Changing Futures – Bridge the Gap Specialist Outreach Service
17th January 2025
Version control
Version number
Date
Author
Comments
001
15/01/25
George Bell
Overview
Name of product under development or review
Changing Futures Bridge the Gap Specialist Outreach Service
Description of the product
The Changing Futures Programme/ Bridge the Gap Service was established in response to Surrey wider-system partners highlighting the challenges, barriers and inequalities faced by people experiencing multiple disadvantage. Changing Futures was a joint initiative sponsored by the Department for Levelling Up, Housing and Communities and The National Lottery Community Fund. It was a three-year, £64 million programme which aimed to improve outcomes for adults experiencing multiple disadvantage including combinations of homelessness, substance misuse, mental health issues, domestic abuse and contact with the criminal justice system. Surrey was one of fifteen areas selected to deliver the programme in England between July 2021 and March 2024. This sustainable work is now continuing into its next phase in Surrey. ‘Bridge the Gap’ is a specialist trauma-informed relational outreach service to support residents experiencing Multiple Disadvantage. Bridge the Gap is provided by trauma-informed specialist workers through an alliance of voluntary, community, and social enterprise (VCSE) organisations in Surrey. People facing multiple disadvantage experience a combination of problems. For many, their current circumstances are shaped by long term experiences of poverty, deprivation, trauma, abuse, and neglect. Many also face racism, sexism, and homophobia. These inequalities intersect in different ways, manifesting in a combination of experiences including homelessness, substance use, domestic abuse, contact with the criminal justice system and mental ill health. The health inequalities and challenges this population face substantially increases their risk of the early onset of chronic health issues, shortened healthy life expectancy and premature death. The Surrey Multiple Disadvantage Joint Strategic Needs Assessment Chapter is estimating there are in the region of 3000 individuals in Surrey coping with severe and multiple disadvantage. The funding approved by the Police and Crime Commissioner will be directed to Specialist Bridge the Gap Community Outreach worker posts to continue to support people experiencing multiple disadvantage in Surrey communities. These roles will be based in Guildford Action – a Homelessness and Mental Health VCSE (1 FTE), and in Oakleaf – a Mental Health VCSE (1.5 FTE).
EIA start date
15/01/25
EIA author and role
George Bell – Criminal Justice Policy & Commissioning Officer, Office of the Police and Crime Commissioner for Surrey
EIA owner and role
Craig Jones – Policy & Commissioning Lead for Criminal Justice, Officer of the Police and Crime Commissioner for Surrey
Date of last review
Date of next review
15/01/26
Key product development dates
Key stage
Date
First Publication
15/01/25
12 month review
15/01/26
Research and evidence
To undertake effective equality assessment that meets PSED compliance standards, you must work from an evidence base. Use this section to list the research you will use to understand the product’s potential or actual equality impacts (for example, surveys, customer feedback, protected characteristic data, academic research).
National Framework for NHS – Action on inclusion health – Surrey Heartlands Self-assessment pilot
Changing Futures Data Dashboard Surrey Data (published in August 2024)
Surrey County 2021 Census Area profile
Consultation record
Stakeholder consultation will give you a better understanding of your product’s impacts and is crucial to satisfying the PSED requirements. Use this section to record the engagement you have undertaken; summarise the feedback received and note subsequent actions. This section can also be used to record nil returns.
Name of group or organisation
Date of contact
Date reply received
Feedback
Action taken or reason why no action was taken
Surrey Changing Futures Lived Experience Network
Ongoing
Regular feedback and input given by those with lived experience at every stage of evaluation of the Bridge the Gap service. Also represented in governance – Surrey Multi-Agency Group for multiple disadvantage.
Changing Futures Bridge the Gap uses co-production with those with lived experience as a core principle of the programme. Employs a Lived Experience Project Manager as part of the programme. Voices of experts by experience engage in strategic conversations and genuine co-production opportunities to improve services supporting people with multiple disadvantage.
