HC 1048-III Health CommitteeWritten evidence from Turning Point (PH 104)

About Turning Point

1.1 Turning Point is a leading health and social care organisation with over 40 years experience of providing support to people with complex needs including those affected by drug and alcohol misuse, mental health problems and those with a learning disability. We work in over 200 locations, providing specialist and integrated services that meet the needs of individuals, families and communities across England and Wales.

1.2 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.

1.3 We are a 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.

Summary of Key Points

The recognition of the need to integrate health and social care is welcomed.

We strongly welcome the recognition made that there is no (public) health without mental health.

However, the challenge will be how this is achieved to provide effective services. The implementation of Health and Wellbeing Boards will require a culture shift which necessitates careful management and planning. These boards cannot be allowed to fail in their pursuit of outcomes; the cost of this will be too high in terms of the continuing health inequalities in the UK.

The local community is best placed to understand how innovation can be targeted and pursued in public services and so should be involved in the commissioning of services.

The period of transition from now until Public Health England is able to deliver its functions is vital. The skills set of professionals should not be lost; this is particularly the case in the substance misuse sector and the changes that are underway to subsume the NTA into Public Health England.

Public Health England

1.4 In setting up Public Health England within the Department of Health, considerations should be given to the relationship with local government and whether there should be a “Duty to provide” for essential services which are proven to provide significant benefit returns to the economy. Public Health England must ultimately hold to account spending on core services, when this may not be happening, ensuring that health inequalities are not worsened. The Secretary of State needs to balance the demands across the remit, particularly with the funding for aspects of mental health and substance misuse all coming from the same budget.

Public Health Outcomes Framework and Commissioning

1.5 Many of the people we support are at the sharp end of the inverse care law. Turning Point exists to reverse the existing trend that those who need the most help receive the least. There is a real opportunity for the health premium and the outcomes framework to integrate the system around this end but this can only be done if both are based on relevant, neighbourhood level intelligence and knowledge.

1.6 Both the Outcomes Framework and the health premium need to be based on an understanding of community need informed by local people. Commissioners need to recognise that people rarely have one public health issue and are likely to have a breadth and depth of need. Commissioning in the past has taken a silo based approach to people’s individual public health needs. We would recommend that an understanding of the whole person rather than a single public health problem should be embedded in every stage of service delivery from assessment to treatment and aftercare.

1.7 Turning Point’s model of community-led commissioning, Connected Care, is based on the principle that if you spend time and resource researching community need and bring this together with commissioner priorities, the redesigned services will be more integrated, inclusive and cost effective. It can also provide a unique insight into the triggers which effect poor public health and wellbeing.

1.8 By identifying weaknesses in service-provision that would not otherwise be addressed, Connected Care is able to demonstrate to local commissioners the usability of current service provision and facilitate discussions as to what more is needed to meet local need.

1.9 This same principle should be applied to the local application of the outcomes framework, along with the consideration of a data set of key measures, and that of the health premium if they are to reduce inequality and advance equality.

1.10 To ensure people from all corners of society benefit from the outcomes Public Health England is setting out to achieve, indicators must provide a profile of each community defined at the most local level (for example a housing estate), highlighting “social connectedness” and encouraging coproduction around community-led issues between communities and their local services. Social Connectedness is also an essential measure, particularly for people with complex needs, if the public health service is to reduce inequalities.

1.11 Data alone can not provide a complete picture of inequality, therefore peer led discussions within communities, as well as with a range of service providers and community support agencies, should be included. This is particularly relevant around data measuring mental health issues where BME communities continue to be significantly under-represented. If services are to improve for BME communities, they need to know where gaps in provision exist – this can only be known through rigorous and reliable information being held at the local and national level.

1.12 The contribution to reducing inequalities by service providers and other agencies should also be considered. For people with the most complex needs, it is often the case that community services, church groups and voluntary organisations have the greatest impact on supporting them to access the information they need; signposting them to the most relevant services and ensuring their most basic needs are met. Many of these groups will be essential but little known to the statutory services, and should be considered by Public Health England as an essential partner to reducing inequalities in all corners of society.

1.13 There has obviously been significant consideration as to how the three frameworks link together however, as we have stated in our responses to the preceding outcomes consultations, it is a shame that the NHS, Adult Social Care and Public Health frameworks are not aligned in one document rather than the three separate ones that have been produced. This would have immediately made the integration of the new public health service, as well as the changes to health commissioning, embedded within existing practice.

