All health and care commissioners should demand social value

This is my blog to support the launch of the Joint VCSE Review’s new action plan. I have also written a piece for HSJ with Glen Garrod of ADASS and Rob Webster of South West Yorkshire Partnership NHS Trust.

“We welcome the new action plan from the Joint VCSE Review, which has set out an important vision in which voluntary, community and social enterprise organisations work with the NHS to co-design and co-deliver health and care services with local people. The action plan has a strong focus on greater use of Social Value Act powers by health and care commissioners which enables commissioners to seek added social value from local providers and more value for public money in partnership with charits and community groups. Use of the Act should be more routine in health commissioning.”

Simon Stevens, CEO, NHS England.

What do voluntary, community and social enterprise (VCSE) organisations want from government and the NHS? Ask our statutory partners and many will say, “money” and then add “but we don’t have any!” The first part of that is true, of course. The VCSE sector can often manage with less money than other kinds of organisation, because it is often better at drawing on different kinds of resources as well: people’s freely given time, support from local community and businesses, use of community resources. But all organisations working in health and social care, whether statutory, private or not for profit, need money to run. The difference between statutory and voluntary organisations is not their need for money, it is that typically statutory organisations control that money, and VCSE organisations do not.

Two years ago the Joint VCSE Review held a full consultation with the VCSE sector and its partners, and produced a report and 28 recommendations based on what we found. We heard that VCSE did not want to be in the position of asking for money: they wanted to share responsibility for the resources available, and to help people who use public services to share that responsibility. When statutory organisations and commissioners say ‘there’s no money!’ they have often started with the assumption that they must keep spending the money they have on what they already do. Local people, particularly from groups and communities who are not well-served by current services, can take a different view, if they have the opportunity to take part in genuine decision-making (as opposed to being ‘engaged’ and ‘consulted’ by decision-makers reluctant to give up any real power). So our key message was that, if we are serious about community-based, community-owned health and care services, which both expect and ask more of citizens, we need to get serious about co-designing those services with the people who make most use of them. VCSE organisations are the only ones with any track record of doing that. The fact that co-design and coproduction are still seen as slow, difficult and optional, rather than essential to improvement and tackling inequalities, is a good indicator of how much current commissioning teams need their voluntary counterparts and the communities they reach.

King’s Fund research commissioned in response to the Joint Review found a clear distinction between commissioners who co-commission and those who see their VCSE partners as there to provide the services designed without their input. So our new action plan’s three actions include co-design becoming a core expectation, with commissioners recognising that some of their scarce resources could usefully be invested in user-led and grassroots groups which are their only viable routes to the people with whom they need to co-design the future. As areas start to co-design in that way, as pioneers like Greater Manchester are already doing, they are hearing a clear demand for health and social care services which help people to live well and to remain independent and resilient in the face of long term health conditions, so our other two actions are to embed wellbeing as a shared goal for health and care services, and to enable local leaders to commission, demand and pay for wellbeing and resilience. We heard from the sector about the need for tools to be freely available to small local organisations, not just to large organisations with research and evaluation budgets. And we were excited by the promising examples of social prescribing and other approaches which, when done well, enable commissioners to work with intermediary local bodies to get their resources effectively to the full range of VCSE organisations. We argued in our original report that fund should always be on a ‘simplest by default’ basis, avoiding expensive, time-consuming and overly bureaucratic processes which are often evidence of a lack of understanding of what the VCSE can bring, rather than reflections of any real regulatory imperative.

Our action plan, which has been adopted by the Health and Wellbeing Alliance, is an attempt to bridge the statutory and voluntary worlds. That bridge will enable people to travel more freely between their lives at home in the community and the world of service support which can too often be inaccessible. One tangible way to bridge between the values of the VCSE sector and what the statutory sector will place a value on, would be to use routinely the existing Social Value Act powers, which allow commissioners to demand social value such as use of volunteers, or employment of people with lived experience, from all of their contracts. Jon Rouse says, “The Greater Manchester Health and Social Care Partnership based our working relationship with the voluntary, community and social enterprise (VCSE) sector on the recommendations from the Joint VCSE Review, which included that statutory and voluntary agencies should work together with local people to co-design better health and care services. We welcome the new VCSE action plan and expect to lead the way in using the Social Value Act powers routinely in our health and care contracting, to get the best value possible from public funds.”

