ORCID

Abstract

Introduction: This case study provides practice-based reflections on challenges and potential solutions for young people with multiple disadvantages across housing, substance misuse, mental health, criminal justice, and domestic abuse systems, informed by 4 local principles: trauma informed, learning based, an alliance commissioning ethos, and workforce development.Description: To improve the current experiences of 17–25-year-olds in service transition iterative insights drew from networking staff across sectors, clinical audit and following live cases, and appreciative enquiries with young people. This was conducted by a practitioner researcher in a local Young Person’s charity and was supported by peer researchers with lived experience and embedded researchers-in-residence.Discussion: This describes the scale of the challenge where compound need and intersectional disadvantage, wider determinants, complex pathways, and public and third sector service systems collide. Relational practices were tested to support navigating system challenges, better tailor to young people’s abilities and needs and improve integrated care partnership working and workforce development.Conclusion: Plymouth has a history of integration with the Alliance for Complex Needs. Context and localised solutions matter for integrating care, yet remain underreported especially for underserved, and marginalised young people and using whole systems approaches co-produced with the third sector. Investment into academia-practice partnerships is crucial to make learning portable.

Publication Date

2025-07-21

Publication Title

International Journal of Integrated Care

Volume

25

Issue

3

ISSN

1568-4156

Acceptance Date

2025-07-14

Deposit Date

2025-10-08

Funding

GD is employed by The Zone, and was matched-funded by both the NIHR Plymouth HDRC (https:// www.fundingawards.nihr.ac.uk/award/NIHR151310; accessed 03.07.25) and Changing Futures Plymouth (https://www.gov.uk/government/collections/changing-futures, Ministry of Housing, Communities and Local Government (MHCLG) and The National Lottery Community Fund. SM was employed by the Zone. SH is employed by Improving Lives Plymouth and is funded through the Changing Futures programme. KK is employed by Plymouth City Council and funded by Changing Futures Plymouth. FG is employed by the University of Plymouth and part-funded by the NIHR HDRC. The Plymouth Health Determinants Research Collaboration is part of the NIHR, hosted by Plymouth City Council in partnership with the University of Plymouth. The views expressed are those of the authors and not necessarily those of the NIHR, the Department of Health and Social Care, or The Ministry of Housing, Communities and Local Government.

Keywords

transitions, young people, multiple and complex needs, trauma, childhood adversity, broader determinants of health, vulnerable, disadvantaged

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