Charities and A&E – quiz the ministers!

Well today’s been good for drawing attention to charities’ work in A&E. We’ve announced a new programme with Red Cross, Age UK and RVS, funded by the Cabinet Office. 700 charity volunteers to work in the 29 most under-pressure A&E departments around the country, and help reduce demand on A&E over the next 12 weeks. See today’s Telegraph for an excellent roundup by Chris Hope.

Naturally, this is the precursor to bigger things. I’m making sure that government collect evidence of how charities can reduce the load on A&E. It’ll be a good evidence base for a wider national intervention in future years. Charities need to be integral to A&E strategic planning in future. This programme will help make that happen.

But what of the parties’ thoughts on the third sector’s role across social care + health? At election time this is the important question.

On 3 March ACEVO’s Health and Social Care Conference is the biggest such third sector event. In central London (and in front of the BBC + other cameras!) we’ll have not only Jeremy Hunt but also Labour’s Andy Burnham and the Lib Dems’ Paul Burstow to put their respective pitches to third sector leaders. With lots of time for questions. And in the morning we have a session with Simon Stevens of NHS England – an excellent chance to discuss progress on his five year forward view.

I highly recommend you come along, whether you’re third sector leader or anyone else. Tickets here: https://www.acevo.org.uk/event/spring-health-social-care-conference-2015. See you there!

Choice and integration

The third sector leads the way in joining social care and health. My recent work on winter pressure in A&E departments has reminded me just how effective we are at reducing demand for hospital services. More news on that to come later in the week...

I've written a piece for the New Statesman today, looking at Labour's plans for a 'National Health and Care Service'. Here it is:

Government NHS reforms adviser: Burnham's plan for patient choice is the right way

Last week, the former Health Secretary Alan Milburn said it would be a "fatal mistake" for Labour to fight the election by spending on, but not reforming, the NHS. He was joined by another Labour luminary – Lord Darzi – on Friday, as a clear group appeared to line up against the shadow health secretary Andy Burnham’s agenda.

These attacks are not just unseemly, but wrong as well. Look behind the headlines and Burnham’s agenda is the right one: to reenvision the National Health Service as a National Health and Care Service. Now we need more detail on how this is to be done.

It’s clear the NHS can’t survive without fundamental reform. As an adviser to this government during the passage of the Health and Social Care Act in 2012, and more recently on care for people with learning disabilities and on winter pressures in Accident and Emergency, I’ve seen the gravity of the situation first hand.

I’ve also seen there are no easy cuts to make. Cuts without strategic thinking have fragmented not only healthcare but also social care across the country. This directly harms our most vulnerable citizens. It means more people falling through the cracks of a breaking structure. We are on borrowed time and on the cusp of a reality where crises like the one we are living through in A&E this winter will become the norm. And it is largely our legislators’ fault.

Poor social care causes more damage every day. Cuts to council budgets have trimmed care for the elderly to the bone. Charity CEOs tell me of reverse auctions for local health contracts being won by the very cheapest service, whatever form it may take. Some private operators – though they are often very effective – may bid so low that they make a loss on social care and recoup the money elsewhere.

In A&E, these cuts send more older people into hospital for preventable problems. Often 20 per cent of beds are filled by elderly people who aren't ill, but end up in hospital because no one else can help. They can't be discharged because there's no social care to help them at home. Cutting costs money; when we run out of beds it can also cost lives.

Burnham's plan is to price in these very real externalities of running a health service. The vision is to change the NHS by replacing competition with integration. When Burnham talks about integrating the work of public, private and third sector providers, he is indicating a situation in which new services are created by new kinds of collaboration.

Collaboration rather than competition becomes the driver of patient choice. This is not merely theoretical. This winter I have chaired an NHS taskforce to get charities in to 29 emergency departments that are under pressure to tackle the immediate problem. We hope to get the charities into action early next week. We will be giving vulnerable patients a choice to receive community care that the market has failed to provide.

No doubt market liberals of the left and right will sniff at this vision of a world of choice beyond how they define it. But politicians of all parties must keep their nerve. The idea of a health service rescued by cuts and efficiencies is debunked. Now they must scale up the radical approach into a sustained plan of action. 

