Skip to content

I am not going to play by your rules! The ‘value’ of Volunteering

October 20, 2014

Volunteering Blog 2

There are many organisations mainly in the voluntary sector that have a tremendous story to tell about what volunteers can achieve – and many need funding in order to sustain and develop this further.

In my previous blog I described the excellent work of 6 organisations and outlined some of the strategies that they have used to make the case for funding.

I think that the challenge we face is that in England we live in a state that is increasingly marketised and centralised.

Marketised

In the marketing paradigm the route to securing funding from the state is an apparently rational one – its something like this:

  • Demonstrate that there is an unmet need that has a cost on society
  • Show how you can meet it – and quantify how much this will cost
  • Evidence that savings can be generated
  • Prove that your option is cheaper than any alternative

Centralised

The UK is one of the most centralised western states. In order to be able to function government and its proxies (Public Health England, NHS England etc) need information that can assure them that public money is being well spent and issues of concern are being resolved.

Here is part of an infographic produced by the Centre for Cities based on information from the OECD contained in their report Cities Outlook 2014

Cities have little control over their own money

Because government and its agencies are so centralised they require a range of metrics that bring local experience closer to them – so we have developed a complex series of standard indicators (Outcome Frameworks, QALYs, QIPP etc) that all serve to provide information to these centralised agencies.

These measures – that we sometimes think demonstrate our technical sophistication at keeping track of population wellbeing can also be seen as showing just how centralised we have become!

What about volunteering?

I think that these two systems (the market and the centralised state) and their need for metrics are antithetical to the premise on which volunteering is based.

Volunteering often arises to meet need where there are no services or where there is a gap in services. Indeed, volunteering often develops in places that officials thought did not exist – and therefore did not fund. This is because these spaces had not been measured before or could not be satisfactorily measured because of their complexity and multi-causality.

For example, a lot of volunteering is concerned with the the relationship between the individual and society or between the individual and other services. Of course just because these areas cannot be easily measured does not mean that they are unimportant – far from it – our connection with the state and other people is crucial to our wellbeing – as some of the excellent national work on loneliness demonstrates.

An example of this multi-dimension benefit of volunteering to volunteers and wider society is set out here in this useful report from Citizens advice that came out last year.

Can we have some funding please?

The problem arises when organisations who provide volunteers are asked to justify their case for public funding. They find that they have to do so using a set of arguments that are designed to determine value in a market place or provide reassurance of impact to a centrally led government agency.

My point is that we – citizens who volunteer – do not go into this gift relationship (for that is what volunteering is) because we want to secure market position, generate savings or meet government targets – we do it because we wish to give our time and skill to help people and generally the only evidence of success we require is what the people who receive support from this volunteering feel and say.

So, while there is policy ambition and rhetoric for increasing volunteering – as long as we continue to try to measure and justify it using models that are about just about market value or government ‘outcomes’ volunteering will struggle to get funded – or risk becoming a commodity.

There is a real risk that this will actually lead to a less innovative, more ossified and less diverse system of delivery and  the contribution that volunteering makes to civic engagement and cohesion will be weakened.

Of course some of the work that is going on at present with regard to implementation of the Social Value Act may offer part of the solution – as part of this I think that there is an urgent need to look again at the respective roles of grants and co-produced service design to ensure that local commissioners are enabled to take a balanced approach when determining which model works best for them.

What do you think?

We need to be much better at understanding the contribution that volunteers make to health and wellbeing.

October 1, 2014

HSCVF Blog

This week the Department of Health’s Health and Social Care Volunteering Fund publish a piece of work that I completed with two colleagues (Sue Cook and Jennie Chapman). We have produced a guide on sustainability for projects that support health and wellbeing through services using volunteers.

The 6 voluntary organisations we spoke to worked with a wide range of people.

Care Network in Blackburn with Darwen – support isolated elderly people through providing an escorted shopping service and through that social contact.

Hull and East Yorkshire MIND – volunteers supporting mainstream mental health services provided by MIND

Opening Doors in Norwich – a self advocacy organisation for people with a learning disability supporting people access health and care services

Unite Carers in Mid-Devon – volunteers supporting carers of people with Alzheimers

Stroke Action – volunteers working as stroke ambassadors

Fast 4WD in Blackburn with Darwen – Recovery support volunteers support current service users

If you would like to get a feeling for what these organisations and their volunteers do – listen to them directly – there are good short videos all about 7 or 8 minutes long, here are links to each video  Stroke Action in Enfield Unite Carers in TivertonFast 4WD, Opening Doors, Care Network and Hull and East Riding MIND – watch them all!

Although at different stages of development these organisations had all been successful in providing services of consistently good quality and in some cases one that is a key part of a health and social care pathway (for example Fast 4WD and Stroke Action).

