OPINION: Why do we need the VCS to be equal partners in our new Integrated Care Systems? And, why is it so difficult?

13 Sept

Summary

The voluntary community sector (VCS) especially grassroots organisations, are well-placed to advance people’s health. Grassroots organisations hold certain ‘superpowers’: they are agile, trusted, knowledgeable, and genuinely motivated to drive meaningful outcomes with the people they work with.
As the UK moves towards the new Integrated Care Systems (ICS), we must examine how and why the VCS is not being leveraged/integrated as an ‘equal partner’ as promised.

Integration is made challenging by: the unequal relationship between the VCS and statutory health systems; their divergent approaches; funding shortages; and other practical barriers to integration.
The solution is not clear, as we learnt in our recent assignment with Hackney CVS. However, from what we know, we have faith in some tangible solutions pertaining to infrastructure support and funding mechanisms. Now is the time for meaningful change and harness their full potential.

What’s been wrong with our approach to health and care?

In the UK, the statutory health system is “not a national health service but a national illness service” (borrowing the words of one Hackney Councillor we spoke to recently). Our purely biomedical approach is focused on treating or managing illnesses rather than actively promoting health and wellbeing. Our health is impacted by the conditions and environmental factors where we are born, live, learn, work, play, worship, and age - the social determinants of health. Without addressing these, and focusing on medicine alone, our population isn’t as healthy as it could be. What is more, the country’s widening social inequality is reflected in adverse health outcomes.

There is only one sustainable solution to ensure we have a healthy population: we need to support people in living healthy lives that result in fewer health issues. We need to prioritise prevention, aiming to reduce illnesses from occurring or worsening, rather than solely curing or treating once they’re already developed. This involves adopting a more holistic approach to health, where individuals are seen as people, and supporting them to leverage the strengths and opportunities in their lives to achieve the best health outcomes possible.

The new integrated care system

Promisingly, change is afoot. The UK is moving towards new approaches to healthcare, embodied in a new model of care: the Integrated Care System (ICS). ICSes are partnerships of statutory and non-statutory organisations that come together to plan and deliver joined up health and care services.

This new system acknowledges the need for a preventative approach, alongside all the clinical work that is carried out by the National Health Service (NHS). Integration is also about being less ‘episodic’ and more joined-up in how medical and clinical care is delivered: different health, care and other services are brought together to meet the needs, choices and aspirations of the holistic individual. The Health and Care Act 2022 established Integrated Care Boards (ICBs) to govern each ICS, acting as area-based agencies responsible for planning local services, focusing on improving health and reducing inequalities.

Why do we need the VCS?

The Voluntary and Community Sector (VCS) has a proven track record of effectively delivering preventive support.

VCS organisations, especially grassroots ones, possess certain “superpowers”: impressive agility, high levels of trust from their community and beneficiaries, deep local knowledge and understanding of the people they support, and whole-hearted motivation to drive meaningful outcomes and change (Civil Society Consulting, 2023). Thanks to these core attributes, VCS organisations have impressive reach - and already live and breathe the holistic approach that the statutory health system is aiming for. The VCS also boasts incredible community insights that can benefit commissioners, along with access to essential data on key sections of the population.

Not only this, the VCS can often deliver preventative, quality and person-centred services at lower cost.

Recognising these integral qualities and unique selling points, the new ICS health system states that the VCS must be ‘equal partners’ in the new system.

Why is VCS integration so difficult?

Across the country, ICSes are finding the transition challenging as they attempt to integrate the VCS as an equal partner in health. As it stands, VCS organisations, for the most part, are not receiving appropriate support, respect, and recognition for their expertise; they are not leveraged as serious partners in delivering support to prevent and tackle health issues.

Certainly, this is what was reported to us in City and Hackney, London, when we were commissioned by Hackney CVS to explore how infrastructure support can be delivered more efficiently and effectively to promote VCS integration into the new integrated system.

