How a collaborative approach is Doing The Right Thing for place-based health and care

With the NHS under strict financial constraints and rising demand for services, harnessing the untapped potential of voluntary and community organisations to bring expertise, provide services and support patients has never been more important.

A challenge is often raised with the voluntary and community sector that it’s complex and uncoordinated, yet size and complexity are also an opportunity – the sector offers a huge amount of assets that enhances people’s lives.

We need to get better at tapping the potential of the sector’s people, resources, energy and drive to do the right thing for others.

In December, the Richmond Group of Charities, a collaborative of 14 leading charities with a particular focus on long-term conditions and comorbidities, held a seminar in London to discuss the contribution the voluntary sector could make to health and care transformation. The seminar particularly focused on Somerset, where the Doing the Right Thing project is focused.

Doing the Right Thing is a collaboration between the Richmond Group of Charities – supported by Public Health England – and statutory partners, working with the South West Academic Health Science Network and the local voluntary and community sector.

The project is scoping a place-based approach to health and care that taps the capacity and value of the voluntary and community sector. A planning phase will begin in the spring, followed by an implementation phase. The ambition is not to invest in small-scale pilots or experimentation, but rather to invest in new ways of working for entire cohorts of people across the whole of Somerset.

‘Charities are improving health and wellbeing around the country, and improving productivity and efficiency for the health and care system’

With the intense pressures facing place-based health and care, particularly the mechanism of sustainability and transformation plans, the seminar brought together project partners to reconfirm their ambition to push hard to achieve “a collaboration of collaborations”, and to take stock of what they’ve learned so far.

Introducing the Doing the Right Thing project, Tom Wright, chair of the Richmond Group of Charities, explained: “A lot of the evidence about the interventions made by the voluntary sector is poorly articulated or is not easy to access for those who commission and plan the healthcare services around the country”.

This is why the Richmond Group of Charities and its partners in Doing the Right Thing commissioned New Philanthropy Capital to develop a framework within which to aggregate the evidence, resulting in the report, Untapped Potential.

Dan Corry, chief executive of New Philanthropy Capital, said the report, published in April 2016, showed that charities are improving health and wellbeing around the country, and are also improving productivity and efficiency for the health and care system.

There are a number of things the voluntary sector can bring to the NHS, Corry explained. The first is the patient voice, helping people through the system and providing a more holistic experience. The second is service delivery, as charities can deliver services well, and often better, quicker and more cheaply than statutory services. Finally, there is work around prevention – which is never going to be the core job of the NHS.

Untapped Potential also highlights some of the barriers to making the most of voluntary sector strengths. The public sector often finds it difficult to work with the voluntary sector, Corry said, because the voluntary sector consists of lots of voices.

“The voluntary sector has got tons to add, but it doesn’t organise itself in a way that helps the public sector.” Conversely the statutory sector use “funny language”, have commissioning processes, and don’t engage.

Having responded to the “evidence challenge”, Doing the Right Thing is now focused on responding to this “working together challenge”, explained Charlotte Augst, director of the Richmond Group of Charities.  The charities are trying to break down barriers by “adopting a very different approach and tone”, she explained.

“There’s something about how we try to influence statutory services sometimes that is quite hectoring.”

’Our job is to develop systematic links at all levels of design and delivery in our system to make sure we’re all working together for the common purpose, which is to add value to people’s lives.’

To system leaders in the statutory sector, charities come across as on “the moral high ground”, by giving the impression that they are the only ones who understand and care about people, with the implication that the statutory sector are just bureaucrats.

“Clearly that is not true,” she said, but there is some difficult learning for both sectors to be done – the challenge for the statutory sector is how to enable us to play a better part, and for the voluntary and community sector it’s how do we collectively communicate better with the statutory sector so as not to come across as a lot of “noise” with conflicting demands.  

The Richmond Group of Charities aims to demonstrate that a strategic partnership between the statutory and VCSE sector, with a focus on people and more collaborative design and delivery of services across and within the two sectors at scale, will lead to better outcomes for people living with long-term conditions and will reduce demand on medical services.

