Voluntary sector turns up the volume on disability services

Leading charities have formed a consortium with the aim of providing disability aids across the country.Could the move herald a 'takeover'by the voluntary sector? Alison Moore examines how the deal could work - and why the sector is in need of radical action

Two weeks ago, the NHS and the voluntary sector signed a strategic agreement pledging to strengthen partnership working. Its warm words called for a joined-up approach and stressed the importance of improving stakeholder involvement and consultation. It had all the hallmarks of a Department of Health paper exercise.

But the sector - which has been crying out for better links with state services for several years - appears poised for action.

HSJ has learned that three leading British charities have formed a consortium that hopes to become a key player in helping people with disabilities.

If the British Red Cross, the Royal National Institute for the Blind and the Royal National Institute for the Deaf get their way, they will be providing disability aids across the country.

Negotiations over the deal could represent the first test of whether the agreement will result in practical and radical changes to the way services are provided.

These will not be before time - disability services have been heavily criticised by the Audit Commission twice in the last four years.

The three charities are unwilling to talk about the details of their plans, but the RNID confirmed that the trio were 'working on proposals to modernise the provision of community equipment by health or social services departments or in the workplace'.

And NHS Confederation policy director Nigel Edwards believes such a move could be just the start of an expanded role for the voluntary sector in providing services currently run by the state.

He believes the provision of disability services could be taken over by voluntary services, 'lock, stock and barrel'.

'It is feasible, ' he says. 'I cannot see any particular reason why not.'

The charities are arguing that their close contact with users and expertise makes them ideally placed to pioneer a new approach.

The RNID has already played a major role in modernising hearing aid services within the NHS (see box) and this could be a template for future involvement.

Audit Commission chair Sir Andrew Foster warned in 2002 that disability services had not radically changed since the commission pushed a critical report two years earlier (Fully Equipped, Audit Commission, March 2000).

This highlighted:

poor commissioning of services that risked putting pressure on other parts of the NHS and contributing to social exclusion;

a lack of information within the NHS about demand;

fixed budgets with little regard for need;

a lack of 'joined up' thinking that would allow services to anticipate changes in demand.

Sir Andrew said the lack of progress 'raises serious questions about whether we need to develop more radical approaches to the way these services are provided which may, among other options, involve the use of the public-private partnerships and an extension of direct payment schemes'.

At the RNID, chief executive John Low outlines the thinking behind the consortium: 'Community equipment can keep disabled or vulnerable people out of residential care or hospitals, prevent falls and increase independence. The provision of community equipment is crying out for change. At the moment we have multiple assessments for all kinds of needs and services.

We would link other organisations offering support in this area to create a holistic service with a universal assessment, a single point of contract for users, and promote the establishment of a national procurement framework for key items of equipment, using the techniques we learned from digital hearing aids.

'At present there is no single contract for sensory impairment; every hospital buys it separately.

This means there is no pressure on manufacturers to improve either the price or the product specifications.

'Our approach is not to criticise and tell the Department of Health that it is doing it wrong, but to look at the needs of the user and see how the voluntary sector can add value.'

The charities already have a strong role in many of these services, and some people in the NHS might feel happier about voluntary organisations providing these services - and ploughing back any profits into improvements - than they would with seeing the private sector get involved, he adds.

But there is concern in the voluntary sector that, despite the national agreement, the decentralised nature of the NHS will make big initiatives covering the whole of the country more difficult to organise.

British Red Cross UK services director Virginia Beardshaw suggests that the RNID's hearing aid scheme might be impossible to set up under the current arrangements because power is diffused across many organisations.

However, the DoH document Making Partnerships Work - and the forum that has been set up to represent voluntary groups and voice their concerns with the government - should help to overcome these problems.

This new policy promises to provide patients with 'real alternatives so they can choose services that best suit their needs', and make the voluntary and community sector 'part of mainstream service provision'.

Primary care trusts will be told they can commission provision from voluntary groups and are urged to involve the sector in assessment of health needs and planning, and recognise that they can deliver some services in a different way to the NHS.