Bridging between those two worlds means building from both sides, so I want to end with a challenge to my own sector. It’s not enough for us to talk about our community roots: we need to demonstrate that they are still strong and healthy. If we are to share in the power that goes with co-owning health and care systems and their resources, we must also be willing to share responsibility. The inequality of our current public services, and their outcomes, was the strongest message we heard during our consultation. As voluntary, community and social enterprise organisations we need to look hard at our practices and the way we make decisions ourselves, to be sure that we are part of the solution to that injustice.

Poacher, gamekeeper – or partner?

Following recommendations made by the Joint VCSE Review, The Kings Fund has produced an important report on the different ways that NHS and council commissioners view not-for-profits (VCSE organisations) and the impact of those views. To caricature the report a little, there is a spectrum, from commissioners who see VCSE organisations as fairly disposable support providers, to be funded with spare cash when they can, to commissioners who want to co-design health and support services with local people, and recognise that they need to see their local charities and community organisations as the way to engage people in doing that. The consequences of those different approaches are profound. They also have ramifications for the new Integrated Care Systems which are planned as the latest ways to join up health and care and which follow on from recent health planning processes (‘STPs’) that rarely involved local people (and were labelled ‘secret cuts plans’ as a result). The report says,

“Changes to commissioning may raise more challenges for successful co-production. As integrated care organisations develop, it is unclear who bears responsibility for supporting and developing community assets. There is a risk that more transactional approaches could
develop in the absence of clear incentives to involve VCSE organisations in co-producing commissioning intentions.”

If we want a genuinely transformed health and care system that not only fits together itself, but also fits with people’s lives, we need health and care planners to see their local civil society organisations as co-designers, and to challenge those organisations to reach and engage groups and communities that have historically been excluded and poorly served.

The Wellbeing Alliance

This is reblogged from my Dept Health blog.

The Joint VCSE Review this year recommended 28 changes to the way national and local government invests in – and works with – the VCSE sector.  We identified a shared goal for government, the NHS and the VCSE sector: to help people, families and communities achieve and maintain their own wellbeing.

There was wide agreement that this is best achieved when people and communities are actively involved in co-designing systems and services.

The VCSE sector, therefore, has two vital roles: 1) To make sure people from all groups and communities get involved in the co-design process and 2) To help deliver more person-centred and community-based services.

Today sees the launch of applications for the VCSE Health and Wellbeing Alliance, which we recommended as the national flagship programme to embed the role of VCSE organisations within the health and care system.

VCSE organisations recruited to the alliance will need to demonstrate their reach into local, small scale or specialist charities, social enterprises and community groups. Likewise, they must be committed to helping the Department of Health, NHS England, Public Health England and other national bodies hear the voices of people and communities who use health and care services, so that policies are truly ‘co-produced’.

The alliance, along with a fund expected to be launched early in the new financial year, form the Health and Wellbeing Programme, which will be the place where central government, NHS England and Public Health England come together with VCSE organisations to drive transformation of health and care systems. This single, integrated programme builds on the successes of its predecessor, the Voluntary Sector Investment Programme.

The final report of the Joint Review was published in May and since then work has been progressing to implement the 28 recommendations made.

An oversight group, which includes representatives of a broad cross section of the VCSE sector and government, has been established to oversee the implementation of the recommendations. Some are long term changes, but I’m heartened by the enthusiasm with which a number of agencies have embraced shorter term recommendations about how the state and the VCSE sector can work more effectively together. For example, CQC are thinking about how to include the value of personalisation, social action and the use of volunteers as they review their Key Lines of Enquiry.

Meanwhile, NHS England and partners are developing a social prescribing programme. Some areas are creating living maps of their VCSE assets, which is a vital first step to treating them as partners.

The Joint Review also set out challenges to the VCSE sector itself: to help drive the shift towards ‘asset-based’ approaches (which build people’s capabilities and resilience), to keep and build its roots in local communities and to demonstrate its impact.

The VCSE Health and Wellbeing Alliance is an opportunity to rise to those challenges, which I hope many organisations in our sector will embrace.