Surrey Health and Wellbeing Board
January 2024
January 2024
The Changing Futures Programme was “spotlighted” at Surrey’s Health and Wellbeing Board as one example of innovative best practise worthy of consideration of long-term sustainability funding.
Surrey – wide workshop regarding the strategic use of the Better Care Fund for preventative projects such as Bridge the Gap Outreach Services.
VCSE Bridge the Gap Alliance of organisations, including mental health, homelessness, substance use & domestic abuse.
Alliance of Surrey’s place-based VCSE organisations created Bridge the Gap – a trauma-informed assertive outreach service.
All CEOs/ Supervisors and Managers of alliance members attend at key meetings.
Surrey Fire and Rescue Service
Ongoing
Surrey Fire and Rescue Service is supportive of Changing Futures programme in Surrey.
Surrey Fire and Rescue Service is sending officers on a bespoke training course to be better able to support people with multiple disadvantage.
General considerations
Use this section to note any general diversity, equality and inclusion activities or considerations that are relevant to the product. Please only document general considerations here. Protected characteristic analysis can be completed in the section below.
The creation of Bridge the Gap services and commissioning of the Joint Strategic Needs Assessment chapter in Surrey for multiple disadvantage. These evidence-based approaches were used in partnership with the Lived and Living Experience Community to co-design the Bridge the Gap Services.
The Bridge the Gap delivery partners underwent rigorous due diligence process to ensure that their policies, practices, events, and decision-making processes were fair and inclusive with regards to participation and did not disadvantage any protected groups. A subsequent evidence based Joint Strategic Needs Assessment (JSNA) for multiple disadvantage has been published.
Continuous and live impact assessments which involves analysing and reviewing client feedback are undertaken by independent external and local evaluators with the results published at various system wide national and local boards.
Impact assessment and actions
Apply learning from research, consultation and project knowledge to consider equality considerations relevant to your project. This should include any potential or actual impacts (positive or negative), as well as how the project will uphold the three PSED aims for each of the protected characteristics.
Eliminate discrimination, harassment and victimisation.
Advance equal opportunity.
Foster good relations between people of different characteristics.
If you have identified a negative impact, note what mitigating action will be taken to reduce or eliminate that impact. If no mitigating action can be taken, please explain why. The issues or impacts identified may change, or new factors may emerge, as your project develops. Use the EIA to document these and how your project has evolved to accommodate equality considerations.
Don’t forget to consider intersectionality. This refers to when characteristics overlap to shape experiences of inequality and discrimination. For further information, please refer to the ‘Addressing Intersectionality within Policing’ report.
Duplicate the boxes below if required. If you need further information about a protected characteristic, open the webpage linked to each subtitle.
All characteristics
Details of positive and/or adverse impact or other issue
Bridge the Gap specialist outreach is identified as a person-centred and led service that better matches the realities of beneficiaries lives and their goals. These include all protected characteristics, as well as their history, their lived experience and life goals.
Mitigating action for any adverse impact or rationale for no further action
Each individual is referred using the Multiple Disadvantage Support referral form for Bridge the Gap. The more information that can be provided within the referral, the quicker a decision can be made to ensure that clients are matched to the correct support and a greater chance of minimising re-traumatisation from the client having to re-tell their story. Consent needs to be obtained to complete the referral. A referral meeting then takes place where they discuss the NDTA (New Directions Team Assessment) score from the application form. They review the NDTA to ensure it is 27 or above, or they decide they need more info from the referrer. At the meeting they consider the clients Mental Health or history on System One, and Social Care history on Social Care Case Management, plus other info captured on ECINS case management. If Bridge the Gap resource is available, they look to establish the best outreach worker/s to match the client’s needs and send a letter back to the referrer. Changing Futures Bridge the Gap uses co-production with those with lived experience as a core principle of the programme. Voices of experts by experience engage in strategic conversations and genuine co-production opportunities to improve services supporting people with multiple disadvantage.
Details of positive and/or adverse impact or other issue
The Changing Futures programme in Surrey is for people aged 18 above as it is adults only. Children are supported by existing services outside of this programme. Catch 22 is an example of one of these services, who are commissioned in Surrey and work in partnership with Surrey County Council and criminal justice agencies. Their services provide targeted, age-appropriate substance misuse services for young people, that put the young person at the centre of treatment (Catch 22).
