Written Evidence Submitted by Turning Point

(CLL0094)

Background

Turning Point is a leading social enterprise providing health and social care services for people with complex needs at 350 locations across England. We have been supporting people to make changes in their lives since 1964.

We support people to improve their health and wellbeing whether that be at home, within the workplace or through our specialist services, building on our expertise in substance misuse, mental health, learning disability, autism, acquired brain injury, sexual health, healthy lifestyles and employment. The impact of COVID-19 and the need to keep the people we support and our workforce staff has been significant, both on our accommodation based and our community services.

The deployment of non-pharmaceutical interventions like lockdown and social distancing rules to manage the pandemic;  

Delivering Substance Misuse Treatment during lockdown

Turning Point’s community drug and alcohol services moved to a blended model of service delivery during the initial lockdown. We continued to provide face to face clinical services to complex, high risks clients, undertaking consultations via video link and moving to telephone 121 sessions wherever possible. As a result, the number of contacts we are having with clients has increased significantly.

Our approach has wholly been guided by Public Health England. Over 90% of our services have been delivered remotely, subject to individual risk assessments, with a preference for telephone over video for many clients. This has proven to be very successful and has resulted in a national increase in individuals accessing services and increased levels of engagement.

During the lockdown, many community pharmacies closed and were therefore no longer able to provide supervised consumption of opiate substitute medication. In response, Turning Point undertook an individualised prescribing assessment for each of our patients and where we were confident that patients were able to manage their own medication and store it safely at home, we moved patients onto a less frequent collection. This was the case for one third of our patients who are now, or remain on fortnightly collection. One third are on a weekly collection and one in ten patients remain on a supervised consumption regime due to high levels of potential risk such as overdose, diversion or to children in the household.   For anyone whose prescribing has changed we have increased the frequency of reviews.

Activity levels have shifted considerably since the start of the pandemic:

• Referrals to community drug and alcohol services dropped significantly between March and May 2020 with self-referrals falling most sharply, although since June they have been above average with increased numbers of alcohol referrals compared to average.
• Exits during 2020 are tracking at 24% down overall on the same point last year. The biggest reduction is opiates clients with 33% down on data point this time last year. This is mainly due to a lack of community support networks available to provide ongoing support.
• At the same time, the number of contacts Turning Point has had with clients e.g. via telephone has actually increased and we have seen rises in active caseloads for adult services.

• The level of need is also higher. This is illustrated by the 60% increase in risk incidents during April – June 2020 against the previous year’s figures within our substance misuse services. 

Lessons learnt

• Lock down and social distancing has had a profound impact on community drug and alcohol services, the way in which services are delivered, the opportunities for ‘move-on’ and the need of clients
• High caseloads within community drug and alcohol services resulting from the pandemic are not sustainable and more needs to be done to support grass roots / low level community support networks to get back up and running because they provide a vital part of the pathway 
• Virtual service delivery (telephone 121s/online group work/naloxone click and collect) have increased engagement with clients but there is more work to be done to support high quality delivery and to build blended pathways for the longer term that are more sustainable and that offer differentiated services based on differing needs
• Face to face delivery cannot be substituted for some groups e.g. needle exchange for intravenous drug users,  supervised consumption of opiate substitute therapy (e.g. methadone) for high risk groups  

Delivering Mental Health Services during lockdown

Over the past few years Turning Point has prioritised investment in technology and digital infrastructure. This investment meant we were in a position to quickly move to digital delivery of IAPT services in response to the Covid 19 pandemic, prioritising the health of our staff and people we support without impacting the quality of our delivery. Our residential mental health services reduced capacity in order to meet infection control requirements and in a number of areas we supplemented this with the introduction of telephone-based services. We also worked with commissioners to adapt our services in order to free up bed spaces in acute hospitals. 

IAPT

We saw a dramatic reduction in referrals to our IAPT services during the lock down. In April referral rates were 10-15% of what we would normally see. In May referral rates were 40-50% of what we would normally see and they are still only at around 2/3rds of what we would expect.  Reduced demand has resulted in a significant reduction in waiting lists and so waiting times for treatment have reduced considerably.

