Written evidence from Turning Point (COM
80)
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: currently working in 10 areas of England to integrate
health, housing and social care.
1.2 We are a large social enterprise reinvesting
its surplus to provide the best services in the right locations
for people with a range of complex needs who need them the most.
1.3 With the biggest change to health policy
since the formation of the NHS over 60 years ago, Turning Point
welcomes the opportunity to respond to the committee's inquiry
specifically into commissioning on behalf of the 100,000 individuals
accessing Turning Point services each year and our 2,000 members
of staff.
2. ROLE OF
ORGANISATIONS IN
COMMISSIONING
2.1 Turning Point believes that there is
an important role for non-statutory organisations to play in ensuring
people have choice not only of treatment but also of provider.
2.2 Civil society organisations provide
a unique link into communities, supporting statutory services
to engage with people they may not otherwise reach because of
their unique position within communities. Organisations like Turning
Point provide services that cross the boundaries of health and
social care and already deliver cost savings to the health service.
Our Crisis model, for example, delivers a 70% reduction in admission
to acute mental health wards while many social care interventions
relate directly to ensuring improved health outcomes.
2.3 However recent survey data from 250
GPs commissioned by Turning Point and conducted by ICM found that:
— Only 9% of respondents felt consortia
would be very likely to commission services from social enterprises,
compared to 46% thinking they would be very likely to commission
services from Foundation Trusts.
— 84% of respondents felt that consortia
were likely or very likely to commission services from GP provider
arms.
2.4 It is therefore important to recognise
the role that social enterprises and charities can play not only
as providers but as navigators between services. With the above
results in mind "any willing provider" could become
an open gate for either the private, for-profit sector or internalism
of the health service, rather than allowing people to choose services
from the not-for-profit sector where so much innovation stems
from.
2.5 Turning Point would therefore be keen
to work with partner organisations and the Department of Health
to roll out a comprehensive training programme to ensure that
all health professionals know what civil society has to offer;
and want to ensure the role of the NHS Commissioning Board in
encouraging cross sector working.
2.6 Currently there are large groups of
people within society, namely those Turning Point supports, who
do not feel able to access their local GP surgeries or are not
registered for a number of reasons. For these reasons Turning
Point is cautious as to whether the proposed plans for GP Commissioning
can work. As this seems the inevitable way forward Turning Point
advocates strongly for a better understanding of the not-for-profit
sector so to ensure people are not left behind.
2.7 Turning Point has recently pulled together
data from our clients, views of those at the sharp end that will
feel the impact of these changes the most and we have included
some of these figures in this response.
2.8 We have sent a questionnaire to over
100 clients accessing Turning Point substance misuse, mental health
and learning disability services and asked them about their experience
of GPs and GP surgeries.
2.9 The results of the above can both be
found in Appendix 1 and are detailed in this response. Turning
Point's clients state a number of reasons why they feel they cannot
access GP surgeries which Turning Point think proves the case
for non-statutory involvement:
— "Doctors end up judging you by your
prescription history".
— "I see a different GP every time
and do not get to build a familiar relationship with a doctor
who understands my situation".
— "My GP is too far away".
— "My GP doesn't understand my needs".
— "I feel more comfortable accessing
an organisation that specialises in issues which affect me".
2.10 It appears that many people feel more
comfortable accessing non-statutory services that are less imposing,
more flexible, locally based and non-judgmental. To this end Turning
Point welcomes the Government's position on "any willing
provider" and the increased role of social enterprise outlined
in the proposals.
2.11 It is therefore essential that health
professionals:
— Understand social enterprises and charity
organisations and the role they can play in delivering primary
and integrated care;
— Support smaller social enterprises and
charities to work together with each other and/or health partners
to offer locally led solutions to gaps in provision; and
— Are encouraged to engage with the "any
willing provider" and consider them on the same footing as
existing health providers.
2.13 To ensure the role of civil society
organisations is at the heart of commissioning and delivering
future health services, Turning Point will continue with our role
to educate health staff and commissioners around the role these
organisations can play but will seek to work with the Department
of Health and other partners to roll out a comprehensive programme
of awareness training across the health service, particularly
with GPs.
3. COMMISSIONING
DEFINITION
3.1 As a national provider of health and
social care services working across specialisms Turning Point
knows from experience that the end product will only improve if
there is a clear, consistent and agreed upon definition of commissioning.
