Why capital funding overshadows the debate on NHS reform

Community providers are being pushed aside as commissioners recognise only those with money, not their track record

• • Share1
  •  reddit this
• Comments (0)

• Allison Ogden Newton
• Guardian Professional, Thursday 23 February 2012 15.25 GMT
• Article history

Stephen Bubb of Aveco says the NHS needs community providers with new ideas about delivering services. Photograph: Graham Turner for the Guardian

In any economy, let alone one in recession, capital is king, so it is a primary consideration when contemplating reform of public services.

As both the chief executive of Social Enterprise London and chair of theTransition Institute, which supports public services, I am an advocate of those independent providers who offer affordable, quality services with social impact and real accountability.

Today we are being asked how we stand on NHS reforms. Through the work we have done in public services and, in particular, health, we have seen some wonderful organisations offer innovative, patient-centred services on reduced budgets. To achieve this does mean acknowledging competition in the NHS.

But here is where I have a problem: almost without exception, the procurement processes that have come from government in the last 18 months have been large – and are getting larger. They have increasingly favoured those applicants with capital, lots of it. In some bidding rounds, applicants have been required to prove the existence of large capital sums or capital bonds as an essential part of the process, which excludes most if not all community-driven providers.

The innovators I refer to offer extraordinary opportunity to link motivated staff with happy patients, such as those treated by City Health Care Partnership CIC in Hull. City Health is an employee-owned service, like Central Surrey Health, that provides award-winning, community-based healthcare. I have to say both these organisations do not have the look or feel of a privatised company, but a new generation of public service, with the strongest possible public service ethic.

I read with interest Sir Stephen Bubb, chief executive of Acevo, the Association of Chief Executives of Voluntary Organisations, and a board member of the Transition Institute, whose article in the Times on Wednesday considered the NHS reforms. Bubb was a member of the Future Forum that reviewed the reforms over the summer and he attended the No 10 NHS summit on Monday.

As someone at the heart of the debate, Bubb tells us: "Almost everyone agrees we have a problem when over 70% of NHS funding is spent on treating long-term conditions, usually in the most inefficient way there is: in hospital.

"And almost everyone agrees that if the NHS is to cope with these pressures, it must shift resources towards preventative, patient-led, community-based services which treat chronic conditions far more effectively and which act to pre-empt acute crises of ill health."

He goes on to say: "Might I also suggest that the majority of observers agree that to carry out this change effectively, the NHS must allow new providers with new ideas to break the bureaucratic stranglehold on service delivery … What frustrates many of my members, the leaders of the country's charities and social enterprises, is that, despite the consensus on both problems and solutions, the debate over reform focuses on the phantom of 'privatisation'."

All of us on the front lines of community service share Bubb's belief that, with a fair crack at the whip, we could make a real contribution, but to do that a number of things have to change.

I don't think this is a debate about whether to privatise or not: the NHS has always been a mixed model and will continue to be so. No, this is about big versus small or, more specifically and sadly, this is about financial versus social capital.

Most of the members Bubb is referring to have a great track record but limited access to capital. Like Social Enterprise London members and those approaching the Transition Institute, they are finding it harder and harder to succeed in a commissioning process that pits them against companies which don't have the track record but do have the cash.

The principle of this debate is clear: everyone wants universal, quality healthcare, free at the point of use, but the means to achieving that are bound to be complex, even if money wasn't so tight. The Transition Institute thinks it has part of the answer in that we can supply willing providers of quality, community-driven service solutions. All government has to do is procure those services and look for capital elsewhere.

Allison Ogden Newton is chief executive of Social Enterprise London

• ITSNEVERDULLINULL

  23 February 2012 7:48PM
  Thank you Allison for this insighttful and appropriate article, the point about the difference between organisations for profit and those for 'better profit' is not at this point in time distinguished in procurement processes across the public sector neither does the process of supporting such staff lead organisation bear the fruits of their committement - it is true that this government sits on the most exciting opportunity to release with proper support the potential drive and enthusiasm of it public sector workers.

  However in health and other sectors it needs to get the credibility and buy in from staff, they need action and many very interesting developments could be on the way that may support this move but they need supporting and that means finance.

