Memorandum from Turning Point
ABOUT TURNING
POINT
Turning Point is the UK's leading social care
organisation. We provide services for people with complex needs,
including those affected by drug and alcohol misuse, mental health
problems or those with a learning disability. We provide services
in over 200 locations and have contact with 130,000 people a year.
Turning Point has long been a social enterprise—a
not-for-profit business with charitable status run for the purpose
of serving our service users in the health and social care sector.
We are effectively a business focused on social capital rather
than profit: more flexible and trusted than many of our commercial
or statutory competitors.
We believe that social care services should
be based on a Person Centred Approach, and we are rolling out
this approach to all our services.
What are the benefits of contestability to the
users of public services?
Contestability is central to the Government's
reform programme for public services. The contestability agenda
is, first and foremost, a mechanism that ensures that all sectors
have an opportunity to contribute to service delivery. Genuine
contestability would lead to service improvements across the statutory,
voluntary and public services.
Contestability may bring greater benefits to
users of public services as the voluntary sector has a long history
of providing user-focussed support and services to disadvantaged
client groups and has the ability to engage with those often considered
hardest to reach. We are able to reach marginalised groups such
young people, offenders from a black or ethnic minority background,
drug users and offenders with mental health problems etc. We are
more able to provide flexible, personalised and tailored services
and are responsive to the needs of users.
The Third Sector Commissioning Taskforce concluded
that commissioners need more clearly to understand the third sector,
the organisations within it and their contribution to the commissioning
process, both to inform service design, and as potential providers.
Contestability will only deliver benefits for users if this is
addressed. Another example is that currently contracts for the
voluntary sector also tend to be fairly short-term and place quite
a demand on the provider in terms of drawing up the terms and
then meeting them. NCVO recently estimated that as much as 40%
of an organisations time could be spent on monitoring, evaluating
and securing new funding rather than actually delivering services.
Turning Point is currently campaigning alongside other voluntary
organisations and sector membership groups to establish more standardised
forms of contract to reduce this demand on resource and place
the sector on an equal footing with public and private in delivering
contracted services.
Commissioners should be flexible enough to allow
different providers to work in partnership with each other, getting
the most out of the different skills available. If social care
services are to reach all of the groups that they need to, planners
will have to depend on an effective mix of agencies. No one provider
can necessarily effectively meet all the varied needs of service
users, which is why providers should be enabled where appropriate
to work in partnership to deliver more tailored solutions and
provide the right support at the right time.
Have services which have been transferred to third
sector organisations shown improvements in quality?
Despite the fact that third sector providers
are strictly regulated, there is a perception that the voluntary
sector has no concept of, or mechanisms for, robust clinical governance.
This leads to the misconception that the sector cannot be viewed
as a credible, alternative provider to the statutory sector. Turning
Point initiated a project with the Mental Health Providers' Forum
funded by NIMHE, to understand the reality of clinical governance
within NHS mental health services and the third sector, to remove
misconceptions on both sides.[8]
It concluded that third sector agencies are monitored regularly
and in depth by numerous bodies, and in many instances by a greater
number of bodies, or to higher standards than the statutory sector.
For example, in National Care Standards, managers should hold
NVQ level four. This applies to both the statutory and voluntary
sector, but is not mandatory in the NHS.
Is loss of accountability a threat of commissioning
services? If so, how can this best be managed?
Turning Point believes that the way services
are currently commissioned and provided needs to evolve in order
to fully meet the needs of the people we support, especially those
with complex needs who often do not get a service at all. Clearer
defined roles and responsibilities for commissioners are needed.
There must also be a better distinction between the overall function
of commissioning which includes assessing, planning and predicting
future need, and the specific task of purchasing services. Moreover,
if the voluntary sector is to play a key role in providing services,
then it must also help shape the commissioning process itself,
acting as broker between those funding and planning services and
the people who will actually use them.
Is the third sector more likely to provide better
public services than the state or the private sector?
Since 1978, research has suggested that voluntary
organisations are, "cost-effective, innovative, flexible
and pioneering".[9]
More recently, a theory of "comparative advantage" has
been developed which suggests that voluntary organisations, at
their best, can offer particular features which are of benefit
to certain groups in society, who are particularly socially excluded:
— Specialist knowledge, experience
and/or skills.
