The Multi-Modality Practitioner (MMP) approach: a technically eclectic, multimodal workforce innovation in the provision of support for individuals and families with multiple needs

Purpose – The aim of this paper is to describe and detail a new workforce initiative developed by a third sector organisation: the Multi-Modality Practitioner (MMP) approach, in the provision of support for individualsandfamiliespresentinginthe communitywithmultiple andvaried needs. Design/methodology/approach – This paper presents a case study on a third sector organisation’s pioneering workforceinitiative – theMMP approach. Findings – The MMP approach has been developed as an alternative to existing approaches designed to address ‘‘single issues’’, providing those working in the fields of health and social care and beyond, with a range of technically eclectic interventions from different modalities and approaches, to enable them to appropriately meet the needs of individuals and families presenting with multiple needs. Research limitations/implications – This case study is limited to providing a rationale for the development of the MMP approach and a description. It does not include any formal analysis as a future evaluative paper will report on an independent theory-based examination of the MMP approach via TheoryofChange and ContributionAnalysis methodologies. Practical implications – This case study describes the innovative role that the MMP approach as a workforce innovation plays in meeting multiple needs in the community when deployed as either a stand- alone approach, or one that can be integrated with existing community-based services including, but not limited to, mental health, employability, addiction, housing, homelessness, public health and child and familyservices. Social implications – The MMP approach constitutes a disruptive, pionneering, client-centred, workplace innovation that is trauma-informed, relational, strengths-based and continuity of care focused, capable of supporting individuals and families with multiple needs, negating onward referral and with potential to reduce demand on public services. It also provides those working in a range of health and social care roles with the opportunity to expand their therapeutic repertoire through high-quality, multi-skilled training in evidence-based and societally important, technically eclectic interventions drawn from a rangeofmodalities. Originality/value – Pluralistic practice and multimodal theories have been in existence for over two decades, the MMP approach however, whilst sharing some of these concepts and philosophies, differs in that it provides those trained in the approach with a ‘toolkit’ of interventions that are technically eclectic, drawn from a range of modalities and approaches and aimed at meeting multiple needs in a pragmatic and accessible manner. Furthermore, the Diploma in Multi-Modality Practice is the first training course of itskind availableatpostgraduatelevel.


Introduction
Public services are often focused on addressing single issues, resulting in clients who present with multiple needs being referred to a range of different health and social care services and required to tell their story repeatedly, which can lead to frustration, despair and despondency (Living Well UK, 2022). At the same time, health-care professionals tasked with supporting such individuals in the community similarly report challenges and frustration in being restricted to offering single-modality interventions, confined to maintaining fidelity to specific models of service delivery and feeling forced to operate within narrow remits (Binnie, 2015). Whilst there have been ongoing efforts to personalise services arising from a broad consensus on the benefits of integrated and personalised services (Institute for Government, 2022), the challenges of responding to the needs of ageing populations, rising costs and workforce shortages in health (Buchan and Campbell, 2013;Salsberg and Quigley, 2017) have placed further focus on the increasing need for primary health-care services to respond (Binagwaho and Ghebreyesus, 2019).
Third sector organisations are known for their responsiveness and ability to innovate, often plugging gaps in statutory sector provision, including responding to service failures (Newbigging et al., 2017). The third sector organisation that developed the Multi-Modality Practitioner (MMP) approach is a social enterprise that operates across the North of England. It delivers public health, mental health, children and family, homelessness, addiction services as well as managing two primary schools and nurseries. Its mission is to change lives by fighting inequality by working with people and places to create opportunities and inspire change.
Clients accessing the organisation's services repeatedly told of their frustration with the current system and of having to be referred to different services when instead they would prefer to have their needs met by one service, ideally, through being supported by a single worker. The organisation previously deployed several initiatives to address this problem including colocation of services, developing multidisciplinary teams, sharing information with relevant services through Information Sharing Agreements, implementing case conferencing and securing commissions for services that adopted a "whole person" approach to the delivery of care. It has also supported staff to undertake specific training to facilitate delivery of a wider support offer to clients, including training in Motivational Interviewing -MI (Miller and Rollnick, 2012). Whilst these approaches were in part helpful, they failed to address the nub of the problem, with some simply adding to the demand for already stretched public services. Furthermore, to date, there has been no comprehensive training course that equips practitioners with key tools and techniques that are drawn from a range of modalities.
Additionally, an unpublished, in-house evaluation of service provision delivered by the organisation concerned, demonstrated a correlation between clients reporting a greater number of needs and a greater severity of barrier, with a reduced likelihood of achievement of positive outcomes. This suggested that such clients face increased difficulties in achieving outcomes than those with fewer needs or 'single issue' needs, and that a different approach than that traditionally available through commissioned health and social care services was required. This paper describes a third sector organisation's approach to developing an disruptive, innovative workforce solution and approach for frontline staff supporting individuals and families presenting in the community with multiple needs, including the co-development and commissioning of a pioneering, level seven, Postgraduate Diploma in Multi-Modality Practice with a local university, designed to enable staff to better meet the full range of circumstances that their clients experience through delivering evidence-based, technically eclectic interventions in a personalised and appropriately sequenced manner.

