Written evidence submitted by Turning Point (RTR0123)

1. Turning Point is a leading social enterprise supporting over 130,0000 individuals and employing over 5,000 members of staff, providing health and social care services for people with complex needs across 300 locations across England. 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, sexual health, healthy lifestyles and employment.

Steps needed to address the recruitment challenge in health and social care

2. Our social care services include registered care homes and supported living for people with a learning disability, mental health issues and drug and alcohol problems. Poor pay in the sector is a key limiting factor in the recruitment and retention of staff. 98% of our revenue is contract income and contracts frequently set out the scope for staff pay and benefits. There is significant variation between authorities in rates of pay. We are often in direct competition with the retail sector who often pay more which makes recruitment in areas with high employment rates a particular challenge. We need pay rates to reflect local market conditions and to be competitive and social care roles to be valued by society and seen to be worthwhile.

3. Additional money has been promised to the sector in the Social Care White Paper however we have concerns about when and how much will be available once the NHS backlog has been addressed and the amount that will be available to increase support worker pay. The Workforce Recruitment and Retention Fund for adult social care is a useful short-term intervention; however, again there is significant variation in what local authorities have made available to local providers.  
4. Turning Point employs significant numbers of psychiatrists, nurses, psychologists, PWP workers and CBT therapists within our health services.  However, as a social enterprise we are unable to compete with the NHS on terms and conditions. Many doctors are reluctant to leave the NHS because of their pensions and broader benefits. Our strategy is to build entry level roles, create career pathways, to support development and offer more flexible working patterns. We believe our staff have ‘more freedom to act’ and are in a better position to shape services and delivery.

5. We would like to see greater financial support for the social enterprise sector to fund training and development and more opportunities to get involved in area-based health and social care training and development schemes. This would enable us to build skills and offer a professional career path. We would also like to see additional funding to enable us to offer competitive pay rates on an ongoing basis as well as funding for attraction and retention bonuses.

International recruitment

6. At present, 30 Turning Point employees (0.7%) are on a work visa and 270 (5.9%) are non-UK nationals who have the right to work here. Turning Point is not currently involved in any overseas recruitment initiatives because the roles where we find it hard to recruit do not meet the salary threshold for visa requirements.  

7. We would like to see the government review current legislation regarding immigration to make it easier to recruit from overseas. Since January 2021, thresholds for skilled migrants have been replaced with a points-based immigration system. New migrants have to prove skills in the English language and have a job offer lined up in a skilled profession, with a minimum salary of £25,600. For jobs in the shortage occupation list (senior care workers were added in March 2021), the salary threshold drops to £20,480. Expanding the occupation list does not ‘fix’ the issue, given the annual average salary of care staff is currently £19,000, so we would like to see the threshold dropped.

Initial and ongoing training of staff in the health and social care sectors

8. As a social care employer we are able to provide all the training required for somebody taking up an entry level role. However, sometimes staff struggle to access training, particularly where there is no protected learning time build into the contract or limited access to IT. This is especially an issue in supported living (i.e., where people are providing support in a person’s home). We would like to see additional funding for local authorities to enable more flexibility within their contracts which would allow better access for staff to training.

9. We would also support increased funding for digital skills and literacy / numeracy programmes which would enable more people to be in a position to apply for entry level social care roles.

10. The bursary changes for nursing degrees, alongside the fact that training is full-time, means it is very inflexible. Moving forwards, we would like to see the bursaries reintroduced or a new system introduced akin to the PGCE training programme for teachers. In addition, CPD funding is not available to nurses working in the 3rd sector. It can only be accessed by NHS staff. This adds to the challenge facing 3rd sector healthcare providers in retaining staff. CPD needs to be made accessible for 3rd sector and social enterprises.

11. We would like to see the Kickstart scheme expanded to include health and social care volunteers with lived experience moving into paid roles. Turning Point’s peer mentors are people with experience of drug or alcohol problems who are in recovery and volunteer within our substance misuse services, supporting others through treatment. Last year we had 168 peer mentors volunteering for us and 22 went on to paid employment. Training and placement of peer mentor volunteers has been more difficult during the pandemic, but we now deliver all training online with good results and we hope to expand this programme.

