WY-FI Project

West Yorkshire – Finding Independence | Supporting people with multiple needs

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Picture1.jpgJoe from the Hub here, thrilled that the Co-Production Team at WY-FI finally has five new members of staff! Their aim is to connect WY-FI beneficiaries with opportunities to participate in the WY-FI Network and other meaningful activities in their local areas. Here’s how each of them found their first week in the new job.


Edmund Abbott (Wakefield)

“There is something different about traveling to a paid job.  I’ve been volunteering for some time but suddenly finding myself employed makes me feel like a part of society again, joining the rush to work like a fully-fledged member of the working world.  This week I’ve been based in Leeds for a 3 week induction and have met my fellow co-production champions.  I think this has been the best part of the week, connecting with my colleagues and feeling part of a team, and a great bunch they are to with a whole host skills and ideas.

Part of the week has been spent meeting other members of the WY-FI team and gaining an insight into their roles in the organization. We have also attended the inductions for the peer mentoring 12 week course in Dewsbury and Wakefield and have given the new course members and idea of what co-production is.  Joe has been great and given us all a good grounding in DISC policies and procedures and all the practicalities of starting the new role of co-production champions.

The conversations between my new colleagues has been most useful and has given me many ideas of how this new role will best work.  We have also met several members of the DISC team and their input into WI-FI. All in all it’s been a productive week and I’m looking forward to the rest of the induction process.”

Vicky Ashington (Calderdale)

“I have been working as a peer mentor for Calderdale for the last year. In that role I’d placed strong emphasis on group working and engaging beneficiaries. I was thrilled when the paid role of co-production champion came up as it seemed a natural and exciting progression.

This first week; leaving the shire! And commuting over to Leeds has made me feel like a professional person again. I’ve loved meeting my team and felt completely supported in bouncing ideas around and sharing our hopes and fears of how we will best meet the needs of our new role. There has been lots of practicalities that have, had to have been worked through, but equally plenty of time to get creative.

The fact that the role has been designed specifically for us has made the (extremely daunting) transition from benefits to paid work seem far less daunting than I ever thought it would as I was supported by both management and my team.

I’m so excited to see not only how my own role develops,  but also to meet weekly with my team and to share what their successes and failures have been to help us all better understand how to move forward within our localities. My experiences has been very positive so far and I know that when it isn’t quite as ‘rosy’ that I’ll be able to open up to great group of people who are able to support me.”

Rachel Boardman (Bradford)

“Coming from the background of a volunteer/peer mentor in Bradford, I have found that my first week has had its highs and lows. I have enjoyed spending time on team building and getting to know the other Co-production champions. By the middle of the week I was overwhelmed, I did not know what would be expected of me or what my job description would entail and I found this to be quite frustrating and felt quite anxious. However, as the week has progressed I feel like I have found my feet and feel like things are sliding into place. I am confident that I will be able to carry out the duties that will be expected of me. We have attended short training sessions on things like health and safety and policies and procedures which I have found to be informative and I am looking forward to the coming weeks and spending time at our location (Bradford).”

Darren Pedley (Leeds)

“I have been asked by DISC and WY-FI as a project to give some feedback on how I have personally found the induction experience of my new Co-production Champion job role.

I have been quite lucky really that our meeting place has being in the Leeds Hub as this has been my working environment for the last couple of years as a peer mentor.

I also imagine of how difficult and challenging this must have been as an idea to develop and manage, in such a way to try to accommodate us as a team individually, as we all have very different personal needs as employees with lived experience.

From WY-FI’s but especially from DISC’s perspective this new role is a completely different job description to any other role within the organisation as a collaborative venture, which is such a great concept to be part of and really interesting from my perspective. Really exciting work. I think our team will bring a creative range of perspectives to this job role.” 

Jon Mills (Kirklees)

“After peer mentoring for a while and some involvement in Co-production projects, I applied for this role believing it was the way to go and that I wanted to be part of it.

