan. This should:
be in collaboration with the person, and with their consent
include paid and unpaid support networks (for example, family, carers and other people important to them).
Social workers should respond to the person and their changing circumstances by:
developing a plan that is flexible and responsive
reviewing and revising the care plan in response to fluctuating, evolving or rapid changes
developing and identifying options according to the person's needs, wishes and preferences (for example, by helping people connect with local communities as described in the section on helping people to connect with local communities and reduce isolation)
ensuring consistency of care by integrating working across the range of health and social care services involved (see the section on the social worker's role in multidisciplinary teams).
Social workers should ensure that, at time of writing or review, care plans:
take account of the person's wishes and preferences
state how the person's eligible and non-eligible needs would be best met
identify how arrangements have been or will be made to meet eligible needs
record any eligible needs which are unlikely to be met or only partially met, the reasons they cannot be met or only partially met and any potential actions that would allow them to be met in future.
The social worker should ensure that the person has their work contact details so they can get in touch if their needs or circumstances change. Document this information in the person's care plan.
The social worker should plan the review date of the care plan with the person (a review should happen at least once a year), or conduct an unplanned review as soon as possible if, for example:
the person's needs escalate or reduce, and circumstances change (for example, after transfer from hospital)
the person, or their carer, a family member, advocate or another person important to them requests it.
Each social worker must (in line with Social Work England's professional standards):
use supervision and feedback to critically reflect on their own practice, including how research and evidence has informed practice
keep their practice up to date, and record how research, theories and frameworks inform practice and professional judgement
contribute to an open, creative, learning culture in the workplace to discuss, reflect on and share best practice.
Where possible, organisations should provide people who receive social work support with a named social worker.
Organisations should provide social workers with regular practice-based supervision and support, ensuring organisational resources are sufficient to allow:
continuity of named social workers or a clear handover if the social worker has to change
adequate time to monitor and review cases
responsiveness to unexpected change
the ability to be flexible, when appropriate, to the needs of the person.
To support people to plan for the future when they transition between services, settings or between levels of care, see the following NICE guidelines:
transition between inpatient hospital settings and community or care home settings for adults with social care needs (in particular, section 1.5 on discharge planning)
transition between inpatient mental health settings and community or care home settings (in particular, section 1.5 on discharge planning)
transition from children's to adults' services for young people using health or social care services (in particular, section 1.2 on transition planning)
intermediate care including reablement (in particular, section 1.7 on transition from intermediate care).
To support people growing older with learning disabilities to plan for the future, see recommendations 1.4.5 to 1.4.7 in the NICE guideline on care and support for people growing older with learning disabilities.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on supporting people to plan for the future including considering changing needs, wishes and capabilities .
Full details of the evidence and the committee's discussion are in
evidence review C: supporting changing needs
evidence review F: individual or family casework.
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# Responding to an escalation of need, including urgent support
When responding to an unplanned escalation of need, social workers should take into account the person's wishes, preferences, social circumstances and cultural background (for example, if someone expresses a strong desire to stay at home, even if necessary care may more easily be provided in a residential or inpatient setting).
In the event of an unplanned escalation of need, social workers (with consent from the person) should:
assess the escalated need jointly with colleagues who have the most knowledge about the person's care, wherever practical (for example, requesting a community Care and Treatment Review or a case conference)
consult on the response to the escalated need with:
-ther involved practitioners and community organisations
relevant family and social networks.
When an unplanned escalation of need occurs, social workers must:
explore the least restrictive alternatives to address the need (in accordance with section 1(6) of the Mental Capacity Act 2005)
seek provision of interventions that will have the least detrimental impact on the person's rights and living situation.
Social workers should establish whether a person with complex needs has any advance statement of their wishes or crisis planning, and must take these into account when planning care during a crisis. Document in the person's records how this has informed decision making and review the plan after an escalation of need.
When responding to an escalation of need, as well as considering an advance statement if available, the social worker should take into account and document:
the person's wishes and preferences
the views of others (for example, family, carers, and other people important to them) concerned for the person's welfare.
Organisations should ensure that social workers have access to prompt support and opportunities to be debriefed during and after their work with someone experiencing a crisis. This should include the opportunity for social workers to reflect on practice and the potential risk to themselves and the person.
Local authorities should have arrangements in place to provide services that:
are available 24 hours, so decisions on applications for detention under the Mental Health Act (in line with section 14.35 of the Mental Health Act 1983: Code of Practice) can be made at any time
can respond promptly to a person's escalating need
communicate any out-of-hours responses to escalating need quickly and clearly to daytime services.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on responding to an escalation of need, including urgent support .
Full details of the evidence and the committee's discussion are in evidence review D: support during an escalation of need.
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# Social workers and multidisciplinary teams: communication, support and collaboration
Organisations should ensure that multidisciplinary teams develop a shared statement of values, core purposes and activities, and have clear objectives and aims to jointly work towards.
Organisations should consider the routine sharing of information (in line with the UK GDPR and the Data Protection Act 2018), and of professional expertise and perspectives, within the multidisciplinary team (for example, with joint working, forums or team meetings, themed discussions, or by championing a particular multidisciplinary approach).
Organisations should ensure there is clear communication within the multidisciplinary team by:
holding multidisciplinary team meetings, including case discussions
having mutual access to diaries when possible
providing virtual means to stay in touch even when team members are working from different locations
making use of informal opportunities to communicate (for example, staff networking events).
Organisations and commissioners should provide interdisciplinary training to promote shared understanding of each role in the team, and the legal frameworks within which they work, as well as an understanding of the range of lived experiences of people with complex needs. This should:
be provided across health and social care including other relevant settings as needed
be co-produced with people with lived experience
be ongoing
be followed up with clear plans for implementing any best practice and lessons learnt from the training sessions.
Organisations should support social workers in defining their role within multidisciplinary teams by:
providing professional social work supervision, in particular when the team manager is not a social worker
providing opportunities for peer supervision
making joint training available that provides clarity about the role of the social worker within a multidisciplinary team
providing bespoke, continuing professional development for social workers
recognising and addressing differences in organisational culture between professionals involved in the team.
To improve the efficiency of referral within multidisciplinary teams, health and social care organisations should simplify referral processes and referral pathways, for example by having clear and simple eligibility criteria.
Organisations should think about co-location to support more efficient responses and opportunities for discussion within multidisciplinary teams where feasible.
Organisations should develop shared formal agreements (including budgets and information sharing) early in the process of establishing integrated working to underpin accountability and decision making.
For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on social workers and multidisciplinary teams: communication, support and collaboration .
Full details of the evidence and the committee's discussion are in evidence review E: integrated working.
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# Terms used in this guideline
This section defines terms that have been used in a particular way for this guideline. For other definitions, see the NICE glossary and the Think Local, Act Personal Care and Support Jargon Buster.

## Debriefing
Debriefing after a distressing or safety-related incident involves the social worker having an opportunity to speak to a manager or senior colleague as soon as possible after the incident. This can be used, for example, to acknowledge the difficult situation and look into any support the social worker needs, including psychological support or counselling. This could start a reflective process to identify any lessons or ways to improve practice in future.