The wholescale shift to telephone and video therapy has resulted in improved engagement and recovery rates. For example DNA and cancellation rates have reduced by half. However, this is based on a small sample size.  Feedback from therapists has been generally positive and people have been surprised by how well clients have been able to engage with it. Therapists report finding it more tiring than face to face or even telephone and that has been factored into scheduling.

Crisis Services

In April and May we saw a 39% increase in incidents in our crisis mental health services compared to the same period last year. We have seen first-hand the increase in demand for mental health support, notably for certain groups and yet the capacity of many of our services has been reduced. This has, however, been supplemented by telephone-based support in many cases. The increase in incidents within our crisis services seen was despite the fact that we had fewer people staying with us  to enable people to socially distance. 

Collaboration across between the statutory and third sectors

Turning Point in partnership with the Leicester Partnership Trust has worked in close collaboration during Covid and closer integration across the mental health pathway has been introduced in response to the pandemic.  Turning Point provides a crisis house (short term accommodation as an alternative to a psychiatric admission), a mental health helpline and crisis cafes across the patch. We are part of a multi-agency Suicide Audit and Prevention Group (SAPG) and have been working over the past 2 years to address higher than average numbers of suicides across Leicester and Leicestershire. The group introduced a Referral and Tracking System to track engagement with services, e.g. mental health and substance misuse services, for all suspected deaths by suicide identified by the police. The SAPG is driving a redesign of the mental health pathway and proposals for a Central Access Point (CAP) similar to 111 have been brought forward in response to the pandemic and the service opened at the beginning of June. For the first time people can now self-refer to the LPT crisis team (previously you had to be referred by a clinician – typically your GP and the Turning Point crisis house team could not refer to the LPT crisis team) which means that the Turning Point crisis house is much more integrated into the mental health pathway.  To date approximately 50% of calls have not required a clinical intervention but rather people have needed emotional and psycho-social support.

During the initial outbreak the health service mobilised to free up acute beds in order to protect the NHS from being overwhelmed at the peak of the pandemic. As part of this national effort, Turning Point worked with South London and Maudsley NHS Foundation Trust (SLaM) to develop a new step-down accommodation for people with mental health issues who are clinically ready to be discharged from hospital but may not be in a position to return home straight away. The new transition service provides a short-stay residential and therapeutic service for up to six people at any one time. The team support residents to sustain their recovery, achieve positive mental health and wellbeing outcomes and explore move-on housing options. The service has helped free up beds at the Trust’s Denmark Hill site which was used for Covid-19 patients.

Lessons learnt:

• Digital delivery of IAPT services is effective but demand is still below expected levels and is likely to increase as a result of the impact of the pandemic  on mental health over the coming months and years 

The third sector is a flexible and responsive partner in the delivery of mental health services and cost-effective support for management of demand and supply e.g. through the provision of step up/step down services.

Helping the homeless population during the pandemic

The COVID-19 crisis has shown that for rough sleepers a quality offer of accommodation with integrated substance misuse treatment and health care can be effective in reaching most. This is the first occasion in over a decade where dedicated funding has been provided to carry out this sort of work and the sector has responded. This wasn’t possible before as funding was not available.

However the government’s response has been far from comprehensive, there has been little additional support provided to this cohort from primary care, mental health services, dental services etc. There has only been a focus on getting people housed and tackling their substance misuse. What’s needed is a more joined up approach to help these people re-engage with society. Without this, in the long term after COVID-19 people will be back on the streets.

Rough sleepers should be offered shorter term accommodation with the promise of longer term support and this offer should be extended repeatedly to those who don’t take up support initially.

What doesn’t work is offering rough sleepers large hostels where little support is provided and there is no proper engagement made with the person being supported.

Lessons learnt

• Everyone In was a fantastic catalyst to support interagency working across the sector and there is significant will to build on the success of this initiative
• The shortage of supported accommodation for people with complex needs is a significant barrier to  tackling street homelessness
• A significant proportion of people who are street homeless have No Recourse to Public Funds. The homelessness problem cannot be addressed without addressing this.

Prisons

Turning Point provides services at both HMP Leicester and HMP Thameside. Governments, according to the World Health Organisation, have “a special duty of care for those in places of detention which should cover safety, basic needs and recognition of human rights, including the right to health.” (UK Parliament 2018). We have seen very limited infection control measures in place in both prisons until very recently (November 2020).