Charities, community groups and social enterprises at the heart of health and care

Today we launch the final report and recommendations from the Joint Review of the Voluntary Community and Social Enterprise (VCSE) sector’s role in the health and care system. This follows a year and a half of hard work by an advisory group (which I have chaired) made up of people from the VCSE sector working together with people from national and local government. It’s been hard work and the co-produced process has at times challenged the usual systems for producing reports, with lots of pragmatism required on both sides. But I feel (and hope you’ll agree!) it’s been worthwhile, in order to build a consensus around a clear view of what the VCSE can and could do, the challenges it faces and the ways in which many of those challenges could be overcome. I’m incredibly grateful to everyone on the group, NCVO who provided the secretariat, communications support and much more, and to lots of colleagues working behind the scenes and in numerous agencies we liaised with, who have all worked so hard to get to publication (see www.gov.uk for full report). Here is the blog which I wrote for the launch:

The goal shared by everyone who delivers and organises health and care services is wellbeing: its creation and its resilience. Whilst we do not want to spend increasing proportions of our lives in medical nor social care, we will all draw upon primary, acute or specialist services at various points in our lives and we want to find them available, caring and well run when we do. However, whether for people with lifelong disabilities, the ever growing older population or those with long term health conditions and support needs, our dreams remain rooted in living well at home as part of welcoming, inclusive communities. To achieve that goal, we need health and care systems which are organised around and support our lives: which can reach us in our homes, support our families to care, and release the full potential of communities.

When people talk about the difference that charities, social enterprises and community groups can make to delivering health and care services, they often focus on the ways that those organisations can reach people whom mainstream health and care services find ‘hard to reach’ or ‘challenging’, get to know them more deeply, and draw upon volunteers to achieve more than paid staff alone can achieve. All true, and extremely valuable, but, our review of the voluntary, community and social enterprise or VCSE sector found, only half the story.

There was indeed wide agreement that good VCSE organisations are better placed than other kinds of organisation to achieve some of the health and care goals which are now seen as crucial to the sustainability of our NHS and social care systems. It is VCSE organisations which often support groups and communities which are otherwise neglected, not only responding to health needs but also starting to address the social determinants (poverty, housing, exclusion) of health and deep-rooted health inequalities. Through drawing on people power as well as money, VCSE organisations are often uniquely able to offer support which looks at the whole person and whole family, thinking preventatively and whole-lifetime. Many of our recommendations are designed to identify, measure and invest in those added kinds of ‘social value’ which VCSE organisations bring into a system desperately searching for more bang for its buck.

The current funding trajectory in some areas is towards large, narrowly focused contracts, which can be appropriate to holding big providers to account, but can be poor ways to create the diverse local marketplace of big, small and niche providers called for by the Care Act and needed to reach whole populations and to offer people genuine choice. The most creative planners and commissioners are drawing on the full range of investment approaches, using contracts creatively alongside grants for community development work, personal budget and Personal Health Budgets for personally tailored support packages, social prescribing to link up vulnerable people with effective charities (with funding following the prescription to ensure that’s sustainable), and social investment to take risks and innovate.

So developing the VCSE sector as a distinct form of health and care provision is crucial and brings value into the system that money alone cannot buy. But for many of the VCSE organisations and local commissioners who responded to our consultation, just as important as how much funding VCSE organisations could win through competing to provide services, was the extent to which VCSE organisations were involved in planning those services: co-designing the local health and care goals and playing a full part in developing responses to local needs and building on local assets and community resources.

Traditionally, the health and care system has been designed largely by the state Continue reading

Ways to wellbeing

Here’s my latest thoughts on the role of the VCSE sector in health and care, reblogged from http://vcsereview.org.uk/2015/10/13/ways-to-wellbeing/ where you can have your say. (I’m also at the NCAS conference this week in Bournemouth so if you’re there and want to meet up please get in touch.)

It says a lot about people who work in the voluntary, community and social enterprise (VCSE) sector that, when asked to decide which of the VCSE review topics they wanted to focus on at the Voluntary Sector North West session this week, delegates quickly decided they wanted to talk about ‘what our sector needs to do to change’, rather than what might need changing about other sectors.

Changing the terms of debate

What needs to change in the sector, and what needs to be defended at all costs, is one of the most nuanced aspects of the debates I’ve heard during this review. There was agreement that the VCSE sector cannot simply say ‘we do good work, it’s your duty to fund us’. We need to be able to present our arguments in an evidenced, professional and compelling way, and in language that statutory sector colleagues can recognise and understand. On the other hand, the sector’s USP is not that it can become identical to the private or statutory sectors. It brings kinds of value and impact that are not readily available to those sectors and which they have not always valued enough to be willing to pay for. Part of the sector’s role is to change the terms of debate, in particular to steer the health and care system away from short term, medical goals and the view that they are there to fix their patients, and towards long term goals, which are based on seeing the whole person and having the humility to listen to that person, collaborate with them and learn from them.

