Examination of Witnesses (Questions 347
- 358)
TUESDAY 28 OCTOBER 2008
MR RICHARD
KRAMER, MS
CATHERINE HENNESSY
AND DR
MILES RINALDI
Q347 Chairman: Dr Rinaldi, Ms Hennessy
and Mr Kramer, welcome. We are very pleased to see you. You represent
a variety of organisations working in this field, which we have
written down so I will not repeat it. I am going to invite you,
in whatever order you choose, to follow the same procedure and
give us your ideas.
Richard Kramer: I will volunteer
to go first. I am Richard Kramer from Turning Point. Turning Point
is a social care organisation that works in the fields of drugs,
alcohol, mental health and learning disability. In terms of the
challenges, Turning Point supports a much more co-ordinated approach
to commissioning, as we have heard, that can meet people's health
and social care needs, the need for assessments to be multidisciplinary,
closer inter-agency working and more involvement of service users,
both in the delivery of services and planning of those services.
I have been asked to talk about Connected Care, which is Turning
Point's model of community-led commissioning, where we seek to
integrate health, housing and social care services in the most
deprived communities, where the communities are central to the
design and delivery of those services. The evidence base was some
work we did with IPPR that showed that those people in the most
deprived communities are likely to have the broadest range of
needs and are less likely to have those needs met. We are working
in Hartlepool, Bolton and have just started work in Suffolk, in
Warrington, and the key issue is that the communities are central
to the whole project; they are part of the governance, so they
are sitting alongside redesigning services with the directors
of adult social care and the PCT. The key part is we train up
members of the community as researchers to research and understand
the health and social care needs of that community, and turn those
findings into a report and then work with commissioners to redesign
services. The service in Hartlepool provides immediate support
to everyone in the community, both low-level support and support
people with complex needs, so that people only have to have one
assessment; they can be helped in a system of health and social
care and they can get support from a multidisciplinary team across
health and social care. I have been asked to highlight how community-led
commissioning and learning what works in the community could be
translated into the criminal justice system.
Q348 Chairman: Are you talking about
a limited number of people within a sub-community within Hartlepool?
Richard Kramer: Yes. We work on
the community base, where "community" is defined on
an estate or ward basis, so a population of between 5,000 and
11,000. It is a solution for the whole of the community, not just
those with complex needs, but for members of the wider community.
Q349 Mr Heath: So "a" community,
not "the" community, in the generic sense; a specific
community.
Richard Kramer: It is a specific
community. What we are able to track, just finally, is that as
well as building the capacity of the community and narrowing the
gap between commissioners' priorities over here and the needs
of the community over there, we also get a change of the perception
of the community towards the community. So at the start of the
process in Hartlepool there was a particularly poor regard for
particular groups, such as people with mental health needs, but
by the end of the process there was a recognition that people
with mental health needs also had housing needs and employment
needs, and they were valid members of the community. So it is
not only leading to better designed services but, actually, strengthening
communities as well.
Catherine Hennessy: I am here
today to give evidence on behalf of the Milton Keynes Link Worker
Plus project, one of 12 pilots funded on a cross-governmental
basis to work with adults facing chronic exclusion. I work for
Revolving Doors Agency and we have long been concerned about the
over-representation of people with a range of needs, as described
by previous speakers, within the criminal justice system, and,
as Angela Greatley mentioned, the fact that often the thresholds
for community services means that their needs in any one area
do not quite meet the threshold for receiving a service. We were
approached by a group of commissioners in Milton Keynes, including
the PCT, mental health services, probation, police and the Community
Safety Partnership, who were concerned about this self-same group,
whom they thought often presented at crisis points in the system,
like police custody and in the A&E department, but often failed
to engage with services. So two workers were appointed to provide
direct support to this group and to work with them to ensure that
they accessed the services that they needed, such as primary mental
health care, as previously mentioned, and, also, housing and other
treatment services for substance use. The service, as previously
described, is persistent in its approach, so workers try repeatedly
to engage with service users. The service map nowadays can be
complex and intimidating, I think, for users who are trying to
engage with it, and the workers help them to navigate that system.