— Particular ways of involving people
in service delivery whether as users or self-help/autonomous groups.
— Independence from existing and past
structures/models of service.
— Access to the wider community without
institutional baggage.
— Freedom and flexibility from institutional
pressures.[10]
A survey of public sector commissioners by Futurebuilders
found that there were some special qualities that Voluntary and
Community Sector organisations brought that were highly prized.
These included links with the community, specialist services that
target people often missed by statutory services, greater flexibility,
a can-do attitude and strong management and leadership.
Recent research by the Department of Health
has also found that local authorities are extremely positive about
services provided by third sector organisations, with overall
levels of satisfaction high (over 80%). 83% of authorities were
either "satisfied" or "very satisfied" with
third sector provision of learning disability services rising
to 89% of authorities being satisfied with the provision of older
people's services by third sector organisations. Many respondents
felt that the third sector was able to provide a high quality
service that was both flexible to the authority's changing demands
and responsive to the needs of the client group. Third sector
providers were also seen as offering good value for money and/or
competitive prices when compared to other external service providers.
Some local authorities had already developed good working relationships
with third sector organisations, which contributed to their level
of satisfaction.[11]
Turning Point is seeking to garner further evidence
of the efficacy of our approach. We are pioneering a new outcomes
project, an organisation-wide data collection system, which will
allow us to manage and measure client outcomes. Turning Point
would recommend that the Government works with the third sector
to develop a better understanding of what third sector organisations
(TSOs) currently contribute, defines more clearly the added value
provided by TSOs and understands the potential for even greater
added value. There is a need for a broader understanding of the
benefits that accrue from a diverse range of providers and for
specific examples to galvanise partnership working.
Is there evidence that where services are provided
by the third sector ,that they are popular with those that use
them?
Turning Point believes that our not-for-profit
ethos means we have a greater focus on service quality and service
user's experience, embracing different ages, needs, localities
and cultures. Many users say that they prefer Turning Point to
statutory providers because we are more independent and better
linked to their communities.
Turning Point is introducing a service user
survey into the organisation later this year so that we can get
more quantitative data in this area. There should be an expectation
that providers from all sectors can demonstrate how they regularly
assess user satisfaction. They should also undertake an analysis
of whether services are meeting whole needs, and how they target
social exclusion.
For Turning Point, our person centred approach
means that a service does not have to have clear parameters; it
moves and develops to fit the needs of the person.
CASE STUDY:
SIMON JOHNSTON
Simon has a learning disability caused by a
brain injury. He decided to set up his own business, and chose
the idea of a cleaning firm, as it is "something people always
want done". With support from Access Point, a Turning Point
outreach service, Simon received advice from Business Link about
setting up a business. He completed a course to develop a business
plan and obtained legal advice on setting up a co-operative so
everyone involved is part of the business. Four other people with
a learning disability joined him and they have contracts for cleaning.
The work is split into shifts and everyone gets paid a wage.
Is there evidence of demand for more services
to be provided by the third sector? If so, who from?
According to research commissioned by the Department
of Health, local authorities want to see more services provided
by the third sector. One in five authorities said they would like
to transfer additional services, but were unable to find external
providers.[12]
Do public services provided by the third sector
more accurately reflect the changing needs of those that use them?
Turning Point's service users have multiple
and complex needs. They are people who the private sector cannot
profit from and the public sector find it hard to reach. The third
sector has become, for them, a more effective intervention, combining
highly responsive services and hard-hitting campaigning.
Turning Point has responded to the complex needs
of our clients by providing person-centred responses working with
whole people not single problems and drawing together whatever
support is needed across the boundaries of social care, including
health, housing and education. We are clear that it is our responsibility
and not the service user's to join services together. We bring
greater responsiveness and flexibility and the ability to deliver
specialist services that target people often missed by statutory
agencies ensuring that services both reflect the needs of communities
we work in, and in turn strengthens those communities through
our involvement in building social capital.
Is there evidence that contracting to the third
sector leads to greater scope for innovation in public service
delivery?