They can build on pilots like the charity intervention into Accident and Emergency, on innovations such as the coalition’s attempts to pilot bringing together budgets for health and social care at a local level, and they can create a new, integrated plan for health and care. The Burnham plan may not be easy to digest or to do – but it is needed.

Recognise what charities can do in A+E

On the sofa at 6.45 this morning! That is, on the sofa for ITV’s ‘Good Morning Britain’, where I was talking about how charities and social enterprises can work with the NHS to relieve pressure on A+E.

Of course we often forget charities have been working in hospitals for centuries. Indeed we used to run them. Not that I want to see a return to those days, but I do think people in the NHS increasingly see the value of our sector – professional staff  and trained volunteers – working alongside medical staff to ensure the right care and treatment for the frail elderly.

It’s scandalous that so many hospital beds are occupied by people who are not sick but cannot get back to home because of social conditions. It’s scandalous that older people who attend casualty are signed off by medical staff but end up in hospital because of a transport breakdown or worries there is no one back at home and it’s bitterly cold. Hospitals are bad places for people who are not sick. And it’s a senseless use of scarce hospital resources.

Addenbrookes, a hospital ACEVO has been working with on this issue, says 20% of their beds are occupied by older people who don’t need medical care. This is not a clever way to run our NHS. And charities can help solve that problem.

Last year I worked with my CEO colleagues in 3 big national charities whose mission is to support older people in the community: the Red Cross, RVS and Age UK. We worked up a proposal for Government that would ramp up the role of our sector in hospitals and in the community. We wrote to the PM setting this out. Letter is here.

We have been working on this since and discussing with hospital CEOs etc. There is great interest, but also, frankly, huge barriers in the system to implementing this.

Yesterday, along with a range of colleagues from the sector, I went to a meeting with the Cabinet Secretary and the Department of Health Permanent Secretary to talk about how to mobilise support for the most stretched A+E departments. It was productive and helpful. I was tasked with providing a report to indicate what we might do in the short term for the highest-priority hospitals and I'm now busy talking with my CEO members on what this might mean. I have until Monday to report back. I have a round table with some of the charities most involved tomorrow morning to discuss practicalities.

Longer-term we need to grip this issue and sort it. The point I made at yesterday’s meeting was that there are 3 main barriers to change:

• Culture – the NHS doesn't generally understand the modern third sector and too often thinks of ‘do gooders’ not professionals.

• Systems – the third sector is not embedded inside hospitals at A+E, or on the wards, in planning or in early discharge teams.

• Commissioning – this is done on transactions not outcomes. There are no incentives for hospitals to work with the third sector and the current commissioning process generally ignores it.

Now we need both to help in target areas, to secure better care for our elderly citizens, and to seek organisation reform. Ultimately we need radical approaches to health and care that galvanise the third sector. Systems that move us from the margins to a partnership approach in the NHS and in councils, that does the best for the individual’s well being.

One of the earliest tasks for our charity sector, a millennium ago, was securing good health and care for the sick and old. It’s time the nation rediscovered the genius of charity.

NHS and charities!

Two weeks ago Simon Stevens published the NHS Five Year Forward View, a high-level strategy document on the future of the NHS. A couple of days later Andy Burnham reiterated his stance that the NHS should be the ‘preferred provider’ of health services, in an interview with HSJ.

Both positions mention the voluntary sector and profess its value. But there’s little hard policy to say how exactly we’ll establish good partnerships with heath commissioners. Enter ACEVO and our new ‘Working in Partnership’ report, published with the Central Southern Commissioning Support Unit.

Our report sets out seven principles to break down the barriers to partnership working between health and social care commissioners and the voluntary sector:

1. Sustainability - Organisations should seek to build partnerships through jointly committing leadership time and resource to understanding each other’s operating environments and contexts.

2. Transparency - Organisations should be open with each other and clear about the purpose and benefits of the partnership for partners, patients and the public.

3. Joint Vision - Organisations should share their vision and plans as early as possible so that they can identify synergies and opportunities to develop a joint partnership vision.

4. Joint Capability - Organisations should seek to enhance each other’s capability through, for example, knowledge transfer or the joint provision of services.

5. Proportionality - Both partners should be equal in the partnership but should be proportionate in their requirements of each other.

