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.

The 'Pickles gag'

That was the way Paul Burstow MP described the news about the DCLG grant condition to prevent the third sector's advocacy role, when he spoke at our health and social care conference today. The Times carried this story front page today.

It’s clear that the idea of banning charities from campaigning, if they get government grants, offends the principle of the independence of the sector. But it is also bad for Government in developing evidence-based policy. Bad laws are made when governments fail to take account of the evidence from the front line of public services - whoever is delivering them. For several centuries charities have brought their lived experience to policy making and campaigned for change. Take smoking, seat belts in cars, sugar and salt in food as just four examples.

Simon Stevens made a similar point in his keynote address to our health conference. The 'creative tension' that our sector brings is very important to them as they develop better services.

Let's hope this is just a Pickles one-off. I'm a fan of Eric so I'm relying on him to see that this is silly idea and drop it. It's a problem we will increasingly face as the election campaign continues and gets more frenetic - the charity sector being seen as a political punchbag. But, if that’s to be the case, then we’ll be robust in our repose. I’ll certainly continue to be so. Speaking truth to power is not just a pretty slogan. It's how we achieve what we do. 

Manchester and Health

The news that the health and social care budgets in Manchester are to be integrated is a massive step forward for better health and well-being there - and a beacon for the rest of the country.

When I wrote the Winterbourne View report I recommended that budgets for health and care for people with learning disabilities must be combined. This move in Manchester will enable better planning and commissioning that ensures community placements,  not placements in institutions. Interestingly, the figures on the use of institutions show that the North uses institutions for people with learning disabilities significantly  more than the rest of the country. Often councils have block contracts with institutions like Calderstones in Lancashire, and it is too easy for them to use those places than make proper provision in the community. And shockingly these cost up to £12,000 a week. Community places are both more cost effective and better care. The move in Manchester and the decision by NHS England to close institutions like Calderstones are welcome.

I had lunch with the pioneering journalist Marie Woolf of the Sunday times this week. She has written many stories on the abuses and problems that confront people with learning disability or autism and told me some shocking stories of abuse in institutions. Some of these come from whistleblowers- the recent report from Sir Robert Francis will hopefully encourage more whistleblowing and help spell the end of institutional care for people with learning disability.

Fascinating to read the reactions to the Manchester announcement. The most surprising was from the Kings Fund which has for years argued how important it was to integrate health and social care, and yet gave a very negative response pouring cold water on a what is an extraordinarily important move to do exactly that. What we now need is to see this followed through for the rest of the country. Starting with London!

The great Bishop Harries, defender of charities’ right to campaign, was on "Thought for the Day" this morning making the very interesting point that this move is very much in line with Catholic social teaching which argues the principle of subsidiarity; where decisions are made at the lowest appropriate level. The Manchester decision is a great example of that. So when you have the blessing of the Church then this has to be a good move!

Charity leaders know from experience on the ground how difficult it is to get effective support for people from the health service and from councils. It is often not remotely joined up, and is beset by arguments over money and actions based on system and process not the individual.

So acevo is going to organise a workshop for our members to hear from the key Manchester leaders in charge of this move to integration. We should give this full support. And we will be talking about it at our National Health and Social Care Conference on Tuesday. This will be the first opportunity to hear from Jeremy Hunt and Andy Burnham on these plans. Indeed the BBC are going to be filming the whole event. Still time to sign up!  You can even come as my guest if you respond to this Blog!

Use comments to register.  Bubb Blog readers most welcome.....

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!

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.

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 ACEVO Health and Social Care Conference

ACEVO’s Health and Social Care Conference on Tuesday was a resounding success, with some really stimulating presentations from Duncan Selbie (CEO of Public Health England), David Behan (CEO of CQC), Sandie Keene (President of ADASS) and Sir Bruce Keogh (Medical Director of NHS England),  as well as some fantastic panel discussions.  The focus of the day was how to deliver the ‘Prevention Revolution’  called for by the ACEVO Prevention Taskforce.

All our speakers were in agreement that health and social care must urgently move towards preventative care that takes place in the community and in people’s own homes, ending the current over-reliance on reactive, high-cost treatment in hospital settings. 

Andy Burnham, Labour’s Shadow Secretary of State for Health, gave the keynote speech and outlined his party’s plans for ‘whole person care,’ which include the merging of health, social and mental health care into a single budget. 

I said that I would make my opening introduction to the keynote speech available on my blog, as I didn’t have time to get through it all, so here it is:

Within 2 years half of all hospitals may be in deficit. Meanwhile over 40% of our population with long term conditions account for 70% of the entire NHS budget. The budget for such conditions continues to grow, as do the number of us living longer.

The overwhelming majority of people with long-term or age-related conditions are treated in hospital. My local clinical commissioning group in Oxfordshire spends around 40% of its budget on the local over-65 population. As many as a third of all older people in hospital beds do not need to be there on medical grounds. There, their condition often deteriorates.

Why do we do this? The evidence suggests that we could spend a smaller proportion on elder care were more elderly people treated in the community. The irony? This precisely is what many elderly people want. And it is those same people who the institutions and processes of the NHS are at present designed to ignore.

