Case study

Lee – I’m staying out of trouble and I’m in the best position I’ve ever been in

How a Multiple Needs Coordinator helped a young person who was in and out of care, used drugs and got arrested regularly.

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Lee – I’m staying out of trouble and I’m in the best position I’ve ever been in

Lee was a concern to many agencies across Cambridgeshire, but none of the multiple interventions he had been receiving were having an impact. Making Every Adult Matter (MEAM) coordinates services for people facing multiple needs and exclusions and improves outcomes.

Watch the video to hear Lee talk about his experience. The video also features Tom Tallon, Lee’s Multiple Needs Coordinator.

Lee’s video youtube

Read the video transcript

Lee’s story

Lee’s behaviour had been a problem since he was a child. He was getting excluded from school and causing trouble at home and his parents were struggling to cope.

“My parents put me in a children’s home for a couple of weeks because we all needed a break,” said Lee. “I came home and was fine for a bit but then I started with the bad behaviour again, so I went back into care. It carried on like that until I turned 16 and left home. For the next 12 years I was in and out of prison for minor offences, bingeing on alcohol and getting into trouble, sleeping rough across Cambridge and going round in circles.”

Making Every Adult Matter

Lee was a concern to many agencies across Cambridgeshire, but none of the multiple interventions he had been receiving were having an impact.

In February 2011, Lee was referred to the Chronically Excluded Adults pilot after being identified as a chaotic person who repeatedly passed through local services. The pilot was one of three being supported by Making Every Adult Matter (MEAM) – a coalition of the national charities Clinks, DrugScope, Homeless Link and Mind – to better coordinate existing services for people facing multiple needs and exclusions, improve outcomes and deliver better value for money.

Multiple Needs Coordinator

The pilot provided Lee with a Multiple Needs Coordinator, Tom Tallon. Tom explains: “I’m service neutral and I work flexibly as a link in the system that otherwise wouldn’t be there. Most services work well for 99 per cent of people. I’m working with that one per cent that people usually give up on. Because of strategic buy in and my close working relationship with all local agencies, I can go to services and ask them to try something different for my client.

“I’m solely here to act in the best interests of Lee. I coordinate everything he needs to do and follow his journey wherever he goes rather than him being passed from service to service with new keyworkers at every stage.

“This is where it can often fall down for people with multiple needs. They’ll be doing ok, then something will happen and they’ll maybe go to prison for a petty offence. When they come out they’ve got a completely new set of workers and everything they had in place before is gone, so they go round in a circle again.

“Lee was banned from most of the places that were there to help him, but I’m able to work intensively with him and now he is on a single journey. We’ll take steps forwards and steps back, but I have that long-term focus for him.”

Tom began by giving Lee a mobile phone so he could arrange appointments with him. He then documented Lee’s health needs, which helped increase his priority for housing. Lee wanted to remove himself from a social group he associated with problem drinking so Tom helped him find a flat outside Cambridge. To prevent Lee from feeling isolated, Tom gave him weekly bus tickets to the city, funded through a small personal budget.

Lee was still binge drinking so Tom worked with him to develop new social networks. Although Lee faced two more court appearances, Tom was able to explain the process Lee was going through, resulting in him receiving fines rather than a prison sentence.

Tom also helped mediate some neighbourhood disputes, always ensuring Lee knew when he was in the wrong. Tom also secured an agreement with a specialist GP to take Lee on as a patient and assess his behaviour, despite Lee living out of the practice area.

Reduction in anti-social behaviour

Tom’s intensive support means he is in regular contact with Lee, even taking him to do his weekly food shopping. Local services have already noticed the reduction in Lee’s anti-social behaviour and Lee is now looking for a job.

Lee, now 29, admits he still has a long way to go: “I still need to sort out my drinking because I use that to cope when things become a struggle. And I need to build up my confidence because having been in care and prison, I’ve always just put a front on.