## Intersectionality
The term describes the interconnected nature of social categorisations such as age, disability, gender reassignment, pregnancy and maternity, race, religion or belief, sex and sexual orientation and other characteristics or experiences listed in box 1, regarded as creating overlapping and interdependent systems of discrimination or disadvantage.

## Professional curiosity
Professional curiosity is to explore and understand what is happening with an individual or family; enquiring deeper and using skilled, proactive questioning and investigation. It is about comparing what the person is saying with what is observed and any other available information, questioning any incongruity, rather than making assumptions or taking things at face value, to provide appropriate and tailored support.

## Rights-based approach
A rights-based approach ensures that both the standards and the principles of human rights are integrated into policy making, as well as the day-to-day running of organisations and social work practice.

## Strength and asset-based approaches
Strengths and asset-based approaches in social care focus on what individuals and communities have, and how they can work together, rather than on what individuals or communities cannot do or do not have. The terms 'strengths' and 'assets' are often used interchangeably to apply to either individuals or communities. Personal strengths and assets can include relationships, experience, skills and aspirations. Community strengths and assets can include knowledge, people, spaces, networks and services.

## Task-focused approach
This approach seeks actionable solutions to specific problems. It usually involves 4 steps:
defining a target area to work on together
agreeing specific goals and actions for both the social worker and the person they are supporting to help achieve these goals
discussion and support about progress with, and impact of, agreed actions
reviewing and deciding whether a further process of task-centred goal setting is needed or the process has been successfully completed.
Task-focused work is typically relatively brief but can be applied flexibly across a range of social work contexts as stand-alone support or within a broader package of care.

## Wellbeing
In the context of the guideline, wellbeing is defined in accordance to regulation 1(2) of Care Act 2014, which states:
'Wellbeing', in relation to an individual, means that individual's wellbeing so far as relating to any of the following:
personal dignity (including treatment of the individual with respect)
physical and mental health and emotional wellbeing
protection from abuse and neglect
control by the individual over day-to-day life (including over care and support, or support, provided to the individual and the way in which it is provided)
participation in work, education, training or recreation
social and economic wellbeing
domestic, family and personal relationships
suitability of living accommodation
the individual's contribution to society.# Recommendations for research
The guideline committee has made the following recommendations for research.

# Key recommendations for research

## Needs assessment
From the perspective of everyone involved, what is the acceptability of strengths and rights-based approaches to social work assessment and what are the barriers and facilitators to delivering these?
For a short explanation of why the committee made this recommendation for research, see the rationale section on needs assessment .
Full details of the evidence and the committee's discussion are in evidence review A: needs assessment.
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## Risk assessment
From the perspective of everyone involved, what works well and could be improved about the use of tools and checklists to support social work risk assessment for people with complex needs?
For a short explanation of why the committee made this recommendation for research, see the rationale section on risk assessment .
Full details of the evidence and the committee's discussion are in evidence review B: risk assessment.
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## Supporting people to plan for the future
What is the effectiveness and cost-effectiveness of early, preventative support for people with complex needs?
For a short explanation of why the committee made this recommendation for research, see the rationale section on supporting people to plan for the future .
Full details of the evidence and the committee's discussion are in evidence review C: supporting changing needs.
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## Responding to an escalation of need
What is the effectiveness and acceptability of social work interventions to support people with complex needs during an escalation of need?
For a short explanation of why the committee made this recommendation for research, see the rationale section on responding to an escalation of need .
Full details of the evidence and the committee's discussion are in evidence review D: support during an escalation of need.
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## Helping people to connect with local communities and reduce isolation
What social and community support approaches are effective in promoting social inclusion of people with complex needs?
For a short explanation of why the committee made this recommendation for research, see the rationale section on helping people connect with local communities and reduce isolation .
Full details of the evidence and the committee's discussion are in evidence review G: helping people connect with local communities.
Loading. Please wait.# Rationale and impact
These sections briefly explain why the committee made the recommendations and how they might affect practice or services.

# Principles of social work for adults with complex needs

## For social workers
Recommendations 1.1.1 to 1.1.10
The committee looked at a range of evidence to inform the recommendations, which are intended to underpin all social work with adults with complex needs. They also took the Human Rights Act 1998, the Equality Act 2010, the Care Act 2014 and the UK General Data Protection Regulation (GDPR) and the Data Protection Act 2018 into account to address potential inequalities and data protection issues (for example, in access to services or in the services that people with complex needs receive). They also drew on the professional standards from Social Work England, the Professional Capabilities Framework from the British Association for Social Workers (BASW) and the Code of Ethics from BASW.
The committee discussed qualitative evidence related to supporting people to plan for the future that highlighted some of the barriers that could influence people's access to and participation with services (for example, poverty, which is associated with inadequate housing and limited access to support). Such barriers could, in turn, result in people who use services feeling shame about their health conditions or living circumstances. This could further isolate them and make it more challenging for providers to support them. The committee therefore made a recommendation to emphasise that social workers need to treat people with respect and dignity to prevent barriers developing, and to understand and take into account the different circumstances of people with complex needs and any of their past experiences of services. This is also in line with the Human Rights Act 1998 and the Equality Act 2010.
There was some qualitative evidence related to approaches to needs assessments that showed people were not always aware of what to expect from an assessment, and that language could be a barrier to communicating with social workers during the assessment. The committee agreed that meeting these needs are important principles that would apply to all aspects of social work, so they decided to broaden the recommendation beyond just the assessment process. They recommended that the social worker find out whether an advocate is needed to support the person and help with communication, information and understanding the legal framework. The committee discussed that some people (for example, people with learning disabilities) may also have particular sensory needs or impairments (for example noise level or brightness of light) and therefore added that this should also be taken into account. Based on the same evidence, the committee also emphasised the importance of ensuring that all the person's communication needs and preferences are addressed, to help them to actively participate in discussions. They noted that this was already covered in the section on overarching principles in the NICE guideline on people's experience in adult social care services so they included a cross reference to this.
There was also some qualitative evidence showing that people did not always understand the purpose of the needs assessment and what it would entail. The committee used this evidence to recommend that sufficient information is provided for all activities and processes so that the person can understand what is going to happen and why. This will mean they can make informed choices and actively participate in the assessment.
The committee discussed the support that people may need to be actively involved in social work processes:
qualitative evidence showed that cultural differences created challenges for practitioners
qualitative evidence showed that not having family support can be detrimental to the person's wellbeing
quantitative evidence showed that differences in perspective because of culture lead to care needs not being raised or recognised by social workers
in the committee's own experience, people's life experiences, expectations and emotional state can have an impact on their care experiences, and consequently lead to inequalities and poorer outcomes.
The committee made recommendations to address these problems. They also highlighted the positive impact of family support (if needed and wanted) which can help the person to be actively involved.
The committee drew on both quantitative and qualitative evidence from the review of individual and family casework. They discussed the qualitative evidence that suggested people's cultural experiences and perspectives can differ from those of the practitioner, and that this may result in the practitioner making assumptions. Based on experience and expertise, the committee emphasised that the starting point would be relationship building to identify a person's characteristics that might predispose them to inequality in healthcare provision, by actively listening to the person. They highlighted that forming trusting relationships is the cornerstone of social work and that looking at all aspects of the person's life would ensure that the social work approach has the person with complex needs at its centre, and that any reasonable adjustments are being made in relation to those needs. They discussed that a record of reasonable adjustment decisions should be made to ensure that this was given due consideration. The committee noted that there was only a small amount of evidence, but acknowledged that this was a key area of social work that could lead to inequalities in access to care and care provision, if not addressed. In the absence of evidence for other experiences and circumstances that may lead to inequalities and discrimination, which may be multiple (see the definition of intersectionality), the committee applied the evidence about the challenges of cultural differences and assumption as well as their knowledge from the Equality Act to cover the protected characteristics as well as other life circumstances and experiences (see box 1).
The committee noted that a lot of qualitative evidence on the social worker's role in multidisciplinary teams referred to information sharing as a potential facilitator to integrated working, as it provides continuity (and conversely, acts as a barrier if not present). They discussed, based on their experience, that information gets shared more about people with complex needs and between more agencies. There were concerns about the extent of information sharing, however. In the committee's experience, people with complex needs value continuity and consistency and generally think that it is a positive idea to share information, but they want to be informed when and what information is shared and with whom (whenever this is possible and appropriate, in line with UK GDPR and the Data Protection Act 2018). The committee decided that this is a principle that should not be restricted to multidisciplinary team working but applies to all social work practice. The committee agreed that people need to be reassured that there are legal limits on information sharing and that their data is protected, but also that sharing where possible would mean that they would not have to repeatedly tell their life stories.
The committee discussed that there are a wide range of conditions, impairments or fluctuating health conditions that lead to complex needs. They discussed that the guideline should be viewed in the context of such needs and that social workers when meeting a person with a particular condition should be aware of the relevant condition-specific guidance associated with this. The committee decided to give some examples of the range of conditions that may be applicable.
The committee noted that most of these recommendations would standardise practice, as they are actions that are mandated by legislation (particularly the Equality Act 2010, the Care Act 2014), and supported by Social Work England's professional standards or BASW's Professional Capabilities Framework. This is particularly in relation to information sharing, and active listening and relationship building.
Return to recommendations