  They may need to understand that unions still may not understand that by creating co ownership in its wider sense is not that appealing whilst understanding that such things as large capital bonds to even bid for work are just not feasible nor are they needed with the stringent processes already wrapped around floatation.

  To allow large corpoarte accountancy firms to set the bar based on such developments as the Foundation Trust accreditation proces at this stage of social business development are and is restrictive. The failure regimen is simple not some big test nor given choice of form does it seem that complex - the next concern a bond to enter the market - for sure it's on it's way more money out of front line delivery to support failed for profit organisation like those who have made money out of cosmetic surgery , great !!!!
• • Recommend? (1)
  • Responses (0)
  • Report
  • | Link

• IanGreener

  24 February 2012 12:56PM
  Thank you Allison, this is a thoughtful piece. I think you reach the right diagnosis, but I'm not sure I entirely agree with your solution.

  I think it is clear that there is a consensus that we need more community-based services to prevent un-necessary hospital admissions, to treat patients more appropriately.

  I will also agree that in order to foster innovation, we need new community-based organisations to work with the NHS as it requires fresh perspectives and new ways of doing things to find new answers.

  However, I disagree that competition is necessary to achieve this. I also have concerns about the NHS relying on non-public provision for the long-term delivery of services.

  It isn't necessary for new organisations providing care for the NHS to be competing with other providers of care. We can do this just as we co-operatively. The NHS can buy care from social enterprises and other non-public bodies without the need for them to be competing with one another. I have no problems with the idea of such services being commissioned, and their impact and effects evaluated through careful research. I'm not sure what the gains from getting social enterprises to compete would be, and think a research-driven approach, for a change, would be a positive way forward.

  Equally it seems to me to be unwise, either for social enterprises or the NHS, for non-public providers to become dependent on public funding. It's a bad idea for the NHS in case those providers run into financial difficulties, and which will result either in them having to be bailed out by the government, or patients face the disruption of having to be reallocated to other providers, possibly in systems which don't have the spare capacity to support them.

  It also seems like a bad idea for social enterprises to become dependent on public funding - their vibrancy is surely based on being able to be sustainable without becoming dependent on the state. If social enterprises are dependent on the state for financing, they might as well be public bodies. The private health sector is, I read, already getting 25% of its revenues from the public purse, so effectively sustained by it. That doesn't strike me as being healthy for either public funders or private companies, and repeating the error with social enterprises would be short-sighted.

  My suggestion then would be a more research-driven approach - asking social enterprises to provide services to the NHS which would be evaluated, and if successful, rolled out across the system, but funded publicly. There is no intrinsic reason why public funding should prevent innovation - that's about good management, and there's no intrinsic reason why good management only exits outside the public sector.
• • Recommend? (0)
  • Responses (0)
  • Report
  • | Link

• janeiwheeler

  24 February 2012 1:53PM
  Alison this is a really interesting article - and our observations would echo yours, namely that current procurement processes pose significant challenges for smaller organisations wishing to retain their services, or expand into new areas.

  We identified this trend not solely in the realm of community services - although over the last year these are the largest contracts that have been procured and so the issue is perhaps more pronounced in this realm.

  Working with Social Entreprises, private companies and the NHS we also believe that this trend isn't just apparent in the independent sector but also within the NHS. Smaller Trusts and Mental Health Trusts are struggling to show the organisational capacity and capability that commissioners require

  It is also worth mentioning, as I'm sure you would recognise, that smaller organisations (which may have local advantages and be strong on innovation) face other barriers than their financial strength or backing. Whilst an organisation may have a great track record of service delivery, frequently the scoring within a procurement will place at least as much weight on track record of managing a transition from an existing provider or implementation of a new service. For a smaller organisation a large scale procurement/mobilisation for either their own core business, or for another local service may well be one of their first experiences of a procurement of this magnitude. Their ability to demonstrate to commissioners the organisational capacity to undertake a complex transfer of staff, due diligence process, IT systems change etc, all whilst achieving tough financial savings can place doubts in assessors mind. Bear in mind that most large organisations undertake this process regularly and can easily draw on recent relevant experience .

  It will be interesting to see how current trends to centralise and procure larger and larger services (for example at cluster level rather than PCT - eg with Out of Hours and 111) will help or hinder the ability of smaller organisations, across all sectors, to be assessed as credible providers alongside their larger competitors.