Routes to resilience

The discussion about impact started with how it can be measured but as one delegate put it, “It’s not enough to be able to measure our impacts, we need to be able to demonstrate that we and the impacts we achieve are an essential part of the care pathway.” Then, as another colleague pointed out, the idea of the care pathway is in itself based on a medicalised view of the world. Care pathways sound clear, but are actually paths which twist, turn and peter out or end at brick walls between one service and the next. If we believe that what we need is a national health and wellbeing service, then the pathways we are looking for are instead ‘ways to wellbeing’ or ‘routes to resilience’. Directions in which people, families and communities can grow, rather than strips of tarmac to follow.

Achieving wellbeing

So many of the discussions I’ve been involved in about the role of the VCSE sector, come back, at a fundamental level, to our ability to translate the rhetoric of wellbeing into the right kinds of goals, behaviours and pressures in the system. People have talked to us about a gulf between local leaders who say all the right things, and the reality of their bureaucracies which remain based on achieving familiar short term targets, with the pressure for quick ‘results’ pushed down the system into stressed and sometimes bullied front lines and delivery partners. Models like Year of Care and House of Care attempt to address this, but we need to base our health and care system on a simpler and more compelling picture of how people move towards wellbeing, so that we can demonstrate the role that every part of the system plays in that. Achieving wellbeing always involves:

  • being informed (not mired in jargon)
  • being valued as a partner (not seen as ‘my patient’)
  • having access to resources (not treated as a customer)
  • having access to expertise and back-up when its needed (rather than having to jump through hoops)
  • being connected to others (not isolated or stigmatised)

Call for action

It should be self-evident that the statutory sector and the VCSE sector play different but equally vital roles in those ways to wellbeing. The statutory sector often holds the expertise, the resources and the capacity to respond in emergencies, for instance, whereas the VCSE sector knows how to get information to overlooked groups and communities; understands how to connect people and tackle isolation; and is based (at its best) upon equal partnerships, not paternalism.

How do we make that picture so clear and compelling that the whole system aims for it, takes risks to achieve it and invests scarce resources in it? Please tell us: www.vcsereview.org.uk

Alex Fox, CEO Shared Lives Plus and Chair of the VCSE Review

They want us to become like them so that they can understand us

‘The majority of procurement practice is stifled by process and bureaucracy, what appears to be text book practice in reality translates into overly complex, process focused exercises.  Such exercises demand a huge input from providers and commissioners and often miss the point of the intended outcome. Tenders now typically require 30,000 word submissions, and the majority of tendering organisations now support sizable bid teams.’

‘When I’m applying for £500 it’s like I’m applying for £500 million.’

‘Providers if presented with a problem will often identify system wide solutions for commissioners; however this approach is limited, and commissioners often commission small silo services in isolation without asking the provider sector to develop and deliver a whole system change.’

‘They say the VCSE sector is good at reaching ‘hard to reach’ groups, but then they want us to do it in exactly the way they think it should be done.’

Two of those comments came from the four largest not for profit housing and care organisations in the country, and two came from very small, grassroots organisations in the North of England, all of which were contributing to the Joint Review of the VCSE sector (http://www.voluntarysectorhealthcare.org.uk/vcse-review/) which I’m currently chairing. It’s been striking that organisations very different kinds and sizes have all been telling us some of the same things about the challenges they face.

The story of the birth, growth – and sometimes death – of a not for profit organisation is too often one which starts with a need identified by a community, and then becomes increasingly a struggle to stay true to that community and purpose, whilst having to chase funding targets set by people remote from that community. As one grassroots organisation put it, ‘They want us to become like them so that they can understand us.’ The more I’ve listened to people in the not for profit sector during this review, the more I’ve felt that the case we need to make is not for the statutory sector funding the voluntary sector, it’s for the two sectors to work together with their communities to define what is needed and what the total resource of that community – state money alongside people’s time, creativity, passion – can do to meet those needs. One participant cited the example of Bradford council doing just that with their Adult and Community Learning Budget, where the outcomes were set with the VCSE sector, who are now bidding for money in an open and fair process which feels more like an opportunity to demonstrate they are good at what they claim to be good at, rather than jumping through hoops.

