Family Wellbeing Partnership in Clackmannanshire: evaluation

3.2 STRIVE Process Evaluation

Below, we present our findings on the impacts of STRIVE on public service delivery and system change in Clackmannanshire according to key themes and outcomes identified in the Theory of Change. We discuss these themes in the context of strengths and challenges of the STRIVE workstream.

Strengths of the STRIVE approach

Improved collaboration, communication and data-sharing across agencies

A notable strength of STRIVE lies in its information-sharing capacity. This enables rapid coordination across agencies, such as housing, social work, and mental health services. As one manager described in an interview,

"The daily meetings allow us to share information quickly, even if we’re not in the same physical space. It’s not perfect, but it keeps us focused on the needs of the families."

An important aspect of the STRIVE model is the necessity for staff to communicate and collaborate quickly with other services. There are a lot of partners in the STRIVE model, as can be seen above at Figure 1, and staff need to be aware of the available support and build ongoing relationships with those services. Collaboration between these services has also been underpinned by the implementation of a data-sharing agreement, which took time and external legal expertise to develop and put in place.

Providing preventative, integrated support through innovative approaches

According to those interviewed, domestic abuse referrals are among STRIVE's most impactful cases. The ability to offer practical and emotional support earlier than traditional routes has led to significant outcomes. One example involved a survivor who received safety measures, including a ring doorbell and letterbox security system, alongside referrals to specialised domestic abuse support services. This combination of proactive and practical interventions empowered the survivor, improving her confidence and capacity to care for her children. As one interviewee stated,

“When we can offer both emotional support and practical safety measures, it gives survivors a chance to rebuild their lives in a way that feels secure."

It is argued by STRIVE staff that a measure of STRIVE’s success has been the increased numbers of domestic violence police concern reports lodged. According to staff interview feedback, women have more confidence to report abuse. Such examples demonstrate STRIVE’s increasing opportunity to intervene proactively in high-risk situations.

Multi-agency and partnership approaches reduce crises and improve outcomes for people

By leveraging multi-agency collaboration where possible, STRIVE has also been able to prevent evictions and improve tenancy stability in multiple cases. For example, in one instance, tenants were connected to housing advice and energy support, reducing financial pressures and sustaining their tenancy. STRIVE's ability to rapidly coordinate financial and housing advice was reported to have mitigated crises for many individuals.

The role of education and social work services in STRIVE are also critically important in assessing the potential impact on children and young people. Education staff’s access to the Scottish Education Management Information System (SEEMiS) - particularly pastoral notes and child protection reports - provides a more comprehensive understanding of a child’s circumstances, enabling targeted interventions that support the entire family. For instance, head teachers may be contacted to coordinate appropriate support through the Staged Intervention process, ensuring children receive the necessary emotional wellbeing and mental health assistance, particularly in cases of trauma. By integrating these insights into STRIVE’s multi-agency approach, the initiative can better address the holistic needs of vulnerable families and improve outcomes for children. STRIVE’s approach in this area is underpinned by the aforementioned data sharing agreement between the services involved.

The STRIVE multi-agency team has also built strong working relationships with numerous third sector partners, and expanding these collaborations remains a key focus through new commissioning arrangements aimed at enhancing referral pathways to further strengthen STRIVE’s impact.

Challenges faced by STRIVE

The STRIVE workstream also faced a number of structural challenges in meeting its vision and achieving the outcomes set out in the Theory of Change. These are summarised below.

Engaging individuals who are reluctant to accept support

STRIVE’s engagement with families is built on trust and addressing practical needs. It primarily supports individuals and families on the edge of crisis, but it has also demonstrated the ability to reach individuals with complex needs who might otherwise fall through the cracks. The approach includes arranging meetings in neutral locations, which are less intimidating for participants. However, barriers still persist in engaging individuals who are reluctant to accept support.

