Health and Social Care Bill
Memorandum submitted by Turning Point (HS 117)
1
About Turning Point
1.1
Turning Point is a leading health and social care
organisation
. We work in over 200 locations, providing specialist and integrated services that meet the needs of individuals, families and communities across England and Wales. We have also developed Connected Care, Turning Point’s model of community-led commissioning, which is currently working in 10 areas of
England
to integrate health, housing and social care.
1.2
We are a social enterprise and reinvest our surplus to provide the best services in the right locations for people with a range of complex needs. Turning Point is responding to the committee’s inquiry on behalf of our 2000 members of staff and the 100,000 individuals who access Turning Point services every year.
2
Summary
2.1
This submission focuses on three key aspects of the Health and Social Care Bill:
·
Arrangements for GP Consortia – focusing on provisions for consortia to seek advice when commissioning services;
·
Public engagement and community involvement;
·
Integration and the extent to which it is promoted by the Bill.
2.2
We make a number of key recommendations to the government:
·
To ensure that consortia receive firm guidance on the nature of the advice that they must seek in order to effectively commission services, as well as the extent to which they must seek this advice, to ensure that they are sufficiently guided and advised on the commissioning of services of which they have little specialist knowledge – particularly for those with the most complex needs;
·
To widen the duty imposed upon consortia (clause 22 section 14O) to seek professional advice, to include a requirement to seek advice from those with expertise in social enterprise and not-for-profit organisations’ delivery of health and social care services;
·
To strengthen the duty upon consortia to promote patient choice and involvement by removing the phrase "have regard to the need to" from these provisions (clause 22 section 14N);
·
To ensure that the duty to involve is not just applied to consortia’s current "patients and carers". but to every member of the local population, including those not registered with a GP practice;
·
To amend section 13J of clause 19 and clause 179 of the Bill to strengthen the NHS Commissioning Board and the Health and Wellbeing Boards’ duty towards integration, replacing ‘encouraging’/’encourage’ with ‘pursuing’/’pursue;
·
To replicate this duty for GP consortia, to ensure that integration is pursued at a local level;
·
To promote a common definition of commissioning to ensure that in every area it is centred in local need, namely: ‘the means by which you understand the needs of an individual and/or a community such that you can build a platform for procurement.’
3
GP consortia: advice and collaboration
3.1
While Turning Point appreciates the expertise that GPs can bring to the commissioning of local services, we are also aware of the need for those with more specialised knowledge to contribute to such important decision-making processes.
3.2
Turning Point believes that commissioning should be a collaborative process, drawing on the knowledge and expertise of professionals from across the spectrum of health and social care, and from the public, not-for-profit and private sectors.
3.3
Research by Turning Point has fuelled our concerns that the generalist position of most GPs may undermine their ability to effectively commission certain services. In one survey of our service users, around 50% did not think that their GPs understood all of their care needs. They attributed this to a number of reasons:
·
‘My GP does not spend enough time with me’ (27%)
·
‘My GP doesn’t listen to my needs’ (13%)
·
‘My GP is not aware of real problems – they are too removed from my life’ (27%)
·
‘My GP is not aware of services that can help me’ (18%)
·
‘My GP is not interested in my needs’ (15%).
3.4
In September 2010, ICM surveyed 250 GPs on behalf of Turning Point. This indicated that they share our concerns:
·
38% foresaw consortia needing a lot of support in order to effectively commission mental health services;
·
40% thought they would need a lot of support to effectively commission learning disability services;
·
32% thought they would need a lot of support to effectively commission substance misuse services.
·
In relation to all three types of service, 98-99% of respondents thought that some level of support would be required.
3.5
Clause 22 of the Bill lays out the consortia’s duties, one of which (section 14O) requires them to "make arrangements with a view to securing that it obtains advice appropriate for enabling it effectively to discharge its functions from persons with professional expertise relating to the physical or mental health of individuals".
3.6
While this is a move in the right direction, we urge the government to ensure that consortia are issued with firm guidance on the nature of the advice that consortia must seek, and the extent to which they must do so.