There is no simple, risk-free way of spending public money on achieving complex health and care outcomes. Risk is a little like the air in a balloon: squeeze it in one place and it threatens to pop in another. Managing risk is too often confused with making a particular part of the system feel better about risk, with the least imaginative commissioners acting like the anxious manager who reduces the efficiency of their team by micro-managing them. To achieve the optimum balance of risk and efficiency will require a much closer and more respectful relationship between sectors, in which state money like the rest of the community’s resources, is seen as owned by us all, not owned by one part of the system to be given – or not – to another. As one BME charity put it:

‘Each time I meet the commissioners it’s like they’re meeting me for the first time. They haven’t taken the time to understand and respect us.’

The alternative to developing a trusting relationship in which risks can be taken and shared, is often presented as efficiency, rigour, transparency, but can actually result in waste:

  • ‘The commissioners hand us over to procurement who don’t know anything about the work.’
  • ‘As a small organisation we spend the majority of our time fundraising.’
  • ‘Hand to mouth funding wastes so much money: our staff are constantly leaving as their contracts near their end.’

Partnership working has become one of the mantras of the VCSE sector, so it’s interesting to hear organisations – especially small ones who lack the back office to develop complex contractual relationships – challenging even that idea:

  • ‘The funders changed their mind about whether the work we were doing with the lead partner (who had received their grant) was a grant or a contract. As a contract it would attract VAT which would have bankrupted us. Luckily we persuaded them to change their minds.’
  • ‘The state sector always wants us to work in partnership, regardless of whether that approach is the best one.’
  • ‘We work well with private sector organisations without the formal contracting required by state agencies.’
  • ‘We are talking less about forming partnerships now and more about solidarity between organisations and causes.’

We are still digesting the views, reports and experiences which many colleagues from the sector are generously sharing with us, and we will do so until the end of the first phase of engagement on March 2nd, but I think we are all agreed that there are some fundamental changes needed in the relationship between the statutory and not for profit sectors. Those changes are hard and they are not being made anything like consistently, but I am yet to hear anyone suggest any change which wouldn’t be achievable, if both sectors agreed it was important enough.

It’s ‘voluntary’ but not optional

I’m re-blogging the post below from http://www.voluntarysectorhealthcare.org.uk/vcse-review/ which is the website for a review of investment in the voluntary, community and social enterprise (VCSE) sector which I’m chairing on behalf of a group of VCSE organisations and the Department of Health, NHS England and Public Health England. The review is based on the view set out in all of those bodies’ strategies and visions for the kind of enabling, collaborative and community-based approach to achieving health and wellbeing which could only be achieved with a thriving and valued VCSE sector. In other words, a sector which might be known as ‘voluntary’, but which cannot be seen as optional:

Having been asked to Chair this review of the voluntary, community and social enterprise sector, I’ve been more thinking than normal about what kind of VCSE sector we want and what kinds of relationships national and local health and care bodies should have with it. For me personally (and in this blog you’re going to find the personal views of advisory group members, not any ‘official’ lines), the real question here is what kind of health and care system do we want in this country?

If we want the same kind of health and care system we’ve always had, then we need a VCSE sector which gets better at delivering on public service contracts, and provides a steady supply of volunteers to help out alongside professionals. Nothing wrong with those goals, but actually I think we need a very different kind of health and care system, and the national health and care strategies all read as visions for something very different, not just a more efficient version of what we’ve always aimed at. This means a different view of what charities, community groups and social enterprises are there for, and how their contribution should be supported and valued.

If the challenges of 1948 were our major challenges now, the health system would be well able to meet them. But our key challenge now is that health and care is not used by only a relatively small number of people for a relatively short time. A quarter of the population now lives with a long term condition and many of those with several long term conditions. Living well with a long term condition, avoiding health and other crises, is not something even a great service and the most expert professionals can do for us, it is something which is only achievable when people with long term conditions, family carers, communities and professionals work together, each making their own kind of contribution, sharing information and expertise, and backing each other up when things get tough. Living well requires joined-up health, care and housing interventions, but also services which can join up with informal action and arrange themselves around our real, messy, lives.

Charities, community groups and social enterprises can do many things well, from delivering huge public service contracts to running campaigns which change the national conversation, but Continue reading