Finally, they provide advocacy and, also, brokerage to enable
people to engage with services. Currently, one-third of referrals
to this service come from police or probation sources, but about
80% of those referred overall have previous or current contact
with the criminal justice system. The project is overseen by a
steering group comprised of the commissioners and leads from the
different agencies who were involved in setting up the service,
and in this way learning from the project is fed directly to local
commissioners. This provides them both with evidence of need but,
also, an awareness of potential gaps in the services that they
run, and thus we think that intelligence from those services can
be used to inform commissioning. The project is unique in that
it has cross-governmental funding, which enables it to run, but
also there is broad local support for it, and this is an undoubted
benefit, we think, given the range of needs of those referred
to the service.
Dr Rinaldi: Miles Rinaldi, from
South West London St Georges Mental Health NHS Trust. I am here
to talk about the New Directions Team which is funded through
the same sources as have just been mentioned. It is a partnership
with the London Borough of Merton but, also, a kind of partnership
with a much wider range of stakeholders in the borough. In essence,
we have put together a very small team—two case managers
and a team manager—to persistently and assertively enable
people who are facing chronic exclusion to be able to re-engage
in the community, etc. The point of interest is that the London
Borough of Merton is not recognised as an inner London borough
and has pockets of huge affluence, but it also has huge dynamics
associated with inner London boroughs, so it is quite an interesting
mix in relation to the ASBOs that are issued, the evidence of
gang activity and the high perception of crime. The partnership
came together in a recognition (and very much touches on what
Angela Greatley was saying) of the toxic mixture of individuals
who do not necessarily meet the eligibility criteria for services
within the borough—so people who have common mental health
problems and may have a low learning disability but are not meeting
the threshold for learning disability services, and drug and alcohol
issues but not necessarily engaging with the services that are
available—and recognised that there is a cohort of people
within the borough who will, therefore, not engage with any service
and there was no service taking any responsibility for them. The
borough also recognised that there were problems with engaging
ex-prisoners with drug and alcohol problems, and what people were
talking around was very much almost like a MAPPA-type system being
needed for this group of people. Through the funding we were able
to pull this partnership together which represents, obviously,
mental health services, social services, the primary care trust,
the housing department, the youth inclusion services, the police,
drug and alcohol services, Jobcentre Plus, Learning and Skills
Council and the local volunteer centre. Through the funding we
have been very able, for the first six months, to actually work
very solidly and consistently on developing that partnership.
Everybody could very much recognise individuals and could even
name individuals who were in the borough who could be eligible
for this service, but as a way of trying to shape understanding
and to actually work towards a shared goal and shared identification
of people we developed what we called "a chaos index",
which was based very much on local case studies from local organisations
about the types of people who they thought would be eligible for
this type of service. Behaviours from that index were identified,
it was mapped against the national assessment criteria, and we
developed an assessment which has now been in operation for seven
months. We reviewed it at six months and it is capturing the types
of individuals that the partnership originally sought to identify.
I suppose the overall kind of aim of the New Directions Team is
around collaborative agency working—it was very much from
day one—and the first six months, as I said, were spent
developing that collaborative working and understanding where
the problems were between agencies to form shared goals in relation
to this project. In terms of jargon, to develop very clear, integrated
pathways to enable people to move from stages of being at risk
to being more settled within the community and to move into education
and employment, the team were there to intensively case-manage
individuals, really focusing very much on the engagement of people
using a whole range of different approaches, including things
like motivational interviewing, which has already been spoken
about, to help people to navigate the local system and the local
services. Whilst that was happening at an individual client level,
we also wanted to look at flexing the existing eligibility criteria
for services. It is one thing to try and navigate the systems
for this one group of people, say, but services may need to do
a bit more work in a different way, and so we have been trying
to test out different kinds of flexions of different organisation
systems—be it the police, housing departments, etc.
Chairman: Thank you very much.
Q350 Mr Heath: Just coming back to
the previous evidence session, and you were in the room, about
the proliferation of pilots and the lack of sustainable pilots,
I just wonder if any of these schemes actually have a clearly
mapped out sustainable source of income which will keep you in
existence, or whether the integration that you are describing
could just as quickly disintegrate as soon as the Government turns
to another direction.