Matthew Dolman, senior responsible officer for Somerset’s STP, believes in the importance of “understanding and developing networks” despite their complexity, and so invited the Richmond Group of Charities to work with the STP team to scope out what this sort of practical collaboration might look like.

This is not about consultation or tokenistic involvement, said Alf Collins, national clinical adviser at NHS England. The two systems need to work more closely. “Our job is to develop systematic links at all levels of design and delivery in our system to make sure we’re all working together for the common purpose, which is to add value to people’s lives.”

The Richmond Group of Charities is essentially pursuing a “collaboration of collaborations”. STPs are the current mechanism through which statutory agencies are collaborating, and Doing the Right Thing is bringing together the local representatives of the Richmond Group charities in Somerset.

But there are often thousands of voluntary and community organisations within any STP area and very few that are organised in a collaborative way.

According to the Charity Commission there are 2,800 registered charities in Somerset, agreed Liz Simmons, strategic adviser to Somerset’s Voluntary, Community and Social Enterprise (VCSE) Strategic Forum.

Early data from a recently commissioned “state of the sector” survey for Somerset suggested that just 1 per cent are large organisations and that the vast majority are micro (with a turnover of less than £10,000 per year). In addition, there will be many informal community groups.

Infrastructure organisations like Somerset’s VCSE Strategic Forum have an important role in bringing voices together and enabling a collaboration of collaborations to happen.

“As a sector we started talking to Somerset County Council a couple of years ago saying we need to find some strategic space to have some conversations where we can bring together the key leaders and their key chief executives across different sectors – not just health and social care,” Simmons said.

That discussion has revolved around building resilience in communities and encouraging neighbourhood activism, and has dealt with common issues such as monitoring and evaluation, and how GPs should pass information to voluntary organisations without falling foul of information governance.

‘There are “pockets of success”, where communities have been working together with medical colleagues to develop new care models’

Recognising the complexity, the Richmond Group of Charities has funded a programme manager to undertake scoping work in Somerset. Their objectives are to focus on relationship building and developing an understanding of Somerset and its population, of its health and care system and pressures, and of the work already under way in partnership with the VCSE sector.

The Richmond Group aims to ensure Doing The Right Thing builds on rather than replaces work already being done, addresses a need or aids transformation in the system, and offers support to people that is meaningful to them.

The first step should be to see what can be done with the big organisations, Corry emphasised, as attempting to involve all 2,800 charities individually would be unworkable.

Aimie Cole, Somerset programme manager for Doing the Right Thing, said there are “pockets of success”, where communities have been working together with medical colleagues, expecially in primary care, to develop new care models, including social prescribing. As a GP, Dolman said, he hadn’t taken the time to map out to his receptionists what the voluntary sector was doing locally so they could signpost patients.

“If you did that and you did no more than that, you could achieve a huge amount,” Simmons said.

The Five Year Forward View outlines a vision for a multidisciplinary team, breaking away from the traditional primary care focused model to include a much wider group of people, said Dolman.

One such model is Symphony, a vanguard project in South Somerset, where Yeovil District Hospital is working very closely with primary care to provide more integrated care. This is now being built on by bolting on community mental health services and VCSE to try to build a more holistic system with connected data.

Next steps

Sally Hughes, head of health services engagement at the British Heart Foundation, agreed that it is about getting the whole team caring for the patient to think differently in terms of how they can work together.

These new models of care that extend primary care beyond the medical “all started from different starting points, and they are all different because all the local communities are different”, said Cole.

The challenge for Somerset is trying to scale them county wide “and at the same time making sure that it is locally driven, led and responsive, because otherwise it is not going to work”.

This is where voluntary sector strengths could be better utilised, said Wright. A lot of the work that goes on across the country takes place as small-scale pilot projects, such as pathfinders and vanguards, and there are examples of social prescribing working well in all sorts of different guises in various parts of the country.

The charities within the Richmond Group have both local and national infrastructure, so are often well placed to facilitate and support scaling and replication.

If Doing the Right Thing is successful in terms of achieving better working between the voluntary sector and health and care, what would be the potential benefits for Somerset, asked Wright.

In terms of long-term conditions, said Justin Parsons, service development manager (South West and South Central), British Lung Foundation, people ideally do not want to get them in the first place, so it is about education and preventative services.