One of the issues that emerged from this work was that despite the fact that these projects had been funded by the Department of Health – the area where they really struggled to get funding was from the NHS. Often, the closest they seemed to come to getting ‘health’ funding was through the Public Health budgets – that are of course now part of local government.

There are of course a number of reasons for this – some of which are explained in the videos themselves. I want to touch on two.

Clinical Medicine is not the whole cure

The NHS still defaults too readily to thinking that heath interventions end when someone leaves the clinic – be that a hospital or a GP. In the past this was excused by the distinction being made between health and social care provision (some will remember the debate about when was a bath a social care one and when was it a health one!). I think increasingly it is understood that the dividing line is not sharp – particularly when we take into account mental health and wellbeing – as some of the stories on the videos eloquently describe.

I would like to think that the repeated statements of the need for greater parity for mental health and proposals for greater integration of health and social care might help resolve this artificial divide..

Local Commissioning

The other thing that was striking about the work was the lack of coherent commissioning strategies that set out the ambition an area has for what sort of voluntary sector provision and what level of volunteering it might like to see there.

Imagine having a commissioning strategy that described the local priorities and then ignored the local hospital or GPs? Well this is what it often feels like for the voluntary and community sector.

It is still the case that too many commissioning strategies fail to recognise the importance of the voluntary sector and volunteering and don’t consider what needs to be done to enable this sector to flourish and grow.

So, all credit to the 6 fantastic organisations (there are of course many more out there) who contributed their experience and wisdom to the videos and the briefing we have produced.

Sue, Jennie and I were inspired by the organisations and volunteers we met – the struggle continues!

What do you think?

Too weak on inequality – Chief Medical Officer Report on Public Mental Health

September 15, 2014

CMO IV

There are important messages in the Chief Medical Officers Report on Public Mental Health that will be welcomed by many – in particular her championing of the need for further investment in mental health services, reduction of waiting times and her call for greater support for people with mental health problems to maintain their jobs. There is a good section on the work of Time to Change a BIG lottery portfolio addressing stigma delivered by MIND and Rethink with strong support for its continuation.

Inequality is in there…just.

However, this is primarily a clinical report (not surprising with approximately 90% of the authors being medics) the wider social conditions that people live in receive insufficient attention. Frankly, given the evidence that the bottom quintile are more than twice as likely to be at risk of mental illness than the top quintile this is more than a small omission – this is very poor – not good use of the evidence.

Risk of Mental Illness Quintile

This failure to give due weight to inequality and in particular the impact of poverty, financial insecurity and indebtedness (for more on indebtedness and mental health see my earlier blog here) on mental health reinforces the focus on clinical solutions to social causes. To the credit of the authors of Chapter 7 (Stansfield, McManus, Bhui and Jones) indebtedness is mentioned in Chapter 7 where they recommend:

“evaluation of the impact of debt reduction intervention programmes is needed. The fact that, before the recession, a quarter of people with mental disorder were in debt has direct implications for effective clinical assessments and care planning as well as for awareness in debt counselling agencies, utility companies and financial organisations”

Shamefully even this recommendation does not float through to the key recommendations made by the CMO.

This is further compounded by the absence of any critique of the impact of Department of Work and Pension policies on the wellbeing of people with mental health problems.

There is one mention of Work Capability Assessments in the whole document with no comment at all on the effectiveness of this service. The current IPPR North briefing “In Safe Hands? Rethinking Employment pathways for ESA claimants with mental health problems” notes that:

“People with mental health problems, who make up 40% of those going through the WCA are being let down by a system that appears to be neither effective nor accurate in determining the appropriate level of financial or employment support for claimant with mental health problems. Equally, the system fails to provide the kind of support for claimants that is adequate or appropriate for people with mental health problems”

This briefing goes on to say that “of the 137,130 participants in the Work Programme with mental and behavioural disorders only 7,060 (5.1%) were successful in sustaining jobs.”

This is not just about stigma – this is a system that is systematically failing people with mental health problems.

Lets take it out on wellbeing

Consistent with the narrow clinical view of much of the document is an attack on the concept of wellbeing. By the way, the CMO clearly thinks that it is more important to spend pages putting the boot into wellbeing than give adequate space to inequality and mental health. The report attacks the concept of wellbeing using a report by CLES consulting and the New Economics Foundation (Big Lottery Fund National Wellbeing Evaluation: Final Report 2013) as a straw man. Frankly, I think it is unacceptable that a senior civil servant uses an official government publication to attack the authors of a report who are given no right of reply in that document.

“One of the most problematic implications of the use of grey literature is the widespread adoption of scientific-sounding statements from well funded but poor-quality studies which are based on flawed methodology. To explain our standpoint more comprehensively, we turn to a case study of a widely cited report covering aspects of well-being and mental health: (prepared by CLES Consulting and New Economics Foundation, 2013). This report offers ‘lessons for service providers, commissioners, the Big Lottery Fund and Government”

This attack is part of a broader critique of the current state of play with regard to what we mean by the term ‘wellbeing’ this leads her to conclude that:

“Well-being interventions should not be commissioned in mental health as there is insufficient evidence to support this.”