## For organisations
Recommendations 1.1.11 to 1.1.16
The committee looked at a range of evidence to inform the recommendations, which are intended to underpin all social work with adults with complex needs. They also took into account the Human Rights Act 1998, the Equality Act 2010 (for example, to address inequalities in access to services or in the services that people with complex needs receive), the Care Act 2014, the UK GDPR and the Data Protection Act 2018 and the professional standards from Social Work England.
The committee used qualitative evidence from the reviews on individual and family casework, and helping people to connect with local communities and reduce isolation. This showed that the social work approach that people received was not sufficiently long or in-depth enough to address their complex needs. Based on this evidence, the committee recommended organisations provide sufficient time to social workers to build relationships in order to reduce inequalities.
The committee discussed that people's life experiences may have an impact on their care experiences, and consequently lead to inequalities in access to care and care provision and poorer outcomes. They recommended organisations support and train social workers to discuss people's personal and social identities, and life experiences. This is in line with professional standard 1.6 from Social Work England that outlines the role of the social worker to promote social justice, helping to confront and resolve issues of equality and inclusion. This would enable social workers to feel confident that they are providing an environment where people feel that they are free of discrimination, and emotional or physical harm, and feel safe in discussing the complex needs that they have. The committee highlighted that this would also improve wellbeing of people, but they discussed that the term wellbeing is sometimes interpreted only in physical health terms. They therefore decided to adopt the definition of wellbeing provided within regulation 1(2) of Care Act 2014.
There was qualitative evidence that social workers value support, supervision and training. The committee discussed that being up to date with relevant legal frameworks was particularly important to their work. They recommended that organisations should support this with continuous professional development so that social workers continue to develop legal knowledge and therefore act in accordance to the law when carrying out their duties.
Qualitative evidence showed that people felt existing services and interventions did not sufficiently address all their needs. This was also consistent with the committee's experience of current practice, and they emphasised that planning of services (commissioning and configuring) should take this into account to address potential inequalities in access to care and care provision.
The committee discussed evidence related to responding to an escalation of need, and concluded as a general principle that organisations should ensure social workers be given appropriate training and support during and after response to an escalation of need. However, the committee also agreed this would benefit all areas of their work, so expanded the recommendation to be one for development of an overall framework for an open learning culture. The committee discussed that this was in line with Social Work England's professional standards which also emphasise that families and communities should be taken into consideration. This will support social workers in learning from each other, and make them better able to appraise situations generally, but also specifically assess appropriate levels of risks that can be taken.
The committee noted that most of these recommendations would standardise practice. The recommendation that organisations should consider making time allowances to build relationships may lead to longer contact times than currently, but this would be balanced against better, individualised services and this was supported by the economic analysis. The recommendation on continuous professional development would address a current variation in practice in getting access and time for such training opportunities.
Return to recommendations

# Assessment  needs assessment

## Providing information
Recommendations 1.2.1 to 1.2.3
As there was no quantitative evidence on the effectiveness of different approaches to social work needs assessments, the committee used the qualitative evidence supported by their own knowledge and experience to make recommendations. They also took into account the legal framework underpinning social work assessments (particularly the Care Act 2014) and standards of practice (according to Social Work England's professional standards or BASW's Professional Capabilities Framework).
There was some evidence showing that people did not always understand the purpose of the needs assessment and what it would involve, so the committee recommended giving people accessible information on why it is needed, the objectives, and how it will be done so that they have time to prepare. This also included raising awareness with carers about their right to have a carer's assessment in line with regulation 10 of the Care Act 2014.
They also discussed that better understanding and knowledge (including of statutory rights) about social work assessments, both in terms of what is involved and the likely outcome, would reduce anxiety and stress for the person with complex needs. They noted that the social work can play an important part in addressing this by signposting to relevant resources.
Most of the recommendations will standardise rather than change practice, as they are actions that are mandated by the Care Act (such as giving sufficient information).
Return to recommendations

