Health and care matters

ACEVO has a strong membership in charites and social enterprises in social care, health and disability, so we hold an annual national conference to debate issues of concern and hear from key people in the sector.

We had a bumper crop this year. All the main parties set out their stalls. Paul Burstow MP, Jeremy Hunt MP and Andy Burnham MP spoke, but perhaps the most interesting session was when Simon Stevens (head of NHS England) set out some of the issues he faces leading NHS England, and asked for our views.

Inevitably, since the emergence of the disgraceful new grant conditions to be imposed by DCLG to snuff out advocacy in our sector (that morning's Times) there were questions on this. Paul Burstow from the Lib Dems was quick to denounce what he called "the Pickles gag" and Jeremy Hunt, though he would not comment directly on the Pickles move, was clear about charities' right to campaign.

We launched our Alliance Contracting report at the conference. There's more details here.

Alliance Contracting is a new way to promote more collaboration in health and care settings - a post-competition approach that builds on more collaborative approaches and consortia-building. Current government procurement is so often costly and overly bureaucratic. It has favoured private sector bodies too much because we don't operate on a fair playing field. Andy Burnham was particularly supportive of this approach.

Indeed his policies of entrenched rights for the third sector in delivering services, and 5 to 20 year contracts were music to the ears of our members. In fact, as I observed to David Brindle of the Guardian, I think this is the most radical approach to the sector of any politician in any party. Much to be supported and perhaps a benchmark to encourage others to follow. We shall pursue at out forthcoming third sector hustings on 24 March - everyone very welcome!

And let me leave you with some photos of our speakers yesterday.

Winterbourne: closures will happen

One of the perils of having a weekend away is getting a cold. And as any CEO knows, taking any time off for a cold is a no-no. So this was perhaps not the best background for appearing before the Public Accounts Committee (PAC) and the formidable but brilliant Margaret Hodge.

The PAC were taking evidence on the recent National Audit Office report on Winterbourne View and the care of people with learning disabilities. Basically, the report gave more detail about the failures of the health system to provide proper care for people with learning disabilities.

Its evidence very much backed up my own report last November, “Winterbourne view – time for change”, so I was pleased to be able to hammer home messages from my report.

I was keen to be fair and constructive in my analysis, and where I had criticisms to couch them positively. There is no point in not being constructive at this point. And I wanted to be fair in the sense that, as I told the PAC, I have agreed to recall my steering group to review progress in 6 months and then in a year. Woe betide them if they are not making progress on what I have told them needs to be done.

As I said, I think the change of leadership in NHS England is now driving institutional change.

I was critical was on the failure of NHS England, in their response to my report, to confront the need for closures. They retreated behind euphemisms like ‘reconfiguration’ and ‘reshaping’. This simply isn’t good enough. Large-scale institutions have to close. Institutional care is not the right way to look after people with learning disabilities. My report could not have been clearer. I recommended they bring forward a timetable for the closure of inappropriate institutions, but their response did not address this. Indeed it was thoroughly mealy-mouthed about it.

So obviously I laboured this point hard in my evidence session to the PAC.

I was therefore delighted when, in response to grilling by the MPs on the PAC, the CEO of NHS England Simon Stevens said that he wanted to see closures – and he did use the ‘c word’ – and that they will indeed provide a timetable for closures within 6 months. He made a very telling point drawing from his experience in Tyneside, working in mental health, where they closed the old asylums but left open the same style institutions for people with learning disabilities.

This new announcement is significant progress. It signals to the system that things must change. That the  ‘revolving door’, whereby people are discharged into community care and find the beds filled up when they leave, will end. All those lazy commissioners who have block contracts and refuse to properly monitor the people in their care will find they now have to look for community alternatives.

This demonstrates real leadership by Simon Stevens. He should be congratulated for taking a bold step and signalling to the system that the end is nigh for institutional care for people with learning disabilities. Of course it will take time. Community facilities must be developed. But the third sector is there – ready and primed to provide that facility. We now need to be engaged, to scale up our work, so that the institutions can close.

So a really positive outcome to the hearings. I spoke to my old friend Margaret Hodge afterwards and she too was pleased at how positive the hearing had been and a good outcome. She is going to review progress in 18 months so there will be a continuous external review of what the system is doing. This will keep them to the mark.

One of the problems is that there a range of players who need to coordinate actions. For example pooling budgets. I don’t believe a simple call for them will work. I told the PAC the Government should use their powers in the Care Act to mandate pooled budgets. It means the Secretary of State for Health can enforce pooled budgets between local councils and health CCGs. Knowing councils like I do, one-third will willingly pool budgets, one-third will decide it’s not a priority, and one-third will actively resist because it’s cheaper for them to have the health service paying the cost of an institution rather than them supporting people properly in the community. Change will come, but we still need pressure at every level both inside and outside government.