Method
Following the routine evaluation of services and feedback from clients and staff, the MMP approach was conceptualised and established by the organisation concerned.
j MENTAL HEALTH AND SOCIAL INCLUSION j A project steering group comprising opinion leaders and key stakeholders from organisations from across the health, social care and children and families' service landscape was developed to oversee the operational development and deployment of the MMP concept, with the aspiration that such involvement would assist with any learning taken from the initiative being used to influence the public service workforce nationally in England.
Having gained agreement from the commissioners of some of our local services (mental health, public health, children and family services) to pilot the approach, this was followed by consultations with several local higher education institutes, leading to a local university being selected and commissioned to co-produce content for a pilot course in Multi-Modality Practice, which subsequently informed the development of a level seven course; both of which were funded by the organisation concerned.

About Multi-Modality Practitioners (MMPs)
Sixteen members of staff from the organisation concerned participated in the initial pilot Multi-Modality Practice training course.
Thirteen members of staff from the organisation concerned completed the level seven Postgraduate Diploma in Multi-Modality Practice.
Two members of staff from an external, public sector service for individuals with complex lives completed the level seven Postgraduate Diploma in Multi-Modality Practice.
All staff had experience of working with individuals presenting with multiple needs with a variety of educational backgrounds ranging from those with degree-level professional qualifications through to experienced practitioners without a degree, who evidenced their eligibility to access the course through Accreditation of Prior Experiential Learning (APEL).
Staff came from a range of roles from across the organisation concerned including Psychological Wellbeing Practitioners (PWPs) and counsellors working in Improving Access to Psychological Therapy Services (IAPT), coaches working in public health services, drug and alcohol outreach workers working in addiction services, family support workers working in child and family services and support workers working in homelessness services.
Staff continued to receive line management and clinical supervision support, where relevant to their role. Reflective practice supervision sessions focused on specific areas of the course including MI, Transactional Analysis (TA) and strengths-based approaches.

Postgraduate diploma in Multi-Modality Practice
The Postgraduate Diploma in Multi-Modality Practice is a level seven qualification comprising 4 modules each consisting of 12 classes (2-h class plus 1 h for self-awareness and professional development groups) all of which are assessed via a mixture of written assessments and oral presentations. The course runs over a two-year period and was adapted because of the pandemic, to be delivered remotely with practical skills assessment sessions inbuilt into the programme. Those trained in the MMP approach develop a wide variety of skills through being taught a range of technically eclectic interventions from a range of modalities, including adopting a trauma-informed approach to care, whilst drawing on a core skillset in relationship and strengths-based practice, alongside interventions from the fields of mental health, physical health, long-term conditions, children and families and employability.
Armed with this unique skillset, those trained in the MMP approach can: work with individuals and families to create personalised and appropriately sequenced action plans for support; directly deliver interventions from a range of modalities that address mental and physical health issues, long-term conditions, relationship, addiction, child and family, housing, homelessness and employment issues including supporting the development of employability skills; and support clients presenting with multiple needs, avoiding and lowering demand by reducing onward referrals to other services including public services.

Results
Staff trained in the MMP approach were deployed in a variety of settings throughout the organisation, as described earlier. These staff initially tested the role in practice via a pilot, under the direction of the MMP project steering group. Learning from the initial pilot was used to develop the first level seven training course of this type in the world, the Postgraduate Diploma in Multi-Modality Practice, with staff trained in the approach operating across the group in a variety of services.