We believe that this definition should be routed in community
engagement—leading to local services, built around local
needs, meeting local outcomes.
3.2 Currently the quality of commissioning
is not consistent and often resembles purchasing more than world
class commissioning of person centred, locally driven services.
Therefore Turning Point sees that it is of great importance that
there is a Government supported definition of commissioning, to
ensure consistency of services at a time when there is fast paced,
all encompassing changes being made. Turning Point's proposed
definition is:
"Commissioning: the means by which you understand
the needs of an individual and/or a community such that you can
build a platform for procurement."
3.3 Turning Point proposes a model of commissioning
services that is embedded in the community they serve. Any future
model of commissioning must be embedded within the community and
work across existing silos.
3.4 The introduction of GP commissioning
will offer both benefits and potential risks for the people we
support and there are mixed feelings as to whether it will improve
access to services or even if GPs are the best placed professionals
to know their local populations.
3.5 According to figures from people accessing
Turning Point services, when asked whether GP commissioning would
enable them to have a bigger say in their care 37% said yes, 48%
said no and 15% were undecided. When asked if our clients thought
their GP understood all of their care needs, not just physical
health, they were divided 50/50. The reasons for people saying
no included:
— 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%).
These concerns from a patient perspective are
corroborated by the figures from our September 2010 survey of
250 GPs which found:
— 38% of respondents stated they foresee
consortia needing a lot of support in order to effectively commission
mental health services. Overall 98% thought that some level of
support would be needed.
— 40% of respondents stated they foresee
consortia needing a lot of support in order to effectively commission
learning disability services. Overall 99% thought that some level
of support would be needed.
— 32% of respondents stated they foresee
consortia needing a lot of support in order to effectively commission
substance misuse services. Overall 99% thought that some level
of support would be needed.
3.6 There are certainly opportunities for
organisations like Turning Point in facilitating and providing
some of this support that GP Consortia (GPCs) are going to need
to effectively commission these services. However it is worrying
that the people who are being positioned as knowing their local
communities seemingly have little understanding of people with
complex needs—many of which cost the health system the most
and already feel disenfranchised by their GP surgery. For Turning
Point this reiterates the need for commissioning to be routed
in a good understanding of community and individual need.
4. COMMUNITY
ENGAGEMENT
Turning Point believes there should be a duty
placed on GPC's to engage with communities to ensure they know,
and more importantly know how to meet, the needs of people not
only accessing their services currently but those in the wider
community they will be responsible for. Without a duty that can
either be enforced or measured by the NHS Commissioning Board,
there is no guarantee that this will take place or that GPs will
effectively be able to commission these services.
The case study of Turning Point's Connected
Care outlines one means of doing this and is detailed below.
4.1 Case study: Turning Point Connected Care
The evidence base for Connected Care originated
from research carried out by Turning Point, in conjunction with
the IPPR in 2004. Meeting Complex Needs found that people
with the most complex needs are often failed by the existing health
and social care services. It brought to light the gaps in current
health and social care services, finding:
— They don't provide joined-up, cost-efficient
services.
— They don't address the whole person.
— They don't meet complex needs.
The report called for the voice of the community
to be central to the design and delivery of all connected services.
4.2 Connected Care provides a means to achieving
integrated services by narrowing the gap between commissioner
priorities and the needs of the local population through community
engagement. By delivering a joined-up, user led approach to health,
housing and social care, greater efficiencies can be achieved
when:
— Services are designed around people's
needs so therefore are more likely to meet them.
— By listening to local people, services
will be located in areas where they are most needed.
4.3 Connected Care follows a seven step
path:
Step One: Establish a steering group—This
is made up of health, housing and social care service Commissioners,
Connected Care staff and community researcher representatives
to oversee the project.
Step Two: Desk research of existing services.
Step Three: Local Community Researchers are recruited
and trained. They are people who live in the local area and often
have had need for the local health and social care services. They
conduct research by talking to local people to find out what people
think of their local services.
Step Four: The Connected Care audit. This determines
the needs and aspirations of the local community, their perceptions
about current services and the extent to which they meet, or do
not meet, need.
Step Five: The Audit Report.
Step Six: A new Service Specification to deliver
more integrated health and social care services based on the feedback
from local people.
5. INTEGRATION
5.1 Turning Point supports the greater emphasis
on integration as an untapped resource to greater efficiency savings.
