Severe and multiple disadvantage (SMD)

A person can be said to be experiencing Severe and Multiple Disadvantage (SMD) when they are affected by more than one of the following domains:

1. Homelessness
2. Substance Use
3. Offending
4. Mental ill health
5. Domestic violence or abuse (DVA)

The categorisation of SMD often uses a numeric index. When two of these sources of disadvantage are present, this can be referred to as SMD2. When there are three, four or five, this can be referred to as SMD3, SMD4, and SMD5, respectively. 

SMD is distinct from other types of disadvantage due to the extent of stigma and dislocation from social norms associated with these experiences, which pushes affected individuals to the extreme margins of society. This occurs because of the interlocking nature of these issues and their mutually reinforcing effects on one another, rather than the severity of any single one of them. It is not included in the formal definition but disconnection from services and other available forms of support is very common amongst people experiencing SMD, who can often be said to 'fall between the gaps'. 

It is often difficult to measure the extent of severe and multiple disadvantage (SMD) due to the categorisation of people's experiences into separate boxes and data not being connected between different services. However, it is known that some domains of disadvantage are more likely to coincide than others. The co-existence of offending and substance use is the most common form of SMD2, followed by the co-existence of homelessness and substance use. 

There are a number of risk factors associated with SMD, often linking to negative experiences in childhood.  

This includes: 

• childhood trauma  
• poor educational experiences  
• wider social and economic determinants 

Those experiencing SMD face significant negative consequences across various domains of their lives. This includes an impact on physical and mental health, employment and ultimately premature mortality. There is also a significant financial cost on wider society due to the use of services and the health and care needs of individuals.

Communities with a higher prevalence of SMD are also likely to experience higher rates of:

• crime
• anti-social behaviour
• street drinking

Around 60% of those experiencing SMD3 live with or have contact with children, many of whom will experience disadvantage as a consequence of parental SMD. This has negative effects on physical, social, and cognitive development. It also increases a child's risk of later experiencing SMD themselves, which leads to intergenerational cycles of disadvantage. 

Other factors that can make life harder for people who experience SMD are:

• feeling lonely - they might not have friends or family to help them
• people being unkind - others might treat them badly or not want to help because of their problems.
• not having enough money - it can be hard to buy food, clothes, or pay for a place to live
• hard to get help - sometimes, it's confusing or difficult to find the right help or support
• being unwell - they might have health problems that make everything else harder
• moving a lot - not having a steady place to live can make it hard to feel safe or get help

Those who are more affected by SMD are:

• care leavers, who may lack stable support networks
• people with experience of childhood abuse or neglect, who often face long-term psychological impact
• rough sleepers, who struggle to access consistent healthcare and housing
• those from ethnic communities, who may encounter additional barriers due to discrimination and cultural stigma

These groups are frequently underserved by mainstream services, making it harder to escape cycles of disadvantage and achieve stability.

Barriers to support 

People experiencing SMD face significant barriers in accessing the support that they need to improve their lives, both at an individual and a system level. 

Individual-level barriers 

Understanding the pathways that lead to complex lives is crucial for developing effective, non-judgmental support models. A qualitative study by Sandu (2021) found that young people experiencing SMD often had poor early relationships, leading to deep-seated shame and distrust of professionals. Many described themselves using highly negative terms and developed protective behaviours that distanced them from support, particularly where the support offered lacks consistency and persistence. This highlights that disengagement from support is not a personal choice, but a survival response to trauma.  

System-level barriers 

It is well-documented that system level factors contribute to poor outcomes for those experiencing SMD (8, 9). The responsibility is usually placed on individuals to navigate a complex and disjointed system which requires them to: 

• repeat their story 
• convey the right need to the right professional 
• seek help for each singular factor affecting their lives 

This leads to care which is un-coordinated, involves several professionals from several services, and demands engagement from the individual in a variety of different interventions at the same time. 