Today's health and social care provision is
failing to support the many people with complex needs who need
the most help. Current arrangements are fragmented and access
for people with complex needs is not straightforward. There is
a significant gap in provision in the most deprived neighbourhoods
and many services focus on people's problems in isolation from
the rest of their lives.[13]
There is an increasing recognition amongst government,
policy makers, commissioners and other providers that social care
is becoming the paradigm within which future mental health services
will be provided and so there will be increased demand for services
for people who have mental health and other needs such as a learning
disability or a forensic history. There are significant opportunities
to present new models of provision, which deliver "connectedness"
with other services. Voluntary sector services are often the glue
between different partners such a housing and health, health and
social services. We can play a pivotal role in making links with
other services and help develop consistent support and help people
navigate between systems.
Turning Point has extensive expertise in working
with people with a range of needs and a readiness to work with
people irrespective of their labels. For example, we know that
half of the drug users we see also have mental health problems
and those same people also need support on issues such as housing,
debt and seeking employment. Our experience convinces us that
in the future, health and social care services will need to be
more integrated. Service users do not want to have to do the work
of "joining up" services themselves: they want services
that fit around their lives. People with serious social care needs
should not have to knock on several different doors of several
different agencies to get help, and in many cases they simply
will fail to access support. As services change to deliver greater
choice to clients, integration will become more and more important.
Turning Point is working to ensure that primary care reform is
inclusive of social care reform and that new services are integrated
in a much more sophisticated way in future. Our aim is to work
with commissioners to advise them on how best to innovate to deliver
services that meet the needs of the whole community, and the most
socially excluded groups.
To this end, Turning Point has developed a new
approach to service delivery, "Connected Care" which
provides a joined up, tailored range of services which are designed
by and respond to the needs of the individuals and communities
they serve. It is designed to focus on neighbourhoods in the most
deprived areas in England. Connected care brings together mental
health, substance misuse, learning disability and other specialist
services. It also offers universal support—housing, education,
employment and benefits—all with one single point of entry.
It is a new way of commissioning services: empowering communities
to have more control to design and deliver their own services.
Another way in which third sector providers
can lead to greater scope for innovation is in the opportunities
for partnership with other sectors, sharing the skills and qualities
that each provider can bring to the service. As with Connected
Care, this partnership should not be limited simply to the providers
of services, but must also be with the consumer. The people with
the most understanding of which kind of services will be needed
in any given area are the people who will (or will not) use them.
The public should have a sense of ownership and control over public
services. Individual budgets and direct payments are examples
of ways in which services can be developed in partnership with
the service user and third sector organisations have been leading
the way in the introduction of this kind of approach.
One area where third sector involvement could
lead to more of this kind of innovation is that of offender management.
Turning Point already works with the Probation Service to provide
drug intervention programs and could build on this experience
to provide innovative rehabilitation services:
CASE STUDY—SOMERSET
DRUG INTERVENTION
PROGRAM
Turning Point staff at the Drug Intervention
Program team in Somerset have an effective partnership with their
Probation Area and with the Prison Service, to address substance
misuse by offenders. They work in multi-disciplinary teams based
in probation offices. The team includes members of probation staff
and an NHS nurse. They not only share an office, but also facilitate
group work jointly, have weekly team meetings, discuss cases freely
and make joint decisions on individual plans. All team members
work out of each other's bases. For example Turning Point run
groups and clinic sessions at the NHS drugs clinic and see referrals
for assessment and 1:1 appointments at the local Turning Point
office. The Turning Point team members are known by the other
individual team members and are warmly welcomed by them. Although
the different workers come from very different professional backgrounds
they work effectively together.
Currently not enough is being done to ensure
that the underlying causes of crime are tackled within the Probation
Service. Offenders often have a range of complex needs which need
to be addressed:
— 78% of people who come into contact
with Turning Point's criminal justice services are unemployed.