Highlights of my week have included …… sharing our experiences with two new groups of ‘cohorts’ from whom I received support and encouragement for the future and….being part of a new team who all have something different to offer and with whom I feel we have bonded well. I look forward to us growing together and supporting each other over the next eighteen months.

My hope for the future is that I will be able to establish and promote a role which plays a significant part in what WY-FI aims to achieve and that I’ll be able to support /enable beneficiaries to engage in such a way that benefits themselves and their communities.”


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daniel-thumbnailDaniel’s story shows how crucial it is to take the time to build a solid and trusting relationship with a beneficiary and how getting to know their interests and hobbies can be one of the keys to success. Read more



“I was in a really dark place and terrified. The support I’ve received from Jamie and James has been phenomenal. The WY-FI Project has given me my life back.” Daniel


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What do you want WY-FI’s legacy to be in 2020?

A poem by Ad Verse

On 22 September 2016, we invited participants of the WY-FI Business Review to describe their vision of WY-FI’s legacy and the barriers to being able to leave that legacy in five words or less. One hour later, Adam – our Ad Verse poet for the day – had written this poem.

Asking for your visions brought ideas a plenty.

No one left outside services and reducing offending.

Barriers broken down and trusting relationship mending.

Creating joined up services with empathy and stability.

Funding, ignorance and inflexibility might hinder progress but we’ll see.

Politics, Brexit, bad service culture and lack of understanding

     could halt progress but positivity and motivation is what we’re demanding.

Co-produced, co-ordinated effective support with heart and soul

Peer led hope and opportunities providing everyone with a role.

Fear and loathing, complacency, reluctance and resistance to change

     can be combatted by never giving up and pride in embracing ‘the strange’.

Services talking to each other, together everyone achieves more.

When handling misinformation and knowledge gaps is training the cure?

Continuing to improve quality of life and expand the organisation.

Listening to beneficiaries and involving The Network in the conversation.

There may be pessimism, hierarchy and people not willing to relinquish power.

But optimism and authentic service user involvement can make the doubters cower.

Continuing achieving with better outcomes and shared care plans.

Overcoming risk aversion and lacking resources by challenging ‘the man’

The establishments established but with co-working change is possible

Allowing all to have their say on matters from the large to the small.

Partnership gaps bridged, trusting relationships enhanced & built

challenging stigma and attitudes allowing prejudice to wilt.

Growing seeds of positive change, watered with determination.

Helping self belief and worth grow by enhancing motivation.

Changing opinions and adapting from a solid evidence base.

There’s been much progress already but many barriers to face.

Will you be a centre of excellence that’s streamlined and accessible?

Will you continue to grow and improve services with empathy for all?

Does more achievement of system change sustain the WYFI vision?

Is an unprecedented wraparound care model your mission?

Do you need to change the ethos of organisations & eligibility criteria?

How will you overcome brainwashing and challenge stigmatizations hysteria?

What about agencies that won’t work together? Will they be left behind?

Do you believe the future is positive despite problems with solutions to find?

Will navigators work with organisations in future to enable everyone to fit?

Rather than people being problems for services isn’t it actually the opposite?

Funding cuts could get in the way and communication might break down

But working together for positive progress smiles can soften the frown.

There’s been much great work already, with success and things to address.

The future will be what you make it. Is it positive? Let’s aim for a yes.

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Fulfilling Lives: Supporting people with multiple needs

“[This programme] has a massive potential to make a difference to people’s lives.” Laura Furness, Head of Funding (Investment), Big Lottery Fund

Hear what the Big Lottery Fund and CFE, the national evaluators of the Fulfilling Lives programme, said following the year 2 evaluation of the programme in this short, 6 minute film.

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I just can’t give it up – addiction and multiple needs

Written by Mark Crowe, WY-FI Research and Evaluation Co-ordinator

What is the WY-FI Project?