1.14 It is too often the case that people with complex needs do not receive the service they require due to teams on the ground working towards different outcomes and priorities. Although there is alignment between the domains and key indicators, there is a risk that teams will interpret them differently, or prioritise one over the other, leading to competing priorities which often act to confuse the person requiring support.

1.15 Turning Point particularly welcomes the emphasis on mental health throughout the indicators and the importance of getting services right for people with substance misuse issues. However there is little mention of people with a learning disability who have historically experienced the most disadvantage when it comes to living “longer, healthier and more fulfilling lives.”

1.16 There also needs to be considerations relating to family or parent interventions. Interventions that address parental issues alongside the child can have a huge impact on inter-generational health and wellbeing and an additional indicator relating to such approaches should be considered.

1.17 In addition Turning Point believes that the substance misuse indicators are crucial in ensuring that there are indicators concerned with how many people leave treatment free of their drug of dependence while also measuring the level of hospital admissions due to alcohol misuse.

1.18 As Turning Point’s Connected Care work illustrates, an individual’s community has one of the biggest impacts on their ability to cope; access services and feel socially included. The current problem is that data collection tends not to go down to a particularly local level but remains based on either the SHA, PCT or local authority areas. This new framework, however, provides the opportunity to set in place indicators that report not only on a national and regional basis, but on a local level which is becoming increasingly relevant, particularly as people take more responsibility for the services they access and giving greater transparency to health inequalities.

1.19 Many of the outcome indicators for public health will not have an immediate impact on health inequalities, but will rather take a longer time for any impact to become evident. To ensure that commissioners and providers are not discouraged from concentrating in these areas, therefore cherry picking those interventions with the quickest results, there will need to be intermediate measures put in place for those indicators which link directly to the health premium.

1.20 The baseline figures need to be taken into account for the health premium not to potentially increase inequality, where more deprived areas which struggle with public health may not benefit as their local areas are affected by variables out of their control for example immigration.

1.21 As well as integrating with existing local authority functions, Directors of Public Health will need to engage with the community and independent sector when developing health improvement plans and breaking down barriers to involvement.

1.22 Turning Point proposes that the following definition of commissioning is used in the provision of public health services which emphasise the need to co-produce services with the local community.:

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

1.23 We believe that the methodology of Connected Care, Turning Point’s model of community-led commissioning, offers one way in which communities can be involved in the co-production of public health services.

1.24 Recent cost benefit analysis of Connected Care demonstrates the model delivers significant net benefit to the public purse - with every £1 invested a return of £4.44 is achieved. When the benefits of improving quality of life are included, a return of £14.07 is gained for every £1 invested.

Abolition of the Health Protection Agency and the National Treatment Agency for Substance Misuse

1.25 The NTA has provided a positive outcome for substance misuse services in increasing the number of people accessing treatment and reducing local waiting times. Nevertheless, the context of substance misuse services has changed and it is right that there should be a greater focus on the holistic recovery needs of an individual. Turning Point has always focused on the wider-needs of the individual and understands how this can promote further progression towards recovery. No one organisation is able to meet these demands alone and this requires providers to work with other organisations. Consequently it is logical that substance misuse is seen through a broader public health vision which is conducive to Recovery-Oriented Integrated Systems.

1.26 Greater integration also ensures that those with Dual Diagnosis and complex needs can be served within the context of the whole public health budget.

1.27 It is important that the role played by the NTA in promoting the wider benefits and impacts of substance misuse are not lost and this expertise is retained in Public Health England. Turning Point is particularly concerned about the wide range of areas which will be contained within Public Health England, areas as diverse as sexual health and national preparedness will be contained within the one body. It is vital this does not result in a weakening of focus on substance misuse services and a loss of knowledge that has been developed in the NTA since its inception in 2001.

1.28 Whilst it is positive that a “ringfence” will be applied to the public health budget, this budget will also absorb the pooled-treatment budget for substance misuse services. There is concern that the wide range of areas this money will be required to fund may mean the importance of substance misuse funding is eclipsed. Substance misuse services already serve a socially excluded population whose needs often fail to be recognised. It is important that the movement of the NTA into Public Health England does not result in this population being further marginalised through public health funding being divided between an ever increasing number of priorities. It is vital that local Directors of Public Health acknowledge the importance of substance misuse services in their local area and provide a balanced treatment system for the local population. To fail to do this will create further inequities in the local area, for example it will result in greater demand being placed on the local criminal justice system, further costs in health care, as well as increase local unemployment and its related costs. Oxford Economics estimates that Turning Point’s integrated drug treatment model prevents criminal activity that saves £23.9 million each year in Somerset alone.