Analysis by Turning Point Connected Care shows that integrated
early intervention programmes can generate resource savings of
between £1.20 and £2.65 for every £1 spent (POPPs,
LINKAge Plus, Supporting People, self care schemes.[147])
5.2 Turning Point has long since advocated
the benefits of integrating health and social care and would like
to see this not only "encouraged" between Local Authorities
and GPCs but monitored in some way through both the NHS Commissioning
Board and the Health and Wellbeing Boards if adopted. Turning
Point will propose in our Consultation response Liberating
the NHS: Commissioning for Patients that the most effective
monitor would likely be through an outcomes framework and/or a
National Indicator that the NHS Commissioning Board would report
on periodically to ensure that integrated services are being commissioned,
designed and delivered where these provide the most effective
solution.
5.3 Integrated outcomes
5.3.1 The importance placed on delivering
improved outcomes for individuals is clear throughout the White
Paper and something Turning Point whole heartedly supports. In
our response to Liberating the NHS: Transparency in Outcomes we
clearly outline what is needed from an outcomes framework and
call on the government to ensure that outcome measures are integrated
so that colleagues in health, housing, social care and employment
services are all supporting each individual to work towards their
person centred outcomes. We have created bespoke outcome tools
we have developed to support those with a learning disability
(SPOT) and those with mental health conditions (ARROW) and have
proposed that Government considers these before reinventing the
wheel to ensure a standardised outcome measurement tool.
5.3.2 Turning Point understands the need
for a consistent level of provision and focus but within the five
core domains there must be nuisances for different client groups
upon which providers will be, in the future, paid against. It
is counter productive to have a system of measurement based on
the mean when personal circumstance impacts so much on an individual's
ability to recover; work towards greater independence; or gain
employment.
5.3.3 Therefore Turning Point calls for
the development of bespoke outcome measuring tools that consider,
for example, the different service drivers for BME committees;
the unique health needs of people with a learning disability;
and the health needs of carers who play such an important role
in preventing readmissions. Indicators need to be disaggregated
by geography and community to get a real grasp of outcomes for
different groups over time.
5.3.4 To ensure outcomes are consistent
and at the heart of every spoke of the wheel, they must be simple
and they must be linked to the Commissioning Framework of both
GPCs and Local Authorities, monitored by the NHS Commissioning
Framework. To bring providers into the system outcomes should
not be imposed but rather driven locally and linked to activity
so to create incentives for providers to improve. The Framework
should also focus on outcomes that are right for each individual—not
just those easily measured.
5.3.5 In light of the tools Turning Point
has developed we seek that the outcome measures used going forward
are both person centred and individually driven within the key
domains and work to integrate service delivery, along with the
role of the NHS Commissioning Board.
6. INTEGRATION
OF HEALTH
AND SOCIAL
CARE
6.1 Integrated health and social care support
allows patient journeys to be simplified and prevents the need
for individuals to repeat their story to several professionals.
It also means that people are able to have an integrated package
of care for their whole-person needs, rather than taking each
individually. Integrating services can improve efficiency as well
as help organisations meet the growing demand for health and social
care services.
6.2 Turning Point has long since advocated
the benefits of locally integrated services and would like to
see this not only "encouraged" between Local Authorities
and GPCs but monitored by both the NHS Commissioning Board and
the Health and Wellbeing Boards if adopted. The measurement of
integrated working should be through either an outcomes framework
and/or a National Indicator that would be reported on periodically
to ensure that integrated services are being commissioned, designed
and delivered where these provide the most effective solution.
6.3 It is not simply a matter of partnership
working but the integration of funding, working practice, back
office functions and ethos that currently stand in the way of
achieving the much talked about results integration can achieve.
6.4 LIS (Locally Integrated Services) seeks
to rectify the current silo mentality by delivering a joined-up
approach to the most complex and entrenched social problems. These
problems, for instance long-term unemployment, crime reduction
and health inequalities, are multi-faceted and are an insurmountable
challenge for discrete agencies to resolve.
6.5 LIS creates new relations between communities,
individuals and service-providers by taking a grassroots approach
to identify what the local area needs from their services. LIS
will help services become more effective meaning resources go
further by removing the confusion and duplication occurring within
public service provision.