Training places for doctors, nurses and AHPs

12. There is a national shortage of training places for addictions psychiatrists. The RCPysc report Training in Addiction Psychiatry: Current Status and Future Prospects (2020) makes recommendations to ensure a sustainable supply of addiction psychiatrists. Turning Point’s Leicester, Leicestershire & Rutland service’s experience of setting up trainee addiction psychiatry posts was featured as a case study in the report. RCPsyc found that the established link between educational commissioning and service posts has broken down in areas of the third sector. Our experience demonstrates that large 3rd sector providers are able to provide high quality training opportunities and can and should (since the sector delivers 2/3s of community treatment services) play a much greater role in addressing the looming addiction psychiatry workforce crisis. This will require:
• HEE to recognise the need to work with third sector providers as well as NHS providers to ensure that training posts are established and maintained;
• Acknowledgement of the role that the service may play in training in commissioning, ring fencing training posts so they will not be affected by any wider resource constraints; and
• Greater recognition from the RCPsyc that posts within the third sector are entirely comparable to posts within the NHS and there should be parity with NHS services regarding funding from HEE. 
13. The number of nurses in training dropped significantly when fees for nursing degrees were introduced (number on mental health nursing degrees dropped by around 20%) and this is impacting on our ability to recruit now and will continue for the next 2-3 years.  

Curriculums for training doctors, nurses, and AHPs

Substance misuse

14. From our experience, there is not enough emphasis on substance misuse training for mental health professionals therefore recruiting clinicians within our substance misuse services is a particular challenge compared to our specialist mental health services.

15. The number of GPs specialising in substance use has reduced and one in three posts for specialty GP training doesn’t result in a GP joining the NHS. Primary care is busier than ever before which limits GP’s capacity to deliver ‘extra’ services such as shared care. Shared care is a very effective method of engaging people with complex needs into mainstream healthcare services and can help support them with other long-term conditions they have. However, young GPs are interested in developing portfolio careers so there is an opportunity to engage young GPs with an interest in substance use treatment.  There are excellent training resources, such as the RCGP certificates. However, this needs updating.

16. There is an opportunity is to engage GPs at a training level. Placements (such as the one we have set up in our Rochdale and Oldham Active Recovery Service) are crucial at getting GPs interested and keeping them within the substance misuse sector. This post will provide GPs with skills and knowledge in substance misuse psychiatry that are relevant to primary care, and which will enable them to provide better quality care for their patients. This scheme covers the whole of Greater Manchester for the next 5 years and we would like to see similar schemes developed in other parts of the country. 

17. There is very little substance use and learning disability care in both the undergraduate curriculum, and in the GP curriculum. Ideally, more emphasis would be placed on addiction, substance use and allied health in medical school undergraduate curricula, and similarly as part of GP training as a postgraduate.

3rd sector training/experience

18. There is a great need to broaden current training to be more inclusive of organisations beyond just NHS providers, but also encompassing 3rd sector organisations and social enterprise as well, so as to better reflect the nature of the health and social care sector.

19. NHS and 3rd sector work environments can differ significantly and in many ways:

• Expectations surrounding roles and leadership
• Attitudes towards autonomous working
• Different challenges presented by workforce and budget constraints

20. These different working environments will better suit some people and by integrating these sectors more within training curriculums, trainee health professionals can get a more holistic view of the health and social care system.

The training period for doctors

21. We do not think that the training period should be reduced; rather, we think it is important to ensure training includes adequate exposure to all parts of the health and social care system. For example, you can qualify without ever being exposed to addiction treatment and learning disability care which are key specialisms, particularly if we want to address health inequalities.

Removing the cap on medical students

22. We believe that more medical places are needed across the country in general.

Factors driving staff to leave the health and social care sectors

23. The pandemic has stretched the health and social care workforce to its limits. Our employee wellbeing arm Rightsteps provides employee health and wellbeing support to a range of health and social care providers and we have seen demand increase across the sector.

24. At Turning Point referrals to Occupational Health and requests for therapy from employees have increased significantly over the past 18 months and some people have left as a result of burn-out. In addition, the introduction of mandatory vaccinations has resulted in many staff leaving the sector.

Health and wellbeing

25. As an organisation we prioritise the health and wellbeing of our staff. Turning Point is an accredited Mindful Employer (we have signed up to the Charter for Employers Positive about Mental Health) and we have adopted the Mental Health at Work standards. We have a number of workforce health and wellbeing initiatives which support retention. These include: a mental health first aider programme; Mindful Monday sessions; mental health counselling support; a national Disability Network for colleagues living with a disability; routine wellbeing check-ins as part of COVID risk assessments for all staff; support for colleagues going through the menopause including webinars and a support group; and a range of support on financial wellbeing including affordable loans repaid through salary, advance earned pay and simple savings. The cost of workforce health and wellbeings need to be reflected in funding for health and social care services.