3.7
We are also concerned that the Bill only imposes a duty to seek clinical advice. GP consortia will be commissioning services not just for their registered patients, but also for hard-to-reach individuals whose needs they may not be aware of; some of whom will not even be registered with a GP practice. They are therefore likely to require guidance from a far wider range of professionals than those confined to the clinical arena, including on non-clinical issues such as public engagement.
3.8
Social enterprises like Turning Point have much to offer to the provision of health and social care, as recognised by the government in its commitment to diversify the provision of such services. Our Crisis model for mental health delivers significant cost-savings to the health service, including a 70% reduction in admissions to acute mental health wards.
3.9
Worryingly, a survey of GPs by ICM for Turning Point found that:
·
Only 9% felt that consortia would be very likely to commission services from social enterprises;
·
46% felt that they would be very likely to commission services from Foundation Trusts;
·
84% felt that they would be very likely to commission services from GP provider arms.
3.10
In order to effectively meet their responsibility to empower patients to make choices about the services they access, consortia need to develop a better understanding of the role that social enterprises and charities can play in delivering primary, secondary and integrated care.
3.11
As such, we urge the government to widen the duty imposed upon consortia to seek advice from relevant professionals, to include those with professional expertise in social enterprise and not-for-profit organisations’ delivery of health and social care services.
3.12
Summary of recommendations:
·
For the government to ensure that consortia receive firm guidance on the nature of the advice that they must seek in order to effectively commission services, as well as the extent to which they must seek this advice, to ensure that they are sufficiently guided and advised on the commissioning of services of which they have little specialist knowledge – particularly for those with the most complex needs;
·
For the government to widen the duty imposed upon consortia (clause 22 section 14O) to seek professional advice, to include a requirement to seek advice from those with expertise in social enterprise and not-for-profit organisations’ delivery of health and social care services.
4
Public engagement
4.1
Turning Point strongly welcomes the government’s desire to better involve patients and the public in the provision of health and social care. We have long advocated for communities to be placed at the heart of the design and delivery of health and social care services, as demonstrated by our ‘Connected Care’ model of community-led commissioning.
4.2
Connected Care emerged from research carried out by Turning Point in conjunction with the Institute for Public Policy Research in 2004, which found that people with complex needs were frequently falling between the gaps between services. The report called for the voice of the community to become central to the design and delivery of connected services.
4.3
Connected Care uses community engagement to narrow the gap between local need and commissioner priorities, training local people to audit the community – contacting its most hard-to-reach members – to uncover their experiences of local services. The results of this audit are then used to reconfigure service provision, designing and delivering new services that effectively address the needs of local people.
4.4
Demonstrating the value of public engagement in commissioning, an independent cost-benefit analysis by the LSE found that our Connected Care project in Basildon delivered to the government a return of £4.44 for every £1 invested.
4.5
In the government’s response to the White Paper consultation, Turning Point’s consultation response was directly quoted and it was stated that the Bill would "place a duty on GP consortia and the NHS Commissioning Board to ensure that people who may receive a service are involved in its planning and development, and to promote and extend public and patient involvement and choice".
4.6
In contrast, the Bill itself merely requires consortia to "have regard to the need to…promote the involvement of patients and their carers in decisions about the provision of health services to them" (clause 22 section 14N(c)). We believe that this represents a considerable weakening of the government’s position on public engagement.
4.7
The wording of this clause means that the consortia do not have a duty to promote involvement, but merely a duty to "have regard to the need to" promote involvement. As demonstrated by a debate by the Health Bill Committee on 25 February, the quoted term is one of considerable ambiguity – such that the Rt Hon Simon Burns was required to offer a legal interpretation.
4.8
We urge the government to demonstrate their previously-stated commitment to public engagement in the provision of health and social care by rewording section 14N – removing "have regard to the need to" – so that the promotion of patient involvement and choice become duties in themselves.
4.9
We also recommend that the government consider the implications of limiting the provisions to the involvement of "patients and their carers". Every member of the community deserves to be involved in the design and delivery of their local health and social care services, regardless of whether they are, at that time, a patient or a carer.