## Planning the assessment
Recommendations 1.2.4 to 1.2.9
As there was no quantitative evidence on the effectiveness of different approaches to social work needs assessments, the committee used the qualitative evidence supported by their own knowledge and experience to make recommendations. They also took into account the legal framework underpinning social work assessments (particularly the Care Act 2014) and standards of practice (according to Social Work England's professional standards or BASW's Professional Capabilities Framework).
Based on their experience, the committee emphasised that social workers should conduct assessments in a way that would minimise stress for the person noting that this would lead to better relationships and engagement and would therefore impact positively on outcomes.
The committee discussed the review findings which suggested people were not always able to express their preferences during assessment. Based on this the committee recommended that there could, in some circumstances, be a preparatory initial contact before the assessment as a way of overcoming these issues. The committee agreed that this can be particularly important if the person may have difficulties being actively involved in the assessment. To address such difficulties, support may be needed from an independent advocate in the assessment. A preparatory meeting could provide the opportunity to assess whether there are any adjustments that can be made or family members who can get involved and could help and support the person with complex needs throughout the process. However, regardless of whether a preparatory meeting is held or not, the committee highlighted that the practical arrangements for the assessments always need to be established before the assessment takes place. They discussed the benefits and challenges of remote (for example virtual) compared to in-person assessments. While there are some advantages of remote assessment (such as when an urgent assessment is needed) there are also disadvantages (such as not being able to get cues from the person's environment). While they could not categorically recommend 1 over the other, they highlighted that in cases of potential safeguarding concerns an in-person assessment would most likely be needed because missing any needs in these circumstances could have serious consequences.
The committee discussed qualitative evidence of possible challenges with self-assessment; for example, participants in a study reported that the self-assessment format was not always adequate or appropriate for people with multiple needs. Based on this, the committee emphasised that discussions should take place with the person about the advantages and disadvantages of this option so that they can make an informed choice, and that the person should be reassured that they will be supported and can change their mind and have an in-person assessment instead.
Most of the recommendations will standardise rather than change practice, as they are actions that are mandated by legislation such as the Care Act or based on Social Work England's professional standards or BASW's Professional Capabilities Framework. The recommendation for a preparatory initial contact is a change to current practice since this is not uniformly done across the country. This may lead to an increase in the number of contacts, which may cause a potential resource impact and increase demands on social worker time. However, the committee noted that a preparatory visit is an option rather than a mandatory requirement and could be a virtual contact or a phone call. The additional resources needed to have some such preparatory visits may be offset by improved outcomes from the person-centred approach, potentially improving quality of life and preventing expensive interventions later on, such as hospitalisation. Also, as it is only an option that services could use rather than something that should be implemented for everyone, the impact may be limited.
Return to recommendations

## Conducting the assessment
Recommendations 1.2.10 and 1.2.11
The committee used the Care and support statutory guidance and regulation 2(1) of the Care Act 2014 to make these recommendations.
The committee noted that if self-assessment is chosen, the Care Act 2014 requires social workers to check that the information that is provided in the assessment is accurate, so they emphasised this in a recommendation. This could be achieved by gathering information from multidisciplinary team members or family and carers, where appropriate.
Based on the committee's experience and expertise of the statutory guidance in relation to needs assessment, they discussed the content of the assessment and the related eligibility criteria. They agreed that it is important to highlight the questions that the social worker should take into account when deciding on the level of support that is needed in compliance with statutory guidance (eligibility outcomes of regulation 2(2) of the Care Act 2014). The committee discussed that some of the person's needs may be outside of the expertise of the social worker, for example communication or mental health needs, and it is important that specialist input is sought to address these needs.
Most of the recommendations will standardise rather than change practice, as they are actions that are mandated by either the Care and Support Statutory Guidance or the Care Act.
Return to recommendations

## Recording and reviewing the assessment
Recommendations 1.2.12 to 1.2.15
As there was no quantitative evidence on the effectiveness of different approaches to social work needs assessments, the committee used the qualitative evidence supported by their own knowledge and experience to make recommendations. They also took into account the legal framework underpinning social work assessments (particularly the Care Act 2014) and standards of practice (according to Social Work England's professional standards or BASW's Professional Capabilities Framework).
Evidence showed that people were not always given the opportunity to review their assessment details, so the committee made a recommendation to ensure that people have the opportunity to check the draft documents are accurate.
The evidence also suggested that needs can be interpreted differently by the person with complex needs and the social worker, which can lead to misunderstandings about the support that is expected. The committee acknowledged that differences of opinion could arise between a range of individuals, such as professionals and family members or others involved. They therefore recommended that a record of such differences should be kept in case any future issues arise. The committee noted that this could lead to tensions between the person with complex needs and the social worker, and could sometimes lead to complaints being made. They therefore emphasised that not only is good record keeping important when differences arise, but also that people should be given information about the complaints procedure, so they know what to do if they feel the correct processes have not been followed or they disagree with the outcome of the assessment.
In the context of self-assessment, the committee noted, based on their knowledge of legislation, that organisations have an obligation to provide the person who self-assesses with relevant information that they hold to help them in the process. The committee agreed that this was not always known by social workers and made a recommendation that this must be done to comply with legislation.
There is a lack of quantitative evidence addressing approaches to needs assessment and their potential impact on wellbeing. Because of this, the committee prioritised this topic for a research recommendation on needs assessment.
Most of the recommendations will standardise rather than change practice, as they are actions that are either mandated by the Care Act (such as giving sufficient information and support, or issues related to self-assessment) or extrapolated from it (such as preferences when arranging the assessment). The recommendation for a preparatory initial contact is a change to current practice, since this is not uniformly done across the country. This may lead to an increase in the number of contacts, with a potential resource impact and increasing demands on social worker time. However, the committee noted that it would not be routinely done and could be a virtual contact or a phone call. This may be offset by improved outcomes from the person-centred approach, potentially improving quality of life and preventing expensive interventions later on, such as hospitalisation. Also, as it is only an option that services could use rather than something that should be implemented for everyone, the impact may be limited.
Return to recommendations

# Assessment  risk assessment

## Planning the risk assessment
Recommendations 1.2.16 to 1.2.19
The committee acknowledged the limitations of the evidence, including the lack of quantitative evidence on this topic, and the limitations of the included qualitative evidence (in relation to both the low number of studies and low quality of findings). They agreed to use the qualitative evidence, supported by their own experience, when making the recommendations. They also took into account relevant legislation, including the Mental Capacity Act 2005 and the Mental Health Act 2007 as well as the Human Rights Act 1998 and the UK GDPR and the Data Protection Act 2018. The committee were also aware that decisions around risk can be influenced by culture, personal beliefs, and coping strategies. They therefore also took into consideration the Equality Act 2010.
The evidence highlighted that when people with complex needs, and their families and other people important to them were actively involved in the risk assessment process, it facilitated discussions with social workers around risks and helped them make decisions about care and support needs. The committee agreed that this was an essential component of social work and consistent with the legal framework. The committee agreed that for people with complex needs, and their families and other people important to them to be actively involved the process, it needs to be relevant to the person and therefore holistic, looking at the person's abilities and needs and taking their preferences into account.
The committee noted that the evidence suggested that people found it useful when family members supported them. However, they cautioned against being prescriptive about this because not every person would want their families involved in the process. Therefore, the committee recommended that social workers discuss the person's views and preferences and that these be recorded and shared (in line with the UK GDPR and the Data Protection Act 2018) so that families are not inadvertently included in discussions if this would go against the wishes of the person with complex needs.
The committee discussed the evidence relating to contextual risk assessment that showed that people found the risk assessment approach worked better when their individual circumstances were fully understood. The recommendations emphasise the need for social workers to develop a rapport with, and engage with, the person at risk. When possible and practical, the committee recommended that ideally this should be done over several contacts so that the person's circumstances and environment is fully understood. While the committee wanted to emphasise the need to build relationships and understand the person's circumstances and environment, they also acknowledged that in some situations when a person is at urgent risk, immediate action needs to be taken which may not allow time for several contacts.
The recommendations reinforce current legislation and usual practice. While conducting risk assessments over several contacts (which could be a virtual contact or a phone call) is not consistently done across the country, and would add time to the assessment, this would improve outcomes through a better understanding of the person's situation and environment. However, rather than this being implemented for everyone the committee thought that this could be one of the considerations around the assessment and would therefore not significantly change practice.
Return to recommendations

