Written evidence from Turning Point (CFI
23)
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 We provide evidence on four points highlighted
by the Committee; namely those relating to paragraphs 96, 107,
115 and 118. We emphasise the need for:
— Assurances
that GPs will seek and be provided with the appropriate support
to commission services that meet the needs of those with complex
needs
— A commitment
to a definition of commissioning that is embedded within local
communities and based on individual and community need.
— The
requirement for GP 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" to be amended to
reflect the stronger wording of the Government's response to the
White Paper consultation.
3 EVIDENCE
3.1 The Committee believes it is essential for
clinical engagement in commissioning to draw from as wide a pool
of practitioners as is possible in order to ensure that it delivers
maximum benefits to patients. GPs have an essential role to play
as the catalyst of this process, and under the terms of the Government's
changes they, through the commissioning consortia, will have the
statutory responsibility for commissioning. They should, however,
be seen as generalists who draw on specialist knowledge when required,
not as the ultimate arbiters of all commissioning decisions. The
Committee therefore intends to review the arrangements proposed
for integrating the full range of clinical expertise into the
commissioning process. (Paragraph 96)
3.1.1 Turning Point agrees that commissioning
should be a collaborative process drawing on expertise from health,
social care and public health, and from across the public, private
and not-for-profit sectors.
3.1.2 We support the duty that the Bill places
upon consortia to obtain appropriate advice to enable it to effectively
discharge its functions, "from persons with professional
expertise relating to the physical or mental health of individuals"
(Clause 22 Section 14), but we feel that more firm guidance or
arrangements should be put in place to ensure that this duty is
discharged effectively.
3.1.3 Most GPs are generalists and are primarily
concerned with physical health issues. In a survey of people accessing
Turning Point services, when asked if they thought their GP understood
all of their care needs and not just those related to physical
health, responses were divided 50/50. Reasons given for negative
answers 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%)
3.1.4 These patient concerns are corroborated
by figures from a September 2010 ICM survey of 250 GPs, commissioned
by Turning Point. This found that:
— 38%
of respondents stated they foresaw 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 foresaw 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 foresaw 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.
3.1.5 For Turning Point, these findings reinforce
the need for commissioning to be rooted in a good understanding
of community and individual need.
3.1.6 GPs must take responsibility for engaging
with other health professionals in their area. They must also
engage with non-statutory providers of health and social care
services, who will be able to offer their perspectives on range
of issues that impact on individual health and wellbeing. This
will also save significant resources by avoiding unnecessary delays,
duplications or misguided diagnoses.
3.1.7 There are likely to be opportunities for
social enterprises and other not-for-profit organisations like
Turning Point to facilitate and provide some of the support that
GP consortia will need to effectively commission services.
3.1.8 Turning Point has developed a model of
working with A&E departments, using partnership to achieve
positive outcomes for individuals with alcohol-related issues
(see below). This kind of work can be applied to GPC arrangements
as their commissioning responsibilities increase.
Case study: Turning Point's Hospital Intervention
Services
In the North East, Turning Point-trained support
workers share expertise on alcohol dependence, brief interventions
and other services with hospital staff. This fosters greater understanding
and enables A&E nurses to make brief interventions with patients
with underlying alcohol-related issues.
By placing alcohol staff in hospitals, Turning Point
brings support directly to people who might not otherwise seek
treatment. Patients screened by hospital workers are referred
(with consent) to Turning Point's hospital alcohol workers. Turning
Point staff then offer:
— One-to-one
support and advice about the benefits of sensible drinking
— Assessment
of those who may require further support
— Referral
to community-based alcohol treatment centres and specialist services
such as counselling, detoxification, and support with housing,
benefits and training
— Advice
for families and carers
— Feedback
on the patient's current levels of alcohol consumption
Good partnership working with other agencies is vital
to the success of these services. We work closely with local partners,
including PCTs, hospitals, mental health teams, local authorities,
GPs, housing and benefit agencies, and Drug and Alcohol Action
Teams (DAAT). As our service is integrated with others to meet
multiple needs on a case-by-case basis, the result is a 'one-stop
shop' for service users.
3.1.9 The above example demonstrates how collaboration
can be applied to individuals who reach crisis point and access
A&E services. This support could have an even greater impact
if applied earlier in the care pathway. Without similar specialist
involvement in the commissioning process, the requirements of
people with complex needs will continue to go unmet.
3.2 The commissioning of services that either
work across [health and social care] boundaries, or are intimately
linked is therefore an issue to which the Committee attaches great
importance, and we intend to review the effectiveness of the structures
proposed in the Bill which are designed to safeguard co-operative
arrangements which already exist and promote the development of
new ones. (Paragraph 107)
3.2.1 Integrated health and social care support
simplifies patient journeys and prevents individuals from having
to give the same information to several professionals. It enables
the development of an integrated package of care for the whole-person's
needs, rather than dealing with each one individually.
3.2.2 Partnership working alone is not enough.
What is needed is the integration of funding, working practice,
back office functions and ethos.
3.2.3 Earlier this year, Turning Point 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.) This research generated 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.
— Early
intervention through housing-related support can also secure financial
benefits, and holds great potential for future programmes. The
Supporting People programme provided net financial benefits of
£3.41 Billion per annum.
3.2.4 Turning Point welcomes the duty the Bill
imposes upon Health and Wellbeing Boards (HWB) to encourage integrated
working between those who provide health and social care services
(Clause 179). However, we would like the Bill to go further in
encouraging integrated partnership work and pooled budgets across
public services. Health and social care providers should work
more closely with those who deliver housing, debt advice, education,
policing for example. By working towards shared targets (e.g.
reducing health inequalities or helping problem families), agencies
can combine their resources and exploit existing connections to
improve lives, at a significantly lower cost to the public purse.