6. Innovation and improvement - Organisations should seek to share, develop and implement innovative solutions.

7. Accountability and governance - Be clear about how decisions are taken within each organisation and within the partnership. Agree how you will hold each other to account.

This is excellent progress. Now we need health commissioning units across the country to take these principles on board. ACEVO’s 2015 Election Manifesto - which we publish very shortly - devotes much attention to this area and will give the political parties food for thought. I’ll have more on this next week...

Winterbourne update

A number of key meetings last week and this. First, with Norman Lamb MP, the Care and Support Minister (who will, incidentally, be speaking at our Lib Dem Conference event). He was the politician who made the brave pledge to move people with learning disabilities into the community and away from institutions like Winterbourne. The pledge has not been honoured, and I know he feels deeply about that, but he was right to make the pledge and right to be holding NHS England's feet to the fire (and indeed mine) on achieving it now. I was able to outline the key planks of the work we are doing in the steering group. We discussed the issue of closing facilites: clearly some are not for the NHS to close, but I argued there is a duty to spell out the journey that means we will close institutional care - so that care and support in the community is the norm not the exception. Of course this means we have to develop community facilities, and the third sector's role here is crucial. We also need proper crisis support. But clarity on the objective is crucial. 

And I saw Norman again at a summit organised by him and the third sector organisation ‘Change’, which I have blogged about before. Philippa Brangan was able to demonstrate what work they do in promoting and supporting professional work for people with learning disabilities. What came across to me is the crucial importance of securing a transfer of power from the state to the citizen in the work we do on a commissioning framework. Norman raised the question of giving people ‘the right to challenge’. Music to my ears. In fact when I presented my report on ‘Choice and Competition’ to the Cabinet during the Health and Social Care Act Listening Exercise, the right to challenge for citizens in their health service was a key recommendation. The NHS Constitution  states that ‘the NHS belongs to the people’ yet this is hardly evidenced! So we will look at the potential for empowerment, challenge and personal budgets. However personal budgets require choice. That requires a bigger provider market and so the role of the third sector - as advocates and campaigners as well as providers of citizen focused services becomes even more crucial.

The clock is now ticking as we aim for our last meeting on the 27th October and all of the discussions with PLD and families to support that. I was able to report to the Department of Health assurance group (chaired by Norman and Gavin Harding, who has been an invaluable member of my steering group) on Monday about what we are up to. Frankly we need to focus on outcomes as what I'm told is people with learning disabilities want progress and action, not more discussion. Exactly what Gavin emphasised on Monday. And what we will try to do at our meeting later today. 

Hospices and health.

 Hospices are a vital and dynamic part of our health system, but run by the third sector. They should be used more and better funded by the NHS. I have always felt that end of life care demonstrates how dis empowering the health service can be. Most people at the end of their life want real choice, where they have that chance, to choose whether to die at home or in the supportive environment of a hospice and yet the majority of people die in a hospital bed.

I have a great membership amongst CEOs of hospices and yesterday spent a fascinating day at the St Joseph's Hospice in Hackney. This is one of the very first hospices in the country, set up over 100 years ago, by Roman Catholic nuns working in a deprived part of London serving many of the Irish Roman Catholic community. Today the hospice is more secular and has a large Muslim population, as you would expect in Hackney, though there are still sisters serving as trustees.  

It's slap bang in the middle of the Hackney community, on Mare St, “the riots stopped just up the road" I was told. I was meeting with Michael Kerin, long time CEO of the Hospice and active ACEVO member. It’s an amazing set of buildings- they pack much into a small plot of land and the gardens are especially peaceful (and have been award winning). Michael told me Prince Edward was a visitor recently to see the gardens as part of the London garden scheme.

And I ought to mention my favourite hospice which is Helen and Douglas House in Oxford, they recently released a fun promotional music video by Out of the Blue which you can watch here: http://youtu.be/bRWVMPnByzo

A great deal of thought and care go into the planning and running of a hospice where the emphasis is on high quality medical care but especially the emotional and loving care people want at their end . I know from personal experience how the final viewing of a departed loved relative can be an experience marred by the surroundings. The hospice mortuary at St Joseph's was a peaceful spot and has much to show the rest of the health service on how to do these difficult things.