## Conducting the risk assessment
Recommendations 1.2.20 to 1.2.34
The committee acknowledged the limitations of the evidence, including the lack of quantitative evidence on this topic, and the limitations of the included qualitative evidence (in relation to both the small number of studies and low quality of findings). They agreed to use the qualitative evidence, supported by their own experience, when making the recommendations. They also took into account relevant legislation, including the Mental Capacity Act 2005 and the Mental Health Act 2007 as well as the Human Rights Act 1998. The committee were also aware that decisions around risk can be influenced by culture, personal beliefs, and coping strategies. They therefore also took into consideration the Equality Act 2010.
The committee noted the evidence related to assessing risk when a person lacks capacity, and so highlighted that risk assessments would also involve planning for the future so that the person's wishes are known in advance and a plan is in place to manage risk. They agreed that this would lead to better outcomes, since any risky situation can be managed in line with the person's preferences even if they later lack capacity to make decisions.
The committee discussed that safeguarding issues can be noticed in the risk assessment process and that it is therefore a legal duty in line with the Care Act 2014 that the social worker adheres to local policies to keep the person safe.
There was a lack of evidence about what works well and what could be improved in relation to the content of risk assessments, but despite this the committee agreed that it was important to provide guidance about what should be taken into account when conducting a risk assessment. They also discussed a guide about risk assessments from the Social Care Institute of Excellence and took this into account. In line with this, the committee recommended that to be effective the social worker should individualise the risk assessment and consider not only harmful outcomes but also where there are low risks and potential for good outcomes (for example, if the risks of harm from others and harm to others is low, it could mean that there is a good support network that the social worker could get involved to help with other potential risks that are high). The committee agreed to highlight categories of risks that would affect the person's safety and the safety of other people, as well as risks to their independence and the independence of others who may depend on them so that plans can be made to minimise them.
The committee discussed their concerns that any risky decisions could lead the social worker to conclude that the person lacks capacity, and they therefore highlighted the legislation of the Mental Capacity Act 2005 which states that assessments of mental capacity should not be based on such assumptions. They discussed that such decisions can be challenging with some cognitive impairments, such as executive dysfunction, and therefore highlighted this in a cross reference to recommendation 1.4.19 of the NICE guideline on decision making and mental capacity.
The committee were aware that people who lack capacity to make decisions related to risk were particularly vulnerable, and that therefore the legislation in section 4(6) of the Mental Capacity Act 2005 needs to be followed so that their current wishes can be established if possible. Even though an assumption should not be made that someone is lacking capacity, the committee did not want to leave someone vulnerable to risk if they do lack capacity, so they recommended that a person who makes a decision that would put themselves at significant risk should be considered for an assessment of capacity. Getting the views of people close to the person and members of the multidisciplinary team may be helpful to determine whether an assessment may be necessary. This is to ensure their safety, and potentially the safety of their family members or carers.
The committee noted the qualitative evidence showing that people agreed that risk assessments work better when discussions take into account the words a person uses to describe risk and their understanding of risk. There was some evidence that checklists can help with this, but the committee was cautious to recommend these as a routine form of assessment as there are only a small number of validated checklists available, and so they would not address the range or complexities of risks for people with complex needs. They were also concerned that this could also be seen by the person as a tick box exercise, and so recommended that checklists be used as a starting point for a wider discussion including previous causes of an escalation of needs and what worked well before to minimise risk. Because of uncertainties with the evidence on the use of checklists and it being restricted to people with complex mental health needs, the committee also made a research recommendation on risk assessment.
When reviewing evidence indicating that risk assessments worked better if social workers fully understand the person's perspectives of risk (when they have capacity to do so), the committee noted that this was consistent with their own experience. They therefore wanted to ensure that this was taken into account when assessing risk, but also that this should not stop social workers from providing necessary support if needed. The committee noted that this was in line with Social Work England's professional standards which advise social workers not to prejudge the person's state and also reflect on their own interpretations (which can be based on their own values), so as to avoid their own feelings around risk influencing their assessment.
The committee discussed evidence highlighting that a risk assessment works well for people who have capacity when it balances a person's risk with their autonomy, and other evidence that showed understanding the person's perception of risk facilitates the process. They therefore highlighted that people can make their own decisions about risks or decline interventions (for example, keeping many personal belongings if they are hoarding items even if it makes it difficult to move around their home). However, such choices should not be a reason to stop working with them or providing care even if the social worker perceives these decisions to be risky or unwise.
There was evidence related to detention under the Mental Capacity Act for people assessed as lacking capacity, and the committee used the principles of the Mental Capacity Act to highlight that the circumstances where potential risks for people who lack capacity could occur need to be carefully considered, including ascertaining the person's best interests, so that any restrictions made are proportionate and justified.
There was evidence highlighting that it is difficult to define the seriousness of risk, which was consistent with the committee's experience that risk would vary from person to person. The committee discussed that in the absence of such definitions, risk assessments can potentially place too much emphasis on the use of generic risk categories such as 'high' and 'low' risk  these do not distinguish the severity of potential harms from their likelihood, and do not take into account the different circumstances and choices of the person at risk. Based on these discussions, the committee made recommendations which emphasised that when recording risks social workers need to assess the severity and likelihood of identified potential harms to inform a risk management plan. This should weigh potential harms against potential benefits of risk taking, and a person's needs and wishes.
The committee acknowledged that the person at risk may not always give consent for their information to be shared. The committee identified the Human Rights Act 1998 underpins such decisions, and this was stated in the recommendations.
The recommendations reinforce current legislation and usual practice. For advance decision making, while this is not a mandatory part of risk assessment it is commonly done, so the recommendation is likely to lead to standardised practice.
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## Recording and reviewing the risk assessment
Recommendations 1.2.35 to 1.2.39
The committee acknowledged the limitations of the evidence, including the lack of quantitative evidence on this topic, and the limitations of the included qualitative evidence (in relation to both the limited number of studies and low quality of findings). They agreed to use the qualitative evidence, supported by their own experience, when making the recommendations. They also took into account legislation, under the UK GDPR and the Data Protection Act 2018.
Based on their experience, the committee were keen to emphasise the need to balance any competing demands and perspectives of different organisations, and for different practitioners to be able to exercise their professional judgement. To achieve this, they recommended that, in complex situations involving potential risks of serious harm (for example these could be situations where there are many different opinions in the multidisciplinary team, potentially different complex harms or where 1 action to avoid 1 risk might bring about a further risk), social workers coordinate a case conference. Usually this would include the person and their family or carers but the committee decided that there are situations where a case conference could be a cause of distress for the person or may put a family member at risk. They therefore made a recommendation to highlight both that the person's and their family's involvement is important as well as situations when this may not be advisable.
Also based on their experience, the committee discussed that, when there are significant concerns about risks, information ought to be shared between agencies to ensure the safety of the person with complex needs. However, they emphasised that this can only be done within the constraints of the legal framework within the UK GDPR and the Data Protection Act 2018.
Evidence showed that people were not always given the opportunity to review their risk assessment, so the committee made a recommendation to ensure that people have the opportunity to check the draft documents are accurate.
The evidence also suggested that disagreements could arise across different organisations and among different practitioners because of the varying ways in which risk is conceptualised and decisions on managing risk are made. The committee also noted that differences of opinion could arise among professionals, the person with complex needs, family members or others involved. They therefore recommended that a record of such differences should be kept in case any future issues arise from disagreements.
The committee also noted that risk assessments need to be relevant, up to date and responsive to change and therefore, based on their experience, recommended that they are reviewed at least annually, or when circumstances change and a new review is needed.
The recommendations reinforce current legislation and usual practice.
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## Organisational support
Recommendations 1.2.40 to 1.2.45
The committee acknowledged the limitations of the evidence, including the lack of quantitative evidence on this topic, and the limitations of the included qualitative evidence (in relation to both the limited number of studies and low quality of findings). They agreed to use the qualitative evidence, supported by their own experience, when making the recommendations.
The evidence showed that social workers valued support, particularly when they have experienced abuse, and ongoing training (including legal literacy). Based on the evidence and potential for high-risk situations, advice for social workers should be available whenever they are working, including outside normal office hours. The evidence showed that positive organisational cultures give social workers confidence in making risk assessments, and the committee drew on this to recommend a written strategy for training and support.
The recommendations reinforce current legislation and usual practice. The availability of training on risk assessment for social workers varies, so there may be a resource impact where it is currently not available. However, this would lead to better outcomes by improving the knowledge and awareness of processes and approaches to assess risks. Having out-of-hours access to advice in relation to risk for social workers who do not work during office hours is common practice (such as using an on-call system), so should not be an additional resource impact in most cases.
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# Individual or family casework
Recommendations 1.3.1 to 1.3.4