Resource constraints

Resource constraints and administrative hurdles have limited the expansion of STRIVE interventions, while the absence of a full-time team lead until recently has created inconsistencies in coordination and delivery. STRIVE has evolved significantly from its original design. Initially conceived as a dedicated, co-located team, this shifted to a situation where, as one interviewee put it, “everybody has it to do alongside their other work.” Driven by the COVID pandemic and resource constraints, this led to a reliance on daily virtual meetings instead of the originally planned in-person collaboration. To address these challenges, the planned introduction of a Community Link Worker role - funded by the FWP, alongside a dedicated manager, is expected to help address these gaps by bridging STRIVE's crisis response with community-based upstream interventions.

Level of mental health demand

Mental health remains a prominent challenge in Clackmannanshire, with service gaps that STRIVE has struggled to fill. While STRIVE has facilitated timely interventions such as connecting individuals to mental health support or coordinating with GPs, there is a lack of resources for immediate, on-the-ground full adult mental health services. For example, in one case, housing officers identified a resident experiencing a mental health crisis, prompting STRIVE to coordinate a proactive GP outreach. This intervention avoided escalation but highlights the systemic limitations in meeting immediate mental health needs. As one interviewee said,

"We’re good at coordinating support, but without enough mental health professionals available, there are limits to what we can achieve in the moment."

The introduction of the Community Connector role, aligned to STRIVE, offers potential in helping to bridge this gap to some extent, by engaging individuals in informal settings like coffee shops, where stigma is lower and trust can be built. This approach to engagement has shown some success in connecting individuals with community-based mental health resources and other wellbeing supports, highlighting the benefit of integrating such roles within STRIVE. In addition, by learning from the provision of digital mental health services for children and young people, the FWP was able to operationalise a new service for adults providing universal access at scale to mental health support that can be accessed with no referral criteria and, crucially, no capacity restrictions. While these approaches enhance access, and engagement and feedback on working this way from staff is positive, it does not replace in-person professional mental health support or fully address systemic limitations in service provision.

Looking forward, in terms of mental health resources, there is a need to address gaps in immediate mental health interventions by embedding specialised roles, such as Mental Health Officers (MHOs), within STRIVE and improving referral pathways to existing in-person mental health services, as well as increase awareness and uptake of digital services. Based on interview feedback from Managers and FWP staff, there is evidence that the Council’s Early Help teams, who are made up of social workers and intensive family support workers, have reduced STRIVE referrals by offering earlier, non-crisis interventions, exemplifying the effectiveness of preventive frameworks in mitigating risks and supporting families.

Integration with wider council services

One of STRIVE's persistent challenges is getting the right balance between its crisis-response role and the broader early intervention ethos of the FWP. While Strive often works with people already facing significant challenges, its approach is fundamentally proactive - focused on preventing further escalation by providing timely, practical support. The team is highly effective in this space and has established strong, trusted relationships across different parts of the system that enable this approach to succeed. Nonetheless, STRIVE remains a small team operating within a much larger and more complex system. Its capacity and influence are necessarily limited, and the wider adoption of FWP principles across the broader pool of services that are relevant to STRIVE’s work is a work in progress. These dynamics are important to acknowledge when considering both the reach and the limitations of STRIVE over the evaluation period.

The influence of the FWP can be likened to a pebble dropped into water: the ripples are strongest at the centre but weaken as they spread outward. In practice, this means the FWP has had its most visible and immediate impact on those directly involved in its work - social work, education, police, community delivery partners. However, its influence has been more limited in areas further from the core, such as wider social care (distinct from statutory social work), the Health and Social Care Partnership (HSCP), primary care teams, and professionals in Forth Valley-wide roles. These parts of the system have not yet fully adopted or been affected by the FWP’s ways of working.

Reassessing STRIVE’s operational model to balance crisis management with preventative work is critical. While STRIVE relies heavily on staff juggling multiple roles, a dedicated team lead (appointed at the time of writing) and sustained funding will be essential to ensuring its long-term viability.

Summary of activities driving changes

Feedback gathered from practitioners working in relevant services across Clackmannanshire has indicated that effective collaborative working, information-sharing across services, and early intervention have been key to enabling STRIVE to drive positive changes in outcomes for service users. At a development day in May 2024, for example, practitioners shared that they felt STRIVE had helped to reduce silo working, brought about a greater focus on early intervention across services, and increased understanding amongst services of other areas’ remits and roles, to the benefit of wider teams and communities accessing services.