  We wrote about our observations here:

  http://damsonhealth.com/archives/255
• • Recommend? (2)
  • Responses (0)
  • Report
  • | Link

• 
  richardblogger

  24 February 2012 10:49PM

  ...on reduced budgets. To achieve this does mean acknowledging competition in the NHS.

  That is economically innumerate. You cannot say that reduced budgets mean that you have to have competition, in fact, reduced budgets mean that you should *collaborate* more. Competition by default means there has to be excess capacity, and that can only be achieved in times of plenty.

  which excludes most if not all community-driven providers.

  Well, that may be because the existing providers are *competing* perhaps if you learned to *collaborate* then you may share some of the funds. For example, my local hospital collaborates with Macmillan. The hospital have recently built a new ambulatory cancer unit and there are facilities for Macmillan in this new building - it is the base for their nurses locally. This makes sense because patients who receive treatment in the unit will be cared at home by the Macmillan nurses. This is joined up, collaborative services. It is a great shame that this nasty, pig-headed government cannot see that collaboration works and is far more powerful than competition at delivering high quality integrated services.

  Bubb tells us: "Almost everyone agrees we have a problem when over 70% of NHS funding is spent on treating long-term conditions, usually in the most inefficient way there is: in hospital.

  In fact this is an evidence-free statement. Many health economists say that care in the community will NOT save money. The proper question to ask is what is the best for patients (amazing, isn't it, that Sir Steve Bubb thinks of money first, and patients second? It kinda sums him up). There is evidence that care in people's homes is better for patients and that they recover quicker. It may cost more, but does that matter if it is better for the patient? However, bear this in mind. If a patient is discharged too early from hospital and into "community care" they may be more likely to be re-admitted and so cost more. So Care in the community should not be seen as a replacement for much of the care in hospitals, it should be regarded as an integrated part of the whole pathway. But integration requires collaboration, and we get back to where I started...
• • Recommend? (0)
  • Responses (0)
  • Report
  • | Link

Tweeting about the riots @NCVO

Riot police charge past burning buildings on a residential street in Croydon: Guardian

Yesterday I went to a summit at SEL member, Rich Mix in Bethnal Green organised by NCVO to analyse the riots. It was the kind of edgy, gritty  debate I hadn't participated in for some time, and you didn't know which way the room was going to go. NCVO had invited over 100 people, which meant that those working at grass roots level were there to talk about what they understood to be happening in communities. Restricted access to the mike usually means the big guns don't turn up, but in the audience and participating at the roundtable discussion panels we had Stephen Bubb, CEO at ACEVO, the Minister for Civil Society, Nick Hurd, and members of the cross-party Riots Panel. I sat next to Stephen, which is always interesting as his views, like those of Stuart Etherington who opened and closed the event, are those commonly heard in Whitehall.

On my table I really enjoyed talking to @AndreHackett a graduate of the School for Social Entrepreneurs who had founded We Make a Change, an interesting organisation that connects communities with people who need to hear from them. I asked Andre the question that was bothering me: were the rioters in fact different groups operating as a mass? When the riots occurred it seemed to me that rioters fell into two groups, those who were angry, with a statement to make, and those who were just there to nick stuff. Given some saw themselves very clearly in one group and not the other and others had begun in one group but shape shifted in the electricity to the other, it was hard to analyse the motivation of the rioters as a single entity. I asked Andre about this as he had been working directly with those who rioted before and after the event, and he agreed. This idea that community is in fact a diverse group of opposing interests even in the manifestation of their rioting was echoed in Stephen's recent blog.

Both men argued, as I did, that young people need the hope of jobs in the communities in which they live. The lack of jobs for young people is a national crisis and one that will end, regardless of punitive action, with people out on the streets again and more worryingly slipping between society's cracks, disappearing without trace. A critical point made by one contributor was that young people are a resource, not a problem, this for me is the point of the exercise. There was a collective call for a young people's employment programme to sit alongside the work programme, which sounded a lot like the Future Jobs Fund. I know I bang on about the Future Jobs Fund, but it did work, the 500 young people we helped to get into work could have been 2,000 if we had been allowed to carry on, and we were just one provider, this is important and worth serious consideration. Yesterday it was announced that a further 77,000 young people had signed on since July. Getting them into jobs is the place to start to avoid future riots and further economic decline. But that takes enterprise - social enterprise if you ask me as the businesses that will be offering jobs to kids with limited qualifications and zero experience, in the places they live, will be social enterprises like Livity in Brixton that worked with over 1,000 kids last year.