Catherine Hennessy: I would say
that in Milton Keynes there is broad commitment from the parties
who are involved in funding the project to its continuation beyond
the pilot period. One of the difficulties that we have encountered
with previous schemes in the past is that, in the words of a local
councillor I once spoke to: "If we succeed in keeping people
out of prison we don't get that money; the prison saves the money
but we don't." I think this goes right to the heart of the
justice reinvestment argument, that often local services, by engaging
and taking up and providing support to this group, initially find
themselves with an additional cost outlay. Over the longer term
that will be rectified, but that is very much one of the difficulties
with schemes that seek to divert people away from criminal justice
and there is not then a reinvestment in the community services.
Q351 Chairman: Do you think you have
established cost-effectiveness measures?
Catherine Hennessy: Like all 12
of the pilots, a robust national evaluation has been carried out
and they are still in their early stages, but I am optimistic
that we will show that those diversions, certainly from the criminal
justice system and over the longer term, will be cost-effective
in getting people back into employment and back into sustained
housing where they can become productive members of society again.
Richard Kramer: In addition to
that, Turning Point is doing some work looking at the cost-benefit
analysis of integrating services together. So we are working with
commissioners to map the flow of resources in health, housing
and social care, and mapping the consequences of bringing services
together. The core dynamic is moving from unplanned services to
planned services, and looking at levels of need across low, medium
and high needs. An example of unplanned care may be presentation
at Accident & Emergency, or an emergency presentation to mental
health services. So the benefit of that is that we are getting
agencies early on to think together to recognise that the cost
borne in one agency may be saved in another agency or there may
be additional cost further down the line. So it is a very useful
tool in getting services to think together to recognise the connectivity
between services and to pull resources together. So, in terms
of criminal justice, we would hope that by bringing police and
probation to the table they will see the cost savings to the criminal
justice system in providing connected care services and having
better connections between services.
Q352 Alun Michael: Part of me is
inclined to react to what you have been saying by saying: "Yes,
it is blindingly obvious and it is good to see progress in that
direction". The other part of me is the pessimistic bit.
I was involved in the project working together for children and
their families led by the late Barbara Kahan 30 years ago, and
the things you are talking about, and that we talked about in
earlier evidence, are very much about early intervention and identifying
youngsters at risk, and joint action by agencies. Getting agencies
to think together is easy (well, actually, it is not; that is
quite difficult) but getting agencies to spend together for each
other's benefit rather than their own benefit is extremely difficult.
So what is different about the evidence that the three of you
are giving us to the things that have been blindingly obvious
for the last 30/40/50 years? What is the trick that brings it
from being a nice project because this group of professionals
in this particular area have responded positively to a joint working
model, to something that actually changes the way in which we
do justice in this country in order to effectively reduce the
offending with the harm that that does to both victims and to
the offender?
Catherine Hennessy: I do not think
there is any easy answer to that. There is something about getting
a common purpose, and I know that some of the early work in Milton
Keynes was on establishing a common purpose. Very early on, people
were reluctant about sharing money and putting money into a jointly-funded
service. There also has to be a preparedness to accept that, perhaps,
the service that I am in charge of and that I represent on this
steering group is not the greatest sometimes at dealing with this
group.
Q353 Alun Michael: What I am getting
at is there have been lots of examples of that. When IT did not
mean Information Technology and it meant Integrated Treatment,
there were some tremendous models of very effective work and joint
working and sharing and all the rest of it. However, it comes
and it goes—it is a policy one moment, it is an intervention,
it is a team here—but actually moving it from projects or
examples of good practice to universality is surely what our inquiry
is about—how you get that strategic change. I do not get
from the evidence yet a sense—I am not disagreeing with
anything you have said—of how you make that leap. I think
that is what we are looking for, is it not?
Richard Kramer: Part of it is
having evaluation at the outset to show that a pilot can be mainstreamed.
Part of it is the cost-benefit analysis that can provide some
of the evidence for change. In our work with Connected Care, when
we start people give a commitment to integrate services and look
at service reconfiguration and how services can be more accessible
to the community. Ultimately, when the communities are devising
their blueprint for change it becomes an excuse remover for commissioners
because the sense of accountability has changed, shifting from
the commissioners to the communities. So the community is saying:
"Actually, we do want this to happen", and so it binds
the commissioners in that way. I agree with you, pilots take time;
being innovative takes time to establish the evidence base and
it takes time for that to be mainstreamed into commissioner thinking.
