Memorandum from Together
The following response is based on the experiences
of a voluntary sector organisation providing services as contracted
by London Probation and other statutory commissioners in health
and social care.
CONTEXT
Together is a leading national charity working
for wellbeing supporting people with mental health needs. The
organisation provides a range of services across the UK; by campaigning
and undertaking research; and by educating local communities about
their own mental health needs.
One of the services operated by Together is
the Forensic Mental Health Practitioner Service:
The service is operational within eight London
boroughs, utilising nine forensic mental health practitioners,
with the aim to help and support offenders with mental health
needs within London Probation, Magistrates Courts, HMP Wandsworth
and the Drug Intervention Programme in Hammersmith & Fulham.
The service provided focuses on:
— first level mental health assessment
and triage service for mentally disordered offenders in court
and, when appropriate, recommendations to facilitate diversion
into health care;
— mental health assessments of offenders
under the offender management of probation, signposting into (or
back into) services and provision of short-term interventions;
— an advice and liaison service to
both Probation and Court staff;
— a specialist mental health assessment
and intervention service to offenders as part of the Drug Intervention
Programme;
— an anger management service to users
of community mental health services;
— an assessment and intervention service
to remand and short-sentence prisoners with mental health needs;
and
— a mental health advice phoneline
to London Probation staff working in boroughs where there is no
direct practitioner service.
1. What are the benefits of contestabilty
to the users of public services?
(a) Have services which have been transferred
to third sector organisations shown improvements in quality?
In the case of the Together Forensic Mental
Practitioner Service (FMHP Service), service-users now have access
to specialist support as part of their offender management by
London Probation (LP). Improvements in quality of the service
provided include enhanced and more effective communication between
services, which is co-ordinated by the Forensic Mental Health
Practitioner (FMHP) to ensure that clients, who are frequently
marginalised and excluded from services, can access and receive
the help from local services that they need.
(b) Is loss of accountability a threat of
commissioning services? If so, how can this best be managed?
London Probation is one of the main commissioners
of the FMHP Service (along with other statutory stakeholders such
as PCTs and NHS Trusts across London). As the FMHP Service is
working closely and in partnership with London Probation, accountability
and responsibility is shared, but decisions in relation to issues
of enforcement remain the responsibility of London Probation.
Ultimately, accountability remains with the Offender Managers.
Contractual arrangements between Together and
London Probation very clearly sets out who is accountable for
what in relation to the management of offenders with mental health
needs. These arrangements, which include operational and practice-based
agreements such as how information is recorded and shared, are
kept under constanct review through quarterly contract meetings
and ongoing liaison between the Together Service Manager and the
LP Commissioner.
2. Is the third sector more likely to provide
better public services than the state or the private sector?
(a) Is there evidence that where services
are provided by the third sector, that they are popular with those
that use them?
Service-users who have had had contact with
both the mental health and criminal justice systems have often
experienced a significant degree of social exclusion and disadvantage.
These experiences may be as a result of their social circumstances,
including traumatic and abusive past events, or may be a direct
result of the discrimination that they have encountered at the
hands of agents of these two systems. Third Sector organisations
are well positioned in order to advocate on behalf of these service-users
and to encourage their engagement and support them to sustain
their engagement with services once their care pathways have been
identified.
The primary aim of the Together Forensic Mental
Health Practitioners working within the courts, London Probation
and HMP Wandsworth is to facilitate a trusting alliance with service-users,
which often requires a level of creativity and flexibility that
is not available to the statutory sector. This more person-centred,
rather than system-centred approach, validates the experiences
of the service-users and increases their confidence that they
will receive the support and help that they are seeking.
(b) Is there evidence of demand for more services
to be provided by the third sector? If so, who from?
(c) Do public services provided by the third
sector more accurately reflect the changing needs of those that
use them?
Offenders with mental health needs who are in
contact with the criminal justice system have long since had their
needs neglected through lack of statutory resources, such as poor
diversion out of the criminal justice system and into (or back
into) appropriate healthcare. It could therefore be argued that
it is not always the case that service-users needs have changed,
but that we are recognising that public services have been failing
in their duty of care to meet those needs.
In the case of the partnership between London
Probation and the Together FMHP Service, there was an explicit
recognition that London Probation did not have the specialist
resources available to meet the needs mentally disordered offenders
and that Offender Managers were also struggling to access local
mental health resources on behalf of their offenders.
(d) Is there evidence that contracting to
the third sector leads to greater scope for innovation in public
service delivery?
The Together FMHP Service has been pioneering
an approach of undertaking the direct supervision of offenders
with mental health needs who are under the offender management
of London Probation. This is in recognition of the criminogenic
needs of offenders, that some offenders committ offences as a
direct result of poor mental health and that diversion out of
the Criminal Justice System is not always possible or appropriate.
By undertaking the direct supervision of those offenders, with
the offender management remaining the responsibility of London
Probation, their needs may be more effectively met with the aim
of reducing their risk of re-offending, improving their mental
wellbeing and reducing the burden on both London Probation.