WY-FI supports people who are not engaging effectively with services and are experiencing entrenched needs in at least three of the following HARM areas:

  • Homelessness
  • Addiction
  • Reoffending
  • Mental ill health

WY-FI does not deliver services but works with existing local services to co-ordinate and work together effectively to fully meet individual needs in a person-centred and co-ordinated way via a Multi-Agency Review Board.

WY-FI Beneficiaries

WY-FI has been working with beneficiaries for just over two years and in that time we have started to build up a picture of what experiences make up life for an individual who has multiple needs. The challenge for service providers and WY-FI Navigators is that there is an interdependence between the four HARM (Homelessness, Addiction, Re-offending and Mental ill health) themes which result in either exclusion from, or ineffective engagement with, services.


In previous WY-FI Strategic Stakeholder Group meetings we have looked at homelessness, re-offending and mental ill health – but noted the impact that addiction has on all three. Addiction can be both a cause and a symptom of a chaotic or traumatic life and addressing addiction where it exists with other needs cannot be achieved in isolation.

The classification of addiction (or “problematic substance use”) is not always helpful as it covers a wide range of consequences and substances – drinking, opiates, prescription drugs, cannabis and new psychoactive substances. The outcomes data from general drugs services shows that there can be equally successful and unsuccessful treatment outcomes amongst the same cohort of drug users undergoing the same psycho-social and extended intervention treatment pathway. It appears that the motivations to start and stop using substances seem at least as important as the treatments on offer.

How does WY-FI make a difference?

WY-FI Navigators make a difference in two main ways, they practically support people to make and keep appointments with drug and alcohol services and they walk alongside the service user and help keep them motivated to make positive change in their lives. A sample of WY-FI beneficiaries completed an Insight Survey questionnaire which gave them the opportunity to explain what difference having a Navigator made. They said,

“I have an excellent and understanding Navigator”

“Staying away from drugs is easier with my Navigator”

“My Navigator gives me the support to move on”

Other results from the Insight Survey show the difference that having Navigator support makes to individual’s experience of services.

Navigators also have a crucial role to play, along with Multi-Agency Review Boards (MARBs) in drawing together packages of support for beneficiaries and obtaining flex from services. Often in the case of addiction, this includes allowing someone to be re-admitted to a service after an exclusion because of their use of substances – which is incompatible with other treatments or service provision because of behaviour whilst under the influence. People experiencing dual diagnosis tend to have much more access to addiction services than mental health services, certainly in the early stages of treatment.


As you would expect, referrals to WY-FI of people with addictions come from a wide range of sources as a number of different agencies have a stake in the individual’s recovery. One of the most notable referrers to WY-FI are addiction services themselves (34% of WY-FI referrals) indicating that there is a proportion of their own clientele that they can’t engage with or are too chaotic or risky to work with, without a navigator.

Even so, not everyone who needs support, makes it to an addiction service. The proportions vary from district to district but there are typically between a third and a half of beneficiaries experiencing addiction who do not access addiction services. WY-FI looked at an area where there was a very low proportion of males experiencing addiction who had not received a service. Reasons for low levels of recorded engagement, even with navigator support, included:

  • Working with people who were acknowledged locally as never having, nor ever likely, to engage with addiction services
  • Individuals being recalled to prison prior to attending their first appointment
  • Individuals dying prior to attending their first appointment
  • Individuals not having attended their first appointment at the point of the data snapshot
  • Individuals disengaging from WY-FI but subsequently attending appointments at addiction services

Are the right services out there?

There are a wide range of services available across West Yorkshire and recent commissioning rounds in each of the districts have moved towards a blend of services incorporating:

  • mandated treatments such as elements of a Drug Interventions Programme/Drug Rehabilitation Requirement
  • substitution and psycho-social interventions
  • early, brief and extended brief interventions – these deal with alcohol, opiates, non-opiates, novel psychoactive drugs as well as dual diagnosis
  • abstinence-based recovery services – these are often peer-led and managed but often new to the partnerships delivering addiction services.