## Why the committee made the recommendations
The committee drew on both quantitative and qualitative evidence to make recommendations.
The committee discussed the quantitative evidence, which showed mixed results for social work approaches to individual and family casework. They discussed the evidence that showed that a stepped care intervention had an important benefit in terms of morbidity outcomes. This intervention had a number of components including guided self-help and problem solving. The qualitative evidence suggested that social work approaches, in particular goal setting, helped people to identify their priorities and think about ways to achieve these goals. Based on experience, the committee discussed the benefits of such approaches  in particular, those with components that seek solutions to defined areas and working to agreed goals to solve problems. They decided that they could not recommend the specific stepped care approach described in the study, as it was done in a different health and social care setting (Belgium and the Netherlands) and had many components that would make it difficult to implement. However, they noted that some of the components would fall into the category of task-focused approaches which are already used by social workers in the UK. Although the evidence showed benefit for a specific group, the committee agreed that the importance of identifying goals and outcomes (as is done in task-focused approaches) could be extrapolated to the wider population of adults with complex needs and recommended that people should be supported in this process.
The committee highlighted legal frameworks that were in place to support the rights of the person as well as the rights of the family. They agreed that by doing this, social workers would better understand that their role is not necessarily to resolve conflict, but to uphold the rights of the person being supported.
The committee looked at evidence around the challenges of involving family members in social work approaches to casework, and potential conflicts which may exist between family members and how safeguarding concerns may arise in some situations. They discussed the difficulties, as highlighted in the evidence, of ensuring family members participate and engage in interventions. However, they noted that there was little quantitative evidence on the effectiveness of any particular family intervention that had been carried out specifically by social workers to address these challenges. The committee was aware that there is a benefit from family interventions (for example, improving communication between family members), but that the evidence originates from other disciplines (for example, research in clinical psychology) and it is therefore unclear what the role of these interventions is in social work. However, to promote the rights and wellbeing of people and families (in line with Social Work England's professional standards) they felt such interventions could be considered with sufficient training, because the benefits of positive family relations and the social support that this could provide to the person with complex needs could lead to positive outcomes.

## How the recommendations might affect practice
The recommendations aim to standardise practice rather than change it.
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# Helping people to connect with local communities and reduce isolation
Recommendations 1.4.1 to 1.4.7

## Why the committee made the recommendations
The committee discussed the quantitative evidence, which showed benefits for some outcomes but no differences for other outcomes. However, because of methodological biases, as well as uncertainty around the magnitude of the findings, the committee were less confident in relying completely on the quantitative evidence to support recommendations. There were some themes of the qualitative evidence that supplemented or provided an explanation for the lack of clear results in the quantitative evidence. This combination of quantitative outcomes and qualitative themes suggested that the relative lack of improvement in the quantitative outcomes could be explained by the qualitative evidence that social workers place importance on taking an individualised approach to achieve positive outcomes. The committee agreed that this was a reflection of their experience of practice and was therefore important to take into account.
The committee made a recommendation based on the quantitative evidence that showed social work approaches to social inclusion had an important benefit over usual practice that mainly focused on the person's existing networks, as there was an improvement in perceived social support. The qualitative findings also highlighted the importance of thinking about the different levels of support a person may need. Based on the combination of the quantitative and qualitative evidence and drawing on their experience, the committee were confident to make a recommendation for the social worker to use a strengths-based, person-centred approach to help the person to develop connections with their local communities. The committee emphasised that approaches that do not solely focus on the person's needs would improve their confidence and contribute to their overall wellbeing by helping them to take steps to reduce isolation.
The committee also made a recommendation for social workers to support access to a range of activities in the community. A number of qualitative themes supported this recommendation, including the benefits of taking an individualised approach to social inclusion activities (as people's preferences and needs will vary greatly). The findings also highlighted that participants felt community-based groups and resources could be more beneficial in matching people's needs than those provided by health and care services.
The committee discussed the qualitative evidence around practitioners' views of social work approaches to social inclusion, which highlighted that the range of available groups and resources for people were not always adequate. As reducing isolation is beneficial to the person, the committee recommended social workers use creative approaches to see whether new resources could be developed. This also include the flexible use of personal budgets to support an activity. Support should also be given at an organisational level to help social workers find activities and groups that might match a person's interests. This relies on information being up to date, so the committee gave some examples of how this could be achieved.
The committee discussed evidence that highlighted that it was important to take into account that the level of support needed varied depending on peoples' needs. They agreed that the support of the social worker should not end once a person has made contact with a group, but that this should be followed up with the person after they have joined a group to ensure that they benefitted from it.
Based on experience, the committee agreed that it was important for organisations to provide information that is up to date about available community resources, as this would minimise barriers to accessing services (such as frustrations around contact details no longer being active, or activities no longer being available).
The committee discussed the evidence around the barriers to connecting with communities or groups, that showed that an NHS trust's catchment area could be a barrier to this because it is assumed by practitioners and the person that people do not have the right to access groups that are outside the catchment area. The committee recognised that it was not within the scope of the guideline to make a recommendation about local authority catchment areas, but agreed to recommend that people are informed about their rights to receive services outside of their catchment areas to help address this. Based on their experience and knowledge, they expanded on this to alleviate other barriers to access, such as eligibility criteria and referral processes.
Even though there was both quantitative and qualitative evidence to draw on, the committee felt that further evidence to clarify the best approach that social workers could take to help people connect with their local community is needed and so made a research recommendation on social and community support approaches to address this.

