You would believe the above heading if you were to rely on Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies for your evidence. Of course this is not the case at all.
I recently facilitated a workshop for Public Health England on “strengthening the voice of the voluntary sector in Joint Strategic Needs Assessments”. As I said at the workshop – I think thats the wrong question.
The key issue for me is how can the experience of the Voluntary and Community Sector be used to improve local commissioning to tackle health inequalities and improve wellbeing?
While I welcome the ambition in plans like the NHS England 5 year forward view and the Due North report on Heath Equity which aim for greater investment in the voluntary sector neither of these quite hits the nail on the head.
Its not sufficient for statutory agencies (local government and NHS commissioners) to try to make it easier for the VCS to bid for contracts. Treating the VCS purely as contractors will fail to allow the experiential wisdom of the voluntary sector to contribute to strategic change for the better.
In order for this to happen the system needs to be much more permeable to the voluntary sector perspective. Crucially, statutory services cannot treat the VCS as though it works to the same rules as big public sector bodies – because it does not.
- VCS organisations use a wide range of different data sets – which do not easily read across to local systems.
- VCS organisations are worried about sharing service data with potential competitors
- Many are not convinced that providing data into JSNA processes will justify the effort involved in providing it, a recent report (In Good Health) by the Royal Society of Public Health supports this view.
- Most importantly, much VCS insight is based on relational rather than quantitative data.
As I noted in an earlier blog statutory agencies and the voluntary sector need to be using approaches that allow the VCS to to share a perspective on its terms.
In an earlier blog I wrote about one methodology that I have developed with Involve Yorkshire and Humber (Rapid Reviews) which led to real change in commissioning priorities, but there are plenty of other examples. Here are some that I have found out about recently.
This is an amazing piece of work undertaken for peanuts by a consortium of Housing Associations with support from the University of York. The organisations involved use the relationships they have with tenants to capture and share a small scale but in depth perspective of the real life impact of welfare reform. Keeping track of 100 households over a period of two years with tracking reports produced every 6 months.
This is an important report from NESTA sharing examples of how voluntary sector data can be used to provide insights into real time and future challenges. One example is a collaboration between Citizens Advice and St Mungos – a homeless charity based in London. There are a number of things that are interesting:
Data Science expertise – through a collaboration with Datakind UK volunteers from the data science community did an initial scoping over a period of two days – this lead to a smaller team of volunteer ‘DataCorps’ working over a longer period of time to resolve tricky issues.
In this case the work led to St Mungos and Citizens Advice working together to share data on clients, and led to three principles:
- Embracing openness – especially ways of sharing data across organisations that did not sacrifice confidentiality
- Democratising access to data – supporting others to have the skills to analyse the data – this has similarities with the GP Patient Survey dashboard that I have mentioned before.
- Emphasis on questions and exploration – Placing analysis and data into the public domain and creating opportunities for others to consider what this data might mean for their area of interest.
More Rapid Reviews and Local Healthwatch
I have already mentioned the Rapid Review work that I have done in Wakefield and Sheffield – another example I came across recently was a project led by the Sheffield Parent Carer Forum which captured the views of parents of children and young people with disabilities.
I am currently completing a piece of work for Healthwatch England and have been impressed by the number of local Healthwatch who are increasingly using this sort of methodology in their investigations.
What will help?
Local Public Health teams should have an explicit longer term and funded strategy (which includes CCGs) to support the local voluntary and community sector build analytical capacity and competence. This could be built around addressing specific priority at the same time allowing it to build competence.
Public Health England and NHS England
These two agencies need to develop a robust long term programme to support sharing of good practice and raise the expectations of local decision makers – in particular CCGs and Directors of Public Health. It is frankly not acceptable for local leaders to assume that current systems and capability need to mirror existing statutory practice.
What do you think?
At the heart of “Due North” is an argument about the need to establish a pan-Northern collaboration which is built on closer relations with the people who live in the North of England.
So, I welcome the call to help communities to develop capacity to participate in local decision making through investing in the VCS and training and action to engage community members. But as I said in an earlier blog we need to do much more than this.
Reading Due North I asked myself the question:
Question – “Does Due North help me champion grass roots action in Sheffield?
Answer – “yes it does bit – but I need more”
Many of us know of good examples at a very local level – the problem is these are not being systemised and local voice is not heard consistently enough at the top of organisations.
The very local story
In Sheffield 4 General Practices now have over 100 practice champions who are working on a voluntary basis supporting GP’s connect with their communities. These are all practices serving very disadvantaged communities.
I am a trustee of one of the voluntary organisations – Darnall Wellbeing – who deliver this service and their Practice Champions are part of a wider volunteering network that connects with the Somali, Pakistani, white working class and Roma communities in that area. Local people in disadvantaged neighbourhoods are working on the ground sorting out community cohesion, advocacy and access to health services. They are capacity building for themselves.
Nonetheless the challenge remains – translating this local energy and expertise into powerful influence at place level. I think that one of the reasons this is difficult is because the city wide commissioning and provider bodies struggle to change their practice to make it easy for community activists to contribute at an organisation or system level.