Certainly the re-configuration and re-commissioning of services offers opportunities to improve the services for beneficiaries. However, the process of procurement, commissioning and subsequent implementation seems to be reducing the capacity of services during the handover from one provider to another or as existing services are re-configured to achieve savings. Whilst services are receiving more and increasingly diverse referrals, clients seem to be directed towards narrower and more prescriptive treatment pathways.

What works for WY-FI beneficiaries?

WY-FI beneficiaries tend to be more complex and more chaotic or entrenched in their substance use than mainstream users of addiction services. A number of them will be mandated to use services as the result of a court order or condition of probation. Individuals with multiple needs want:

  • to feel safe about using services
  • to be listened to
  • to be respected by workers, and
  • to have a say in their treatment and support plans.

There was a strong message that people with multiple needs were “stuck” in substitution-based services and often couldn’t progress because they had been excluded because of their behaviour or because they had missed appointments. In some cases people didn’t get the support they needed after leaving prison quickly enough. There was a lot of support for abstinence-based recovery groups and the notion of “recovery” became a central tenet of WY-FI. Many experts by experience and beneficiaries value the abstinence support from people  who have experienced problematic substance use themselves. This seems to work well with detox in the community, clinical detox and/or rehab. The ongoing support is critical and is often linked to support around other challenges in the lives of beneficiaries. There is also a recognition that recovery groups don’t work well for everyone – just like other treatments.

Drug related deaths

Recent media reports highlighting the increased death rate of drugs service users for example in the Guardian and BBC demonstrate the change in the demographic profile of drugs services’ clients. Reasons for the increased death rate include: increasing age of drug services’ clients (particularly opiate users) and the additional health problems attributed to their drug use or lifestyle since the 1980s and 1990s (the last “waves” of heroin epidemic in the UK).

Also on the increase are deaths from New Psychoactive Substances (what were “legal highs”) which in WY-FI’s experience tend to be more heavily used by younger and more chaotic beneficiaries. The reports point towards the personalisation of services and multi-agency work that addiction services could be a gateway to, if they were designed differently. These reports also illustrate some of our previous findings that there are possibly two distinct types of people experiencing multiple needs: older more entrenched beneficiaries who are more sceptical about the help offered by services and younger, more chaotic beneficiaries that services can’t maintain engagement with. This is an area which the WY-FI Research and Evaluation Team will explore further.

The figures

The WY-FI Research and Evaluation team have collated a powerpoint presentation to illustrate some of the points made in the above blog. Download the presentation

Case studies

Here we present two case studies showing the costed journeys of two WY-FI beneficiaries, both experiencing addiction but receiving very different treatment/care. The two cases presented show different aspects and outcomes of beneficiary experience of services. We don’t yet know if they are representative of a wider pattern.

The first beneficiary is on  a substitution programme (methadone script) and  is someone who is particularly high risk both as a victim and someone who presents as very chaotic. Drug use is for self-medication and there is the use of street drugs on top of erratic use of prescribed methadone. The use of street drugs has led to a series of physical health complications. The ongoing prescription of methadone does not appear to be associated with improvement in other aspects of the beneficiary’s life, which appears to be governed by a fragile psychological state which so far doesn’t seem to have been treated (or treatable).

The second beneficiary was cared for in a “wet house”. The beneficiary is a more entrenched drinker with a history of trouble with the police when “in drink”. The beneficiary spent a period in a “wet” hostel where he was able to drink moderate amounts and rarely to excess. There seems to have been a series of low level incidents which culminated in his discharge (eviction) from the hostel. However, the beneficiary has maintained navigator support and after a period of sofa-surfing and street-sleeping the beneficiary is now sustaining their own property and needing little WY-FI support. The beneficiary continues to drink, but in a much more managed way than previously. The beneficiary also reports that he can manage better around other people when he has taken drink and this has reduced his offending record.