— 1 in 3 prisoners are without permanent
accommodation before their custodial sentence. A lack of suitable
housing can affect an offender's ability to find work. The Social
Exclusion Unit found that three times as many offenders with accommodation
on leaving a custodial sentence found paid employment compared
to those who left without having accommodation. Without suitable
housing, it may also be difficult to register with a local GP
and benefit claims may be adversely affected.[14]
— Around half of patients in drug and
alcohol services have a mental health problem.[15]
— 8 out of 10 male remand prisoners
who were drug dependent had two additional mental health problems.[16]
In the past, people with such complex needs
have not been given the right support. Funding has often only
been available to tackle single problems, making it difficult
for the voluntary sector to develop the right kind of "holistic"
care. Integrated support services across mental health, drug and
alcohol misuse for offenders within community sentences could
revolutionalise probation services and improve the health of offenders.
Tackling the underlying causes of criminal behaviour will in turn
reduce reoffending and bring savings to the taxpayer. An expanded
role for the third sector could build on providers' experience
of working with partners in probation and of linking offenders
to wider community-based services to put social care at the heart
of the criminal justice system.
Does commissioning benefit the third sector?
Will contractual relationships with the state
improve stability within the third sector?
Turning Point is a third sector organisation
which exists for public benefit. Our aim is to "turn lives
around". We do not make a profit, nor do we have shareholders.
The income we receive from the provision of public services is
ploughed back into service delivery for the benefit of our clients.
Such funding gives organisations like ourselves the stability
we need to continue to achieve our aims.
We deliver services which help some of the most
socially excluded people in the country. The reality they experience
in general is that they frequently struggle to find the support
they need. Without Turning Point support funded by contractual
relationships with the state, these people very easily fall between
the gaps in traditional public services.
Because of the stigma and problems associated
with substance misuse or mental health problems, our client group
are often the people left at the back of the queue when it comes
to charitable giving. Therefore to support them effectively, we
need to broker contractual relationships with the state. It is
the state's responsibility to fund services to ensure that these
people get the support they need, but the state does not have
to do all the work alone.
Will close involvement with service provision
prevent third sector organisations retaining the ability to be
critical of government?
There is no evidence that charities involved
in public service provision are wary of being critical of government.
Turning Point received 97% of its funding from contracts and grants
from central or local government to provide public services. However,
as a third sector organisation, this has never stood in the way
of our work in giving our service users a voice to speak to the
heart of government. In fact, the opposite is true; we are an
effective campaigning voice precisely because of our frontline
experience. Our research and policy work has always been rooted
in making practical recommendations on how we can best turn lives
around, taking those ideas to government, the media and the public
and directly piloting innovative new services. Thus our campaigning
and service delivery roles are complementary: the way we deliver
services is informed and strengthened by our direct role in campaigning.
Examples of Turning Point's effective campaigning over the last
few years include:
— Routes into Treatment: A hard-hitting
campaign calling for a radical rethink of criminal justice responses
to drug problems highlighting the dangers of ignoring the public
health and social care impacts of substance misuse.
— The Crack Report: A pioneering
piece of research into the rise of crack use in the UK and the
changes in policy needed to tackle the issue effectively.
— Hidden Lives: A shocking analysis
of the stigma and inequality faced by people with a learning disability:
Despite the Government's stated commitment to tackle social inequality
and exclusion and to create an "opportunity society",
people with a learning disability who have high support needs
are too often socially and financially poor—living in, but
rarely part of their communities.
— Bottling it Up: A campaign
to highlight the needs of the one in eleven children in the UK
who live with parental alcohol misuse. This previously neglected
issue was as a result of our campaign, mentioned by Tony Blair
in his speech to launch the government's Social Exclusion Action
Plan in September 2006: "One of the biggest problems we face
is parents who misuse alcohol. One in eleven children in the UK
live with at least one such parent".
Is there a risk that the service providers will
become increasingly bureaucratic?
There is a risk that if commissioning is not
got right, too much of service providers' time will be taken up
dealing with the bureaucracy of the tendering process. This is
not, however, an argument for there to be no contractual relationship
at all. By standardising and streamlining the contractual process,
as the government aims to do, statutory commissioners will be
able to get the most out of their providers, no matter what sector
they come from.
Is there a risk that third sector organisations
will lose their independence, their identity or their distinctive
ethos?
Turning Point delivers a much needed service
to the public, but that is not the same as becoming a state-run
public service. It is precisely our values as a charitable, social
enterprise, unencumbered by shareholder interest that makes us
so responsive and engaging for those who need us. It is interesting
that the idea that the "independence" of private sector
providers of public services is rarely questioned to the same
degree.