Lessons learnt

• The failure to enforce strict infection control in prisons is a failure of the Government’s duty of care towards people detained in prisons in England.

The impact on the social care sector

COVID-19 and its impacts will be widespread and longstanding, not least in the social care sector. We are pleased that the COVID crisis has shone a light on the vital support delivered by social care services. At Turning Point we specialise in supporting people with a learning disability, supporting over 900 people to live as independently as possible across the country. We deliver high quality social care for people with complex needs, including autism, behaviours that challenge, mental ill health and dementia.

Through our supported living and outreach services, we support people as they develop independent skills, become active participants in their local community and gain training and employment to enable them to make a vital contribution to society.  In our residential care services, we use technology and specialist aids to support people to maintain and increase their independence.

Delivering Learning Disability services during the lockdown

During the early stages of the pandemic, the impact was most acutely felt within our residential and accommodation-based services where we had to help protect some of the most vulnerable people while also keeping our workforce safe. Our staff acted heroically, coming into work where the people they support had tested positive, isolating with the people they support and showing great creativity in helping people keep busy and positive in the midst of the crisis.

To ensure people within our learning disability services receive the best care during these unprecedented times we introduced a number of structural changes:

• Centralised daily monitoring of staff absence hotspots and redeployment of staff to ensure safe staffing levels at all times
• Sharing easy read info on COVID-19, PPE, health and wellbeing etc. with the people we support
• Stopping visitors coming into services in line with government guidance. We appreciate that spending time with family plays a significant role in people’s health and wellbeing and so we worked hard to keep in close contact with families, to provide updates on how their family member was doing, facilitating digital conversations or window conversations wherever possible.
• We have been able to secure PPE for our staff throughout the pandemic, to ensure that they and the people we support are safe, monitoring stock on a daily basis through a bespoke app developed by our IMT team. This is key for maintaining high levels of infection control within our services.

We have faced significant additional costs as a result of the pandemic. Generally these have been reimbursed by our commissioners although the response across the country was extremely varied and the picture for 21/22 is uncertain.   Infection Control Funding is confusing in our experience and geared towards care homes which is not helpful for other accommodation-based services where we must push to get the same level of support. There is a real concern over how this will play out when the vaccine is released. We are awaiting the outcome of the consultation into stopping the movement of staff between care settings. It appears unclear if this applies only to care homes or to supported living services as well. It could cause increased costs of working and would be difficult to operationalise. It is inconsistent with the way MDT teams, cleaners, Registered Managers etc work. Those already on low pay will likely be negatively impacted and there would also be a disproportionate impact on BAME individuals and women. There is a big question mark over whether there would be enough people in a workforce configured in this way and there could be harmful unintended consequences.

Lesson learnt

• Ensuring compliance with infection control requirements e.g. ensuring people use PPE correctly requires continuing effort and good quality communications with staff
• The government continues to neglect supported accommodation in the guidance in favour of care homes which causes difficulties for supported living providers, the people being supported and their families 
• The variable response from commissioners on reimbursing costs will no doubt have put some smaller social care providers in a difficult financial position and the lack of future guidance or information makes planning for the next financial year very difficult

DNACPRs

DNACPR stands for Do Not Attempt Cardio Pulmonary Resuscitation (CPR) - doctors put a DNACPR order in place when someone is at the end of their life to make sure a person’s death is as peaceful and dignified as possible . Where someone lacks capacity – which means they don’t have the ability to use and understand information to be consulted about a decision such as putting a DNACPR in place - the law says there should be a meeting to decide what is in the Best Interests of that person – which involves the people that know the person best such as their family members and support workers who are with them every day.     

We received an unprecedented number of DNACPRs during April and May 2020. We immediately challenge any that do not meet the requirements of the MCA or the Equalities Act (e.g. where Best Interest process hasn’t been followed or where the reason given is ‘learning disabilities’).  

Though we are seeing many more of these DNR instructions on the basis of learning disability or autism, it is not a new problem. Last year’s LeDeR report recommended that the Department of Health and Social Care “issue guidance for doctors that ‘learning disabilities’ should never be an acceptable rationale for a DNACPR order”. This a human rights issue. Even during such testing times as we are in now, these freedoms are sacrosanct and protected by the Human Rights Act (1998), Equality Act (2010) and United Nations Convention on the Rights of Persons with Disabilities (2006).