4.10
Many of the people who Turning Point support are not registered with a GP practice or, as outlined above, feel they lack understanding of their needs and thus avoid visiting them, instead seeking help elsewhere. It is vital that these people – many of whom have a complex (and expensive) mix of needs – are taken account of and involved in the commissioning of their local services.
4.11
The recognition of Joint Strategic Needs Assessments (JSNAs) within the Bill’s provisions is welcome. It is vital, however, that JSNAs are strengthened and draw on and report on local people’s lived experiences and perceptions of services. This is best achieved by directly involving local people in gathering the evidence required, and is the only way that services can be designed around a full understanding of the local population.
4.12
While a JSNA based on a true understanding of local need has the potential to improve the quality of commissioning, standards across the country are likely to remain inconsistent – with some bearing more resemblance to purchasing – until there is a commonly understood, universally accepted definition of commissioning. Turning Point therefore proposes the following definition:
‘Commissioning is the means by which you understand the needs of an individual and/or a community such that you can build a platform for procurement.’
4.13
Summary of recommendations:
·
For the government to strengthen the duty upon consortia to promote patient choice and involvement by removing the phrase "have regard to the need to" from these provisions (clause 22 section 14N);
·
For the government to ensure that the duty to involve is not just applied to consortia’s current "patients and carers". but to every member of the local population, including those not registered with a GP practice;
·
For the government to promote a common definition of commissioning to ensure that in every area it is centred in local need, namely: ‘the means by which you understand the needs of an individual and/or a community such that you can build a platform for procurement.’
5
Integration
5.1
Turning Point welcomed the White Paper’s emphasis on integration as an untapped resource to greater efficiency savings. Many of the people who we support would benefit greatly from better integration of health, social care, and other related services (such as housing, employment and debt advice).
5.2
Integration has great potential to deliver significant cost savings to the government, while simultaneously improving the lived experience of people with complex needs and reducing the risk of them falling down the gaps between different services.
5.3
Many people find current service provision confusing, repetitive and frustrating. Integrated services enable people to access a whole package of support for a variety of needs, rather than dealing with each problem individually.
5.4
Integrated, early intervention can have enormous economic and societal benefits. The New Economics Foundation has estimated that, if the government invested £190 billion on a range of preventable problems (all of which involve multiple services at present), such as teenage births, crime and neglect, the total saving over a ten year period would be £460bn. This amounts to a net return of £269 billion.
5.5
Turning Point are concerned that the Bill’s provisions on integration are far too weak to make a significant difference to the way in which services are designed, commissioned and delivered.
5.6
GP consortia are excluded from any duty to promote or pursue the integration of services, while the NHS Commissioning Board and Health and Wellbeing Boards are required only to "encourage" integrated working (clauses 19(13J) and 179).
5.7
We contend that this wording is too weak, and that, if integration is to be effective, the responsibility to pursue it needs to be at a local level – with GP consortia. While Health and Wellbeing Boards will be responsible for encouraging integration in their localities, it is not yet clear how much power they will have to hold consortia to account for their commissioning arrangements.
5.8
We recommend that the government:
·
Amend section 13J of clause 19 and clause 179 of the Bill to strengthen the NHS Commissioning Board and the Health and Wellbeing Boards’ duty towards integration, replacing ‘encouraging’/’encourage’ with ‘pursuing’/’pursue;
·
Replicate this duty for GP consortia, to ensure that integration is pursued at a local level.
6
Conclusion
6.1
Turning Point welcomes many aspects of the Bill, but urges the government to strengthen the provisions for public engagement and the integration of services in health, social care and beyond.
6.2
While the government’s evident faith in GPs is positive, we are concerned that it has overestimated their ability to commission many specialist services without additional support, as well as their understanding of different types of provider. We hope that consortia guidance makes it clear that they must seek advice from specialists with not only clinical knowledge, but experience in engaging with local communities and in the role of social enterprises and not-for-profit organisations in delivering public services.
6.3
We would welcome any opportunity to engage further with the government over this highly significant piece of legislation.
March 2011
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