Mitigating action for any adverse impact or rationale for no further action
Age data, with consent, is collected on the multiple disadvantage support referral form for Bridge the Gap. This data is quarterly reported and is subject to full independent evaluation. According to data gathered up to February 2024, the age ranges of the beneficiaries of the programme are spread. 24% of beneficiaries are aged between 40-49, 22% are aged between 30-39, and similarly 22% are 50-59, with 8% 60 years of age or older. 18% of beneficiaries are 20-29 (Changing Futures Data Dashboard Surrey data).
Details of positive and/or adverse impact or other issue
According to the data gathered to February 2024, 93% of the beneficiaries of the programme have a disability and/or long-term conditions. Additionally in terms of neurodiversity, 24% of beneficiaries have ADHD, 23% have a learning disability, and 8% of the autism-spectrum disorder. Furthermore, 19% did not want to say, thus highlighting the issue of under-reporting of disability and neurodiversity, and potential issues around stigma.
Mitigating action for any adverse impact or rationale for no further action
Bridge the Gap has a full-time post of Clinical Psychological Consultant who is seconded from the local NHS Foundation Trust to support the Bridge the Gap Workers. Specialist trauma-informed outreach workers are actively supporting beneficiaries. All workers have access to Trauma Informed supervision from SABP Consultant Clinical Psychologist. Reflective Practice and peer support sessions held regularly to bring workers from different providers together from across the county cohesively to create a peer support forum and share learning and good practice. Disability and neurodiversity are represented within the staff and Lived experience network of the Changing Futures programme. The use of the National Framework for the NHS – Action on Inclusion Health can also lead to a tangible focus to reduce system and healthcare inequalities. Inclusion health is an umbrella term used to describe people who are socially excluded, who typically experience multiple interacting risk factors for poor health, such as stigma, discrimination, poverty, violence, and complex trauma.
Details of positive and/or adverse impact or other issue
For context, across Surrey, there were responses from 921,833 residents (94.79% of the population aged 16 years and over). 94.42% of residents answered “Yes”, indicating that their gender identity was the same as their sex registered at birth. 0.37% of residents answered “No”, indicating that their gender identity was different from their sex registered at birth. Within this group: 0.14% answered “No” but did not provide a write-in response, 0.08% identified as a trans man, 0.08% identified as a trans woman, 0.05% identified as non-binary, 0.03% wrote in a different gender identity. 5.21% did not answer the question on gender identity and therefore data for this group is unknown (Census 2021 Surrey data).
Mitigating action for any adverse impact or rationale for no further action
Bridge the Gap specialist outreach is identified as a person-centred and led service that better matches the realities of beneficiaries lives and their goals. These include all protected characteristics named, including gender reassignment as well as their history, their lived experience and life goals. Changing Futures Bridge the Gap uses co-production with those with lived experience as a core principle of the programme. Voices of experts by experience engage in strategic conversations and genuine co-production opportunities to improve services supporting people with multiple disadvantage. Bridge the Gap will monitor any disproportionality in terms of gender reassignment and beneficiaries on the programme.
Details of positive and/or adverse impact or other issue
The Census 2021 classified a family as a group of people who were either: a married, civil partnered or cohabiting couple with or without children (the children do not need to belong to both members of the couple); a lone parent with children; a married, civil partnered or cohabiting couple with grandchildren but where the parents of those grandchildren were not present; or a single or couple grandparent with grandchildren but where the parents of those grandchildren were not present. Therefore, a multiple family household could include a household with more than one family living together (e.g., grandparents, parents, and dependent children) or a household where unrelated adults lived together. The most common type of single-family household was those with a married or civil partnership couple and dependent children (19.8% of all households). The second and third most common family type in Surrey were one person households, with 14% of Surrey households only containing one person aged 65 or under, and 13% containing only one person over the age of 65 (Census 2021 Surrey data). Bridge the Gap specialist outreach is identified as a person-centred and led service that better matches the realities of beneficiaries lives and their goals. These include all protected characteristics including marriage and civil partnership, as well as their history, their lived experience and life goals.