At the recent Due North/Health Equity North one year on conference Tony Dylak from Royds Community Assocation in Bradford helpfully summed up these challenges calling for among other things – a greater recognition of the contribution that ‘patients’ can make and the need to see the voluntary sector as an equal partner.
Service and System
So, system level organisations and agencies need to consider what they can be doing to strengthen citizen voice. I think that this is where it gets really hard. A lot of the structures that operate at a system level are dominated (with the exception of local councillors) by professionals who speak on behalf of local citizens. By professionals I mean primarily managers from public sector bodies (mainly the NHS and Local Government) and the Voluntary and Community Sector.
Of course they are well intentioned people – but they are constrained by their own organisation and services (they don’t usually have whole system view) and by their responsibilities for meeting their targets and contracts. This too often leads to relationships that operate within a paradigm that ignores conflicts brought on by competition and mistakes activity for systemic action.
Again, in Sheffield the Sheffield First Partnership has been trying to get to grips with this. They set up what was in effect a select committee process to seek to understand what good might look like with regard to community cohesion and voice; taking evidence from a range of witnesses – including voluntary sector organisations, the police, fire service and private sector.
The outcome of this investigation is a “Fuzzy Framework” that seeks to provide a platform for a more self aware collaboration on this agenda across the city. It is very much a work in progress – but is a positive attempt to try to be more self conscious about this issue.
When Trade Unions are mentioned there is an awkward grin and shuffling of feet
Finally, at the recent Due North/Health Equity North conference in Chester someone in the audience raised the point that well established forms of collective solidarity such as the trade union movement are too easily ignored when it comes to seeking to strengthen public voice. Its interesting because public health and the NHS are often keen to develop relationships with the private sector – there is a hard edged glamour to this. Yet when the trade union movement is raised the response is usually an awkward grin and shuffling of feet.
The role of grass roots community organisations and Civil Society
So, I think we need to be much harder on ourselves if we are to make progress here. This agenda is moving on rapidly – in an excellent blog Catherine Foot from the Kings Fund calls for “not forgetting engaging patients and communities” in the implementation of the NHS England 5 year forward view.
At the moment it is striking that few local Health and Wellbeing Boards have clear strategies that set out how they will create an environment where grass roots community organisations or volunteering can flourish.
I think we need to be more self aware about how we connect with citizens – this means doing more than talking about apparently value free ‘interventions’ such as ‘building capacity’ or ‘funding the voluntary sector’.
I would also go a bit further than Catherine – if we are to rebalance our relationship with citizens we must see this work as sitting within the wider responsibilities that local government has for local democracy.
It means generating a debate with a purpose – what sort of civil society do we want and why?
Then taking action to strengthen it.
What do you think?
In February there is a ‘one year on’ conference at the University of Chester to consider progress and next steps, since the launch of Due North the report that seeks to articulate a North of England analysis of how we tackle health inequalities.
One of the key points made by the original report is:
“The most disadvantaged members of society lack influence over how public resources are used”
Recommendation 3 of the report focusses on this area specifically:
“share power over resources and increase the influence the public has on how resources are used to improve the determinants of health”
Actions for bodies in the North of England include:
- Regionalism and government structures – bringing policy making a bit closer than Westminster and developing a stronger collective local government voice across the North of England
- Access to information – greater transparency of decision making at a local level
- Participatory Budgeting – more involvement for citizens in financial decisions
- Mutuals – create more collective forms of ownership
- Building capacity in communities – to strengthen engagement
There are also a set of actions that government should consider which include:
- Strengthening the role of local government – increase proportion of public expenditure spent locally, prioritising health equity spend, increase ability of local authority to raise funds
- Expand role of local healthwatch to hold govt to account for action and progress on health inequalities
- Co-produce national programmes with local government
There is nothing intrinsically wrong with these recommendations but I think they lack coherence and don’t sufficiently address the original challenge.
The actions feel as though their starting point is concerned with what local public sector bodies consider to be important, their role, their relationship with government; rather than challenging the way in which local public sector bodies relate to communities.
There is not enough about the lived experience of citizens and the relationship that the local state has with them. This means that this section (indeed the whole report) is weak on the role of the community and voluntary sector – especially grass roots community organisations.
So, while I support the calls for more regional government, greater access to information about need and services, and participatory budgeting I think the document over emphasises these at the expense of a weak section at the end (where else!) on community capability.
Regrettably this is reflected by the general lack of emphasis on the contribution of the voluntary and community sector as a whole.
We need more honest local debates about relationships with communities and citizens
If Due North is to achieve real change then I think it needs to revisit its approach to citizens and communities.
Lets face it the arguments articulated in Due North for localism are predicated on the belief that the strongest relationships with citizens happen best at a local level.
The credibility of any proposal to shift power from Westminster or to redress inequality rests on our ability to demonstrate that we can deliver these powerful relationships with citizens.