In 2011, I was asked by the Government to chair the ‘choice and competition’ strand of the consultation exercise in advance of the Health Bill. This was highly contentious in the health service and highly contentious politically. The conclusion that I and my fellow NHS Future Forum members reached was that competition can provide greater choice for patients - but only in certain circumstances. Our report emphasised that competition must always serve "the interests
of citizens and the choices they wish to make.” For example we argued that the legal provisions in the Localism Act that give citizens a “Right to Challenge" be extended to the health service. Why, we asked, can citizens challenge social care providers but not the health service?  We said that competition must always be bottom up, driven by citizen rights not top down imposed by Government or Monitor. And there have been some perverse decisions made in the name of competition. This policy is clearly not working and we need to move the debate on. A competition framework that believes there is a fair playing field between the private sector and charities is nonsense. The NHS is based on the ethos of public service and the general good. That is what charities also believe. We can all understand why people do not like the notion of private profit in the NHS. But that should not stop our sector being able to expand because we offer the delivery, research, campaigning and advocacy that the NHS needs.

There is little sign that the health service, configured as it is, is currently capable of translating the changes we need; moving resources from acute care into community and prevention and this closing hospitals. Day by day, the barriers to alternative approaches have become more insuperable. The Government argued that the new, localised clinical commissioning groups would be able to engage closely with their local communities to commission better-targeted, better-designed services. Yet their implementation of much new localised commissioning has seen less money spent in the community with more services moving back into hospitals to protect their budgets. There are specific examples of perverse practice. Consider: much chemotherapy and end of life care can be provided at home. However, home-based support is often not commissioned because it undermines the hospital providing this service.

A radical change is needed: a new vision for NHS commissioning and a new set of incentives to take on vested interests within the NHS.

Within the charity and social enterprise sector there exists a huge range of providers developing innovative approaches to managing long-term conditions that reduce the demand on hospitals. When a patient's diabetes has deteriorated their feet are chopped off. The conservation trust charity runs a “green gym" which takes referrals from doctors of unemployed people with type 2 diabetes and gets them out in parks and mediates their condition. Charities like the Red Cross and RVS can work on elderly wards and in A&E to support older people getting home and getting the care they need their , as they are already doing in some hospitals now.

Citizens should always have the opportunity to choose such approaches over hospital-based provision. I would argue that 'citizen’s rights' and their “right to challenge” must now be entrenched in legislation. With such rights in place, citizens' choice would drive reform, rather government-imposed competition policies. Such rights are already part of the Government's rhetoric but after a promising start they have fallen by the wayside. The regulator Monitor has still not produced its long-awaited Choice and Competition Framework, which is intended to help commissioners and providers understand where change may deliver improved outcomes for patients.  The Government have a policy to encourage the "right to provide ", encouraging staff in the NHS to spin out, yet this has not been pursued.

A good example of the problem we now have is the fact that most people, given the choice, would choose to die at home, supported and cared for medically and in a caring environment. Yet most die in a hospital bed. So Andy Burnham's proposal to entrench the right to choice at end of life is an excellent example of this rights based approach. Entrenching rights in the NHS Constitution will give confidence that the NHS does truly belong to the people.

Change will not only involve entrenching social rights; it will also involve realigning the NHS' perverse incentives. For example,  when acute hospitals are paid according to volume of activity, they have no incentive to reduce admissions - quite the reverse. As ACEVO articulated in a 2013 report entitled The Prevention Revolution, there is an urgent need to develop outcomes-based funding schemes that will reward reductions in admissions and incentivise the growth of preventative care and support.

The key to delivering on these aims is robust political leadership. There has been criticism that   the rhetoric on competition has become muted, but actually that is no bad thing. Competition is a means to a better NHS, not an end in itself, and any Government must focus on the key strategic tasks: tackling long term conditions, prevention and community solutions for the elderly. Rather than talk about competition, we need our politicians of all parties to provide the cultural and systemic leadership for better commissioning to move resources from hospitals in order to increase the diversity of providers and approaches available to our citizens.

Andy Burnham has been brave in arguing for radical changes to provide integrated care. The Oldham report is marking out a radical path for change. This is essential.

Successive governments have failed to understand commissioning, and have failed create a system in which a diversity of health providers can flourish. The impact on our hospitals continues to be
grave. A  Government post 2015 has a chance to change this; and the politician that leads on this agenda will be the key to saving our NHS.

Over to you Andy!

The Top 500

A miserable Sunday as I trudged through Brockwell Park with the drenched Hound. But it was much enlivened by the Sunday Times! They have published a list of the Top 500 key influencers in Britain, and I appear in this list as one of the 20 most influential people in health. Other sectors featured include politics, broadcasting, finance, sport and the like.

As it says in the ST blurb “It's not about how much money you have, or who shouts loudest." Just as well, at least re. the money bit. Debretts helped compile the list with panels of judges who were tasked with finding the top 500 people who "demonstrate outstanding qualities of influence, achievement and inspiration".

It was neat for me that my brother Nick was the Panel Chair for retail so, as far as I could see, we were the only 2 brothers to appear on the list.

I know I have just written a piece with that bold headline about leaving your ego at the door, but I have to admit to being dead chuffed about this. It does highlight the work that ACEVO and I have been pioneering in health and social care, carrying the baton for reform and change and new ways to deliver better services for citizens. It’s a boost to us as we continue to push for a bigger role for charities and social enterprises in delivery and in advocacy. The health sector is such a closed shop of those who work within the NHS that I was delighted to see recognition for our third sector.

And nice to note a number of others from the sector like ACEVO members Ciaran Devane (Macmillan Cancer Support) and Gillian Guy (Citizens Advice), though the charity section of the list was light on charity leaders. The 20 top influencers in the charity section were dominated by philanthropists like Branson, Elton John and Lord Sainsbury. I like to think I was holding the umbrella for our professional sector too!

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....