This is clearly a hot topic as the twitter stream from the event,  has continued at least in my tweet world. We don't have quick answers but I do think we are getting there in the spirit of community, by working together.

Survival of the fittest?

How's that for a sunset? As viewed from our front garden

We are in the cottage we have rented every summer for the last ten years, something I was reminded of when our youngest, Katie, wanted to swap rooms with our eldest, Joe, as we arrived. He dismissed her with, "You’re joking right? I’ve had that room since I was five.”

Diary of a work placement newbie: Imogen Morrell tells us about her week at SEL



Sophi Tranchell and I at the ACEVO lunch

Arriving at Social Enterprise London (SEL) I realised what a complete novice I was to the ‘the workplace’. I finished my GCSEs only recently and since then have spent two weeks sleeping and sitting on the sofa watching Jeremy Kyle getting cross. I was ready for some structure.

You can't run the country like a bring-and-buy sale

I like a bring-and-buy sale as much as the next bargain hunter, but it's no way to run a country. I emailed Sir Stephen Bubb, CEO at ACEVO to that effect this morning as he was about to go on the Murnaghan Show on Sky

Launching Lambeth as the 'cooperative' Council

Today Steve Reed, leader of Lambeth Council launched its strategy to achieve the status of the cooperative council a process I have thoroughly enjoyed being a part of as one of their Commissioners. In the last four months the Commission have met some of the leaders in the field of community engagement, mutualism and public sector reform. People like Ed Mayo ceo at Cooperatives UK and Ben Page the MD at Ipsos MORI who gave a memorable presentation that statistically proved the hopelessness of basing any strategy on volunteers. Thankfully Lambeth's plans do not rest on the hope that people will do something for nothing, but that if there is something in it for them, like free access to council services or safer streets. I have to say although finding the time to be a commissioner was always tricky, I have really enjoyed being part of it. In some ways it was, inevitably, a talking shop, but in others it was a unique opportunity to examine and test what is meant by 'handing back power to the community' the overarching aim of becoming 'the cooperative council'.

Tessa Jowell, now shadow Minister for the Cabinet Office and 2012, since the reshuffle, was our keynote. She was enthusiastic about the program telling us that "reciprocity is at the forefront of labour thinking." She went on to say that "Big Society is anti government but the cooperative council concept was about sharing risks, decisions and responsibility with government." Before she spoke Tessa introduced Maurice Glassman, a new Lord whose involvement in London Citizens has broken new ground in successful interaction between the state and formerly excluded citizens.  Maurice gave a haltering impromptu address that none the less, conveyed his conviction that community counts, he seemed like a really nice man who asked me later if his speech 'was all right?'

Fellow commissioners Sir Stephen Bubb ceo of acevo was also there as was, Lord Victor Abedowale from Turning Point who was really spot on when he talked about bureaucractic Government engaged in "undue diligence' and the need to move from risk adverse to risk aware.

It was, as I told the audience later, far from a cynical process but one that really has the potential to address the perennial question, how can we make government work for us?

Happy New Year! 2011 is going to be a wee bugger

New Year finds me clear headed in Cornwall. Last night we were invited by my friend Emily Scott to her fabulous restaurant, The Harbour, in Port Isaac. Emily is a stunning chef and last night she really treated us. We had red onion jam and goats cheese tartlets, locally caught crab in a light salad, monkfish in pancetta with lemon mash and pannacotta and raspberries followd by chocolate truffles, yum! The village gathered outside the restaurant which is at the head of the slipway for some super fireworks and a male (nude) swimmming race across the harbour which the health and safety police have not been able to put a stop to, yet. This morning I have awoken to views of the surrounding countryside, including an unbelievably large cow.

Scanning Twitter I see many are posting their predictions for 2011, whilst I'm tempted to join in, I think it will be a bugger of a year with much rear guard action and can only advise we keep our spirits and left hook up, and not pull our punches as my dear old Dad used to say.