We have to recognise that we need to put our own house in order, a culture change is required at a local level too. The way Due North is written does not convince me that this is sufficiently recognised.
We need to recognise that there needs to be ongoing debate with citizens and community organisations to develop a shared view about how to strengthen engagement, involvement and yes…..solidarity.
There is plenty of hopeful stuff going on. I am impressed by the work of the Co-operative Councils who have been leading some of the work here. Local Authorities such as Lambeth are doing really interesting stuff – including developing their Competency Model for Co-operative Councils looking at how to change their relationship with local citizens. I suspect that some of this work is informed by seminal reports like “The Relational State” whose strap line calls calls for “recognising the importance of human relationships could revolutionise the role of the state”
There is a great deal out there – the challenge is to locate this promising activity within a broader analysis of why this is important, where current deficits are and what we need to be doing differently.
We need to avoid leaping into our usual behaviour of renewing neighbourhood committees, laying on a bit of community capacity building and providing some better information and then saying job done”
What do you think?
I am surprised to be writing this – but the NHS England 5 Year Forward View is rather hopeful – there is no reference to waiting times in the whole report!
It affirms the resilience of the NHS despite the government’s austerity programmes.
“No health system anywhere in the world in recent times has managed five years of little or no growth without either increasing charges, cutting services or cutting staff. The NHS has been a remarkable exception.”
Its honest about where the NHS needs to improve, in particular the:
- failure to implement the Wanless ‘fully engaged scenario’ by respective governments and the impact this has had on prevention
- impact of barriers created by ‘artificial boundaries between hospitals/primary care, health/social care and generalists/ specialists
- impact of austerity on funding
- failure to shift funding from hospital to community
“hospital consultants have increased around 3 times faster than GPs and there has only been .6% increase in the number of nurses working in the community over the past 10 years”
It identifies three key gaps:
- Health and Wellbeing – and the risk that ‘deep’ health inequalities will widen
- Care and Quality – highlighting some of the particular challenges for a number of groups in particular vulnerable people over the age of 85
- Funding and Efficiency – the need for ‘reasonable’ funding
It sets out a range of actions – some of them are helpful while others recycle existing NHS cultural approaches.
So we see the usual focus on behaviour change (hard hitting campaigns, labelling, targeted personal support….yawn) but not enough on advocacy, welfare rights and debt advice – even though there are many NHS services that do provide these. For these we need to turn to the recent Kings Fund/Joseph Rowntree report Tackling poverty: Making more of the NHS in England
“England is too diverse for a ‘one size fits all model’
There is a welcome emphasis on localism with a call for more power for local leaders and commitment to support whole system wrap around service models that bring together health care and community. Two models are proposed – one feels more General Practice led (Multi-Speciality Community Providers) and the other more Hospital led (Primary and Acute Care Systems).
What feels particularly hopeful is an assertive shift to break the purchaser provider split:
“It may make sense for local communities to discuss convergence of care models for the future. This will require a new perspective where leaders look beyond their individual organisations interests and towards the future development of whole health care economies and are rewarded for doing so”
Finally, there are some sections on the importance of the voluntary and community sector and communities. There appears to be a growing understanding of the important role that the VCS can play in building relationships with citizens and helping to bring a whole person approach to support through initiatives like social prescribing and volunteering.
This includes recognising that funding regimes must be more accessible to the VCS.
“we will seek to reduce the time and complexity associated with securing local NHS funding by developing a short national alternative to the standard NHS contract where grant funding may be more appropriate than burdensome contracts and by encouraging funders to commit to multiyear funding wherever possible”
Lets face it NHSE has inherited a cultural legacy that is too often hierarchical, target led, out of touch with place and used to pleasing government first and communities and citizens second. Thus far its approach to commissioning primary care has felt removed and not sensitive to local need – particularly with regard to disadvantaged communities.
If this documents ambition is to be realised NHSE needs to review its existing structures and the skill sets of its staff. There is talk of an ‘organisational fitness review’ the outcome of this will be crucial to the success of this forward look.
While the front end of the report has solid reference to the impact of inequalities and its causes the actions towards the end of the document are not so crisp. The clearest call seems to be the expectation that hospitals will step in to create community services in disadvantaged areas using the suggested Primary and Acute Care Systems model. If I was in General Practice I would feel uncomfortable about this.
There needs to be an explicit programme of work that focusses on the most disadvantaged communities with a commitment to ensure that additional resources for primary care are fast tracked to these communities.
The voluntary sector
While it is refreshing to see a stronger recognition of the contribution of the VCS and of volunteering there needs to be a major shift in investment and capability. The commitment to simpler procurement, grant aid and longer term funding is welcome. However, there needs to be more substantial and long term investment in:
- Capturing good practice and improving VCS capability
- Using portfolio approaches – as pioneered by the BIG lottery and the Health and Social Care Volunteering Fund to drive innovation and capture learning
- Infrastructure Organisations – both local and regional
- small grants – targeted at “below the radar” community groups – The Community Development Foundation have produced a good briefing on this recently.
What do you think?