An analysis of case note data carried out by a previous evaluator of STRIVE further suggested that the connections between STRIVE and other services have been key to bringing about positive impacts for many of the individuals supported. The multi-agency approach helped increase individuals’ knowledge and awareness of the full range of support available to them, for example around housing and benefits, which in many cases they had been unaware of prior to the STRIVE intervention. The analysis also indicates that the proactive elements of STRIVE’s approach have been crucial in driving positive change, for example conducting home visits, connecting with appropriate agencies, or cultivating connections for the individual being supported.^[28]

3.3 STRIVE Impact Evaluation

Below, we present our findings on the impacts of the support on STRIVE participants according to several key themes (linked to outcomes in the ToC Framework).

3.3.1 Impacts of STRIVE on FWP Participants

Prevention of crises

There is evidence to suggest that STRIVE is having a positive impact on those it engages with in relation to the prevention of crises. In one case study (described in the Clackmannanshire Story of Change FWP report^[29]), the STRIVE team received a call from health professionals concerned about an individual with mental health challenges who had recently returned home after receiving care. Additional information indicated that household members had taken measures to ensure their safety, and a neighbour had reported hearing distressing sounds. As a result of the STRIVE team's connections and relationships, an appropriate intervention was actioned that day involving reclassifying the case, going out to the home to manage the family’s safety, putting a safety plan in place, and avoiding any delays which may have led to an even worse crisis.

Another individual who had received STRIVE support, described in an interview how the intervention had contributed to the prevention of potential crises in their life. For this individual, accessing STRIVE services involved simply “picking up the phone” to social work, at which point a significant amount of support was offered. This support included placements in temporary accommodation, emergency financial assistance and access to other elements of FWP support. A second interview participant explained that without the support of their social worker and accessing a vital piece of technology, they would not have been able to feel safe or secure within their home.

In addition, an analysis of case outcomes data indicates that STRIVE interventions have had preventative impacts amongst many of those in receipt of support, although evidence of longer term follow ups are sparse, making it challenging to state whether the supports put in place worked longer-term. Between November 2023 and July 2024, for example, a total of 93 referrals were made to STRIVE. Most of these referrals did not become full cases as referrals were discussed by the STRIVE team, referred to relevant services for assistance, and closed once the team ensured that all relevant and deliverable support was in place. Of those which did become full cases, the following outcomes were recorded as a result of the STRIVE intervention. These are short-term outcomes of STRIVE support which in the longer-term can be expected to result in reduced need for crisis support:

• The provision of ring doorbells as a safety measure at the homes of individuals requiring support in relation to domestic abuse;
• The provision of income maximisation and debt relief support, contributing to improvements in financial situation;
• The provision of information and advice regarding tenancies, resulting in more sustainable tenancies / a reduced likelihood of eviction;
• Advice provided regarding homelessness and housing options;
• Access provided to emergency support from the community mental health team and digital mental health supports;
• Mobile phones provided to help individuals receive support from partner agencies;
• Individuals referred to and engaged with the home energy advice team, leading to reduced fuel poverty;
• Support provided to help individuals obtain essential household items, improving their living conditions.^[30]

Stakeholders also identified: improved material wellbeing, greater knowledge and resilience when making decisions about the future, reduced social isolation, and outcomes relating to sustaining tenancies and substance use, as particular areas in which they felt STRIVE had made a positive impact in the lives of many of the individuals they had engaged with.

Looking at who has benefited from STRIVE interventions, an analysis of STRIVE referral data between November 2023 and May 2024 shows the most frequent main referral reasons amongst full cases to have been:

• Concerns raised in relation to mental health;
• Advice needed around money and benefits;
• Support required following a domestic abuse incident;
• Support required relating to a housing issue;
• Support required relating to potential adult welfare issues.

Overall, the evidence suggests that most of those receiving support from STRIVE are individuals who are at risk of experiencing (potentially additional) crises in the future. The outcomes data indicates that, in many cases, the STRIVE intervention has led to actions being taken which should have a preventative impact, such as the provision of housing advice for those at risk of homelessness and the provision of ring doorbells for those at risk of domestic abuse.

