Individuals with Complex Needs

This contract is a Direct Award made under the Provider Selection Regime (PSR) - Direct Award process A.

The Service is to address inequalities and sustaining targeted interventions for high-risk cohorts.

The service model reflects a whole-system, integrated approach, bringing together clinical expertise and social care-led coordination to address both the immediate healthcare needs and the wider determinants of health. This includes a strong emphasis on outreach, relationship-building, and person-centred support to re-engage individuals with mainstream services.

The service is designed to address gaps in provision, enhance system integration, and support a coordinated approach to improving health outcomes for some of the most vulnerable residents in the borough.

The target cohort for this service includes individuals who experience overlapping and inter-related challenges, including but not limited to:

• Drug and alcohol dependence
• Mental ill health and co-occurring conditions
• Homelessness or insecure housing
• Social exclusion and financial hardship
• Safeguarding concerns, including self-neglect
• Poor engagement with primary care and preventative services