The not-for-profit sector is distinct from other sectors, and this is a strength
For years, charities and social enterprises that deliver support services have been told to emulate the private sector: to become more efficient and bigger through growth and mergers. We increasingly use the language of customer service, despite the fact that our ‘customers’ often have not chosen to come to us and are not spending their money. