Ave et Vale

So it’s hail Brooks Newmark and farewell Nick Hurd.

I think the fact there has been such a strong response from sector leaders paying tribute to Nick says a lot about how well he has done his job. He cared about the health of our sector, and avoided the political extremes inhabited by some in Parliament on both sides who want to relegate us to the margins.

I always enjoyed talking to Nick. I'm sure he always thoroughly enjoyed my helpful texts of advice and occasional expletives about "developments". He was a strong supporter of social finance and did much to promote it. He should also be remembered for his acts of omission. He refused to get sucked into the nonsense of CEO pay and refused to attack charity campaigning. He lived by his mantra of "do no harm".

So his final advice to me about Brooks (he'll forgive me for repeating his text I'm sure) was "Good guy. Bright. A good listener. Nice and genuine. Business background. Think you will get on despite everything I tell him about you!"

And I also had a great intro to Brooks from Crispin Blunt MP who is on my SIB Board and who also gave him a strong write up.

He said he was, “imaginative, open minded and convinced by argument. Not a zealot".

Finally, though he is relatively unknown to us at present my Deputy, Ash Singh, knows him and some of his team and he likewise tells me good things about him. Harvard and Oxford. Involvement with various charities, including one he set up.  Work in Rwanda. Treasury whip. This bodes very well.

And I speak to him today. I shall remind him of some of his illustrious predecessors. Indeed one Party Leader began his ministerial career as the first third sector Minister, so the auguries may be good for us all hearing much more about Brooks. 

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!

Yes we can!

So the Lords have come up trumps! We won the amendment to remove constituency limits in the Lobbying Bill. Acevo welcomed the Government changes to the Bill but we said there were 2 remaining obstacles; staff costs (we won that one last week) and constituency limits.

It’s actually quite unusual to win an amendment at the third reading stage of a Bill. As reported by Politics Home,

"16:55 Peers vote 248-222 on #LobbyingBill 3rd Reading (tad unusual) amendt re: NGO/charity campaigning activity."

It reflects the strength of feeling across parties on this measure and the power of the cross-sector Commission on Civil Society that ACEVO helped form.

So the pressure is now on government not to try and overturn these changes in the Commons. That would be unwise and I urge them to accept the strength of feeling on these 2 issues. They are both major changes to the previous electoral regime and represent a huge barrier to charities playing their full role in the democratic process; engaging with the top national debates and ensuring challenge and scrutiny for our putative legislators. This lobbying bill has done significant damage to our international reputation and the standing of our charity sector. Good sense would point to the Government accepting this cross-party consensus. 

The wider message is one I'm going to talk about tonight at our ACEVO AGM. We faced a range of challenges last year. But we go into 2014 in an optimistic frame of mind. Our message about how democracy relies on a vibrant civil society and how our public services need more third sector delivery is gaining traction.

I got the good news whilst having dinner in Westminster with a fundraiser for social finance. I raised a glass to our wise and sensible Lords, and to the skill and sagacity of The Lord Harries of Pentagarth who has so expertly led the Civil Society Commission.

I’ll post my AGM speech later. Bet you can't wait! Which reminds me that Twitter has been alive with comments on my recent leadership article in the Guardian. Headlined "leave your ego at the door" it has divided those who got the irony and those who were outraged. It certainly got a titter round the office - though I can't imagine why? And proves the point that a great headline gets your articles read!

Lobbying Bill; breaking news!

Today the government will table significant amendments to their ill thought through Lobbying bill. ACEVO and key Commission members had a helpful meeting yesterday to be told of the concessions. Good.

ACEVO resolved to help set up the Commission on Civil Society with more than a hundred civil society organisations because the charity sector works best when we work together. We now have begun to see the fruits of that engagement. Greg Clark MP (leading on Bill) and Nick Hurd MP have done a great job of listening to the Commission’s concerns.

So credit where it is due. Too often the sector can seem grudging when we achieve change. Or we turn a victory into defeat. So ACEVO is happy to acknowledge the major shift since this Bill was introduced.

We recognise that the government has listened and we welcome the amendments proposed. I thank Lord Harries of the Commission and its members (who include our ACEVO Chair, Lesley-Anne Alexander) for their excellent work in the last few months on the sector’s behalf.

Clearly, there remain outstanding issues with the bill. And we will continue to push for change. We would still like the government to consider removing staff costs from the bill’s restrictions. We must continue to make the argument against the proposed £10,000 cap on spending in one constituency by a charity or campaign group. But we believe that the commission has established a positive dialogue with government and we look forward to discussing these matters going forward.