Aaronovitch, Leeds and Winterbourne

Another great ACEVO leadership lunch yesterday, this time with Dave Aaronovitch – the well known broadcaster, journalist and Chair of Index on Censorship. I say ‘Dave’ – as I knew him when he was one. But as he said when he got to 28 it became David so he always knows if someone calls him Dave it’s a very old acquaintance. As I said to him, the same applies to me. Only very old friends call me ‘Steve’ (‘Tony calls me Steve’ as a famous Guardian profile of me headlined).

But I digress. We had a fascinating discussion on the state of the electorate and likely outcomes in May. As he had said in his Times opinion article that morning, pace Alice in Wonderland, ‘none shall have prizes’ next May. And perhaps the parties don’t even want to win. Very interesting also to hear from Peter Wanless, CEO of the NSPCC and author of the recent inquiry into historic child abuse records at the Home Office. He had been on the BBC the day before having to contradict the PM who had said his report showed there was no cover up. ‘He's wrong’ he said trenchantly. Good for Peter – a fine example of a third sector leader speaking truth to power.

Earlier in the week I was at the Leeds Jewish Welfare Board for an ACEVO regional forum; a chance for our Chief Executives to get together to network and share. As is so often the case, thoughts were much around problems on governance and money. Interesting to speak to Liz Bradbury who runs a superb outfit that supports young and old with practical companionship and a raft of services, as well as running a service for people with learning disabilities. We had a chat about my recent work on the Winterbourne report. Indeed another member there talked to me about how they are setting up a new community facility, with social finance support, to enable people to move out of hospital and back into the community.

The report of my steering group on Winterbourne is now finished. Our last meeting has taken place, and the report is off to the printers. It will be launched later in the month. We will have to wait to see the recommendations published  and how they are then received. And then the real work begins in implementing what we say.

I get a strong sense of consensus around what we are saying but we will see. And after all a report is only as good as what people do with it. After 3 years of failure to deliver on the pledge to move people from inpatient institutions there is cynicism around whether there will be action. But I’m optimistic. From what I have heard from all those who have taken part and been involved there is a strong sense that we can now move forward on an action plan for change. We shall see.

But before we get to that launch its the ACEVO Annual Dinner and Annual Conference next week. We will have a rather splendid document to launch.... but I'm not saying on what. And our guest speaker will be old friend Eric Pickles, the Secretary of State for Communities of Government. And we are overflowing with guests like Francis Maude MP, Simon Stevens, Will Hutton, Lady Smith, Lord Wood, and our Minister Rob Wilson MP. But the stars will of course be the charity and social enterprise CEOs!

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. 

Winterbourne View, progress

A recent article by my old friend David Brindle in the Guardian highlighted the problem we face in moving people with learning disabilities out of hospital into the community and reflects the background of the work we are doing on a commissioning framework in our NHS England steering group.

The problem we need to tackle is that more people with learning disabilities are being placed in hospitals like the one at the centre of the Winterbourne View scandal than are being moved out, despite a brave government commitment to move all people out of inappropriate inpatient facilities. Latest official figures released four weeks ago show that in the three months to the end of June, 358 people were admitted to so-called assessment and treatment units in England. Only 261 were discharged.

A subsequent review by the Government following the scandal concluded that personalised care and support in appropriate community settings is vital. There is a strong consensus around that aim. But so far the transfer programme was supposed to have either moved people out of the units by 1 June or given them a firm date for discharge. So progress is painfully slow. However much work has gone on and since taking this area of work on, NHS England has put in place urgent actions to move towards securing the goals on transfer.  I believe we have an opportunity now to make real progress and secure the community support for people with learning disabilities that they and families want. The current system places too much of the power of decision out of the hands of people with learning disabilities and their families and we need to devise a system that shifts that power from the state to the citizen. That aim must underpin our work in devising a new national framework.

The latest figures, collected by NHS England, show that the number of people given a date for transfer did double over the three-month period to 577. However worryingly, in almost four in 10 of these cases, the local councils concerned did not know that the individuals would be returning to their home communities.

In 50% of all 2,600 cases – which include 147 children – councils had no idea that they would need to help make provision for people returning from Assessment and Treatment units.  Jan Tregelles, the CEO of Mencap is quoted in David's article: "We know people with a learning disability need joined-up local health and social care support. This is clearly not happening. When this is not in place, people are more likely to end up right back in the very units they are being moved from."

NHS England has recognised this and with the steering group I have been asked to chair we are looking at how a national framework for commissioning and social finance could enable the build-up of community support. We are reviewing the work that has already gone on so we can build on that. The aim is "personalised care and support in appropriate community settings " and a shift to a system that emphasises citizen rights in the care system. Our last steering group meeting looked at an initial paper from Bob Ricketts, someone I regard as one of the country's top experts on commissioning which posed questions we need to consider in developing our recommendations on commissioning. We also looked at issues facing a large scale move to community support in the training and development of the workforce. And shortly an expert reference group on social finance will meet to examine how to fund community support. And as we committed, we will be publishing the minutes and papers of the meeting from last week on the NHS England website.

