The NHS must not ignore charities' contribution

Tribalism is a besetting, if not unique, sin of the world of care. Health and social care; clinicians and managers; acute and primary care; public, private and voluntary sectors – we spend much energy and effort defending historic interests rather than celebrating the contribution that differences in tradition, knowledge and perspective can bring to the common objective of improving patient care.

It’s been a good time to reflect on this as I have moved from being the leader of a major patient organisation (also a significant provider of NHS services) to become chief executive of a foundation trust. It has reinforced my belief that the NHS and the voluntary sector must find ways of working more effectively together if healthcare, free at the point of delivery, is to remain sustainable in this country.

‘Few voluntary sector organisations are big enough to be able to deliver whole system change’

The voluntary sector itself carries out an enormous diversity of activity. The largest health charity has an annual income of over £500 million but the vast majority, especially the newer generation of service user-run organisations, are very small. That diversity is one of the strengths of the sector. Mergers do happen but the voluntary sector does not have the obsession with structural solutions that so characterises the NHS. Complexity and fragmentation can be frustrating things to work with but they also reflect where the creative energy of the voluntary sector lies.

Closer working

So what are the cases for closer working and what are the obstacles?

The heart of the issue relates to meeting the needs of people with long term conditions with the most complex needs – the 10 per cent of people using services who consume 40 per cent of resources, and for whom the NHS is often poorly equipped to provide the kind of holistic response required. 

Patient organisations bring a number of strengths in this area. They are, by definition, close to individuals using services and their families and bring a powerful insight into where the system is failing to meet their needs.

‘Many NHS organisations were founded as voluntary organisations and still have some of that DNA’

As service providers they can be innovative, fleet of foot and – most importantly – unconstrained by the boundaries of clinical practice and thought. The development of the better care fund offers significant opportunities to exploit this unique insight and capability and it will be crucial that the sector is around the table in the discussions about how these resources are used.

But in my experience patient organisations also need the NHS. Few voluntary sector organisations are big enough to be able to deliver whole system change. Working in partnership with the NHS offers the opportunity to make patient organisation’s ambitions to transform models of care a reality and at scale. The NHS can also offer access to systems of clinical support and governance that most patient organisations will not have but that are undoubtedly necessary when working with those with the most complex needs.

Positive collaboration

There are many advantages to the two sectors working together and in many places this is well recognised and positive collaboration is taking place. Mental health, with the legacy of the closure of the long stay hospitals, which gave many voluntary organisations their first significant taste of service provision, is particularly well developed and there are many other areas.

But there are obstacles. While there are many leaders and practitioners in the NHS trying to forge positive relationships, there are too many others who look down on the voluntary sector, have insufficient understanding of it or have failed to give proper thought to the role it could play.

‘A final dimension of the debate is whether the NHS should move closer to the voluntary sector in models of governance and operation’

At times the voluntary sector can be too hostile; after all, many patient organisations were formed in response to failings in care, or they can be too preoccupied with influencing the political or media debate about healthcare.

Sadly, economics also get in the way. The voluntary sector can be seen as the dispensable element when NHS organisations are under significant pressure to balance their own books. Good partnership needs long term commitment and the willingness by larger NHS partners, whether commissioners or providers, to treat voluntary sector partners fairly and with an understanding of their different financial circumstances.

This won’t be easy as the NHS faces unprecedented financial challenges, but it would be a shame if the consequence of that was a culture of retrenchment that saw the voluntary sector, much of which has already suffered badly as a result of the much deeper spending cuts in local government, squeezed out of the areas where it might make the biggest difference.

Social enterprise

A final dimension of the debate is whether the NHS should move closer to the voluntary sector in models of governance and operation. Many NHS organisations, my own included, were founded as voluntary organisations and still have some of that DNA.

The foundation trust model was a step in that direction but my sense is that models of membership do not yet capture the spirit of bottom-up ownership that is characteristic of charities. We have also seen the shift of some community services to staff-owned social enterprises and there is enthusiasm in some quarters to see this go further. 

Such a trend could be built on giving organisations greater freedom to set their own purpose, freeing them up from some of the day to day control of the managed market and giving local stakeholders, including service users and staff, a greater say in their governance. As well as social enterprises, charitable status could be another way forward.

We know we live in interesting times. The NHS cannot afford to ignore the contribution the voluntary sector can make to unlocking better care for the most vulnerable patients. Creating the environment in which partnerships can flourish should be a priority for NHS commissioners and providers alike.

Paul Jenkins is chief executive of Tavistock and Portman Foundation Trust