Now precisely what does the CMO mean by the above sentence?

What do you think?

Long Term Conditions, Poverty, Welfare Rights and Health

September 1, 2014

welfare rights and health

Just before the summer I participated in a round table discussion on the relationship between health, wellbeing and welfare rights services. This discussion was supported by the excellent Baring Foundation and involved a range of welfare rights organisations including the Advice Services Alliance, Youth Access, the Low Commission and others.

There is a growing body of experience and evidence across a wide range of advice services of the relationship between access to advice and health and wellbeing.

I have written before about the experience of Sheffield Mental Health CAB (now part of Sheffield Citizens Advice and Law Centre) in this regard. What is clearer to me is that there is a strong relationship between increased vulnerability due to poor health and need for advice – I think the relationship is a bit like this:

image

 

The experience of MacMillan Cancer Care confirms this, in their report “Cancers Hidden Price Tag” they tell us that following a cancer diagnosis four in five people (83%) are affected and, on average are £570 a month worse off because of a cancer diagnosis with one in three people experiencing a loss in income averaging £860 a month.

Unfortunately it is still the case that many NHS commissioners are still unconvinced – they usually ask this question:

“Can you demonstrate that there is a causal link between receiving welfare rights advice and being well?”

They should actually be asking another question of course:

“What can we do to stop people with a progressive long term condition falling into poverty?”

For an eloquent and clear statement about the urgent need for reform of social welfare support see this 5 minute interview with Simon Duffy from the Centre for Welfare Reform.

What is to be done?

Despite these challenges and the continued attacks from central government on local authority funding there are some some opportunities that we need to respond to.

The Department of Health draft Care Act guidance recognises the importance of access to welfare rights and advice.

“Information and advice is fundamental to enabling people, carers and families to take control of, and make well informed choices about, their care and support and how they fund it”

The guidance notes that local authorities must ensure that information and advice services established cover more than just basic information about care and support.

The service should also address:

  • prevention of care and support needs
  • finances
  • health
  • housing
  • employment
  • what to do in the event of abuse and neglect

This draft guidance combined with the focus on integration through the Better Care Fund has the potential to transform the position of welfare rights and advocacy provision in the health and social care sector.

It could help ensure that welfare rights services in particular are targetted on the most vulnerable, that their contribution to wellbeing is recognised and that the NHS understands the importance of jointly commissioning services with local government.

What do you think?

Who really makes decisions about local health funding for the Voluntary and Community Sector?

June 9, 2014

FPHN Image

A summary of the governments policy on health and social care is a bit like this:

  • focus more on prevention
  • support people to live longer in their homes through better integration

…..and the solution is to take money out of acute care and invest it in communities

This should represent a real opportunity for organisations with expertise in working in communities and on the social determinants of health – in particular the local voluntary and community sector – to contribute and get access to funding. It does not feel that this is the case!

In part this is because we are locked into an analysis of how commissioning works that does not reflect reality.

The official commissioning model.

  • Assess need at local authority level using the JSNA
  • Debate and agree local priorities through the Health and Wellbeing Board
  • Put these priorities into the Joint Health and Wellbeing Strategy
  • The JHWS drives commissioning plans of CCGs who then rationally commission local services

…….and so we achieve the shift from acute to community.

The problem is this is not how the system works.

The Real World

Most funding is tied up in the acute hospitals and care trusts and although in theory this can be released and reshaped as contracts are tendered and renewed there is huge inertia in the system. Not least because even if the provider changes – local commissioners do not usually build in voluntary sector provision into these contracts at a sufficient scale.

This is often because they are searching for evidence of impact (savings, better outcomes) that does not exist and probably never will – at the level they require.

At the same time we see an increasing number of examples of clinicians who are convinced of the role of the VCS – this is because they are on the front line and see and feel the impact of the VCS. So, the expertise in making decisions about service design and development rests primarily with providers rather than with CCGs or NHS England.

The governments creation of the Better Care Fund (ring fencing existing funding) is a recognition that the local commissioning model described above is not sufficient to achieve change.

At the moment the organisations with the power are the NHS Trusts and GPs – they receive most of the funding and have some freedom to design services to deliver outcomes. They are more important and relevant because they have a better analysis of the challenges and opportunities in providing relevant services to improve wellbeing.

Government led marketisation means that these organisations know that they are in a competitive environment where their services may be up for tender or at the least market testing. They have a huge self interest in retaining control of this funding and of course ensuring their survival at a personal and organisational level. They also have a great deal of influence with the CCG and with NHSE.

What can the voluntary and community sector do?

I think there are two key actions.