Families have an increased level of trust in services

There has been a total of 675 cases opened by STRIVE since its inception in 2020. The STRIVE pilot evaluation report found that the majority of referrals came from core partners, with housing, police and childcare services accounting for two-thirds of referrals between February 2020 and February 2021.^[31] Since this time, STRIVE operational updates show that police services have become the largest source of referrals, which is attributed in part to a rise in referrals for domestic abuse incidents. Case note analysis (of cases taken on by STRIVE between January and March 2022) suggests that STRIVE has provided a connection to services for community members who would otherwise find such connections difficult to form, and has supported these individuals to form relationships with practitioners and services with the ability to be responsive to their needs.^[32]

Case note analysis also indicated, however, that there remain elements of mistrust within the community about the STRIVE project (or of particular partners associated with it), which could be hindering the ability of STRIVE to provide effective support to some individuals. The analysis recommends that STRIVE seek to develop an increased community presence, including in community locations such as schools, in order to create more opportunities for personal connections to be formed and increase the openness of some individuals to engaging with services.^[33] It is intended that this will be progressed after the recent introduction of a community connector role and the arrival of the dedicated team manager for STRIVE, now appointed.

3.3.2 Outcomes achieved by engaging across workstreams

Collaboration between STRIVE staff and practitioners across other FWP workstreams continually takes place through day-to-day conversations and specifically through the FWP Collaborative group, which was established to share and connect practice. In addition, the 2023 FWP Annual Report sets out an ambition for STRIVE to make further links with schools, health centres and community groups in the Alloa South and East area, in order to pilot the use of an earlier pre-crisis response. STRIVE staff have also attended sessions with parents and carers at two local primary schools to discuss available support, with parents and carers showing most interest in voluntary parenting support, benefit/money advice and housing support. The success of these sessions has led to future dates being arranged to ensure the maintenance of a STRIVE presence in local schools.^[34]

Feedback gathered through the FWP Stakeholder Survey also provides some evidence of potential for outcomes to be achieved through collaboration between STRIVE and other FWP workstreams. For example, one respondent who delivers activities through the CWP workstream described part of their role as referring families to STRIVE for support where appropriate; while another respondent most closely linked to employability support described part of their role as delivering pre-employability and literacy/numeracy support to individuals referred to their service by the STRIVE team.

3.4 Summary

Overall, there is evidence to suggest that STRIVE has provided more holistic and joined-up support to people in Clackmannanshire at risk of crises, with the potential to help them avoid experiencing such crises in the future. Key strengths of the STRIVE approach have included its multi-agency approach which has improved collaboration, communication and information-sharing and capacity across services, the preventative and integrative support offered to individuals, and the working relationships built with third sector partners; while challenges faced by the team have included resource constraints, administrative hurdles, meeting the level of mental health demand in the local area, engaging with individuals reluctant to access services, and balancing the crisis response elements of its role with the broader preventative ethos of the FWP.

The evidence suggests that STRIVE’s multi-agency daily meetings and proactive approach have helped many people gain improved access to tailored services, such as housing advice, mental health referrals/access to digital mental health services, and safety measures for domestic abuse survivors. Outcomes for service users to date have included improved financial situations, the installation of safety-related devices, and increased sustainability of tenancies following the receipt of housing-related advice and support. Interview feedback gathered from individuals who have received STRIVE support, as well as interview and survey feedback gathered from practitioners associated with STRIVE, indicates that the workstream has had positive preventative impacts in the lives of many of those with whom it has engaged. Feedback from practitioners, as well as analysis of case notes, suggests that STRIVE’s facilitation of effective collaboration across the system, information-sharing between services, and early intervention have played key roles in bringing about these positive impacts.

Finally, while there is evidence to suggest that STRIVE's interventions have helped to build trust between individuals and services, specific evidence of individuals actively initiating new social relationships or engaging in broader community networks is not available. While STRIVE is designed to provide a supportive multi-agency response for people in crisis, ensuring longer-term sustained engagement with services after the crisis is complete is ultimately the responsibility of all relevant public services in Clackmannanshire rather than solely that of the STRIVE team. Long-term follow-up data, tracking subsequent service use of STRIVE users, is currently unavailable.