“But working with Tom has been different because all the other agencies told me what they thought was best for me and what they wanted me to do. The really big difference with Tom is that he listens to how I want to go forward and what I want to do, then he tailors my support to that.

“Tom has bent over backwards to help me. I’m staying out of trouble, I’ve got my first proper flat, a great girlfriend and I’m in the best position I’ve ever been in.”

Video transcript


I ended up being diagnosed ADHD as a kid, it doesn’t really affect adults. But as I wasn’t diagnosed until 13 a lot of problems had already happened at school.

I ended up getting placed in care for two weeks just so my mum and dad could have a break you know, but that was my first taste of that. I went back home and everything was fine and then went back in again for a period of time. That’s when I first got arrested. I was 13 years old, hanging around with 18/19 year olds. Started smoking grass, you know, just getting with the wrong people and it was just basically the start of a downward spiral.

I saw a load of different organisations to try and sort things out, got close to sorting it out, didn’t really happen. And I mean the organisations that I go and see it’s pretty much down to what they do; specifically what they want you to do.


Making Every Adult Matter is a coalition of four national charities: Clinks, DrugScope, Homeless Link and Mind, who together represent about 1600 frontline agencies operating across the criminal justice, drug treatment, homelessness and mental health sectors.

The charities came together to look at policy and practice change for a group of individuals facing multiple needs and exclusions. We estimate there are about 60,000 of these individuals in the country at any one time. Therefore these individuals end up living quite chaotic and expensive lives, making use of expensive emergency interventions such as the police or accident and emergency services, rather than the cheaper planned interventions that can really help change lives. So that’s what Making Every Adult Matter is there to do.

One of these services is based here in Cambridgeshire and Tom Tallon will tell you a little bit more about the work he does on a daily basis as the co ordinator of that MEAM service.


Working with the clients, I come in and I am service neutral so I don’t have any remit with those individual clients. What I try and do is coordinate existing services for the improvement of the client’s situation.

One of the key elements also in what we’re doing is I’m able to follow the journey of each individual. Traditionally what happens with clients is that they get passed from one service to the next as their situation changes. So for example, if they are in a night shelter and they have a package in there of people supporting them, working with them, they then move into a hostel or any other form of move on accommodation, they lose that support and a new package of support comes in from the new accommodation provider. Clearly there is some crossover; they try to feed information over. But what I can do is actually follow that journey throughout and bring new elements of support into the package, rather than start a fresh package which doesn’t necessarily quite coordinate with where the previous support was coming.

Using the senior management ‘buy in’ that we’ve been able to establish with this pilot, we were able to navigate a housing system that didn’t work for Lee because he didn’t fit into any of their criteria in terms of medical needs or in terms of overcrowding, he was just a very chaotic young man. But we were able to navigate that and relocate him to another area which has broken the negative connotations of this city for him and he’s been able to establish some new networks in that area. And while things aren’t totally straight forward and there will be slips back as well as there are steps forward, we’ll be able to continue to follow Lee’s journey until he’s at a point where we think he’s going to manage perfectly capably himself.

He has in fact managed to sign off JSA; he’s been doing bits and pieces of work which is a wonderful result for him as well. It’s boosted his confidence, so it makes him feel as though he’s actually able to give something back and he’s doing things for himself rather than other people having to pick things up for him.


I should be more optimistic, things are quite good right now, the best I suppose they’ve ever been. But I’m just not too optimistic because I’m just so used to everything going wrong. So it’s just maybe looking at being at a bit more confident, optimistic about my future because with the support of Tom and everyone I’ve got around me, if I don’t do it now I don’t think I’ll ever do it.

End slide

MEAM is a coalition of four national charities – Clinks, DrugScope, Homeless Link and Mind, working together to help people with multiple needs.

MEAM aims to coordinate multi-agency interventions, to reduce chaotic access to emergency support in favour of planned and targeted services which actually transform lives.

“Things are good right now, the best they’ve ever been”.

Published 16 April 2013