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.
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:
- St Mungos relationship with University College Hospital on Homeless Pathways
- Sheffield Citizens Advice relationship with Sheffield Health and Social Care Foundation Trust
- Darnall Wellbeing working with GPs in Darnall in Sheffield to support patients identified through a risk stratification process as being most at risk of admission.
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.
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?