## How the recommendations might affect practice
There is variation in practice in how much time is spent by social workers helping people connect to local communities. The recommendations will increase the time social workers spend researching, supporting and helping people to make connections in their communities. However, this potential change in practice could lead to improved outcomes by reducing the detrimental effects that loneliness can have on the person's health and wellbeing.
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# Supporting people to plan for the future, including considering changing needs, wishes and capabilities
Recommendations 1.5.1 to 1.5.13

## Why the committee made the recommendations
The committee discussed both quantitative and qualitative evidence. The quantitative evidence was of limited value because of the quality of the studies and applicability, as most of the included studies were not conducted in the UK so the care provision and legislation were different. They therefore focused on the qualitative evidence as it was of better quality, with themes that the committee agreed were more generalisable to the wider population (with more UK evidence and a wider range of complex needs included).
The evidence suggested that when people have information and support in advance and understand the care planning process, this helps them to participate in planning for the future with their social worker. The committee highlighted the key role social workers play in communicating relevant information to people with complex needs, as well as to their support network, in a timely manner throughout the whole process. The committee emphasised that this would also include information and support for carers, which would have a positive impact on their own wellbeing as well as that of the person that they are providing care for.
There was evidence that highlighted that the environment and service location can be an important facilitator to help the person feel safe and relaxed, and there was also benefit in having a location that provides easy access to case management services (this included visits to the person's home). The committee drew on this to recommend that care planning take place in the person's preferred location whenever possible.
There was some limited evidence about the importance of building relationships and trust. This was consistent with the committee's experience that good relationships that include meaningful conversations to engage individuals are an important aspect of case management and care planning. Drawing on their own expertise, the committee recommended a rights-based approach to case management and care planning, focusing on the individual's rights according to the principles of the Human Rights Act 1998. This would improve people's outcomes by promoting their dignity and wellbeing, building on their strengths and supporting both their participation in the community and engagement with services.
The committee discussed the qualitative evidence that highlighted the importance of existing relationships between adults with complex needs and their family members and carers, and also the wider community. Promoting such relationships may enhance the support networks available to adults with complex needs, which may in turn help minimise the potential for isolation. They discussed the importance of both paid and unpaid support networks (for example, family and personal assistants), and agreed that their input should be reflected in the care plan where appropriate.
Based on evidence that highlighted that a barrier to successful planning for the future was not recognising quickly enough when needs change, the committee highlighted the benefits of a flexible and responsive approach. This should include regular reviews so that plans can be adjusted to ensure the person's safety and wellbeing.
Based on the evidence about the challenges of planning and addressing all the person's needs, and supported by their own knowledge and experience, the committee were aware that social workers may not always be able to address the whole range of identified, eligible needs successfully at the point when the care plan is written or reviewed. It was acknowledged that in accordance with section 18 of the Care Act 2014, a local authority, having determined that a need is eligible, has a legal duty to meet this need. (See also section 10.10 of the Care and support statutory guidance, which describes what is meant by 'meeting a need'.) The committee decided that when writing or reviewing the care plan, social workers should note when a need has not yet been met, or is only partially met, to make it explicit that the need has to be addressed to meet the local authority's legal obligation. It was noted that the social worker and the person may have different views about the extent to which an eligible need has been sufficiently met, but it was decided that this could be captured in the care plan or at review. Exploring this when writing or reviewing the care plan would help identify reasons why some needs have not been sufficiently met, and indicate what might be needed to achieve this in future.
In relation to this, the committee cited section 13.13 of the Care and support statutory guidance which describes the routes to reviewing care and support plans. While, based on their experience, a review should be planned with the person and take place at least once a year, the statutory guidance highlights that there can be situations where an unplanned review is necessary (for example, if needs change or if it is requested by the person or other people important to them).
The committee discussed findings around working arrangements which identified certain conditions that enabled social workers to fulfil their roles more successfully, including autonomy, training, support and supervision. However, the evidence suggested that most social workers reported a lack of support from managers from their own organisations. The committee were keen to emphasise the importance of supporting social workers in their role so that in turn, adults with complex needs would be effectively supported. This was reflected in the committee's recommendation that organisations provide social workers with regular, practice-based supervision and support so they can be responsive to people's complex and fluctuating needs, and keep their knowledge and practice up to date.
The committee discussed the evidence showing that continuity was valued in care planning, particularly because people with complex needs felt frustrated about having to tell their stories repeatedly. The committee noted that this was consistent with their experience that offering people access to a named social worker would benefit them in terms of providing such continuity of care, which would in turn enhance their health and wellbeing (where there are changes in social workers, continuity could be maintained by having clear handover processes in place).
The committee made a research recommendation on supporting people to plan for the future to inform future guidelines that would address the gap in the effectiveness evidence relating to the evaluation of specific models of social work case management.

## How the recommendations might affect practice
The recommendations will mainly standardise practice. There is some variation nationally in provision of a 'named' social worker so increased provision may have some resource impact, but this is already common practice for many services so this may be limited.
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# Responding to an escalation of need, including urgent support
Recommendations 1.6.1 to 1.6.7