But this work is one part of the much wider ongoing system change that is needed. If this is to work in practice, there needs to be an ongoing engagement and dialogue with the people with learning disabilities, and their families and carers. Without that, this simply will not work.

Oh my heart!

A fascinating few hours with the CEO of the British Heart Foundation on Monday, though it did make me think about whether I'm getting enough exercise (as he gently reminded me). I took a lovely leaflet from reception, “put your heart into walking" which is worth getting. And as I mentioned I do a lot of walking with the Hound.

I met for lunch with Simon Gillespie who has been a longstanding and valued member of ACEVO for many years (he was previously at the MS Society). This is one of the country’s biggest charities. Over 3000 staff and turnover above 200 million. It plays a vital role in the research that goes on into discovering the causes of heart problems and working on cures. Much of the advances in heart research has turned strokes and heart attacks into a long term condition as opposed to what carried you off into the next world is down to this wonderful charity. As I remarked to Simon, too often the NHS claims all this research as its own. In fact a third of all medical research is carried out or funded by charity.

They have great offices in Mornington Crescent, ironically in an old cigarette factory (a glorious Art Deco building). And as they have a big staff group over 2 massive floors they have their own cafe and outside balconies looking out over North London to the glories of Hampstead and Primrose Hill (but couldn't see Ed Miliband's house)! So lunch was at his office which is a change as most of my members don't have such a facility!

Simon has been in post less than 2 years but has been reviewing and revising their strategy, recently appointing new top directors. As the country understands better the importance of prevention and the care of people with long term conditions the work of charities like BHF become more important. There is also crucial work to do in how to reorganise the NHS to provide top quality care hospitals.  The reorganisation of London stroke services which moved to treating heart conditions in just 8 hospitals and not all 30+ London A+E showed the importance of rationalising cardiac services across the country. The idea that you need to be treated in your nearest A+E as opposed to the best centre for your condition is one of those myths we need to bust. And we need fewer hospitals and more resources in community and prevention.

And on health generally worth mentioning that all our Winterbourne deliberations are up on the NHS. England website; terms of reference, Membership and first meeting notes.  We agreed that we would make all our discussions accessible. So see them here.

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.

Mental Health Matters

Mental health problems touch most families in our country at some time. It has certainly touched mine as I have spoken about at a MIND conference. Our attitudes to mental health have been changing - but more remains to be done - so I was glad to be able to take part in a discussion this morning with Nick Clegg MP and Norman Lamb MP (the care minister) about the Government's action plan; "Closing the Gap; priorities for essential change in mental health".

This has 25 top action points to try to achieve a change to ensure equality between mental and physical health.

Nick Clegg , fresh from having to talk about Lord Rennard rather than the mental health action plan on the Today programme,  made the point that it's still difficult to discuss mental health conditions. He paid tribute to how far the mental health charities have been able to change attitudes by their campaigning. So the charity campaign "Time to change" is crucial to an attitude and culture change. "Time to bring mental health out of the shadows," he said. Absolutely right. 

I raised the issue of how people with mental health problems interface with the State in our welfare system. That system has got so much worse, and this is not just about the behaviour of ATOS. The tighter and more punitive aspects of the system work against people with mental health problems who find it difficult to get into work, or keep a job down. The reality of employer attitudes to staff with mental health often means anyone being honest about their condition will face discrimination. The welfare reform changes have impacted seriously on claimants who have a serious condition. Attitudes at job centres and in ATOS etc. have hardened, and there is not enough understanding of why someone with a mental health condition may not have attended a work interview or finds it almost impossible to get a job interview at all. They are not "shirkers", yet that is how they get treated.

Norman Lamb spoke about the underlying need to change attitudes. There is an institutional bias in the NHS system, as elsewhere, against mental health. Mental health is a top priority for NHS England but the institutional bias to acute services will make this a challenge for them.

2 decades ago I chaired Tooting Bec Hospital - one of the Victorian mental asylums. I was Chair when we closed that hospital and moved resources into the community. Largely successful, though many battles had to be fought with the consultants at St Thomas' hospital who had other plans for the money!

The closure marked a changing attitude to those with mental health problems; not locked away from sight but supported in the community. Brixton has one of the highest rates of mental health problems in any community across the country, and I know first hand of the problems as my partner works in mental health at the sharp end. 

Time to talk about mental health Clegg said! Which would have been good this morning but one of the media lot had to raise Rennard - she got roundly booed. Rightly so. It is a sad reflection that on the day Clegg launched this important action plan he gets confronted by a media obsessed with what is little more than an internal party matter for the Lib Dems.

Alastair Campbell, yes that one, who was there and who has bravely spoken about his own battle with depression,  pointed out that it's good that Clegg talks about mental health - but to his knowledge neither Cameron nor Hunt have ever made a major speech on mental health ! A rather good point....