Q354 Alun Michael: It sounds as if
you are saying that it is embedding the right methodology that
is the key.
Richard Kramer: It is getting
buy-in for the project and buy-in to the vision, which makes it
easier for decisions to be made on changing funding, ultimately,
when decisions are made on service configuration. So, yes.
Q355 Chairman: Your expression "excuse
remover" I think I could use again in certain contexts!
Dr Rinaldi: I suppose what we
are trying to do is cost-up each individual who comes into our
service, based on previous behaviours and, also, the trajectory
of the behaviour if there was no intervention, and to then look
at what saving is made by providing this intervention—to
look at the cost benefit from that. If I give you just a practical
example of that: somebody who had been in contact with the police
a lot and it was part of a condition of bail that he had been
told not to go round to his mother's house, he breached that the
same day and was then put into HMP Wandsworth. So there is an
associated cost with that. At that point the team came into contact
through intense case management over a short period of time, and
the drug and alcohol issues have started to be reduced, the individual
has had no contact with the police since the team have been involved
and the individual has just started an education training course
and has also just secured part-time employment. So we are trying
to look at what would have happened from his behaviour to date,
from everything that we know, through to previous short-term interventions;
what the results are and associated savings. One of the challenges
for our partnership is once we have got past the issues around
information-sharing and confidentiality the individuals we were
talking about were all known to the various different agencies.
So there was a commonality; these individuals that we picked up
are actually bouncing between different agencies causing, at a
local level, issues in terms of cost through people being banned
and being struck off from services, trying to engage them and
not being successful, to all of a sudden having a pathway through
which is connecting people back to those services, so that there
is not the cycle in terms of police, criminal justice or turning
up at Accident & Emergency. So there are quite clear, transparent
savings to be found. We are only seven months through our operation.
Q356 Julie Morgan: My question was
very similar to Mr Michael's, because it did seem to me that they
were excellent presentations of what you were achieving and obviously
reaching a group that was very important when you referred to
the low-level people who did not really reach the threshold—the
sort of issues that we are all well aware of. To me the issue
is how is that evaluated? How do you establish the best practice
and then make it something that is used throughout the country?
I was thinking back to the previous evidence that Professor Shepherd
was giving about having somewhere that was an institute of excellence
where you were able to measure all these different projects that
have been done. I do not know whether you have any comments on
that. Otherwise, you fear that there would be another evaluation
at the end, and it would all come out very well and then there
would be a struggle for funding—the patterns that I have
certainly seen with very good projects in the past.
Catherine Hennessy: I think there
is an increasing body of evidence about the needs of this group
and, also, the evaluation of these projects, amongst others, will
give evidence about a range of practice ideas. Probably one of
the other issues to be addressed, though, is the way in which
areas which do respond to the needs of this group are incentivised
to do so financially. That is a key issue: if there could be some
mechanism whereby local areas which respond in the ways that we
have described in an attempt to address the needs of this group
and how money can then be levered from the criminal justice system
to reward that local effort, evidence of practice will help. In
the time-honoured phrase: "money talks", and I think
if local areas can be in some way incentivised for so doing.
Q357 Alun Michael: Can we ask how
you would do that? I think that is right and I think this is very
much at the core of what we are trying to get at: how you allow
the money to follow the problem in order to solve the problem
rather than money following the problem in terms of merely perpetuating
it. It is how you crack that.
Catherine Hennessy: The growing
evidence around personalised services may provide some answers,
but I think there are difficulties around personalisation, and
packages for care following the individual. The individual choosing
their own support mechanism may go some way to addressing it.
However, at the level of commissioning and at the level of the
more global overarching structures for systems there needs to
be some mechanism which incentivises local areas to respond more
positively to this group and, as results are achieved, it is in
some way incentivised, which I understand to be one of the principles
at the heart of justice reinvestment, really.
