The conclusions of the Joint Voluntary Community & Social Enterprise Review

Overview and main recommendations

The Joint VCSE Review was initiated in November 2014 by the Department of Health, Public Health England, and NHS England to describe the role of the VCSE sector in contributing to improving health, well-being and care outcomes; to identify and describe challenges and opportunities and make recommendations for national government, local government and the NHS. After an interim report, there was a full public consultation, a detailed report, updated by a concise action plan in 2018. The group overseeing production and then implementation of the recommendations, chaired by Alex Fox OBE, CEO of Shared Lives Plus, comprised representatives of charities and social enterprises of all kinds and sizes, and civil servants from the three system partners.

The review co-designed the Health and Wellbeing Alliance (20 consortia of VCSE organisations working with government and NHS to coproduce health and care policy and practice) and the Health and Wellbeing Fund. The VCSE Action Plan, published by government and sector, set out two system shifts we consistently heard are needed to build a more sustainable and impactful VCSE sector, with closer and more productive relationships with national and local government and the NHS:

  1. The shift towards co-designing health and care systems with citizens and communities, through working with community-rooted organisations which can reach and engage citizens from all parts of local communities.

That change would lead us to redesign health and care services to be more personalised and to focus on building wellbeing and resilience, which would lead to the second shift:

  1. A core role for those VCSE services which demonstrate they can provide support which is whole-person, whole-family and whole-community.

We identified three key actions to achieve these shifts:

  1. Define and measure wellbeing, embedding it as a core outcome across health and social care systems and demonstrating the links between achieving wellbeing, and improving the bottom line of local public service economies.
  2. Co-design health, care and public health systems with local people: particularly with those who make most use of health and care services, and with those groups and communities who are most excluded from those services.
  3. Develop and test ways for commissioners to invest in and reward the successful creation of wellbeing and resilience. These include models like social prescribing which attempt to bring statutory resources into small community organisations, in ways which work for statutory budget holders, and for civil society.

This briefing sets out the Chair’s final report on the progress made and the actions still needed.

Progress and next steps

There has been progress in all three areas and there is much more to do in all of them:

1. Define, measure and embed wellbeing as a core outcome

There is good evidence of the links between mental health, physical health and wider aspects of wellbeing, such as the well-established link between loneliness and mortality. Health and care leaders recognise that in inclusive, strong communities with fewer challenges around poverty, poor housing and other inequalities, people live healthier lives and are more resilient when experiencing long term conditions, make less use of acute and crisis services.

However, many areas continue to talk about the importance of prevention, tackling inequalities and community, without making the commensurate significant investment in their communities and community organisations. A focus on building communities must be at the heart of planning and design in Integrated Care Systems (ICS), if ICSs are to be more successful than past attempts to integrate services and shift resources into prevention. A few areas like Greater Manchester’s devolved health and care authority (and Wigan in particular) have identified a basket of health, wellbeing and community outcomes to work towards. The What Works Centre for Wellbeing has produced useful modular outcomes measures which could be much more widely-used by VCSE organisations. The NHS Long Term Plan sets out a role for VCSE organisations on ICS Boards: given the variation in local levels of understanding of working with the sector, a model of good VCSE leadership and engagement is needed to make this meaningful and I am encouraged that NHS England is currently working with STPs and ICSs to test promising practice.

The reasonable challenge to the VCSE sector to demonstrate and evidence its impact is too often made without recognising the narrow range of outputs and clinical outcomes in which the statutory sector is willing to invest, regardless of how well-evidenced other kinds of impact are. The new NHS Universal Personalised Care model could signal a strategic shift in national health policy towards a more integrated view of what makes for good health and wellbeing, and ultimately good lives. This needs to continue to be co-designed and implemented in partnership with the VCSE sector for its vision to be realised, drawing on the VCSE Health and Wellbeing Alliance (HWA). The Care Act set out wellbeing as the core purpose of social care, but did not set out how it would be commissioned and regulated for; the long-awaited social care Green Paper should take a whole-system view of how different kinds of support and community action can together build better lives and the Prevention Green Paper should include a strong narrative on the role of communities and community organisations in building individual, household and neighbourhood wellbeing, capacity and resilience. Without these changes in what is seen as ‘core business’, the VCSE’s work will continue to be seen as peripheral, resulting in short term funding and mission drift for VCSE organisations.

2. Co-design health, care and public health systems with local people

Coproduction with citizens remains absent in too many areas, with others using it only in limited areas of system design (e.g. co-designing small pieces of preventative work and community initiatives, but not major changes such as ICS). Some commissioners lack confidence in how to coproduce, particularly during austerity when some of the most engaged citizens are also those most angry at cuts to services. There are enough tools and guides (from Think Local, Act Personal; the Coalition for Collaborative Care, SCIE and others): they need to be more widely shared and used.

To move from anger at what is not working, to co-designing what could work, local areas must invest in those user-led and grassroots VCSE organisations which can reach and engage the two key groups of co-designers:

  • those which make most use of health and care services (and their families),
  • those most likely to be excluded from or poorly served by those services.

