Why do vulnerable people need statutory services to help them access their own community?
Personalisation, Social Prescribing and Communities
At the end of last year I was part of a bid that Locality put together to NHS England who were looking to recruit a pool of voluntary organisations who could act as advisors on a call off basis to inform the work of the integrated personal commissioning pilot sites.
We were surprised to be invited to interview, because our impression was that NHSE were looking for voluntary organisations working with particular ‘client groups’. The majority focus on particular client groups as follows:
We felt that a neighbourhood, community centric model might bring added value to this programme – as opposed to the client/condition specific focus of most of the pilots.
The pilot sites are seeking to create a health and care pathway that has the individual at its heart.
I see the logic to this – we are all individuals with our own aspirations, abilities and needs and our circumstances vary. It is important that services bend to our needs and wishes. However, this approach carries with it the cultural heritage and statutory responsibilities of statutory professional services. So, the language includes terms like ‘assessments’, ‘pathways’, ‘reviews’, ‘care plans’.
This model assumes that the first step to support is determined by engagement with the professionals employed by organisations with statutory responsibilities.
Another pathway approach is social prescribing. Many models assume that someone turns up at a GP (one of the champions for this is Dr Michael Dixon), once there an assessment leads to a referral to a ‘broker’ who connects them with a range of community organisations who help address wider issues (such as indebtedness) or help people strengthen social connectedness and regain confidence through doing an activity they enjoy (eg dancing) or giving something back through volunteering.
The difference with this model is the that its focus is on broadening the traditional health and care offer, recognising the important multi-layered contribution that connection with community can have on wellbeing, social determinants and health.
This is all good stuff – however, both of these models are about changing how professional, statutory services behave.
There is a clear need for this…………..but!
Why do vulnerable individuals have to go to statutory service in order to access community and voluntary services where they live?
There is another way in which the same outcomes are achieved and this does not require the initiative to come from health or care professionals.
Community Anchor organisations are a good example of this – many of them are members of Locality. These are organisations like the eponymous Bromley by Bow but they exist all over the country in Sheffield they include Manor and Castle Development Trust, Darnall Wellbeing, SOAR and ShipShape they have roots in neighbourhoods and take a whole person approach – responding to individuals needs and interests but also providing opportunities to contribute, create and get involved.
The way that community anchor organisations work is based on a different set of assumptions. At their best they work to make places better through building services that are run by community members and that are lightly stitched together – responding to the whole person.
Central to this is a recognition that long term relationships are important – community anchors are not going anywhere – they are part of the neighbourhood.
This assumption about relationships and longevity and the more organic way they work; where entry points are many and various is different to the professional model which has clear points of entry, is constrained with regard to the type of services that can be offered and to whom, and relies on professional review and assessment.
At our interview we were not arguing against the professional care pathway – but were saying that there needs to be a balanced approach which recognises the relationship between the professional care pathway and the fuzzier relationships that exist within communities.
It is very important that statutory organisations such as big NHS providers, Clinical Commissioning Groups and those professionals funded by the state like GPs understand that it is not good enough to just design pathways that reconnect people with communities.
Communities are not just waiting with lots of spare capacity for people to be referred to them. They need investment too – the Rotherham Social Prescribing scheme, one of the biggest in the country invests two thirds of its resources in local community and voluntary organisations.
We should support social prescribing and personalisation pathways but commissioners need to give at least as much weight to investing in grass roots community organisations and building their capacity.
What do you think?
Yes, all well and good but still some missing links to real (disabled) people and patients driving local services and support through co-production as in user-driven commissioning!
It’s still professionalisation (and business / service responses to need) which often stand in the way – not personalisation. Why do we not call for self-assessment, self-referral and peer support to become regular, formal components of commissioning contracts?
Mark, thanks for this, and Bernd for your comments here too.
There’s lots to think about on this. It would be interesting to understand more about the perceptions and insights of these commissioners/planners – why they construct their system response as a pathway – which to me infers a linear course – I’m sure it’s not like that for many of us! Also, who decides on vulnerability – to what? Shouldn’t we be speaking of opportunities, aspirations, as well? Part of me thinks such commissioners need to be very bold and run with investment on community led action that builds health. But then the results aren’t readily evidenced in year to that years outcomes framework….
My other reflection is on the creation of a mirror infrastructure world – that commissioners spend/invest in community sectors orgs that mirror in terms of process, language and “performance” that of the commissioning world – I’d be more interested in seeing how such public sector agencies used resources (£) into local neighbourhoods for direct action on stuff that keeps people well, resilient etc. And, we know the ‘evidence’ is there for this….The very stuff that isn’t “delivered” through a “(social) Prescribing” protocol and which isn’t accessed through the GP setting!
However, I don’t think it is an either / or scenario. I think the public sector involved in health and all that means should recalibrate toward a community and neighbourhood located agenda – where individual and more so collective action can be affected that brings about social supports and connectivity, from which much can and will flow!
Back to the coffee pot ….
Mark – delighted to read your post above. I work for NHS Wakefield CCG. We are very interested locally in the greater potential of our communities (and the grassroots resources within them) to advise, educate, support and to hold or resolve as greater part as possible of their own health and well-being needs. I accept THE comments re the mirror infrastructure world challenge – but would argue as an experienced NHS commissioner that an ‘intermediate period’ is practically required where some ‘bridging’ can occur – this will I believe – necessitate some unwanted (but temporary) mirroring as what we are talking about here is new territory for many health commissioners and they currently lack ability to call upon the ‘re-assurance’ of substantial NHS policy, practice and procedure (de rigeur for confident commissioning in the NHS) in achieving the future conditions you refer to.
Thanks for your comments Lee – I think it is really positive that CCG commissioners are engaging with this agenda – I agree we are in a transition phase – the key bit is of course to recognise this – as you have done. I note your point with regard to NHS Policy and Procedures, there is an ongoing debate about trying to rebalance NHS Commissioning so that it favours innovation a bit – even though that may bring greater risk with it. I suppose the latest NHSE Guidance on Five Year Forward View implementation is meant to help free the system up a bit. In Wakefield you do of course have some excellent work and organisations already – not least the contributions of NOVA – who I am sure you will be familiar with – best wishes – Mark
Delighted to have had your blog shared with me by Alison Haskins, CEO of NOVA Wakefield… Echo many of the thoughts/contributions above & would add that the ‘Whole-System’ approach we have adopted here in Wakefield via its Provider Alliance, (which is being led by NOVA, in the case of Social Prescribing – or what we like to describe it as Community Solutions) is facilitating a pace & dynamisms which is both healthy & constructively challenging – long may it continue…. JJ, Director Provider Alliance Wakefield
The NHS and Social Services ( adult and children) serve individual patients/clients. At best they work with families. This has always seemed to
me to explain why there has been a struggle over many years to help those agencies understand that the communities in which their patients/clients live have a fundamental role to play (for good or ill) in the quality of life and outcomes for those individuals. Whilst there is a failure to grasp this, there will be a failure to invest in community infrastructure that can make a powerful, positive difference that saves both lives and public money.
Hi Elaine – good to hear from you. I agree – it is interesting and a bit dispiriting that community work, community development, etc is one of those agendas that comes and goes on a cycle that probably lasts about two parliamentary terms. Ironically the strand that should provide one of the greatest sources of stability and support – community and neighbourhood – is too often treated in an impermanent and marginal way at a policy level.
Love this, Mark. Very well articulated set of observations / arguments. Interested in thoughts on how digital (especially) social media and connectivity tools fit into the equation if at all?
Cheers Sam – hope Poczero and you are doing well over in the Midlands!