Milton Keynes P3 Linkworker+ Scheme

Milton Keynes P3 Link Worker+ Service

Background to the service:

The service was started by Revolving Doors in July 2007 as an ACE pathfinder and was taken over by P3 in September 2007. There are two full-time link workers who hold a caseload of 32 clients at one time. Since the start of the project, link workers have received 884 referrals from more than 50 different agencies.

Funding arrangements:

Since March 2011, the project has been funded by the Milton Keynes Council. This funding expires on 31 March 2013.

The partnership:

The housing service offered by P3 is delivered in partnership with Milton Keynes Council who lease 12 privately owned properties. The properties are then managed by P3. They also have a number of informal partnerships with the police, probation, mental health services, substance misuse services, housing services and A&E, who refer clients (clients can also self-refer).

The client group:

The criteria for the Link Worker+ client group is really broad but is described as adults with chaotic lifestyles and complex needs, such as housing issues (more than 50% of link worker clients do not have a fixed address), mental health issues and/or drug and alcohol dependency, offending behaviour, social and relationship issues – people that “don’t fit anywhere but are known to a lot of services”. The only groups ineligible from Link Worker+ are priority and prolific offenders (PPOS), clients who have CPA care plans provided by secondary mental health services or who are subject to MAPPA arrangements as there is a statutory responsibility for these individuals and they should not ‘fall between the gaps’ in service provision.

How it works:

In simple terms, they offer a service to people who having difficulty coping and are not receiving support from other agencies to link them up with services which can meet their needs and support them in the long term.

Once a referral is received the client is offered an initial assessment which will give them to opportunity to discuss their current circumstances and needs in detail and identify their priorities and goals. The needs assessment is a holistic process which considers the clients housing situation, mental state, drug and alcohol use and history where relevant, financial situation, employment and education history, family situation, physical health, previous and current offending behaviour and risk assessment. Following assessment a link worker will agree an action plan with the client to meet their needs. The link worker works in a flexible manner when it comes to arranging appointments – in the case of rough sleepers, they will occasionally meet the client where they are sleeping on the street because “sometimes [we have to] work with chaotic people in a [seemingly] chaotic way, ...[but] from the beginning, we pick apart the chaos”.

Due to current high demand on the Link Worker+ service in Milton Keynes, a waiting list has recently been put in place to manage the volume of referrals coming to the service. The current case load has been limited to 32 to ensure a high-quality service. The waiting list is managed by a senior link worker who will ‘triage’ the referrals received to assess urgency of need. All clients who are referred to the service will be contacted by a senior link worker to discuss the referral, advise them of the waiting list and if appropriate offer initial advice or signposting to the client. The maximum time on the waiting list currently averages four weeks.

The service model:


To support people to engage with the right services to meet their needs, to make positive changes to their lives and improve their outcomes in health, well-being, and relationships. To offer successful and lasting routes out of social exclusion.


Depending on the client’s needs, the link worker creates a plan with the client and helps them with the issues they are currently facing. Examples include attending the job centre with a client to explain processes and model good behaviour, supporting clients to access hostels, supported accommodation and liaise with private landlords to access housing, helping them with benefit applications, making referrals and supporting clients to engage with drug and alcohol services.

As part of the action and support planning, link workers will give the client tasks that the client can achieve on their own, such as registering with a local GP. Many of the clients who receive link worker service present with ill-defined mental health needs such as anxiety, depression, poor coping strategies and difficulty managing stress. Link workers provide practical and emotional support to help them to address the issues that are impacting their mental health. If appropriate link workers will refer a client to counselling or secondary mental health services and support them through the assessment process. They encourage clients to get back into education at some level or take up volunteering opportunities, both for their own empowerment and to assist them with gaining employment in the future.

They also run a housing service for people who would not have a housing opportunity elsewhere or where there is a concern they may not be able to sustain a tenancy. They tailor each tenancy agreement around the clients’ needs. Conditions can include partaking in an alcohol treatment programme, repayment of arrears on previous properties, or a limit to the number of visitors they can receive at the property because “a P3 tenancy is also about a lifestyle change”. After six months, if all has gone well, they can then nominate the client for social housing.


While the service was initially focused on mental health outcomes, it now predominantly focuses on housing, but the “flexible model applies to different settings”. Out of the last 100 clients, the link worker facilitated engagement with other agencies for 87 of the clients and their interventions prevented homelessness for 32 of the clients.

Clients are encouraged to complete a questionnaire after working with the service. Out of the last 100 clients, 80% said their housing situation had “improved a lot”, 55% said their knowledge of where to get help had “improved a lot” and 56% said their health had “improved”.


The design and delivery of the service is informed by the needs of the clients it seeks to engage, and continues to evolve in response to these. As the link worker commented, “we are trying to include people, not exclude them. People are allowed to fail, just because they get it wrong at the start doesn’t end our involvement with them. Being located within the housing department of the council’s offices allows for the informal sharing of knowledge and professional support to improve outcomes but we value our independence as a charity.” 

What would help to improve outcomes for those with multiple needs?

The link worker felt it would be helpful if more people with multiple needs had access to a link worker service and in a variety of settings, such as through-the-gate prison services. Also, if the Milton Keynes service had greater resource, it would use volunteers more, but the link workers currently don’t have sufficient time to recruit and train volunteers while managing a heavy caseload. Ex-clients were seen as particularly valuable volunteers as they could share their experiences and learning with new clients.

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