Richard Kramer: There is sufficient
incentivisation—if that is the right word—in relation
to commissioners in the community through world-class commissioning
providing a lever to think about joining up services and making
sure users are at the centre of commissioning. Perhaps there is
not that same leverage to connect community and the criminal justice
system, and the issues around personalisation and money following
the client are probably less advanced in the criminal justice
system. In terms of personalisation as a term—different
targets and priorities—the different dynamics in terms of
the criminal justice system is much less advanced. So the key
is trying to have greater connections in terms of commissioning
priorities between the two and greater flexibility of funding
between community and criminal justice interventions. That is
why I think health and social care has a key role in terms of
reducing offending, in terms of looking after people's housing
and employment, health and social care needs. That can play a
big part in reducing offending. There is some cost-benefit work
nationally and through individual projects, and I think we need
to look to mainstream those pilots so they do not remain pilots
but become part of the business of commissioning and delivering
services.
Dr Rinaldi: I suppose there is
a part where I do not think any of us, really, could say with
all honesty that the services that we are running are the absolute
answer. I work for a mental health trust that covers five London
boroughs, and whilst I know that this seems to be, after seven
months, working effectively in one borough I am not sure that
we could kind of "cut-and-paste" it into the other boroughs,
yet I know from each other borough that they have a cohort of
people that they are very concerned about. I think there are lessons
to learn, and I think it does come back to the points that Professor
Shepherd was making about evaluation. If we look at things like
I alluded to earlier, in terms of one of the aims of our project,
which is looking at the MAPPA framework, there is a part which
is to say that, as far as I know, partnership working has not
actually ever been evaluated, but when you talk anecdotally to
different parts of the country about MAPPA, what different services
say is actually it has been a really helpful mechanism. I know
we talk about partnership working a lot but all organisations
still work very much in silos, and the feedback on MAPPA has always
been it is a coercive mechanism which has forced us around the
table and actually has been really beneficial. It has got us talking,
it has looked at our commonalities, and we have jointly worked
out solutions to the problem. There is a kind of lesson there,
because I am not sure that saying X service or Y service is actually
the answer, but having some kind of mechanism that brings together
the different agencies and looks at solving the problem in their
own localised way, which may be cutting-and-pasting or it may
be doing something very different, but giving them that coercive
mechanism to bring them together and get them to sort it out,
I think, is probably part of the answer.
Mr Turner: I am concerned about the fact
that, to start with, two of the three of you are from London and
one is just outside London, Milton Keynes. What is the position
for rural people? My constituency has two towns of 20,000, and
that is all—and other towns of a smaller size. I guess you
are the same.
Mr Heath: Only one town.
Q358 Mr Turner: I am getting the
impression that we tend to be neglected. There are a lot of questions,
but what do you do, first of all, to identify what is happening
outside in the rural areas and the small town areas? Is it proportionate
or are we actually quite good at looking after people, which big
towns are not capable of doing?
Richard Kramer: We have just started
in a rural area in Suffolk, where we are able to test out the
model of community-led commissioning in a rural area. Of course,
a rural area will have different needs and priorities and different
challenges facing that community—it may be through a big
distrust of services and a feeling that rural areas are ignored.
There are also some issues around low-level depression or mental
health linked to unemployment; issues around young people and
anti-social behaviour. So the actual response of Connected Care
will really need to reflect those specific needs of that community.
However, a rural approach will be very different because the needs
and challenges facing that rural area will be very different.
The way Connected Care works is that the Connected Care response
will be specific; there will be some common approaches in terms
of joining up services, building the capacity of the community,
making sure that services are easy to navigate, and getting a
workforce that can work differently across different boundaries
of health, housing and social care, but it has to work differently
in a rural area because, as you said, the issues are very, very
different.
Catherine Hennessy: I would echo
that. In relation to one of Angela's earlier points about, say,
the diversion of police custody, one of the projects we are currently
involved in is in North Devon where just the volume of people
passing through custody every day does not necessitate a full-time
presence in the way that you might have in an inner city custody
suite, but the issues are nonetheless serious. So we have been
working to try and think of a creative response too.
Chairman: Thank you very much indeed.
We are very grateful for your help. That ends our proceedings
today.
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