## Why the committee made the recommendations
While some quantitative evidence was available, the committee decided not to make use of it when making recommendations, as only 1 small observational study with methodological limitations (such as lack of comparison group) was identified and the population was restricted to the specific needs of people with mental health conditions. Therefore, it was difficult to generalise to the wider population of people with complex needs. The committee drew on the more substantial qualitative evidence (from 8 studies) and supplemented this with their experience and knowledge to make advice applicable to the wider population of adults with complex needs.
The committee used their expertise and knowledge of BASW's Professional Capabilities Framework  which sets out the ethical principles and critical reflection practices that a social worker must apply to guide their decision making  to recommend social workers consider a person's wishes, preferences, social circumstances and cultural background when planning during an escalation of need. This would help ensure that any decisions that are made are not based on the social worker's assumptions.
The committee discussed the evidence that suggested practitioners who used the wider support network of friends and family to help with decision making during a Mental Health Act assessment facilitated the social worker's response to an escalation of needs. Based on this evidence and their experience, and statutory requirements, they decided to generalise this to the whole population for all situations of unplanned escalation of needs. They agreed that gathering information about the situation not only from the person's family and social networks, but also relevant practitioners would create a clearer picture of the situation (and any previous, similar situations) and would therefore likely lead to better solutions. The committee noted that usually this information could be gathered by phone or using virtual meetings (for example, virtual case conferences or Care and Treatment Reviews).
The evidence that showed there was a lack of time and resources for social workers to look at alternative options to detention under the Mental Health Act in response to an escalation of need. However, in accordance with the Mental Capacity Act 2005 other less restrictive options need to be considered which can take time. They discussed that social workers in such circumstances can feel under pressure and may make rushed decisions. They drew on 1 of the principles of the Mental Capacity Act that highlights that whenever possible, options must be explored that are less restrictive of the person's rights and freedom of action. To ensure that this principle is upheld and to ensure that people with complex needs can maintain their independence and autonomy as much as possible in the event of an unplanned escalation of need, the committee made a recommendation to reinforce this legislative requirement.
The committee used their knowledge, supported by legislation, to make recommendations on the use of a person's advance statements during decision making to ensure a personalised approach to care is taken. The committee noted that an advance statement could be any statement of a person's wishes and preferences which is not to be confused with a formal written document like an advanced directive related to medical treatment decisions. An advance statement should lead to better outcomes and satisfaction with services, as a person's wishes and preferences may have been informed by what has worked previously. However, the committee noted that individualised approaches are always needed, even if no advance statement has been made, to provide support in accordance with the person's wishes and preferences.
The committee discussed the review finding that showed there was dissatisfaction that out-of-hours services were not always available. The committee were aware of legislation that supports 24-hour services and made a recommendation in favour of them so that prompt support can be provided in situations of an unplanned escalation of need in the context of Mental Health Act assessments in accordance with legislation (section 14.35 of the Mental Health Act Code of Practice). They noted that availability of services out of hours may prevent some hospital admissions or presentations to accident and emergency departments. They noted that, in their experience, use of out-of-hours services was not always well communicated with daytime services, so recommended that timely and clear communication take place between services to enable better continuity of support.
To address the identified evidence being restricted to a narrow population, the committee made a research recommendation on responding to an escalation of need.

## How the recommendations might affect practice
Most of the recommendations aim to standardise current practice and are supported by legislation. The recommendation for a joint assessment in some crisis situations would not have a significant resource impact or cause a change of practice, because this would usually be done by phone or virtually. The current availability of out-of-hours services is varied in the context of Mental Health Act assessments, but according to legislation (section 14.35 of the Mental Health Act Code of Practice) decisions on applications for the detention under the Mental Health Act should be covered over 24 hours so services should have such arrangement in place already.
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# Social workers and multidisciplinary teams: communication, support and collaboration
Recommendations 1.7.1 to 1.7.8

## Why the committee made the recommendations
The committee agreed that the features of the integrated services covered in the quantitative evidence were not directly applicable to the whole population of people with complex needs. They also noted other limitations in the evidence, such as concerns about the way the studies were conducted and had mixed or contradictory findings, with uncertainties about the size of effects that decreased the confidence in this evidence. Therefore, the committee made recommendations using the qualitative evidence together with their experience and expertise and legislation (the UK GDPR and the Data Protection Act 2018) as well as drawing on BASW's Professional Capabilities Framework and BASW's Charter for integrated working. They agreed that the qualitative evidence highlighted specific aspects that were key to successful integrated working.
There was evidence indicating that having shared visions and aims helped to promote integrated working, because it led to an increased understanding between organisations and disciplines. The committee discussed the importance of this to help everyone in the team understand the context in which they work, even if they come from different disciplines. Having a clear strategy should improve team working because overall purposes and objectives can be defined, and everyone knows the part they play.
Most of the available evidence related to organisational matters that can help or hinder multidisciplinary team working, rather than focusing on actions taken by individual social workers. This was consistent with the committee's experience of team members' willingness to work together, that they felt could be better supported by the organisations members work for. Supporting information sharing (in line with the UK GDPR and the Data Protection Act 2018) and providing opportunities for clear communication should lead to better teamwork, because members would understand each other's expertise and roles and have opportunities to share knowledge and learn from each other. It would also help team members define what role they can play in providing support to the person with complex needs. The committee also decided that information sharing relies on clear communication within the multidisciplinary team and suggested some measures to increase efficiency.
The committee agreed that joint training opportunities would enable the sharing of skills and knowledge between professionals and help them understand each other's roles and responsibilities across different health and social care roles (as well as other relevant settings, for example voluntary sector organisations). This would enable team members to direct the person with complex needs to the practitioner who can provide the most relevant support. Based on the committee's experience, it was noted that training would need to include the views and perspectives of people with lived experience to give team members greater confidence in understanding the role that each of them can play in providing individualised care (as outlined in BASW's Professional Capabilities Framework). This would address addressing people's needs more effectively and in turn lead to improved outcomes. The committee agreed training should not only be about the theory, but also contain practical information with examples of best practice or lessons that have been learnt. This would mean training can be followed up and implemented to improve team working and to benefit people with lived experience (for example, using case studies that show how the principles of best practice of multidisciplinary team working could be applied).
There was evidence on barriers to integrated working related to a lack of clarity of roles within integrated teams. Using the evidence on facilitators of integrated working, and drawing on BASW's Charter for integrated working, the committee made recommendations to support social workers in retaining their professional identity when working in an integrated team. This can lead to better outcomes, as the person with complex needs knows what to expect and from which person, so that they are aware which needs can be specifically addressed by a social worker.
There was evidence that bureaucracy was often viewed as a barrier to effective integrated working within multidisciplinary teams, negatively impacting efficiency of referral within the team and causing delays. Simplifying referral processes and pathways (for example, with clear eligibility criteria) was seen as a solution for this and would likely improve outcomes by improving the speed and accuracy (in terms of going to the person most able to help) of referral.
The committee discussed the evidence related to potential benefits of co-location which was assessed as high-quality thematic evidence and was also supported by the mixed method analysis of qualitative and quantitative evidence. They acknowledged that this could have a positive impact on services but would not always be feasible, practical and could be costly (particularly if it involves new premises), and therefore cannot be routinely implemented. However, the committee recommended that organisations should think about whether this could be a beneficial and achievable option for their particular service (for example, having a social work team in a hospital co-located with healthcare staff may improve joined-up services and could have practical benefits).
The committee discussed evidence suggesting shared formal agreements help integrated working. This was in line with their experience, so they recommended such agreements should be used to support integrated teams, particularly in terms of shared decision making and accountability. The committee agreed this should also cover budgets, as the evidence showed that a lack of access to pooled budgets could create barriers to integrated working.

## How the recommendations might affect practice
The recommendations largely reinforce current regulation and usual practice. There may be some short-term costs if office accommodation needs to be reconfigured to allow for co-location, although there should be no difference in costs once this has been achieved and potential cost savings through working efficiencies and economies of scale. If physical co-location is not feasible, measures to allow virtual co-location (such as diary sharing and virtual meetings) should involve negligible costs, if any, while allowing potential savings from more efficient and integrated working.
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