3.2.5 We are also concerned that, since this
is a duty imposed upon HWBs and not consortia, there is insufficient
clarity on how the HWBs will hold consortia to account for their
commissioning decisions. If their level of influence is insufficient,
this duty will have little impact on the integration of health
and social care. We recommend further clarity on this issue, and
for the same duty to encourage integrated working to be imposed
upon GP consortia and the NHS Commissioning Board.
3.3 The Committee intends to review the arrangements
proposed in the Bill for enabling consortia to reconcile this
potential conflict [between patient choice and commissioning]
by enhancing patient choice at the same time as delivering the
consortium's clinical and financial priorities. (Paragraph 115)
3.3.1 The mantra "no decision about me
without me" is a powerful one, and defines a way of working
that many in the social care sector have adhered to for a number
of years. At Turning Point, we involve our service users, where
possible, in as much of the service as they choose. This includes
everything from the way the service looks to the recruitment of
staff and the content of their care plan.
3.3.2 We support the choice agenda that the Government
is pursuing, and welcome the Department's recent efforts to ensure
that people with mental health conditions are supported in making
informed decisions. We look forward to similar work being done
around the needs of people with learning disabilities.
3.3.3 For the NHS to be truly patient-centred,
however, there needs to be a culture change that affects the way
in which professionals work with patients, colleagues and non-statutory
organisations.
3.3.4 Our concerns around GPs' understanding
of social enterprise have been fuelled by a recent poll of GPs
by ICM for Turning Point, which found that:
— Only
9% of respondents felt consortia would be very likely to commission
services from social enterprises, compared to 46% who thought
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 form GP provider arms.
3.3.5 Turning Point, as a large social enterprise,
already sees the dividends that our services can pay. 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.
3.3.6 It is therefore essential that GPs balance
their duty of care with their role to empower patients to make
choices. This will involve developing better understanding of
the role that social enterprises and charities can play in delivering
primary and integrating care; supporting smaller organisations
to work together and with local health partners to fill gaps in
service provision; and supporting patients to make treatment choice
based on all the information available.
3.4 The Committee does not find the current stance
on patient and public engagement in commissioning persuasive.
The National Health Service uses taxpayers' resources to deliver
a service in which a high proportion of citizens take a close
interest both as taxpayers and actual or potential patients. While
the Department may be right to point out that there is no special
virtue in uniformity of structure, the Committee regards the principle
that there should be greater accountability by commissioners for
their commissioning decisions as important. We therefore intend
to review the arrangements for local accountability proposed in
the Bill. (Paragraph 118)
3.4.1 Central to the reforms within the Bill
is the need to improve not only the efficiency of the health system
as a whole, but the quality and effectiveness of service delivery.
As a national provider of health and social care services working
across specialisms, Turning Point knows that the end product will
only improve if there is a clear, consistent and agreed definition
of commissioning.
3.4.2 The current quality of commissioning is
inconsistent, often bearing more resemblance to purchasing rather
than a person centred, locally driven commissioning of services.
Turning Point therefore proposes the following definition of 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."
3.4.3 To this end, our response to the Health
White Paper called for a duty to be placed on GP consortia to
engage with communities, to ensure that they understand the needs
of the local population. The duty within the Bill - 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)) - represents a weakening
in the government's position from their response to the White
Paper consultation.
3.4.4 The response recognised Turning Point's
recommendation explicitly, and 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". We recommend that the
Bill be amended to strengthen and elaborate the duty in this manner.
3.4.5 Without a solid duty that can either be
enforced or measured by the NHS Commissioning Board, there is
no guarantee that this engagement will take place, and thus no
guarantee that GPs will be able to commission services effectively
and with sufficient regard to the needs of the local community.
3.4.6 Turning Point's Connected Care model of
community-led commissioning (see below) provides one example of
how commissioners can truly engage and involve the local community
in the design and delivery of health and social care services.
Case study: Turning Point Connected Care
The evidence base for Connected Care emerged from
research carried out by Turning Point in conjunction with the
IPPR in 2004. Meeting Complex Needs found that people with
complex needs are often failed by existing health and social care
provisions, falling through the gaps between services. The report
called for the voice of the community to be central to the design
and delivery of all connected services.
Connected Care provides a means to achieving integrated
services, by using community engagement to narrow the gap between
commissioner priorities and the needs of the local population.
Greater efficiencies can be achieved when local people are listened
to and services are designed around people's needs.
Connected Care follows a 7 step path:
Step One: Establish a steering group
- 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.
Step Four: The Connected Care audit -
carried out by Community Researchers, with the aim of determining
the needs and aspirations of the local community and their perceptions
about current services.
Step Five: The Audit Report
Step Six: A new Service Specification,
based on the local feedback collected by the Researchers, to deliver
more integrated health and social care services.
Step Seven: Evaluation.
CONCLUSION
10.1 Due to the widespread nature of these reforms,
it is essential that commissioning is delivered in a consistent
manner. Turning Point believes this can, in part, be addressed
through a shared definition of commissioning that recognises the
needs of the individual and the community.
10.2 Turning Point believes that there should be
a stronger duty placed on GP consortia to engage with the community,
to ensure that their needs are truly recognised and services are
developed through clear mechanisms of accountability.
10.3 Turning Point would welcome any opportunity
to give evidence to the Committee at future sessions.
February 2011
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