 But our campaigners believe defeat is still likely in the House of Lords next week unless there are further concessions on the a2 key issues we have raised.

It all proves again just how much clout the Lords can wield with sufficient cross-party backing. Yesterday saw the 84th Government defeat in the Lords since 2010 (on the ‘criminalise annoyance’ plan), which given the Coalition’s increase in peers is all the more remarkable.

Our revising chamber is doing its work. And our charity world has risen to the challenge posed to our right to speak truth to power; another example of the danger that awaits any Government that attacks the charity sector. 

Dementia...

David Cameron (and Jeremy Hunt) have shown real leadership on dementia, putting it high on the political agenda at yesterday's G8 summit at Lancaster House. Doubling funding to research is a start but charities want much more action. With 400m people worldwide (and 800,000 in the UK) affected by one of the tragic consequences of ageing populations, progress is urgently needed.

Jeremy Hughes, ACEVO member and CEO of Alzheimer's UK set out a powerful argument in the Guardian. It’s worth reading. (http://www.theguardian.com/society/2013/dec/11/dementia-disease-care-g8-action-plan )

I liked the comment from Hunt on Daybreak yesterday,

“The year I was elected to Parliament – 2005 – Tony Blair...did an amazing thing because he had a G8 summit on HIV aids and he got the world’s leaders to agree that everyone who needed an anti-retroviral drugs should be able to get them by 2012 and he basically achieved that and we really have turned the corner on HIV aids.

“The job isn’t done, but if you can get countries together and you can get collective commitment and dementia is the big disease that no one likes to talk about; everyone’s worried about it; everyone’s scared about it; one in three people are going to get it and what we’re really trying to do is normalise it and say ‘this is sadly going to be a big part of our lives but let’s talk about it, let’s fight it and let’s deal with it – let’s not try and sweep it under the carpet and get more and more worried about it.”

The decision to give dementia a priority billing at the G8 is a real breakthrough. But much remains to be done. But let’s just remember as we praise the politicians, this is yet another example of the superb work that our charities do in their advocacy and campaigning role. 

And that vital role was the backdrop to our meeting in the Lords yesterday when I joined the members of the Commission on civil society who were meeting with the Government to discuss the recommendations for essential changes to the lobbying bill. It was goof to see Greg Clarke MP who is the lead Minister on this. Greg is a star act and I know him well from his time as shadow third sector Minister. He gets the sector. He engages with us and was a strong force behind the rights for the sector that were entrenched in the Localism Bill. He engaged with us and although we were not told of any changes I get the feeling we will get progress. How far that goes to meeting the objectives of the Commission remains to be seen.

Ethical Investment

Time to pull our socks up.  The Panorama programme this evening, which in many aspects was rather thin, has nevertheless highlighted an issue the sector needs to grapple with.

When organisations have endowments (like many Foundations) or big reserves they must invest these both for the good of their beneficiaries, and ethically, for the wider good.

Charity Commission advice used to be too blunt and unhelpful: that trustees should only invest for the maximum return. Now their advice (CC 14 to be precise) is more nuanced and encourages 'mission driven' investment. Not enough charities are taking notice of this new more flexible approach. They need to.

Because, quite simply, it doesn’t seem right that charities invest in tobacco or arms companies.

We need more people in the sector looking seriously at ethically managed funds. The argument is that they don't give as good a return. But you might be surprised to learn the size and strength of the ethical investment industry. There is around $34 trillion under management in funds that subscribe to the UN’s Principles for Responsible Investment. That’s about a third of all money under managed funds anywhere in the world. So there’s plenty of choice and we expect that choice to grow.

Impact investment funds, though in their infancy now, may also become an investment option of choice for charities further down the line. Why shouldn't our sector be looking at how we can expand opportunities for social finance; for loans to develop and grow our sector

So, I'm giving our sector and those associated with it a call to action. I have two messages.

One is to the fund managers themselves. Why are you not alerting your charities to ethical problems with proposed investments?  Before you put our money into an investment you think raises issues then consult the charity trustees responsible. Fund management companies need to get their act together and understand the ethics of their investment decisions.

Secondly, to charities. Charities traditionally delegate their investment decisions to a sub committee and they in turn appoint fund managers. So many trustees simply do not know where their investments go. Time for the full board to review investment policy. The full board should review the Charity Commission advice and question whether they are investing in line with their mission and with their own ethos.