And from Hospices to personal budgets; an insightful informal meeting with a number of members and Simon Stevens of NHS England and colleagues. The whole area of choice for us as citizens and as patients in our health and well being service is strictly limited in our interactions with NHS or social care. Personal budgets has been an important development over the last decade but as yet remains an area limited to a small group, whereas there must be more scope for expansion to tackle long term conditions. And continuing the health theme I went off for lunch with Goldman Sachs to talk about cancer research; a subject of both great personal and ACEVO interest.

Winterbourne

One thing I learnt from my time in the big move from institutional to community care in mental health in Lambeth (Tooting Bec) in the 80s was the need to ensure the voice of the client, carers and families are heard.

I know that my recent blog post caused concern because it implied only the providers have the answers and that we already had the worked up plan.  I know that the issues raised from Winterbourne View, and what has happened since, are of deep concern, and I'm sorry that my blog caused upset. It was certainly not my intention. A sin of omission not commission.

None of the providers have all the answers.  But along with others they are clearly part of the answer and we now have an opportunity to work together to develop solutions that meet the needs of people with learning disability, their families and carers.

We have our first meeting of the Steering Group on developing a new national framework for learning disability care on Monday. We have a tight timetable. And as with any group we will need a strong focus on outcomes and a relentless drive that ensures the plans deliver better outcomes for people with learning difficulties.

Speaking to Philipa Bragman of Change (http://www.changepeople.org/) yesterday she stressed the culture change needed in the way services and support are delivered to people with learning disability.  Change is a leading national human rights organisation led by disabled people. Based in Leeds they have employed people with learning disabilities. She told me about their experience of a co-working model of employment which means people with learning disabilities co lead on projects with non learning disability people on equal terms and pay.

I contacted Vivien Cooper of the Challenging Behaviour Foundation (www.challengingbehaviour.org.uk) as a number of people suggested she could connect me to people I need to engage with.

As Vivien wrote on her website,

"I hope that this group will be an opportunity to address the lack of progress so far and to overcome the significant barriers. We know what needs to be done, and we get it right for some people – it cannot be beyond us to all to work together to deliver the outcomes we want to see.”

I wrote last week to members of the national Forum and had a lively discussion with Gavin Harding (Voices for People - gavinvoicesforpeople@gmail.com) who will Co-Chair a new DH assurance group with Norman Lamb MP.  He was keen to work with us to get positive change. Alongside that I have written to the families of people who were at Winterbourne View

One of the ideas put forward is a forum, where we can bring together all the stakeholders in a Summit so we can discuss the steering group's ideas and plans as they develop. There has been support from many people for this approach.  Gavin made the point we must do this so we can practically discuss how we can work together on the task.

The whole country was shocked by the serious abuse and appalling standards of care at Winterbourne View.  Without a detailed plan and collective action, progress on putting this right has slipped. Three years on, there has been hardly any movement towards helping vulnerable people with learning disabilities move into local communities.

It’s a scandal that only a third of the people who were in the so called Assessment and Treatment Centres last April have been transferred out and that even today, more people are being sent into them than are being discharged.

So, our focus as a steering group over these next 3 months must be how we can provide a national framework for local delivery which will ensure the pledge that was made is honoured.

I hope that people will want to work together – and will share their knowledge, expertise and experience to shape what we do and how we do it. I know that if we don’t do this, we will have wasted an opportunity.

The Winterbourne View Concordat and Bubb's challenge

I was surprised. I had gone for a meeting with Simon Stevens, the new NHS England Chief. As with all such meetings, I had my requests. But instead he got there first. "I have three asks", he announced.

The first was what the third sector could do to support the implementation of the Government's pledge on Winterbourne.  Following the Winterbourne View scandal, the Government promised to move all learning disability clients out of inappropriate in-patient facilities into the community. The appalling abuse of people with learning disabilities exposed by the Panorama programme in Winterbourne View, an institution meant to care for them had shocked a nation. Norman Lamb MP, the Health Minister rightly said that not only must there be serious consequences for the Winterbourne View abusers, but that there were also wider issues in the care system that needed to be addressed. In particular, he insisted that all clients in inappropriate in-patient settings should be cared for near their families and in community settings. It was a courageous move.