Specific challenges include the following:

1. The relationship between statutory services and VCS is not equal.

The statutory health system wields control over funding. In essence, therefore, statutory health systems act as ‘kingmakers’ because they can determine which VSC organisations receive funding and where across the country. There is also a longstanding history and culture of the statutory health system “treating the VCS as outposts”, and VSCs find it uncomfortable to engage with the statutory system. It’s difficult to mitigate this inherent power dynamic.

2. The statutory health system’s approach does not match up with how the VCS see and do things.

Often, public health priorities do not fully capture community priorities as they are perceived and experienced by the VCS. “ideas/priorities have come from the bottom, but once they’ve reached the top they’ve not been heard in a way that’s recognisable so do not reflect what communities (in which VCS is embedded) originally said”.
Additionally, the approach adopted by the statutory health system (e.g. commissioning procedures) often doesn’t align with the practical realities of frontline work for VCS organisations; for example, those working in the NHS favour a neighbourhood lens, but VCS often don’t work in this way according to the same geographies.
What’s more, the statutory sector is characteristically slow to change. By contrast, being dynamic, the VCS is always changing in composition; it is made up of agile organisations that quickly respond to critical changing needs.

3. There are funding shortages left right and centre.

Both the statutory health system and the VCS are working with ever-shrinking budgets while simultaneously facing rising demand for services. In City and Hackney, funding for the VCS is often earmarked for 'new and innovative models', rather than providing ongoing or core investment in initiatives that are already effectively meeting the needs of residents. As a result:

VCS organisations are not as resilient and sustainable as they could be, primarily due to the constraints imposed by short-term and project-specific funding models.
The VCS is overwhelmed by demand. While there is signposting from the statutory sector (e.g. through social prescribing), this is not accompanied by funding. It is neither appropriate nor ethical for the statutory sector to dictate the agenda for what the VCS should prioritise without providing adequate funding
Funding shortages lead to higher levels of stress among the workforce. In times of high stress, individuals tend to resort to their ‘default settings’ and encounter difficulties in implementing new behaviours. These conditions are far from ideal for implementing new ways of thinking and developing new systems.
The VCS, particularly smaller organisations, just do not have capacity to engage in tendering or responding to bids from multiple sources.

4. Both sectors are “vast” and difficult for the other to infiltrate:

The statutory health system is vast and can be perceived, at times, as an inaccessible “beast”. What’s more, the system is undergoing constant change; for example, many place-based systems are still reviewing their governance structures and procedures as the new ICS develops.
The VCS, on the other hand, is similarly vast, but it is also dynamic and diverse, so there is no hard and fast rule for mapping or understanding the local sector in any one area. Notably, there is inequity within the sector, leading to markedly different experiences for different VCS organisations. For instance, smaller organisations led by and for marginalised communities often lack the necessary resources, capacity, and confidence, yet are extremely well-placed to be valuable partners in providing cost effective and preventative health care and support delivery if adequately supported. In contrast, larger VCS organisations find it easier to have their voices heard by the statutory health system.

These challenges are well-documented and can be seen as the underlying causes of many practical barriers, on which the NHS has recently produced a report (NHS, 2023).

The solution?

While a definitive answer remains unclear, there are tangible solutions that can be considered.

Certainly, infrastructure support provided by an independent intermediary offers one solution.

Infrastructure support can effectively address immediate practical barriers and simultaneously tackle some of the underlying root causes associated with these barriers; for example, City and Hackney is ahead of other localities, having had the infrastructure support dedicated to promoting collaboration, understanding and integration between statutory and VCS since 2021.

Tackling the underlying barriers caused by funding and resource control: Many of these barriers outlined above may indeed originate from the significant power imbalance, with the statutory sector holding control over resources and, consequently, having a dominant say in decision-making.

This power dynamic could potentially be mitigated if funding were channelled to the VCS through other routes (not directly via the ICS): Central Government could provide adequate funding to the VCS through alternative means, or ICSs could consider involving intermediary grant-makers to deliver funds to the VCS sector.