Mitigating action for any adverse impact or rationale for no further action
Details of positive and/or adverse impact or other issue
Bridge the Gap specialist outreach is identified as a person-centred and led service that better matches the realities of beneficiaries lives and their goals. These include all protected characteristics, including pregnancy and maternity, as well as their history, their lived experience and life goals.
Mitigating action for any adverse impact or rationale for no further action
Details of positive and/or adverse impact or other issue
Ethnicity data, with consent, is collected on the multiple disadvantage support referral form for Bridge the Gap. This data is quarterly reported and is subject to full independent evaluation. According to data up to February 2024, 87% of the beneficiaries of the programme were white (Changing Futures Dashboard Surrey data). Whereas approximately 77% of Surrey residents reported that they identified as White British in 2021, alongside 9% who reported that they were ‘White Other’. 14.5% of Surrey residents reported that they identified as non-White, with residents who identified as Asian made up the largest percentage of non-White population in Surrey (Census 2021 Surrey area).
Mitigating action for any adverse impact or rationale for no further action
Bridge the Gap specialist outreach is identified as a person-centred and led service that better matches the realities of beneficiaries lives and their goals. These include all protected characteristics, including ethnicity. Bridge the Gap will continue to monitor any disproportionality, in terms of ethnicity, with referrals in and beneficiaries on to the programme.
Details of positive and/or adverse impact or other issue
Bridge the Gap specialist outreach is identified as a person-centred and led service that better matches the realities of beneficiaries lives and their goals. These include all protected characteristics including religion or belief, as well as their history, their lived experience and life goals. In Surrey, 50.2% of residents are Christian, making it the largest religious group. 36.3% of Surrey residents were of no religion. Non-Christian religions were reported by 7.0% Surrey residents, where Muslims represented 3.2% of Surrey residents (Census 2021 Surrey data).
Mitigating action for any adverse impact or rationale for no further action
Religion or belief data is collected, with consent on the multiple disadvantage support referral form for Bridge the Gap. This data is quarterly reported and is subject to full independent evaluation.
Details of positive and/or adverse impact or other issue
Sex data, with consent, is collected on the multiple disadvantage support referral form for Bridge the Gap. This data is quarterly reported and is subject to full independent evaluation. According to data collected up to February 2024, 59% of the beneficiaries on the programme were male, and 39% were female. Whereas in Surrey (latest data 2021), 51.3% of the population is female, with 48.7% being male. Bridge the Gap will monitor any disproportionality in terms of sex, with the referrals and beneficiaries on to the programme.
Mitigating action for any adverse impact or rationale for no further action
This data is quarterly reported and is subject to full independent evaluation. Bridge the Gap specialist outreach is identified as a person -centred and led service that better matches the realities of beneficiaries lives and their goals. These include all protected characteristics including sex, as well as their history, their lived experience and life goals.
Details of positive and/or adverse impact or other issue
Sexual orientation is an umbrella term covering sexual identity, attraction, and behaviour. For an individual respondent, these may not be the same. The statistics should be interpreted purely as showing how people responded to the question, rather than being about whom they are attracted to or their actual relationships. In total, 93.1% of Surrey residents answered the question. 90.66% of the Surrey population (aged 16 years and over) identified as straight or heterosexual. 1.17% described themselves as gay or lesbian, with 1.05% describing themselves as bisexual. 0.26% selected ‘Other sexual orientation’. The overall number of residents of Surrey who identified with an LGB+ orientation was therefore 2.48% (Surrey Census 2021 Surrey data). Bridge the Gap specialist outreach is identified as a person-centred and led service that better matches the realities of beneficiaries lives and their goals. These include all protected characteristics, including sexual orientation.
Mitigating action for any adverse impact or rationale for no further action
Sexual orientation data is collected, with consent, on the multiple disadvantage support referral form for Bridge the Gap. This data is quarterly reported and is subject to full independent evaluation.