Chaos and Outcomes Scores

The graphs show costs associated with each beneficiary’s journey as well as the number of hours support provided by WY-FI. Costs ‘above the line’ are for positive rehabilitative interventions. Negative costs ‘below the line’ include expenses to the public purse related to homelessness, addiction, re-offending and mental ill health.

Both graphs track each beneficiary’s Chaos Index Score and Homeless Outcomes Score. The Chaos Index Score (also known as NDTA score) is an assessment undertaken by a navigator to establish whether an individual will benefit from WY-FI support against a series of need criteria. This is repeated regularly to measure progress. The maximum Chaos Score possible is 48. The Homeless Outcomes Star Score is a self-assessment tool for beneficiaries to measure their distance travelled. The maximum score possible is 100. Where progress is positive, we would expect the Chaos score to decrease and the Outcomes score to increase.

The Housing Outcomes Star scores have steadily improved for the beneficiary being prescribed methadone but the Chaos scores, having initially improved, have worsened (but not as bad as initially) and have plateaued. As a result, the beneficiary’s offending behaviour has not reduced and nor has her drug misuse.

Download the case studies


These case studies highlight the ongoing nature of addiction and recovery and the inter-relatedness with other issues – particularly how the beneficiary relates to others. Certainly, with the first beneficiary there is a strong sense that some form of confidence building and motivation is necessary to mitigate against the damaging cycle of vulnerability, addiction and psychological distress but possibly even more intensive and co-ordinated support is required to achieve that.


We welcome your comments and thoughts on this blog and evidence.



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I’m looking forward to the rest of my life…

“I am 5o years old and I’ve spent 32 years of my life in addiction.

I started injecting amphetamines aged 16. I managed to stop when I was 22, but used alcohol and cannabis to ease the come down. I drank excessively and quickly became alcohol and drug dependant. At first it didn’t seem to be a problem but my using and drinking progressed until, whilst under the influence, I repeatedly stabbed a neighbour in a frenzied attack. Scarily, I have no recollection of this incident.

I stopped drinking but it sent me back to drugs, I was injecting again. Over the next decade I did several prison sentences and have also suffered from drug induced psychosis and been homeless for years at a time. I had got to the stage by then where I had lost all my teeth, I had Hepatitis and I didn’t expect to live for long. I couldn’t cope with life and my addictions. I was very afraid.

I knew that I had to stop so that I could go to my son’s wedding but when I realised that I couldn’t, I knew I needed help. I didn’t know where to go but someone on the street helped me. I went to the Corner which is part of the Basement Recovery Project and signed up to NA and I haven’t looked back since.

I got clean in May 2013. I went to my son’s wedding and saw my Mum and Dad who thought they would never see me alive again. On Christmas Eve, I went to see my youngest son. That was the first time I had seen him since he was 16 and he was 24 then.

The people that I listened to when I was trying to get clean were the people that had been in recovery and that’s what made me realise that if they can do it, I can do it. You get inspired by people who have been to hell and back.

I am an Expert by Experience for the WY-FI project, I volunteer at the Recovery Café for Bridge in Bradford, I also co-facilitate a group there and I do peer mentoring and outreach work with one of the WY-FI Navigator teams. I really enjoy that. On a Monday I have college because I am studying for my level 3 NVQ in Health and Social Care.

In the future I’d like to work for the WY-FI project as a Navigator because doing things now to help people that are in the situation that I was in helps me tremendously. I enjoy giving my time, it’s a positive. I have taken so much from society for so long, I need to give something back. It helps me feel good about myself but it also gives me a purpose.

I will be 17 months clean next week, and I am really happy and doing well in my recovery. I am in a healthy relationship and looking forward to the rest of my life.”

Sue, WY-FI Expert by Experience and Peer Mentor