This is also particularly evidenced by the increasing
acknowledgment that offenders with personality disorders, who
often present with distressing, destructive behaviours and problematic
personality traits, challenge agencies' capabilities to manage
and treat their syptoms and behaviours. Specialist case management
as part of their offender management and improving the co-ordination
of services, is more likely to lead to better risk management
and a decrease in the risk of harmful behaviours either towards
themselves or others.
3. Does commissioning benefit the third sector?
(a) Will contractual relationships with the
state improve stability within the third sector?
The current contractual relationship between
London Probation and the Together FMHP Service has been agreed
for a three year duration. Previously, the agreement was reviewed
on a yearly basis making service planning and development more
problematic. In essence this arrangement has increased the stability
for over half of the funding of the service, although a clause
in the contract allows for termination of the contract by LP giving
a period of notice. The relationship has also allowed for closer
working practices between Together and London Probation, with
the Together service more accurately demonstrating that it is
supporting London Probation to meet its targets and responsibilities
in relation to offenders with mental health needs.
Service Level Agreements with other commissioning
bodies, such as the PCTs and Mental Health Trust, are generally
more at risk to cuts or withdrawal in funding particularly in
the current climate. As the FMHP Service operates in a number
of different London boroughs, the risk varies as grants may be
reviewed on an annual basis or a three-year period. Limited or
no annual inflationary uplift is also a common feature, which
may contributory factor to deficit budgets for proceeding years.
(b) Will close involvement with service provision
prevent third sector organisations retaining the ability to be
critical of government?
(c) Is there a risk that the service providers
will become increasingly bureaucratic?
In order to demonstrate effectiveness of service
provision through demonstrating positive outcomes and value for
money, organisations are already involved in a certain amount
of bureaucracy. However, this is essential to promote good practice.
If anything the closer involvement with service provision by the
Together service with London Probation and other key stakeholders,
the more focused the service has become in terms of raising standards
and striving to providing a high quality service and providing
the evidence that we are achieving our aims and objectives.
(d) Is there a risk that third sector organisations
will lose their independence, their identity or their distinctive
ethos?
In the case of Together, as one of the main
national mental health charities in the UK, the infrastructure
of the organisation which has a distinct focus on service-user
involvement and campaigning (for example as part of the Mental
Health Alliance) provides the kind of framework that allows services
to maintain their independence and integrity. This may be more
problematic for smaller organisations.
(e) Might the third sector become polarised
between large service providing organisations and more radical
groups? If so, would this matter?
The third sector in general has always fulfilled
a vital role of agitating for change and pricking the social conscience
of the state and within that there have always been more radical
groups who have driven the agenda, particularly in key areas such
as social exclusion and discrimination. If large organisations
predominantly provide the services, there is a real risk that
these smaller groups will not survive. This is why initiatives,
such as the LankellyChase Foundation/Tudor Turst focusing on supporting
smaller organisations in the South West in the NOMS process, are
key to ensuring that innovation and creativity is not lost from
the third sector.
4. Does commissioning services from the third
sector have any benefits for the state?
(a) Does the state risk losing control of
service delivery in a way which might be damaging?
In the case of the Together FMHP Service and
providing specialist support of offenders with mental heath needs,
the statutory responsibility remains with London Probation even
if some of the legal requirements are undertaken by the Together
practitioner. Agreed protocols, such as around information sharing,
ensures that the Offender Manager is fully aware of the service
being provided to the offender, the offender's engagement with
that service etc and, thus enables the Offender Manager to ensure
that the statutory responsibilities are being fulfilled.
(b) What capacity will the state need to ensure
that it can be an intelligent customer of services?
(c) How is duplication of effort in order
to monitor and manage contracts best avoided?
Through a single point of contact and through
agreed expectations in terms of the kind of data required to effectively
monitor contracts—for example, the Together FMHP Service
is required to provide monitoring data to London Probation and
a number of PCTs and MH Trusts across London. Agreement was recently
reached in terms of what each of the commissioning stakeholders
required in terms of measuring service outcomes and how this could
be incorporated into one set of monitoring requirements. This
has primarily been facilitated through a working group from Together
and London Probation and aims to avoid undue time being spent
on producing different sets of monitoring data for each stakeholder.
Piloting of the new monitoring practices further allows for each
commissioner to review and comment.
(d) How good is the state at managing bidding
processes and defining contractual obligations when commissioning
services?
Practices vary greatly and some support to manage
the process of commissioning through defining standards would
be helpful to ensure transparent processes, value for money and
good outcomes for service users.
5. What are the financial implications of
providing services through the third sector compared with directly
provided state services?
(a) Are services cheaper to provide?
Commissioners shouldn't expect third sector
organisations to be cheaper—Together expects to demonstrate
value for money and we should be judged on this as well as service
quality. It is right that we should expect to recover our full
costs from contracts—something that most third sector organisations
are saying that they don't do on most contracts at the moment.
(b) Are there "hidden costs" such
as contract oversight?
Yes, contract oversight is a cost.
(c) 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?
This may well depend on the kind of services
that are required. As already outlined, the independence of the
third sector can be particularly attractive to marginalised and
socially excluded service-users with the result that they may
be more likely to engage with services provided by the third sector
than by other sectors. If services are designed to be responsive
to the needs of the service-user, financial rules may well be
required to support the benefits that the third sector brings
to service provision.
February 2007
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