Operational/Service Level

VCS organisations need to focus on co-producing with NHS providers service models that build VCS provision into clinical pathways. There are a growing number of examples of these – these are some that I know about:

I think that these co-produced relationships often work to a more realistic view of what evidence is. Clinicians on the front line can have a more sophisticated view of impact than a commissioner who will only feel able to fund a service if it can demonstrate measurable savings or direct health outcomes.

System Level

This is more challenging, the better care fund despite justifiable cynicism about it does offer hope here. Arguably this is where CCGs can play a role – leading a co-produced approach across sectors through Health and Wellbeing Boards. Nicola Kingston has drawn my attention to the Whole Systems Integrated Care approach being taken in North West London which does look like a genuine attempt to co-produce a solution.

It is important to note though that the VCS does not appear on the list of partners – it does feel very statutory. Nonetheless if voluntary organisations have been able to play in on the coat tails of some of the partners mentioned here in the way I describe above then there may be some traction.

What do you think?

Working with the local voluntary sector to tackle Inequality and Exclusion – a better JSNA

May 6, 2014

Book 70_0004

This is a story about some work I have been doing for the last year or so to improve the way the expertise of grass roots organisations is heard by local commissioners.

The problem

There’s nothing inherently wrong with the Joint Strategic Needs Assessment (JSNA) and the Joint Health and Wellbeing Strategy (JHWS) but the way they have been developed means that they are:

  • read by few,
  • provide a very high level view of need that is largely based on a set of standard national measures
  • struggle to bend system priorities to complex, small and pressing issues that too often slip below the radar.

It is often the case that it is these small, complex ‘wicked’ issues that grass roots organisations are tackling on a day to day basis – and they feel frustrated that the problems they are addressing do not seem to be understood at a JSNA or JHWS level. This of course is one of the reasons why commissioning continues to favour big statutory and private organisations.

I think that one of the reasons this happens is because we fall into the trap of thinking that the JSNA process is primarily a linear one – gather up all the data, put it all in one place – a web site or a report and then analyse it.

I am not arguing against this process – its good to have a population level view - but it is not sufficient if we want a genuinely responsive, inclusive and integrated approach to local commissioning, specifically one that is able to bring issues forward that:

  • Affect small populations
  • Are complex – multi-causal
  • Have poor incomplete data sets
  • Are about power, exclusion and inequality

Many of the organisations that work in this area are voluntary and community sector ones. If you work in areas that are easily ignored with people who are unpopular with policy makers then you are likely to struggle to be heard too. Witness the Trussell Trusts exclusion by Ian Duncan Smith.

So, we need a more asset based approach. One that gives voice to these organisations, playing to their strengths and allowing them to share their analysis of the issues they are tackling. This means providing opportunities for the expertise of these organisations to play in and for the voice of the people they serve to be heard.

It also means making it worthwhile for these very pressured organisations to contribute to the process.

Rapid Intelligence Review

About a year ago I started a project to try to come up with a rapid way of trying to address this problem – this is not rocket science. Working in partnership with Involve Yorkshire and Humber and funded by what was then the Yorkshire and Humber Public Health Observatory (now Public Health England Knowledge and Intelligence Team) we devised a model based on the following principles:

  • It had to make little demand on the voluntary and community sector in terms of time or resource
  • It needed to be led by a VCS view of what issues we should focus on
  • It had to capture a more complete story – so a mixture of qualitative and quantitative data
  • It had to be cheap
  • It needed to make some recommendations

The VCS in two areas (NOVA in Wakefield and Voluntary Action Sheffield) with their respective local authorities worked through the process with us. In Sheffield they identified food banks and specifically the people who use them as the priority area and in Wakefield they identified Pressured Parents.

The Wakefield Report is available here
The Sheffield Report (which I referred to in an earlier blog) is available here

Jake Abbas (Interim Director, PHE Northern, Knowledge and Intelligence Team) and I have written an overview report on the process which has now been published by Public Health England. This is titled:

Using rapid intelligence reviews to strengthen the voice of the voluntary and community sector in local commissioning.

Implications

The experience of doing the two reviews has led me to the following conclusions:

  1. the JSNA process cannot just be about putting all the data into one place – it must also include a continuous process of small reviews that focus on “wicked issues” and the process for determining these should be jointly agreed with local civil society organisations.
  2. it is important to have actions and recommendations – but for a number of these issues just using the review to create a debate at a place level is a step forward.
  3. we need a more inclusive view of evidence – lack of population level data or RCT evidence is not a good reason for failing to investigate a topic – its actually an abrogation of responsibility.

What do you think?

Footnote

Jake and I will be sharing this work at the Local Area Research and Intelligence Association Conference this year – and hopefully at other national events – if I can get the abstracts done!

Follow

Get every new post delivered to your Inbox.

Join 1,983 other followers