Sadly, the pledge that those people would be moved by 1st June this year was not met. Not only has that not happened but there are now more people in such placements.  Simon Stevens was clear that only the third sector could deliver the promise and he wanted me to look at a plan for "co-commissioning" between the NHS and my members.

A challenge, clearly, but one I was  up for. I gathered together my top provider members in learning disability for a breakfast to discuss our options . They were enthusiastic for the task; people like Jan Tregelles of Mencap, Steve James of Avenues Group, Robert Longley-Cook of HFT, Mark Lever of NAS, the indomitable Su Sayer of United Response and Ben Rick of the Social Investment Business.

Turning words and talk into a plan requires some skill. Fortunately I have the team at ACEVO that can do this. Mark Winter, my multi-talented Head of Health Commissioning wrote up our Plan on the back of that breakfast, which we characterised as a "national framework, locally delivered".

In essence this envisages the closure of most or all of the current inpatient facilities and the transfer of clients to appropriate community placements near their families . This will require investment in buildings,  converting houses or building new. However social finance can cover this on the back of sensible commissioning i.e. 10 year contracts.  With will,  it is entirely  doable. And if we all share the interests of the 3,250 clients we need to move into better community settings we will do it. Of course with any such task there will be a multitude of views and interests but I've been pleased so far that we all seem to be on the side of sorting it out : and that means being client focused.

We submitted The Plan and it was accepted. And I have now been asked to Chair the Steering Group that will guide the development of that, "national plan, locally delivered". The deadline is October. I report to Simon Stevens.  The group first meets on the 28th but already we are working on outlines and challenges.

I'm both pleased and daunted by this task. So far the system has been unable to implement the Government pledge - so what makes me think I and my third sector colleagues can? I guess it's my strong belief in the power of the third sector and our ability to deliver against the odds, as well as our passion to succeed for our people.

The task is in fact not  dissimilar, if  smaller, than that faced in the 80s when it was determined that all mental health asylums be closed and people cared for in the community. A patchy programme but one everyone now knows was exactly right. I chaired Tooting Bec Hospital (a large asylum in South London) then and I worked to ensure its closure but with a proper community provision in and around Lambeth. We know that institutional care is not the answer and if we put the needs of the citizen first we will work to support them in the community whatever their challenges.

If we do succeed we show the NHS what our sector can achieve.  This is the first time the NHS has undertaken "co- commissioning" with the voluntary sector so it's a challenge for us and for them. Many of the challenges faced by the NHS require the fuller involvement and commissioning of the third sector. This may prove a model for wider use. Central to delivery not peripheral to it.

Jan Tregelles, the determined CEO of Mencap, organised a visit for me and my ACEVO colleague Mark to the home of five people in London where Mencap provide support. What I saw was incredibly positive and made me determined that we will succeed because this is ultimately about better lives for people who have not had the life chances many of us enjoy and who are to open to abuse or neglect. Our sector has the skill to give them a better life and the stronger outcomes that hospitals and places like Winterbourne View have not always given them.

So just as well I haven't got any holidays booked over the next few months!

UPDATE

Well I see that my blog has attracted some attention! Good. This issue needs as much energy behind it as possible. However, just to be very clear, we are at the early stages of scoping the remit of the steering group. We have already contacted user led organisations and will be contacting families and people with learning disabilities today, as we had planned to do all along. It would be quite unthinkable to do otherwise.

Bad food and MPs...

Well done to Michael Gove MP for the new guidelines on food in schools, cutting out fries and sugary drinks. High time too, as obesity among kids soars and the rise in cases of diabetes and pre-diabetes is increasing significantly. And what may you ask is our health service doing about it? 

Well, in hospitals, sweet nothing as they say. Walk into most hospitals and the tempting offers on chocs and coke from vending machines and cafes are all around. Why, Guys hospital even has a McDonalds on the premises. And at Tommies you walk in past an array of retail outlets piled to the gunwales with unhealthy food options. It's time hospitals got on message. I realise they are turning a fast buck on these outlets but I thought they were about improving our health! Could Jeremy Hunt take a leaf out of Michael Gove's book on this? And let's face it. Most elderly people in hospital for a long period emerge malnourished - Age UK has run their excellent campaign against malnutrition in hospitals for almost 10 years now. Hospitals just don't get good food, let alone healthy food. End of rant. 