Socio-economic background
Our socio-economic background is a combination of different factors, such as our income, occupation and social background. A person’s socio-economic background can expose them to inequalities, so it’s important to understand how your project could affect different socio-economic groups. Further information about socio-economic status can be found in the Cabinet Office Measuring socio-economic background in your workforce guidance.
Details of positive and/or adverse impact or other issue
In the Census 2021, Households were also classified by dimensions of deprivation and were considered deprived if they met one or more of the four dimensions of deprivation: employment: where any member of a household, who is not a full-time student, is either unemployed or long-term sick.education: no person in the household has at least five or more GCSE passes (grade A* to C or grade 4 and above) or equivalent qualifications, and no person aged 16 to 18 years is a full-time student.health and disability: any person in the household has general health that is “bad” or “very bad” or has a long-term health problem.housing: the household’s accommodation is either overcrowded, with an occupancy rating of negative 1 or less (implying that it has one fewer room or bedroom required for the number of occupants), or is in a shared dwelling, or has no central heating. Surrey, on average, had less households which were deprived than other parts of the South East and England with 57.1% of households which did not meet any of the dimensions of deprivation. Overall, 42.9% of Surrey households (representing 206,798 households) were deprived in at least one of the dimensions, which was lower than the national (51.6%) and regional (48.0%) averages (Census 2021 Surrey data). In terms of the Bridge the Gap service, according to data gathered up to February 2024, 72% of beneficiaries on the programme in Surrey were receiving benefit entitlements, and additionally a further 10% were in the benefits system and working to address issues (Changing Futures Dashboard 2024 Surrey data). Bridge the Gap specialist outreach is identified as a person-centred and led service that better matches the realities of beneficiaries lives and their goals. These include all protected characteristics, including socio-economic background, their history, their lived experience, and life goals.
Mitigating action for any adverse impact or rationale for no further action
No further action identified due to the programme having a clear focus on those most deprived and experiencing multiple disadvantage, with a specialist service which is person-centred and led by the person.
Other characteristics
Use this section to consider the PSED aims and any impacts your product may have on characteristics that are not protected under the Equality Act 2010 but are still significant to equality and inclusion. For example, your product may have a particular effect on people with caring responsibilities or on people with English as an added language, or you may need to consider the Welsh Language (Wales) Measure 2011 in delivery. Think creatively and invite input from stakeholders.
Details of impact or other issue
Mental Health Mental health is one of the key characteristics with supporting people with multiple disadvantage. The vast majority of participants stated that they had experienced trauma or an adverse childhood event. A history of trauma can be viewed as a distinct feature of the Bridge the Gap cohort. The rate of anxiety and depression amongst service users appears to be higher than is the case for the general population. Personality disorders have also been linked to childhood experiences of trauma.
Mitigating action or rationale for no further action
Bridge the Gap has a full-time post of Clinical Psychological Consultant who is seconded from the local NHS Foundation Trust to support the Bridge the Gap Workers. Specialist trauma-informed outreach workers are actively supporting beneficiaries. All workers have access to Trauma Informed supervision from SABP Consultant Clinical Psychologist. Reflective Practice and peer support sessions held regularly to bring workers from different providers together from across the county cohesively to create a peer support forum and share learning and good practice. One of the posts which this current funding has been approved for is a Bridge the Gap specialist worker who is based at Oakleaf, a mental health charity in Surrey.
Details of impact or other issue
Digital Exclusion According to data gathered up to February 2024, 45% of the total beneficiaries of the service have experience of previous support services (Changing Futures Dashboard 2024 Surrey data).
Mitigating action or rationale for no further action
Digital exclusion plays an increasingly significant role in the lives of people who struggle to access services and forge social connections – whether with family, friends, or supporters – and was an important theme identified through needs assessments on the Changing Futures programme. Struggling to access services and being bounced from one service to the next is one of the key reasons Bridge the Gap service was formed.
Action log
Record EIA actions and monitor action progress in the optional action log.