RNID head of media Clarinda Cuppage says: 'We have the ability to think differently - we can think outside the box and come up with solutions to these problems.'

Virginia Beardshaw of the British Red Cross says: 'We are asking for a fraction of the management time spent dealing with the private finance initiative.

'A lot of central government appears to have clocked it, but we need the same sea change to happen among the alphabet soup of local providers.'

In the British Red Cross's case, many PCTs and local authorities already commission services from it - for example, commissioning Home From Hospital services that prevent bed blocking. The difference between an early discharge and weeks in hospital can sometimes be as simple as a fridge stocked with food to enable someone to live at home, suggests Ms Beardshaw.

The RNIB is also piloting low-vision services for patients with chronic eye diseases in some PCT areas. These also include some rehabilitation services to help patients live more comfortably at home.

NHS Alliance public health spokesman Professor Chris Drinkwater says commissioning from voluntary groups should be 'mainstreamed'.

But he warns that PCT commissioning consortia, designed to improve secondary care commissioning, could make it harder to commission from smaller, local groups who may be more responsive to local needs.

But there may be more prosaic advantages from the agreement, too. Turning Point, which provides substance misuse and mental health services, hopes the agreement will lead to more uniform contracts. At the moment it has to renegotiate each time, spending a great deal of time on details which could be templated.

'We are hoping we could get to the point where we could get a standard form of contract for particular services, ' says a Turning Point spokesman.

It also hopes for longer contracts, which would allow it to invest in facilities, potentially borrowing money against the income stream.

Ultimately this could reduce the cost to the NHS of commissioning such services.

The NHS Confederation's Nigel Edwards agrees that the NHS often commissions services on a short-term basis - and then cuts back when money is tight.

The voluntary sector is sometimes seen as a 'cheap option' run by well-meaning amateurs supported by coffee mornings. But Turning Point is a£50m a year operation helping 100,000 people a year - with almost all of its income coming from the NHS and local authorities.

The new agreement 'is about giving the voluntary sector a seat at the table, ' adds the spokesman. That seat may also involve giving advice on commissioning to PCTs as well as service delivery. Many voluntary organisations see themselves as close to patients and able to represent their views - and are often close to hard-to-reach groups such as the homeless.

But the voluntary sector may need to change itself to adequately take on these roles, suggests Virginia Beardshaw.

It needs to offer good user engagement and quality assurance of the services it provides.

NHS bodies will need to be assured about standards in the way they are when they commission from the private sector.

'The key thing is professionalism, ' says Mr Edwards. 'Many of these organisations - not all - are as professional as the NHS. As long as they can perform to the standards required, there is no argument about it.'

Sound initiative: RNID's audiology service

A few years ago if you wanted to buy a digital hearing aid you had to buy one from a high street retailer and pay£2,000 for the equipment plus fitting.

Now you can have one fitted on the NHS, which pays a basic cost for the hearing aid of just£55. It would be natural to put that astonishing reduction in cost down to the purchasing power of the NHS.

But the campaigning skills and expertise of the RNID have played a key part in revolutionising the service, which it has managed on behalf of the NHS.The charity has used the massive purchasing power of the health service to reduce the cost.

More than 150,000 people have already been fitted with a digital hearing aid under the£125m scheme to modernise audiology services.

By the end of this financial year the scheme should cover all of England and, in some cases, patients will be 'referred' to private clinics to have their aids fitted.

The RNID had not only campaigned for the switch to digital services but has played a crucial role in implementing the changes and in suggesting changes to the way the NHS runs audiology.

For example, it knew that many hearing aid users did not get the full benefit of them because they were poorly fitted; now users are offered a follow-up appointment to adjust the fitting.But it realised some appointments could be carried out over the phone to reduce pressure on audiology services.

'The most significant thing we have done is set up a private public partnership whereby we have looked at the efficacy of the private sector fitting digital hearing aids to NHS protocols on the NHS, ' says head of media Clarinda Cuppage.

'We got companies to bid to work with us under a national framework agreement.'