7. JOINT COMMISSIONING
7.1 Joint commissioning can deliver more
for less by working alongside local communities to redesign services
through a programme of change management and cost savings. Through
co-production between the local authority, PCT and community greater
efficiencies can be ensured by getting rid of duplication and
encouraging the sharing resource.
7.2 Earlier this year Turning Point Connected
Care published a benefits realisation report, "Assessing
the evidence for the cost benefit and cost effectiveness of integrated
health and social care" (Turning Point, Feb 2010.)
The research in this report led to a number
of conclusions:
— Services that are designed to ensure
that people can retain their independence and quality of life
can deliver cost savings through the prevention of hospital admissions
and residential placements.
— There is a growing body of evidence to
suggest that integrated health and well-being services can realise
significant financial benefits. In particular, integrated early
intervention programmes can generate resource savings of between
£1.20 and £2.65 for every £1 spent (POPPs, LINKAge
Plus, Supporting People, self care schemes.)
— Early intervention through housing related
support is also an important way in which to secure financial
benefits and holds great potential for future programmes. The
Supporting People programme provided net financial benefits of
£3.41 Billion per annum.
8. COST BENEFIT
OF EARLY
INTERVENTION
8.1 Research has consistently shown that
investment in integrated solutions and early intervention, not
only have societal benefits but economical ones too. For people
with complex needs this is especially the case as they tend to
cost the system more by being in receipt of multiple interventions
while also being the most isolated from society and only reaching
services when at a crisis point.
8.2 Turning Point particularly welcomes
the increased role for Local Authorities, especially in integrating
services and ensuring public health is at the centre of local
accountability. The role of local Health Watch will help to monitor
much of this activity as people try to navigate their way between
the plethora of services on offer. The proposed Health and Wellbeing
Boards will also be a positive platform to raise any concerns
around the lack of integrated solutions and the possible sharing
of best practice locally.
9. THE ROLE
OF CITIZEN
ADVISORS
9.1 As the results of our GP survey have
indicated, GPCs are likely to need support to ensure navigation
to and between services, particularly if they are to be outsourced.
It is essential that people are not lost in transition or further
distanced from the health service, therefore public services must
start from a patient perspective.
9.2 Communities have a role in achieving
good outcomes from public services. Turning Point also know that
some communities need extra support to access services, and often
don't receive support they need because they find it difficult
to navigate their way around the system. This is of particular
concern if GP Commissioning is to add another layer to the service
supply chain by outsourcing those services it does not understand,
ie common mental health or learning disability services.
9.3 Turning Point Connected Care have written
a report that recommends an approach provided through Citizen
Advisors, to support people to interact and engage with services,
and to build up their resilience and community capacity.[148]
9.4 The report brings together and appraises
the international evidence-base of citizen advisor type functions.
There are good examples of services performing different aspects
of these roles: but most have struggled to meet the challenge
of both having the confidence of the local community, and also
providing a sufficiently strong and acceptable mechanism for working
with other professionals across public services. Turning Point's
vision is for Citizen Advisors to help people access the variety
of services they require to meet their needs. Citizen Advisors
can help assess, signpost and support people into local programmes
while enabling them to interact more effectively with services
when they exercise their option for self directed support and
personal budgets.
9.5 At the heart of Liberating the NHS
is the aim of opening up services to patients in an unprecedented
way. Its proposals focus on providing greater choice of providers,
choice of treatment and more transparent information on the quality
of local services. This "choice and information revolution"
makes the role of Citizen Advisors essential if people are to
navigate their way around the health service and truly experience
the best it has to offer.
9.6 Citizen Advisors could play a critical
role in brokering the new relationships the government is seeking
to establish between health, social care services and communities.
There are a number of approaches that would support this process.
One solution would be for Citizen Advisors to support GP-led consortia
so that both GPs and patients know more about the range of local
services and community resources that might be available. A second
approach would see Citizen Advisors linking health services to
the wider community to help ensure more equal health and wellbeing
outcomes are experienced across different social groups.
9.7 A third role would be in support of
the integration of services with Citizen Advisors providing the
much needed link between often fragmented services that many families
currently find difficult to access as a joined up, coherent whole,
available at the right time and in the right place. Finally, if
the newly proposed Health Watch is to be the "Citizens Advice
Bureau for health and social care" then Citizens Advisors
can help makes this a reality by putting a community—based
workforce behind it. In our communities, and particularly those
that are the most deprived, there is huge benefit by having local
experts by experience based at libraries or communities centres
or on the end of the phone, guiding others to seek the advice
and support they need.