Improving support

Evidence-based principles underpinning good practice 

Evidence supports approaches that are: 

• person-centred - support should be person-led (for example, directed by the person receiving the support) and tailored to match the person's specific needs and strengths 
• relational - consistent and trusting relationships are the foundation for providing effective support (these often take time and persistence to build, requiring approaches that are person-led, open-ended, long-term, non-judgmental, and utilise small caseloads) 
• trauma-informed - support should be provided through a trauma lens, recognising that people may have experienced trauma which can impact how they feel, think and behave, and responding accordingly 
• flexible - offering support in a flexible way, and encouraging other services to work more flexibly too, enables people to access support that might not otherwise be available or accessible to them 
• peer support-based - support from peers is consistently identified as helpful in relation to different models and approaches, particularly in the way that they support the development of trusting relationships but also through the provision of a positive role model 

Examples of good practice 

The best approach to implementing these principles in practice will always be shaped by the local context. Whilst no single model fits all, various examples of good practice exist. For example, Changing Futures is a £98.1 million programme which gave funding to 15 areas across England to improve outcomes for people experiencing multiple disadvantage, with various different approaches trialled. Evaluation of the programme offers valuable transferrable learning.

Visit the evaluation of the changing futures programme page on the GOV.UK website for further details.

People experiencing SMD exist at the most extreme margins of social disadvantage. They have often faced significant trauma and are failed by systems that are not designed to support their multiple interconnected challenges. The evidence presented in this chapter demonstrates that the consequences of SMD are far-reaching, affecting not only individuals and families, but wider society too, with significant demands placed on public services. There is a need for improved data collection systems which enable the systematic monitoring of SMD across Stockton-on-Tees, providing local insights on prevalence, trends, and risk factors. 

Despite these challenges, there is a growing body of evidence highlighting effective approaches to supporting people experiencing SMD. There is a need to move away from siloed service delivery towards integrated and flexible models of support, which focus on building meaningful relationships and improving people's capabilities.  

Stockton-on-Tees Borough Council is taking steps in this direction through its Complex Lives transformation programme.  

This work focuses on: 

• identifying new models of support to improve outcomes  
• reducing costs for those already experiencing SMD  
• intervening early to prevent SMD from developing amongst children and young people at risk 

This will draw on learning not only from other areas, but also our own local initiatives, such as the work already being undertaken to test a peer advocacy approach across Stockton-on-Tees, led by the Health and Wellbeing Board. 

The following resources have been used as references for the analysis of SMD in this chapter of the Stockton-on-Tees JSNA. 

1. Bramley G, Fitzpatrick S, Wood J, Sosenko F, Blenkinsopp J, Littlewood M, et al. Hard edges Scotland: new conversations about severe and multiple disadvantage. 2019. 
2. Bramley G, Fitzpatrick S, Edwards J, Ford D, Johnsen S, Sosenko F, Watkins D. Hard edges: mapping severe and multiple disadvantage in England. 2015. 
3. Sandu RD. Defining severe and multiple disadvantage from the inside: Perspectives of young people and of their support workers. Journal of Community Psychology. 2021;49(5):1470-86. 
4. Making Every Adult Matter (MEAM). Reviewing the deaths of people facing multiple disadvantage. 2021. 
5. Groundswell. Healthy Mouths: A Peer‐led Health Audit on the Oral Health of People Experiencing Homelessness. Groundswell London; 2017. 
6. Department for Work and Pensions. Improving Lives: Helping Workless Families. An evidence resource on family disadvantage and its impact on children. 2017. 
7. Moreton R, Welford J, Howe P. Why we need to invest in multiple disadvantage. Evaluation of Fulfilling Lives: Supporting people experiencing multiple disadvantage. 2021. 
8. Fulfilling Lives LSL Research and Learning Partnership. Systems change for people experiencing multiple disadvantage: What have we learned about the system and how it can change? ; 2022. 
9. Little M, Sandu R, Truesdale B. Bringing everything I am into one place. Lankelly Chase Foundation; 2015. 
10. McCarthy L, Parr S, Green S, Reeve K. Understanding Models of Support for People Facing Multiple Disadvantage: A Literature Review. Sheffield Hallam University Centre for Regional Economic and Social Research; 2020. 
11. Department for Levelling Up, Housing & Communities. Trauma-informed approaches to supporting people experiencing multiple disadvantage: A Rapid Evidence Assessment. 2023. 
12. Department for Levelling Up, Housing and Communities. Frontline support models for people experiencing multiple disadvantage: A Rapid Evidence Assessment. 2023.