1.29 It is positive that the transition plans for the NTA indicate that support will be given to local areas to seek alternative commissioning models as well as ensuring the transfer of best practice. Nevertheless, it is important to consider that many local areas are facing a new frontier when it comes to the commissioning of substance misuse services through the pursuit of payment by results and Recovery-Oriented Integrated Systems. For instance, local areas which are not involved in the piloting of payment by results are being encouraged to develop plans for a local area single assessment and referral system (LASARS) while not being given the same level of support in making such a wholesale change. It is important that local areas are able to provide access to balanced treatment systems which are able to progress people towards recovery by addressing wider health and wellbeing concerns.

1.30 Furthermore, there should be a “Duty to Provide” a balanced treatment in substance misuse similar to the level which is currently being provided and this duty should be overseen by the Government through Public Health England.

Role of local government in public health

1.31 Turning Point welcomes the intention of health and wellbeing boards to integrate health and social care. There is a recognition that health is far more than an individual’s physical state but is very much dependent on the wider environment the individual lives in and the effects this has on their wider wellbeing. Local authorities will have pre-existing links with social care, education, leisure, transport and housing services. These are the services which are vital to integrated health and wellbeing service provision and so the movement of Directors of Public Health to local authorities provides an opportunity for the links between health, social care and local services to be fully exploited.

1.32 While these reforms are very positive in recognising the links between local authorities and the health system it is important that the difficulties facing local authorities in terms of their budget constraints are recognised. Cuts are already being made to frontline services and it is important that the value of early intervention services and integration of services continues to be acknowledged. This requires local authorities to take a long-term view which understands that the returns from investments can take some time to accrue. For these reforms to be successful, innovation in services must be embraced as it is only this which will ensure that integration between health and social care services occur.

1.33 There has also been little explanation or guidance as to how health and wellbeing boards will operate in practice. It is necessary that local areas are given the ability to reflect their own local needs but it is also important that this adds to the process of working towards effective services rather than detracting from the intentions of public health to reduce health inequalities.

1.34 Health and Wellbeing Boards demand a shift in culture in the working practice of many professionals. We should not expect such a shift to occur smoothly or naturally, rather some conflict and tension should be expected. There has been little explanation as to what happens if Health and Wellbeing Boards are unable to map a course through pre-existing individual priorities. There is also the related issue of mandates. It is suggested that local councillors are involved in the Health and Wellbeing Boards. While elected officials certainly have a place on the boards through their role in maintaining public accountability, it may be the case that the democratic mandate this membership will hold could be used as a veto against other professionals on the board.

1.35 There could be the possibility that these boards could breakdown through gradual erosion of relationships between the membership and this would have a huge effect on the functions of public health in the local area. This is something which should be further explored and explained. There is a need for the Terms of Reference of the boards to take this into account. Such issues should not be allowed to detract from the important role the Health and Wellbeing Boards will have in holding local Directors of Public Health to account.

1.36 The point has already been made that Health and Wellbeing Boards will cover a wide range of different areas of public health and that they will not only have to have broad expertise but will also have much ground to cover. The remit of Health and Wellbeing Boards is expanding and it is vital that they are given sufficient time to undertake these tasks effectively. It is essential that Health and Wellbeing Boards are driven by outcomes and are not burdened by processes which detract from their original function. There is always a danger that such organisations become talking shops which achieve little in the long-term, if this happens there will be further long-term costs that, in the current climate, will be too much to bear. This will have further effects on the quality of services in the long-term.

1.37 A further practical point is how Health and Wellbeing Boards will interact with Police and Crime Commissioners. This proposed role will hold responsibility for the levels of crime in area. As low-level crime is often the product of unmet need, there is a direct link between the role of public health in addressing health inequalities and the attempts to reduce crime rates in a given area. However, the area covered by Police and Crime Commissioners will be far larger than that covered by Health and Wellbeing Boards and so there needs to be further consideration of how Health and Wellbeing Boards will reflect the criminal justice needs of a local area. This could have a particular impact on local substance misuse services which significantly contribute to reducing crime in the local area. It is vital that Health and Wellbeing Boards utilise the understanding of the Police and Crime Commissioners.

1.38 The importance of the JSNA in creating the development plans for the local area, means that greater neighbourhood information must be included in the assessments, to allow a higher level of understanding of the local area, to ensure that need is met and that further inequalities are not created. Reference to JSNAs should not be precursory, but a full requirement.

June 2011

Prepared 28th November 2011