Mandatory vaccinations

26. Approximately 8% of employees who were in scope left Turning Point when C-19 vaccinations became mandatory for staff working in CQC registered care homes. From April a much wider section of health and social are staff will be required to be vaccinated. We are currently assessing the risk for staffing levels. This is a resource intensive process and we have had to invest in additional administrative capacity.  If we see similar rates of people leave the sector, we may see 350 people leave the organisation, as a result of mandatory vaccinations, which represents a huge potential loss of skills and experience. Some geographies are particularly challenging, reflecting take-up rates in the local population.

27. Our strategy involves supporting managers to have coaching conversations with staff who are vaccine hesitant, for example in one service 7% staff initially said they would refuse to have the vaccine but this has reduced to less than 1% following targeted conversations with those individuals, ensuring they have all the information and support they need.  

Specific roles, and geographies where recruitment and retention are a particular problem

28. Turning Point’s biggest recruitment challenges are: 

• Talking therapies (IAPT) – in particular the recruitment of Psychological Wellbeing Practitioners (PWPs)
• Nurses  
• Recruiting support workers in particular geographies (e.g. Greater Manchester and Kent)
• Expanding the substance misuse workforce. Additional funding which has come into the sector is enabling us to increase the workforce but this has required us to recruit and train people without a background in substance misuse

IAPT

29. There is a national shortage of qualified PWPs although the situation is improving.  Last year turnover was 38% in our mental health services (Feb 20-Feb 21). This compares to 27.5% across Turning Point as a whole.  We have introduced a range of home-based roles. The opportunities to do this have increased significantly as a result of the pandemic and the shift to telephone/video therapy in response. We deliver high quality training for trainee PWPs (staff can join as trainees – an entry level role for a psychology graduate).

30. The IAPT workforce is predominantly white, female, aged 26-45, meaning it is not always representative of local populations and people we support. We are currently doing a piece of work to identify how we can better attract black and people of colour. This involves working closely with local communities to better explain what the PWP role is and the opportunities available. We are also looking at how we can support people to be successful in the recruitment process e.g., CV skills, interview skills to help people secure a role with us.

31. Before joining Turning Point, Yahya had been involved in mental health and substance misuse community-based work (rehabilitation and education) for many years. Yahya had always been exposed to mental health issues throughout his work, both on a local and a global scale, including war-torn places. Yahya’s own background meant seeing poverty, crime, violence, racism and a lack of opportunity; he had experience of mental health issues with his family and friends too. Yahya is passionate and believes that this sort of work (and awareness-raising) is critical, especially in minority communities; his approach developed through his volunteering role at our Wakefield Talking Therapies service. As a community coordinator with Turning Point, he would work at schools and hospitals raising awareness of Turning Point and its work. This has led to him seeking to become a psychological wellbeing practitioner and he is now employed by Turning Point as a trainee. Yahya says: “We may not be able to change the world all at once, but if we can change it on a local level for individuals, we’re a step closer.”

Support worker roles

32. Recruitment for social care roles is a challenge in areas where there are high levels of employment and are placed in direct competition with the retail sector. Voluntary turnover is currently 33% and 34% in Tameside and Kent respectively, compared to 27.5% across the entirety of Turning Point services. We devote additional resources to recruitment and retention in these geographies.

The next iteration of the NHS People Plan, and a people plan for the social care sector

33. We would support the development of an integrated health and social care workforce plan, recognising the interdependencies across the system, and a joint workforce strategy that aligns workforce initiatives across all providers.

34. The role of mental health and addictions in social care needs to be recognised.  To support this we believe that there needs to be data gathered on workforce availability and workforce challenges with the mental health social care sector, so that there is a comprehensive understanding.

35. As members of the Association of Mental Health Providers (AMHP) we have contributed to their report Developing The Mental Health Social Care Workforce and we support their recommendations.

Contractual and employment models

36. Changes to the IR35 rules introduced in April 2021 have impacted on doctors who work for Turning Point on a freelance basis. Tax and NI contributions are deducted at source at standard employment rates which has reduced income for some doctors who are self-employed without increasing extending the protections afforded a standard employee. This has made recruitment more difficult, particularly in a sector where there are a shortage of specialists. 

The role of integrated care systems in ensuring that local health and care organisations attract and retain staff with the right mix of skills

37. We would like to see ICSs prioritising workforce planning within their geographies - supporting across all health and social care organisations (including 3rd sector and social enterprises as well as NHS providers). Place-based partnerships can help create a more joined-up approach to resource management underpinned by shared priorities and an ethos of ‘one place, one budget’, even if they do not become budget-holding entities in their own right. 

Jan 2022

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