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:
- 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:
- 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:
- 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.
- 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.
- 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.
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