I was over the moon yesterday when the announcement came that my friend Stephen Bubb, ceo of acevo, was to be made Sir Stephen. As Vice Chair of acevo I have had the chance to work closely with Stephen who is a very rare bird indeed. Whilst he cultivates a persona based on hedonism he is, in fact, like a swan, frantically paddling under the water to promote and these days, preserve all that is best in the third sector. I have always admired his approach which, if you are a fan or irony, which I am, is self deprecating. In any event, Stephen is bloody effective and a good laugh, so well done to you dear and the team at acevo who, like my SEL lovelies, work like stink for the sector!

Other honours included OBE's for SEL board member Gordon D'Silva, founder and leading light behind the ground breaking Training for Life, and Steve Wyler, Director at our old friends the Development Trust Association. It will be organisations like Training for Life, the DTA and Community Links, featured in a shattering article by Patrick Butler in last weeks Guardian, that will be picking up the pieces of the cuts. I could not believe my eyes when I read the piece, much of it in the words of David Robinson, one of the most respected leaders of community work anywhere in the world. He told us that this beacon of good practice, much needed in such trying times, was itself facing closure. That can only mean one thing, no institution, group or icon is above the waterline.

So, when the going gets tough the tough get going? Well yes, but many of us don't work for the tough, we represent society's least heard, least valued and most vulnerable, so that isn't terribly helpful. We shall all need this break, like boxers we have gone to our corners for some refreshment, and when the bell sounds we will have to come out fighting!

If I had a hammer

As the heavens open, again, I think of Noah, the patron saint of forward planners. Even without Mr Fish, those of us working with Government can read the signs.  Only strong swimmers need apply.

So if you can hear the sounds of busy hammers its the strategists determined to keep their head above water by building vehicles fit for the new era. Anyone labouring under the misapprehension that the status quo will prevail should check their water wings for holes, cos they're gonna need 'em.

I do think a lot of wonderful social enterprises will go. Those too small to respond to the meta programs the Government are constructing, and too bespoke to fit into the new o/s era. I don't know about you but I have never looked good in o/s, and an o/s society seems counterintuitive to Big Society to me.

But it is possible for some to construct a mighty ark. I had a meeting with the fantastic Sue Slipman yesterday, Director of the Foundation Trust Network, and she has some top tips on boxing and coxing for success. Sue and I had a really good explorative talk about her model and what makes it so perfect for the times. Sue helped develop my thinking on hybridisation and its profound relevance for social enterprise. As I said to Sue, and to anyone who will listen, the strength of social enterprise is in its ability to maximise social value in any commercial transaction. For me Foundation Hospitals are not only social enterprises but bloody good examples of it. What we need are more of the same and there is a high probability that if we are clear in our thinking and articulate in our approach we will have the opportunity to strut our stuff.

I had lunch on Monday with Stephen Bubb ceo of acevo the wonderful organisation I have the privelidge to be Vice Chair of. I was horribly late because getting around London can be a joke, which upset both of us. Stephen and I really enjoy one another's company. Stephen is the consumate advocate who does not take himself seriously, which is precisely why he has been spoofed, and why he is very good company. Oh we do have a laugh, although we got quickly to the very serious business of working out how to offer direction to our movement when all but the rhetoric seems disasterous for small, local community based groups. As Stephen has said in his blog, the Ministerial visits are sure to dry up with the funding.

Yesterday I was met by Giles Wilkes, Vince Cable's Special Adviser, to talk about the plight of the social enterprise regional support bodies. Giles confirmed what I suspected, which is that in closing the RDAs there was no intention to deconstruct the social enterprise support infrastructure. Giles could not of course make any undertaking but did say he would make enquiries and see how the land lay. Sitting in BIS for what must be the hundreth time I was struck at actually how many times I have had that conversation. In one form or another I have explained to at least four Secretary's of State, a dozen Ministers and a bus load of officials how our fledgling movement has grown sometimes in spite of Government "support". We have survived to date because we are clever and able and we have members who respect and need us. But we could have done more with a leg up from BIS and if they want unprecidented social enterprise growth in the public sector, we of the supra local networks, would be a very good place to start.

Maybe its time to see a fully fledged return of social enterprise to BIS?