The sector needs to do more to engage with ethical investment principles. Ensuring that their investments conform to the particular and the wider good will help ensure that our sector remains true to our collective mission in all aspects of our work.

This is our wake up call.

Doing radio on our Plan for A+E.

I hate early mornings. So reluctantly I was up to do an interview at 7am with BBC Radio 5 Live. But a good slot to talk about our plans to help relieve pressure on A+E departments this winter. I'm seeing Jeremy Hunt this afternoon to talk about it.

And then off to Millbank to do all the local radio stations. Stuck in a small room - with my headphones on - I was busy for a couple of hours chatting away to radio York, Essex. Lincs etc etc. Good to know all the hundreds of regional ACEVO members would be hearing me as they drive about their business!

So what is it we are proposing?  In October I was asked by No. 10 what we could do to help reduce pressures on A+E this winter. We know that much of the increased demand in a cold snap is from more elderly people. And we know that many elderly people end up in hospital beds unnecessarily. This winter’s crisis is likely to be especially bad, as seen by the PM’s decision to get personally involved. It’s clear that charities could be an important way to cope with demand and improve the quality of care in A+E.

So I met with the heads of our 3 largest national charities dealing with these issues; RVS, the Red Cross and Age UK. In a week we had produced and sent off a plan to No. 10 and DH.

It’s worth reproducing that here. This is the short paper I sent and we will discuss later today with Jeremy Hunt. I'm hopeful we will get traction. It’s sensible and affordable, and in fact it will save money longer term.

Here it is.

Proposed crisis programme from charities to support A&E services this winter.

Issue

Every winter, tens of thousands of older people die or become seriously ill due to the cold placing huge strain on A&E. Age UK has calculated that the annual cost to the NHS in England of cold homes is approximately £1.36 billion - not including the large associated costs of social care.

Plan

ACEVO has identified three of its members that have the scale and experience to be able to implement a crisis support service to work with hospitals and GPs to identify and support targeted frail elderly, reduce A&E attendance, reduce admissions and secure early discharge.  Working with AGE UK, Royal Voluntary Service (RVS) and the British Red Cross, these crisis services could be provided this winter to the target 53 hospitals if decisions are made quickly. 

1. Reducing the amount of time that people spend at A&E 

• As part of a triage team who try and re-route people away from A&E with treatment being supported at home or via primary care.   
• Providing an ambulance support model whereby when an older person calls an ambulance, Age UK attends too with the effect of supporting people who don’t need to go to A&E.  Age UK has experience of offering this service. 
• Provision of A&E assisted discharge services for vulnerable people where there is no clinical need for them to remain in hospital but there is concern that there is no support at home.  The Red Cross currently has support at home schemes in 162 locations in the UK.  Age UK operates a similar service. 
• ‘Home from Hospital’.  A package of care provided by Age UK for older people recently discharged from hospital which prevents re-attendance and readmission to A&E.  Support involves linking person to support services and acting as GP liaison. 
• Supporting early discharge of patients from hospital .Patients who are poorly but stable (commonly frail elderly people with LTCs) remain under the formal care of the hospital consultant but cared for at home. At home they receive extra nurse-led support for several days and help such as washing and dressing. (RVS has experience delivering this  support; readmission rates since its introduction at the Royal Free have fallen from about 20% to 3.5%.)
  
  

2. Providing support on A&E and elderly wards

• Managing the volunteers in the hospital as a total group and expanding their role to work on-ward alongside the medical, nursing and staff teams to improve patient outcomes.  Help with people’s hydration and feeding as well as providing company and interactions to improve recovery time.

AGE UK, RVS and BRC all providing services in this area.  

3. Providing support to GPs with most vulnerable patients

• Working with local doctors and CCGs to catch those older people who are habitual attenders at A&E, consumers of blue-light services – generally because of loneliness and isolation.
• A home health check – 100 local Age UKs delivering a check to 5,000 of the most vulnerable older people’s homes (identified by GPs). To ensure they are safe and ready for winter (e.g. no trips/falls hazards, energy efficiency measures in place).  
• 1m leaflets via local Age UK and GP surgeries on “Stay well Choose well” supported by Age UK telephone line.  

Crisis package: Management of  relationships, plan and coordinate the work to be undertaken by each of the charities and to provide a formal evaluation of this crisis intervention for future planning.   ACEVO is in a prime position to coordinate these activities and would be keen to do so.