Discussion
Third sector organisations are often at the forefront of innovation, addressing gaps in public service provision along with finding solutions to service failures (Newbigging et al., 2017). Where workforce innovation has taken place, new roles that have been created have focused on the delivery of brief interventions based on a specific modality, for example, PWPs, where interventions are based on the principles of Cognitive Behavioural Therapy (Clark, 2011), and do not fully meet the requirements of clients with multiple needs. Augmenting the Behaviour Change key-worker approach, developed in 2013 by the organisation concerned, the MMP approach consists of a modular training programme of technically eclectic, evidence-based interventions and assessments related to mental health, employability, public health, homelessness, Evidence-based interventions for adopting a whole family approach to assessing need, exploring and identifying aspirations and developing an appropriate sequence of interventions to address issues that parents and families face 30 credits addiction, housing and child and family issues, equipping those trained with tools needed to support clients with multiple needs. The conceptualisation and development of the MMP approach addresses the identified gap in support for individuals and families presenting with multiple needs in the community and, importantly, the lack of training for frontline staff to provide the necessary skills to facilitate the delivery of support in a technically eclectic, multimodal manner, with the aim of improving outcomes, through increasing the skills mix of staff.
Since the conceptualisation and implementation of the MMP approach, there have been several challenges, as is to be expected with any disruptive innovation. These included the following: Staff turnoverstaff moved into new roles within the organisation, for example, transitioning to management roles and therefore had less opportunity to undertake direct client work and use their newly acquired skills. Staff also moved into external roles, which it is assumed, was because of acquiring new skills resulting from undertaking training in the MMP approach.
The MMP approach currently sits outside existing career development pathways. A challenge has been to integrate the approach to ensure that it is an attractive proposition to staff in sectors where well-defined career pathways exist.
Having adequate opportunities for staff to regularly use skills derived from undertaking training in the MMP approach because of commissioned service delivery restrictions and capacity issues, with staff unable to work to their full MMP potential and full realisation of the role being impeded.
Whilst level seven qualifications necessitate an academic approach, this can be a barrier to those staff without formal qualifications who could benefit from the training; however, to attract staff who already had such qualifications, it was necessary to set the course at this level. Funding for the Apprenticeship Levy is often a major vehicle for workforce training in the England. To develop an apprenticeship, a role must be a recognised occupation with employer adoptionthis presents a challenge for new roles such as the MMP both in terms of funding as well as intellectual property and recognition for organisations for the development of the original concept.
Providing an appropriate professional and clinical infrastructure support for MMPs with case management supervision being provided by supervisors trained as MMPs has proved an ongoing challenge in terms of maintaining sufficient supervisory capacity and meeting continuous professional development needs.
Much learning has been derived throughout the period of the initiative, which is still being applied in practice in services. This has included staff who accessed the course through the APEL route experiencing at times, challenges in meeting the academic requirements and/or commitments and demands of the course, resulting in their discontinuation. On a related theme, additional learning has been that it is necessary to allocate additional study time to staff to complete the MMP training. As an organisation that prides itself on valuing the lived experience of staff, it is recognised that there were constraints in terms of adhering to a training format that did not fully meet the organisation's needs, and to date, it has not been possible to agree an alternative approach with education providers, i.e. a modular delivery of the course. This would have been possible with larger numbers of students; however, because of budgetary limitations, it has not yet been possible to fund a high volume of course places.
It has also been recognised that it is essential to have a mix of frontline staff and managers undertake the training so that MMP-trained staff have line managers with experience of the MMP approach and the relevant skills to provide professional and clinical support. Furthermore, ideally, it would have been preferable to have had a similar number of staff from each of the four key divisions of the organisation, whereas in practice, there were greater numbers of staff from the public health area.
An unintended outcome has been that of staff leaving the organisation because of acquiring new skills as well as progressing into new roles within the organisation, which reduced the number of overall MMPs operating in services. Additionally, as a result of the COVID-19 pandemic, the course had to move entirely to being delivered on a remote basis, which in turn, has subsequently increased its accessibility.
The opportunity for staff to practice their newly acquired skills needs to be embedded at service level which can often be challenging when the remit of such services is restricted to the practicing of one modality or approach. Staff have therefore had to operate within a narrow remit, limiting the full realisation of the role, this being a phenomenon reported in the literature regarding other workforce innovations, such as the advanced clinical practitioner role in primary care (Evans et al., 2020).
The chief learning however has been that of the difficulties encountered when trying to develop and embed a new workforce initiative in terms of funding and wider adoption of the MMP approach, particularly within commissioned health and social care services. As Imison et al. (2016) state in their 2016 report for the Nuffield Trust, London: The hard labour of workforce redesign is done at a local level. This is also the primary source of innovation. But if we want to deliver the scale of workforce change needed, safely and sustainably, active support is needed from national bodies. (p. 66)

Limitations to the study
This study solely describes a new conceptthat of the MMP approach and does not describe any clinical outcomes or wider impact on clients accessing the service or the impact of the approach on public services or MMPs themselves.

Implications of the findings
The MMP approach represents an exciting, innovative workforce development with implications for the public service workforce and for commissioners and others, responsible for procuring and delivering services to support individuals and families presenting with multiple needs in the community.

Next steps
Having established the concept of the MMP approach, the next study will report on an independent theory-based examination of the MMP approach via Theory of Change and Contribution Analysis methodologies, followed by evaluation of the effectiveness and acceptability of the approach from both client and staff (MMP) perspectives.