Those most excluded and poorly served often include black and minority ethnic communities, disabled people, older people and the rapidly increasing number of homeless people. These and other excluded groups are themselves diverse, so a range of grassroots community groups are needed to reach the whole community. Mainstream VCSE organisations need to do more to address the inequalities that they themselves sometimes perpetuate through a lack of attention to the diversity of their teams and leadership and to making their services accessible.  Where areas do invest strategically in the VCSE sector’s coproduction role, this can reduce inequalities (see Wigan’s impressive public health data for instance).

The HWA, which we co-designed, is a way for government to role model coproduction with the VCSE sector. System partners, which have limited ‘in-house’ engagement capacity, need the HWA to be effective. For instance, NHS England drew heavily on the HWA when drafting the Long Term Plan. To realise its full potential, the HWA needs more investment of time, money and senior leadership from system partners, more commitment from VCSE partners, and specific investment in communication capacity to be visible and accessible to the wider VCSE sector. There was an overall reduction in the programme’s total funds in 2018/19 and as yet no public confirmation of this year’s budget. The decision making processes which make in-year budget decisions a familiar reality for the government’s VCSE partners could be much-improved. The HWA has huge potential, and feels very much like a work in progress to its members and the wider sector. I welcome plans to recommission the HWA for 2020-23 and hope these are fully developed and realised.

3. Develop and test ways for commissioners to invest in creating wellbeing and resilience

There has been much promising development in this area of change. The Universal Personalised Care model sets out ambitious targets for growing personal health budgets, social prescribing, self-care, peer support and other approaches which will require sustained local NHS and council investment in VCSE organisations and infrastructure to achieve. There is also an encouraging cross-government focus on the potential of the Social Value Act to enable commissioners to place a value on the achievement of social value: we saw powers in the Act as having huge potential to level the playing field for effective VCSE organisations, adding value to the public pound and keeping local taxpayers’ money local. We heard arguments for those powers becoming duties, or at least, the default, expected approach in all service commissioning. There is however, a general reduction in investment in prevention during austerity, despite Care Act duties to have preventative services in place, and consistent government messages about its importance.

The King’s Fund research into commissioning approaches to the VCSE sector, commissioned by DHSC in response to the Joint VCSE Review’s recommendations, found a wide spectrum of commissioner attitudes to the VCSE: from traditional procurement-focused commissioners who see VCSE organisations only as providers, to strategic commissioners who aim to co-commission with the VCSE sector, as a way of coproducing health and care with citizens. There is more work to do by the Commissioning Academy and wider sector, to embed co-commissioning as the expectation.

The Health and Wellbeing Fund (HWF, which we co-designed), focused first on social prescribing which has huge potential to bridge the gap between the NHS and the VCSE sector, providing more is done to resource VCSE organisations participating in social prescribing programmes. The VCSE sector was disappointed to lose 2017/28’s budget from the HWF and I would hope that future delays in budget-setting can be avoided. The Fund is an important way for government and its partners to role model investment in the sector, and its focus on scaling and embedding ‘what works’ could help to fill a significant gap between the wide range of support available for start-ups and the difficulties faced by models which have been shown to work and are trying to achieve real scale. At present, it can be easy for innovations to win short-term funding, but these ‘pilots’ are rarely accompanied by an investment plan for shifting resources from less cost-effective models into the new ones, after they have demonstrated their potential. This remains a consistent challenge to the most successful VCSE sector work. Furthermore, we heard from innovative local VCSE organisations which had invested unpaid time in helping councils or the NHS to co-design new services, only for those services to be put out to competitive tender, which may then be won by less innovative organisations with larger back office functions. We called for “simplest by default” funding approaches and heard a strong case for a renaissance of grant giving alongside more formal investment approaches.

The experience of coproducing the Joint Review

The innovative and unusual coproduced approach to the Joint Review has been complex and at times difficult, relying on considerable commitment to working together from both the VCSE and statutory sector colleagues in the first phase in particular. Coproduction has though resulted in consistent support for our vision and actions from both sector and government. It has been positive that we were able to publish actions, jointly agreed upon and owned by government and sector, rather than external recommendations for government to agree or reject. However, longstanding governmental conventions on policy production and communications do not appear to be an easy fit with coproduction with sector bodies, so at times ownership of messages and sign-off processes has been unclear, particularly as sign-off has been required from DHSC, NHS England and PHE, all of which have different processes and culture. The boundary-crossing nature of the review and the advisory and implementation groups has at times made it commensurately harder to be clear on ownership and responsibility for pushing forward and resourcing actions, with the chair and group relying heavily on good relationships with Ministers and senior leaders at a time of frequent personnel changes. I would recommend that government works with the VCSE sector to develop clearer coproduction processes, with a focus on how to make national policymaking more inclusive of excluded groups and communities, and the often smaller and less well-resourced organisations which reach and represent them. This would contribute to tackling the structural inequalities which feed down from inaccessible and highly-pressurised national decision-making processes into the inequalities embedded in too many of our public services. The HWA could aid this.