We had a Social Investment Business reception at the House of Commons this week (more sticky buns on offer there; I said no!). We were introducing some of our investees to MPs and we had a good cross-section of Members from all parties, as well as Ministers and their Shadows. Nick Hurd MP gave a great speech and emphasised the point I had made about how social finance is one of those subjects where you do find cross-party consensus. The Big Society Capital started off as a Labour idea, but was taken up enthusiastically by the Conservatives, and David Cameron is a great advocate of social investment. And Minister for Civil Society Nick Hurd has been a great champion for our sector. He has a lovely approach to the role which combines an oft laconic style with wit and passion for the sector. He even went so far as to describe me as ‘an institution’. Obviously kind comments by him about me simply reinforce my view he is a perceptive chap.

The event was sponsored by Crispin Blunt MP, a former Prisons Minister and a non-exec on my Social Investment Business Board. His comments on a range of issues make great common sense, as I told him, now that he has been freed from the cares of office! But the fun of this event was in meeting the many charities and social enterprises that have taken loans to promote their ambitions. 

SIB has made over £350m worth of social investment to over 1000 organisations. This makes us the UK's largest social investor. I'm chuffed to be their Chair. And in the spirit of keeping fit I can report I spent an hour in the Brixton gym last night. Needed to after that rather splendid dinner at the Cass Business School on Wednesday.

The NHS ignoring the third sector....

Interesting to see 2 recruitment adverts from the NHS in the Sunday Times appointments section this week.

The first was from the NHS Leadership Academy. It is calling for “experienced business leaders" to join the NHS fast track executive programme.  And I suspect in framing this advert they did not think that the charity or social enterprise sector has “business leaders”?

Indeed a news story accompanying this from the DH made the point, that they want people from the private sector. So presumably not the third sector then. And certainly I doubt any leader from our sector reading this will think an application from them is welcome.

The other is from Oxford Health, a foundation trust providing mental and community services. It is looking for non exec directors. It says it “requires an outstanding individual offering substantial senior level expertise gained in the private or public sectors". Note the exclusion of the third sector. So as this is a "requirement" presumably no one from our sector need apply. What sort of message is that Oxford Health?  Especially when they go on to say want “patient safety" experience!

There are 2 problems with this discrimination (direct or indirect it’s hard to say?).

First, it ignores the huge significance of the third sector in delivering services, promoting prevention, acting as patient’s advocates and campaigning. As we need to move resources into community and prevention it is stupid not to want experienced professionals from the third sector in leadership positions.

Second, it ignores the wealth of knowledge and experience of our sector's leaders. We know in ACEVO that many of our members come from significant jobs in the private or public sectors. For example, just recently Jane Collins took up post as CEO of Marie Curie - she was previously CEO of Great Ormond St; the famous children’s hospital.

The head of the British Heart Foundation was previously in charge of a battleship. I could go on...

 

And the leadership of a top charity needs strong “business skills". Many business thinkers believe the sort of leadership skills displayed in our sector are exactly the sort of skills needed in 21st century businesses. It’s particularly true in a health and social care service.

 Many of our top national charities are big business. They employ thousands of staff as well as volunteers, for example the Red Cross employ3000 staff and 30,000 volunteers.  They have to manage difficult political and stakeholder interface work effectively with clients and patients and manage big budgets. They have exactly the leadership experience the NHS needs.

It’s particularly extraordinary that a mental health trust has publicly demonstrated its lack of interest in recruiting to their top board people from exactly the constituency they need to work with. After all, it’s the third sector that now delivers a third of all services in mental health. So I suggest that the trust and the head hunters Veredus look seriously at changing this advert; on the assumption it was not a deliberate attempt to discriminate against anyone from our sector.

And I suggest that the Department of Health similarity look at their recruitment to the NHS Academy. They need the leadership skills of top charity and social enterprise leaders. Its just plain stupid to ignore them. 

Is this symptomatic of the culture of an NHS that, when it thinks about charities and social enterprises, thinks first of volunteers making people cups of tea, or wheeling trolleys around wards rather than a professional service that delivers for patients? 

You might think its just 2 adverts, but this is a sad indication of how little the NHS thinks the third sector matters.