SPN welcomes the opportunity to comment on the consultation on
the commissioning framework. We are a web-based network of 1400 members drawn from service users, carers, academics and mental health professionals .
Putting people at the centre of commissioning
Qu1. Are these measures set out in this section sufficient to enable people to take greater control of decisions about their health and care? What further action could central government take?
Qu2. What special arrangements might be needed to ensure that the views are heard of those who do not routinely use local services?
The measures set out in page 19 taken together will help to extend the range of choice available to service users. They require however a fundamental reorientation of existing provision including GP services which tend to be reactive rather than proactive and are not geared to the needs of service users in terms of access, information and choice.
While strongly supporting moves to self-care, use of the Expert Patient Programme and a focus on the needs of carers, the measures in themselves will not meet the needs of those who are socially isolated through physical or emotional disability. We therefore welcome the imaginative measures for reaching out set out in the paper and the emphasis on advocacy. ‘Talking the talk’ however will inspire only cynicism if it is not matched by action. For example the dropping of the advocacy provisions from the Mental Health Bill currently before Parliament does not suggest a government wholly committed to extending choice and voice.
Understanding and planning for the needs of individuals and of the local population
Qu3. Will the approach set out in this section and in the supporting Annex A (on joint strategic needs assessment) help commissioners to undertake: (a) an assessment of an individual’s needs, (b) an assessment of the needs of particular groups or communities and (c) joint strategic needs assessments?
Qu4. How can we shape the duty of Joint Strategic Needs Assessment to have the greatest impact on health and well-being?
Qu5. How will this approach to needs assessment described in this section be suitable for children and young people, for whom services are commissioned through children’s trust arrangementsQ3/4/5
The proposals for Joint Strategic Needs assessments are welcome. It is
however important to sound a cautionary note based on the experience of social services departments in drawing up Community Care Plans as required by the NHS and Community Care act 1990. There is a danger with all planning documents that process comes to subordinate outcome in that the focus of the team is on the production of a portmanteau document and the necessary approval processes rather than the simple test ‘ what difference will this make to people’s lives?’
The Care Programme Approach (CPA) referred to approvingly in para 3.6 is an illustration of a process which has signally failed to engage with users and failed to touch on some of the key areas of users lives eg employment, leisure and social relationships. This is recognised in the current consultation on the CPA. Making care genuinely person-centred requires a major cultural shift in
service delivery which will need reinforcement at all levels of public policy.
Processes such as CPA will not produce the required information because the data is rarely set out in a way which can be aggregated. There is also a reluctance to identify unmet needs because of the potential demands for provision. We suggest that focus groups including service users and carers, practitioners and clinicians should be a requirement of the Joint Strategic Needs Assessment Process.
There should be greater emphasis on protective factors which are implicit in the text rather than explicit
Assuring high quality providers for all services
Qu10. Will these proposals in this section support commissioners to assure a range of high quality providers for all services?
Qu11. Should the Department develop one contract template for out-of-hospital services (except GMS and PMS) or one for each of the main service segments (e.g. mental health, long-term conditions, etc.)?
We greatly welcome the proposed focus on outcomes as the basis for future commissioning. This meets the test set out above in response to Q3/4/5. We also welcome the recognition that desired outcomes are what the service user requires and need to be defined in conjunction with users. Targets set out in Richmond House cannot be sufficiently flexible to respond to individual need and circumstances but too often service users feel that those targets rather than their need are shaping the pattern of assistance available to them.
The proposals to strengthen the provider market are welcomed. The point in section 5.6 is particularly important in the context of mental health. There has always been anxiety that the growth of the independent sector in both health and social care will lead to a temptation to ‘cherry pick’ the less difficult and complex clients. Measures to ensure that this des not happen and to ensure that those with mental health difficulties have equal access to high quality service need to be written into contracts and service agreements.
Organisations could be required to have social inclusion policies and to include an explicit statement of welcome for people who have experienced mental health problems. Training in mental health awareness should be offered.
Recognising the interdependence between work, health and well-being
Qu12. Does this section set out sufficient levers and incentives for commissioners and employers to improve health and well-being?
Well being is a laudable goal for public policy. The section focuses on the role of employers. The emphasis on liaison with employers, the Department of Work and Pensions and the employment service is welcome.
More could be done to encourage employers to recruit people with experience of mental distress. The stigma attached to mental illness makes it difficult
for people with a history of mental illness to rejoin the workforce. Policies like the changes in incapacity benefit are perceived as sanctions against individuals. It is our view that the public sector should use its contracting powers to exercise leverage on employers in the way outlined in section 6.7 to bring about changes in attitudes.
It is disappointing that carers are given no attention in this section. A bald statement that they need support to maintain their own health and well-being would have been hackneyed twenty years ago! Today it is wholly inadequate. There are many schemes which could have been commended as examples of good practice in this section.
Developing incentives for commissioning for health and well-being
Qu13. What practical, legal and financial issues need to be considered in enabling PCTs and practice based commissioners to spend effectively on non-health interventions, as described in this section?
Qu14. What further changes would make it easier for resources to follow individual service users beyond those described in this section?
Qu15. What considerations do you see in increasing the use of single audit arrangements for pooled budgets?
Qu16. How can we ensure that practice based commissioning and children’s trust arrangements work effectively together to improve outcomes for children?
We support direct payments and individual budgets as a means of adjusting the current power imbalance between service users and social care workers. The initiatives suggested as appropriate uses of NHS resources are admirable. There is a problem neatly –if unconsciously- encapsulated in para 7.9 which reads ‘if practice based commissioners wish to pursue such flexibilities, they should submit a business case to the PCT for a decision’ .
Crisis avoidance and social and practical support for older people –to cite just two examples- demand speedy and flexible responses. Nothing could be more guaranteed to prevent a speedy and flexible response than the requirement to prepare a business case and submit for decision to the PCT.
If current statutory provisions obstruct this flexibility, they should be changed as otherwise the bold vision of this section will not be realised.
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