The unprecedented increase in DNACPRs prompted us to audit the records for all the people we support to check any DNACPRs on file and to construct a challenge as appropriate. In addition, we worked with Learning Disability England to develop resources to support families and support staff to challenge DNACPRs that do not meet the requirements of the MCA or the Equalities Act. It includes a:

• DNACPR Checklist
• DNACPR Legal Guidance Document
• DNACPR Example of Complaint Letter
• DNACPR Template Letters
• Example of a DNACPR Form

Lessons learnt

• People with a learning disability continue to face discrimination as illustrated by the spike in DNACPRs
• There is not enough information in the public domain for carers/family members about DNACPRs  and how to challenge them

Workforce well-being

As a 3rd sector provider of over 300 health and social care services and with over 4000 employees based across England, supporting employee wellbeing whilst they maintained service delivery in face of the pandemic presented a significant challenge to Turning Point.

Within days of the situation escalating in March, Turning Point’s employee wellbeing arm – Rightsteps – brought together a multidisciplinary team of wellbeing experts and organisational representatives to swiftly analyse and respond to employees’ wellbeing needs. The requirement for Covid-specific support solutions that reflected the emerging needs was immediately recognized, as was the need to deliver support in ways that were accessible and could reach colleagues from across the country working in new and extremely challenging situations.

Rightsteps’ clinical psychologists started developing weekly online support packages that were distributed via text message to all staff as well as via Turning Point’s internal communications network. A microsite of wellbeing resources for managers and staff was created in days and then developed over the following weeks and months to provide a ‘one-stop-shop’ for all wellbeing support. Team and individual de-brief sessions were delivered remotely in response to difficulties arising from the challenging situation employees faced and access to emotional related support sessions over the telephone was provisioned for all staff. To support staff further weekly open access webinars were developed, delivered and facilitated by subject matter experts on key themes such as resilience, anxiety and loneliness, with all activities coordinated by the single multidisciplinary team, communicated via Turning Point’s employee engagement specialists and led by the Chief Executive.

Within 6 months and through a highly demanding situation, Turning Point’s wellbeing approach saw the online support packages accessed over 3,400 times by Turning Point employees, over 500 employees attended the Wellbeing Webinars with representation from across the organisation, and a staff survey showed a massive increase in how employees feel their wellbeing is valued and supported.

However, wellbeing of the social care workforce continues to be a massive challenge and poor pay across the sector is a serious problem which needs to be addressed through wider reforms.   

Lessons learnt

• Social care staff have done an amazing job through the pandemic but they are tired and the risk of burn out is considerable. This adds further weight to the argument for widescale reform to the social care sector which recognises the vital contribution made by the social care workforce during the pandemic
• Ongoing and regular communications on health and wellbeing are essential to support employees doing very demanding jobs on the frontline as is choice in terms of how and when support is accessed.

Future of social care

For 10 years government has promised a long term plan for adult social care but only piecemeal change has arrived. Some ways in which social care could be reformed are as followed

• A shift in rhetoric - Discussions around adult social care often focus on care for the elderly. This is of huge importance but can put in the background the needs of those with learning disabilities. We need a wide ranging discussion which includes all stakeholders.
• Funding - According to LGA figures by 2020, local authorities will have faced a reduction to core funding from the Government of nearly £16 billion over the preceding decade. Moreover, councils will have lost 60p out of every £1 the Government had provided to spend on local services in the last eight years. Reinvesting in our local authorities will give them the ability to fund these services and be more resilient when crisis strikes.
• Concrete proposals - We have had an untold number of green papers on social care over the past decade, but nothing has come of them. There must be a process put in place which timescales the journey from consultation to legislation.
• Ambitious change - We can’t afford in another 5 years to be in a similar position; governments cannot tinker at the edges. Just as the NHS has had its funding guaranteed for a multi-year period, why shouldn’t social care have the same?
• Engagement with stakeholders is vital - From local authorities, to third sector providers like ourselves at Turning Point and to people we support who are the most important in all of this.

(November 2020)