Might the third sector become polarised between
large service providing organisations and more radical groups?
If so, would this matter?
This question implies that larger, service providing
organisations are not "radical". Thinking of national
organisations, such as Turning Point, as one homogenous service
provider misinterprets how we operate. Turning Point has individual
contracts with many local authorities, commissioners, and primary
care trusts to provide bespoke services for which we are locally
accountable. This gives us the freedom and flexibility to radically
respond to the different needs of our service users in different
areas of the country. On the other hand, our size enables us to
share best practice and to deliver better value for money, as
well as giving us the ability to champion the needs of our service
users in our national campaigning role.
Our experience has shown us that it is when
we are commissioned to work in partnership with local providers,
all the stakeholders benefit from that partnership. It is essential
that the commissioning practice is inclusive of smaller organisations
and that consideration is given to sub-contracting to smaller
organisations.
We believe that more can be done to encourage
growth in the third sector and support smaller organisations to
become more sustainable. The Government's Change-Up programme
should be used to enable larger voluntary sector providers to
build the capacities of particularly small organisations to enable
them to participate effectively.
As part of this programme, Turning Point was
funded by the Home Office to support small voluntary organisations
with a substance misuse connection to become more sustainable.
Support offered by Turning Point included advice on setting up
new services, training for staff on harm reduction and other drug
issues, linking with similar organisations in other parts of the
country, support with research projects and marketing advice.
Does commissioning services from the third sector
have any benefits for the state?
Turning Point, like other social enterprises
and third sector organisations delivers all the wealth of benefits
to society that meeting the needs of our service users can bring.
Moreover, we contribute to the wider economy through our services,
turnover and employment, but unlike a business, we are not driven
by the need to maximise profits for shareholders and owners.
Are services cheaper to provide?
It is a common misconception that services provided
by the third sector will be cheaper than those provided by any
other sector and that as a result either cost savings can be made,
or increased capacity can be achieved for the same level of resources.
Statutory commissioners can sometimes take the attitude of "This
is the service we need provided, here's the money we are willing
to give you get on with it", and third sector organisations
can often be the first target for cuts in funding.
At Turning Point we believe in the principle
of full cost recovery for our services. The third sector should
not be seen as a cut-price alternative to statutory provision.
Are the benefits of the third sector participation
in public service provision so great that it is appropriate to
have financial rules which encourage this, or should the aim be
to have "competitive neutrality" between public, private
and voluntary sectors?
Third sector organisations need to be involved
from the start in planning and providing services for the people
they work with. This requires fundamental changes to the way voluntary
organisations are treated. Turning Point has argued that we need
a more strategic relationship that doesn't treat the voluntary
sector as amateur or as a cheap alternative. The professionalism
and expertise of not for profit agencies should be recognised
both in the way they are funded and in the influence they have
on the development of projects and social policy. Just as voluntary
agencies should not expect handouts on the basis that their work
is "worthy", service commissioners should not expect
them to run services at a loss because they are "charities".
Based on these principles the charity sector should be treated
as one element in providing effective social care to every member
of society, even those hardest to reach.
Third Sector organisations are not asking for
special treatment. The sector needs to get better at contracting
and understanding the commercial environment in which we operate.
Third sector organisations should be judged with the same high
standards on responsiveness, accountability and quality as any
other sector. They should, however, be able to operate on a "level
playing field" when it comes to public service provision.
The sector as a whole has been, and in many respects continues
to be, on an uneven footing with other providers:
— Unfavourable and short-term contracts
are the norm. "Sudden death" contracts are not uncommon.
— There is a suspicion that voluntary
or social enterprise organisations are less professional and business-minded
than private sector providers.
— The costs of the Department of Health
are included in PCT contracts; private sector organisations are
expected to have overheads but the voluntary sector has to continuously
justify and defend its own corporate costs.
To redress the balance, Turning Point has a
number of recommendations to build the capacity of third sector
providers.