’About a third of the population have very low levels of knowledge, skills and confidence to manage their health and well-being on the patient activation measure, and we know that the more support that they are given the better they do and the less they cost.’

If they do develop, then people look for an early accurate diagnosis, and finally they want support and information that is going to help them self-manage their condition. “Patients are not averse to the idea of looking after themselves,” he pointed out.

People with a long-term condition often develop others, and that is preventable to some extent, outlined Brian Dow, director of external affairs, Rethink Mental Illness. For example, a patient with a serious mental illness might take medication that will lead to weight gain, so is disproportionately more likely to develop diabetes, and ultimately have a cardiovascular event.

Making sure that the voluntary sector works well with clinicians to ensure that people with those very predictable set of outcomes not only get the right treatment, but also get access to the right support from voluntary groups at the right time will lead to much better outcomes, he said.

Dow said many patients with different diagnoses will require the same types of support and services, so commissioners should move from commissioning primarily by diagnosis to commissioning more by common pathways.

Many people with a long-term condition have “a degree of complexity” in their lives, Augst said, which may be other co-existing long-term conditions, or factors such as lack of money and unsafe housing.

Doing the Right Thing will be successful if some time is put in place for someone, who is not a clinician, to unpack that complexity, and put support in place that deals with issues such as loneliness, low mood and money advice.

We’re three months into a six-month scoping exercise, said Wright, what next for Doing the Right Thing?

Finding some examples of need that the voluntary sector can deliver quickly on to show the benefit of collaboration is the best way forward, as it will get a relationship going, Corry said. “You change cultures that way.” Unfortunately, Corry cautioned, not all voluntary sector organisations are good.

When asked why they don’t commission the voluntary sector much, privately, NHS and local authority commissioners will say because they don’t do due diligence, and there is a risk they may fold.

It is essential that any intervention is provided where it will generate the most benefit and a benefit that is measurable, said Wright, “this means better stratification”. Collins added that we need to think more about segmentation too. “Risk stratification gives you a highly disaggregated population of people with very different needs and I think needs to be associated with a population segmentation approach.”

Meanwhile, better patient activation could benefit a wide range of patients, he said.  “About a third of the population have very low levels of knowledge, skills and confidence to manage their health and well-being on the patient activation measure, and we know that the more support that they are given the better they do and the less they cost.”

‘That is what patients say is important to them” – they want to live as well as they possibly can’

Commissioners in Somerset have around £1,300 per patient under STP funding, but Dolman said that Doing the Right Thing was about looking wider than the health service and considering what is spent in the community as a whole to realise the value of that sum.

Engagement with health professionals is crucial, Parsons said. “We all know there’s a massive amount of scepticism at large about STPs,” he warned, and talk of transformation in healthcare breeds fear among health professionals in terms of what that means for their service, its resources, and ultimately their jobs. Let’s do something and keep it practical.

It will let people see what a different service can look like and reassure them it can work – without any politics. But it’s not just about raising the awareness of health professionals, Dolman added. The expectation of the patients who walk into my practice is that they will stay within a medical pathway. There needs to be engagement with the public too.

Once the voluntary sector can demonstrate that initiatives are making a difference, momentum will build, Dow said. “So I would just say put in place some sensible benchmarks that can say this is what it was like when we started, this is what it is like now, and this is where we are moving to.”

Realising the Value proposed using broader well-being measures as measures of success in the system, Collins said. “Currently the system is driven by clinical outcomes and by length of stay and the number of unscheduled admissions. Let’s broaden our minds and start to support people to deliverable wellbeing outcomes. Ultimately, Parsons said. “That is what patients say is important to them” – they want to live as well as they possibly can.

The financial challenges for STPs may yet prove insurmountable, but as large organisations “we can both think and do”, reflected Augst. “There are people running around doing things on the ground and there are people who write very clever papers, but there is very little in-between. We can bridge this space”.

The scoping phase of Doing The Right Thing runs until April, when the project will move to a planning phase and then to implementation. You can follow progress via the Richmond Group of Charities’ website and on Twitter @RichmondGroup14