(This article, written with Halima Khan, was previously published in the Health Services Journal on 1st February 2019)
Today, NHS England published its Universal Personalised Care strategy, following up from the long-term plan. We strongly support the strategy as a detailed plan of action to enhance people’s choice and control over their health and care.
The strategy is a major stepping stone. Consensus has been growing over recent years that citizens should have more choice and control over healthcare, and that the social and behavioural aspects of health are just as important as the biomedical. But this strategy is a step-change in both profile and specification. Crucially, it now all depends upon implementation.
In fact, the long-term plan is making a new set of promises to the people of England about what it can, with them, achieve in terms of health over the next decade. The plan’s success will be closely intertwined with the fate of social care and public health and whether these sectors receive an equivalent funding settlement. However, even if this were to be the case, the NHS will also need a lot of help from the rest of society to make the plan work.
This is because the strategy and the wider long-term plan represents more than just an internal NHS reset. Both are a recognition that while medical intervention is a big part of the solution, it is only one part of the support needed to meet growing and changing demand. In particular, the plans recognise that social and behavioural factors are an integral part of healthcare alongside medicine.
Feeling lonely, not feeling able to exercise, or feeling overwhelmed in your everyday life all have an impact on your health and wellbeing, including your ability to get better when you are ill.
This is where the voluntary, community and social enterprise sectors comes in. As doctors themselves know, it is seldom enough to suggest to someone they should get out more, do more exercise or get on top of things at the end of medical consultation. It’s hard to break a habit, particularly when you don’t have the confidence or motivation to do so.
For doctors, time is the major limiting factor, but also the coaching skills needed to support people in this way. The result is that, despite good intentions on both sides, not much, if anything, changes as a result.
But outside of the NHS, there are many thousands of voluntary and community groups who know how to support people in this way – enabling them to build their confidence, motivation and sense of hope. There are well-established support services that help people take steps to healthier behaviours and which combat loneliness and build social fabric along the way.
So this should be a win-win. However, the reality is that the relationship between the NHS and the voluntary and community sector is full of challenges.
One is the sheer gulf in scale between the two. The NHS is the fifth largest employer in the world and consumes over a hundred billion pounds of public money every year. The voluntary and community sector stretches from multimillion pound national charities through to tiny organisations on a shoestring budget with a workforce of unpaid volunteers.
This means the NHS struggles to engage with a highly fragmented market where it’s hard to know who can do what best. At the same time, the voluntary and community sector are often excluded from procurement procedures set up for much larger organisations.
As well as scale, another challenge is power. The voluntary and community sector have to balance their role as champion and advocate of the citizen with their role as service provider. The former requires an ability to stand up to authority and challenge the status quo, while the latter requires working in partnership across sectors.
This results in an often uneasy tension in which both sides feel frustrated. On the NHS side it can feel like the voluntary sector struggles to move out of “lobbying mode” and can feel “relentlessly critical”.
On the other hand, the voluntary sector often feels shut out of key forums, unable to have a seat at the table and tasked with delivering services without enough funding to do the job properly.
But if the NHS wants to empower people to maintain and improve their health and their care through social and behavioural interventions, these challenges need to be addressed.
So how can civil society and the NHS work much better together?
For a start, the issues associated with scale can be addressed. The NHS should do much more to level the playing field for voluntary sector involvement in the market.
Procurement processes can be improved to make them genuinely open to smaller providers.
And there should be further innovation in procurement, such as greater use of alliance contracts in which groups of providers (often from the voluntary and community sector) come together in a consortium to bid for and provide services.
There are also some mitigations to the issue of power. This is a delicate issue, but it’s clear that it is incumbent on the side with most formal power (the NHS, for the avoidance of doubt) to ensure it acts in a way that enables the voluntary sector to be a strategic partner.
The voluntary sector should look for opportunities to recognise and acknowledge when the NHS shifts in the right direction, as well as hold them to account.
This leaves a final challenge: funding. Neither the issue of scale nor power can be solved if the services provided by the voluntary and community sector are not adequately funded.
The voluntary sector cannot survive on fresh air – their contribution needs to be properly recognised and supported and this can’t be done for free.
In fact, without adequate funding from the NHS to the voluntary and community sector, the ambition in the long-term plan will not be possible and the promises made won’t be kept.
Investing in these services now will mean more sustainable care for the future, with a network of skilled VCSE organisations who are supporting people and, by doing that, are also helping the NHS achieve its long-term plan.