It is vital that the national system partners continue to role model coproduction through the HWA and partnerships such as Think Local, Act Personal and the Coalition for Collaborative Care.

Conclusion

I’m encouraged that the NHS Long Term Plan and the Universal Personalised Care model acknowledge the role of communities and the community sector as strategic partners in design, citizen voice and delivery, and start to lay the groundwork for a more rigorous approach to inequalities which couldn’t be achieved without investment in user-led, BME and other local grassroots organisations. The Social Value and volunteering agendas continue to gather pace. I hope to see similar messages reflected in the delayed social care Green Paper and the Green Paper on prevention. Meanwhile, the overall picture of local relationships with – and investment in – the VCSE sector is one of widening gaps between local systems which recognise their community organisations as vital to their success and sustainability, and those areas which continue to withdraw funds and support from local organisations doing crucial work.

Our key message remains our first: that the fundamental shift which is needed is towards codesigning a new health and care system with the people who use it most, and those who miss out most often. Statutory organisations have not consistently shifted resources and power from their own bureaucracies towards citizens: effective community organisations are essential partners in this.

Not all VCSE organisations achieve that shift either, but the best do. The ability of the best community organisations to see the world from the individual’s perspective, and to shape their services to individual lives, is vital to achieving real change, and nowhere more so than in driving the changes needed to address the inequalities experienced too often by those communities who have been least listened to, and who rarely see the reality of their lives reflected in statutory plans. That change cannot be pursued as an afterthought. Every council and local NHS system must invest strategically in its communities and community organisations.

I would like to thank the sector representatives and officials who have worked together producing actions and recommendations, and the hundreds of people and local VCSE organisations who have contributed to our work.

 

Alex Fox OBE, Independent Chair

Alex@sharedlivesplus.org.uk

 

New action plan for VCSE Review published

“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 charities 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.

Read the action plan

New Action Plan for VCSE Review launching soon

Given the changing health and care environment, a second phase of the Joint VCSE Review will be launched on 16 May 2018 to refocus local and national action around a revised set of recommendations.

We invite you to join Alex Fox OBE (Chair of the VCSE Review), Glen Garrod (Executive Director of ADASS) and Neil Churchill (Director, NHS England) at the webinar on 16 May from 3.30pm. The webinar is aimed at statutory organisations, the VCSE sector, commissioners and other health and care organisations.

To book your place on the webinar, please e-mail england.voluntarypartnerships@nhs.net with ‘VCSE Review’ in the subject header.

Progress on implementing the recommendations of the VCSE Review

The independent Chair of the VCSE Review, Alex Fox OBE, has published an update on the progress of implementing the recommendations of the joint group’s final report.

The report, based on the largest ever review of the voluntary sector’s involvement in statutory health and social care, urged local hospitals, clinical commissioning groups and councils to do more to involve expert charities in the design and delivery of services of all kinds. It included 28 recommendations which were jointly agreed by the Department of Health, Public Health England and NHS England.

Download the Chair’s update.

Final report published

The final report of the VCSE Review has been published.

The report, based on the largest ever review of the voluntary sector’s involvement in statutory health and social care, urges local hospitals, clinical commissioning groups and councils to do more to involve expert charities in the design and delivery of services of all kinds.

The report includes 28 recommendations which have been jointly agreed by the Department of Health, Public Health England and NHS England.

Alex Fox, who chaired the review has written an article summarising the findings.

Download the full report or download a short version comprising the vision and recommendations.

Collaboration around the needs of people not the needs of bureaucracies

Barbara Gelb OBE, Chief Executive, Together for Short Lives

If ever there was a need to build understanding, partnership and collaboration acrossCapture sectors then it is now. But this collaboration must be centred around people not built round bureaucracies.

As we mark Children’s Hospice Week, the publication of the VCSE Review final report is both timely and welcome but, like many, I hope the positive words and reflections move quickly into clear and beneficial actions. Continue reading

Final report of the VCSE Review launched

Alex Fox is CEO of Shared Lives Plus and independent Chair of the Joint VCSE Review. Read the final report.

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 meet to local needs and building on local assets and community resources.

Traditionally, the health and care system has been designed largely by the state, with civil society invited in from time to time for consultation and all but a few citizens struggling to have their voices heard. If we are to have a health and care system which is designed around individuals, which draws fully upon their capacity to self-care and the hugely under-valued role of family carers, and in which people are supported to remain included and active members of their communities, then the voices of people who make long term use of health and care services and their families, must be at the heart of planning processes from the start and throughout. It is the VCSE sector which has consistently demonstrated it can reach and engage with local communities: helping even those most often overlooked to speak up, contribute and take the lead. Our recommendations set out how VCSE organisations can be supported – and challenged – to do this.

VCSE organisations want to share in the health and care system’s limited resources, but they also bring resources of their own and they are willing and able to share in the risks and responsibilities of creating a health and care system which supports us all to live well, with the people we live, in places we are happy to call home.