10. CONCLUSION
10.1 With the wide spread nature of reforms
there needs to be a consistent way of delivering Commissioning,
Turning Point believes that this can be addressed in part by engaging
with a definition of Commissioning which recognises the needs
of the individual and the community, giving Commissioning a clear
distance from procurement or purchasing.
10.2 Turning Point believes that here needs
to be a duty placed on GPC Consortia to engage with the community
to ensure that the needs of the communities are truly recognised
and services are developed through such accountability. Community
engagement activities aimed at building social capital, and changing
behaviour, such as the Connected Care model, are a necessary pre-requisite
to a truly patient centred health service and deliver true community
led commissioning.
10.3 Turning Point would welcome giving
evidence to the Committee in future evidence sessions.
October 2010
APPENDIX 1
SERVICE USER SURVEY RESULTS
HAVE YOUR
SAY: CHANGES
TO THE
NHS AND GP'S
110 people who use Turning Point services were
asked a series of questions relating to the future GP Commissioning
proposals. These were to gauge how our service users felt about
their GP being given more control over the direct commissioning
of their services.
1. Do you have a GP?
| Yes I see him regularly
| 74% |
| Yes but I never go | 25% |
| No | 1% |
2. Do you think your GP understands all of your care needs,
not just physical health? For example issues relating to your
mental health, employment, housing etc
3. If you have concerns around your GP understanding your
needs (as in Q2) why do you have these concerns?
| Not enough time spent 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%
|
| Other comments | GPs do not understand the roots of substance misuse and cannot understand my problems
|
| GPs are not usually knowledgeable in areas other than physical health
|
| My GP does not have enough knowledge of support available in my area
|
| I do not always see the same GP so it depends
|
| My GP does not take my concerns seriously
|
| My GP tries to palm me off with labels and it doesn't feel like they're listening
|
| I don't feel comfortable speaking to my GP about my mental health issues
|
| GPs think they always know best and don't always listen to patients concerns
|
| GPs do not generally have first hand experience and can't relate to my problems
|
4. Are there any problems to accessing your GP or reasons
why you don't like accessing your GP?
| The staff at my GP surgery are unwelcoming (ie receptionists, nurses, doctors etc)
| 17% |
| They just prescribe medication which I'm not interested in
| 8% |
| My GP is too far away | 5% |
| My GP doesn't understand my needs | 15%
|
| N/A—I have no problem accessing my GP
| 50% |
| Other | 5% |
| Other comments | Doctors end up judging you by your prescription history
|
| I see a different GP every time and do not get to build a familiar relationship with a doctor who understands my situation
|
| GPs are just that—general practitioners and not specialises
|
| I feel more comfortable accessing an organisation that specialises in issues which affect me
|
5. If GPs were to take control of commissioning your services
do you think you would have a bigger say in your care?
| Yes | 37% |
| No | 48% |
| Undecided | 15% |
| YES |
| Other comments | I will be able to inform my doctor of services available that sound helpful and he wasn't aware of
|
| I have a good relationship with my GP and he is an easy point of contact
|
| There will be less paperwork
|
| Giving doctors more control to make decisions will give patients more control to influence doctors' decisions
|
| NO |
| I think the GP will decide what is "best" according to what saves most money in his budget
|
| GPs will want to save money for themselves
|
| GPs won't have the time to deal with the added responsibility
|
| Too many issues for GPs to handle, need sector specific staff
|
| I don't think my GP would be open to suggestions from me
|
| I don't feel like my GP really cares
|
| My GP would consider cost before anything else and compromise the quality of services available, the same way it is now
|
| GPs are not equipped or trained to handle the added responsibility
|
| GPs have a big enough workload already
|
| GPs tend to have a tendency to be biased and ignorant towards users so I don't trust my doctor to make well-informed decisions
|
| Could lead to preferential treatment
|
147
Assessing the evidence for the cost benefit and cost effectiveness
of integrated health and social care" (Turning Point, Feb
2010.) Back
148
Further information can be found in Citizen Advisors: A Review
of the Evidence Base, August 2010,. A full copy of the repart
will be submitted along with Turning Point's response to Liberating
the NHS: Local democratic legitimacy in health. Back
| 