A VOLUNTARY FINANCE
INITIATIVE
Steps have been taken to help increase the capacity
of the third sector. For example the Futurebuilders fund is designed
specifically to provide investment support for organisations that
want to take on a role in public service delivery, or expand their
existing role. Turning Point would like the Department of Health
to address the third sector's access to long term capital finance.
In the United States, the not-for-profit sector is able to borrow
money through bond issues and have access to capital. This gives
greater flexibility to the voluntary sector. 60-70% of the market
place is dominated by the non-profit sector to the exclusion of
the private sector. In contrast, the voluntary sector in this
country is unable to access loans for large scale capital projects
as it is unable to compete with the private sector. Although Futurebuilders
heralds increased opportunities to expand service delivery, the
part dedicated to capital investment is a small part, of a relatively
small pot of money. This has encouraged practitioners in the voluntary
sector to look to new forms of accessing capital finance. Turning
Point would like to see the development of a Voluntary Finance
Initiative (VFI) to allow not for profit organisations to raise
capital finance to compete more directly with private and public
sector organisations. Currently, contracts are often short-term
and charities are forced to spend a large amount of their time
working on contracts and securing funding. This is time that could
be better spent on delivering the services that are needed. VFI
would ensure longer-term and more standardised contracts that
voluntary agencies could borrow against to invest in capital or
other development costs of the service. The benefits of VFI would
include:
— Increasing larger TSOs' capacity
to deliver services, funded by PCT contracts.
— Increasing the supply of services
which meet the long-term care needs of socially excluded groups,
and in certain politically sensitive and pressing areas such as
substance abuse, in which the private sector is relatively weak.
— Reduced pressure on other services,
including hospital waiting lists.
— Increased competition and choice
for commissioners and service users.
— Enabling PCTs, and other purchasers/funders,
to maintain a share in equity.
— Over the longer term capital investment
would return to government rather than to private investors.
— Reducing the risks of over-dependence
on private sector providers.
One area where VFI could be particularly beneficial
to the health service is "out of area placements". Local
authorities without enough specialist services, for example mental
health support, are forced to fund patients to access services
out of their area. This is costing the NHS huge amounts of money
each year. VFI would allow agencies to borrow money to develop
services in that area, leading to long-term savings and allowing
service users to stay close to their homes, families and carers.
A STANDARD FORM
OF CONTRACT
Third sector organisations should be able to
expect fair and consistent procedures to negotiate with local
authorities, and such procedures would encourage greater enthusiasm
from the sector for providing public services. Currently, there
is considerable variation in contracts between local authorities
and third sector providers. The nature of the contract itself
can undermine what a voluntary sector organisation wants to bring
to a service, for example, if it is overly prescriptive about
processes rather than outcomes. Turning Point believes that a
standard form of contract between the voluntary sector and local
government would ensure fair contracts and efficient use of resources
for both parties. A standard form of contract would clear up the
anomaly, whereby a voluntary organisation has a fixed contract
with central government (the voluntary sector compact) but must
renegotiate new agreements with local authorities. A standard
form of contract has the potential to enhance focus on the actual
service rather than the legal framework it is going to be delivered
under. It will also make services easier to monitor and will enable
commissioners to draw comparisons across different providers and
between different localities. Already tested at national level,
the Standard Form of Contract is a practical step that promotes
a contestable welfare market. Turning Point has developed its
own standard form of contract which could be adopted across local
government. This would make the contracting process more consistent
and equitable.
March 2007
8 Mapping Clinical Governance in Voluntary Sector
Organisations, Mental Health Providers' Forum, National Institute
for Mental Health in England. Back
9
Wolfenden Committee (1978) The Future of Voluntary Organisations,
Croom Helm, London. Back
10
Billis and Glennerster (1998) "Human services and the voluntary
sector: towards a theory of comparative advantage", Journal
of Social Policy, 27(1): 79-98. Back
11
Research Report prepared for Department of Health by IFF Research
Ltd, 13 February 2007. Back
12
Ibid. Back
13
Turning Point/IPPR report 2004. Back
14
The Social Exclusion Unit. Back
15
(Dual Diagnosis Manual Royal College of Physiatrists (2002).
Dual Diagnosis, Good Practice Guide (2002 Department of Health). Back
16
Ibid. Back
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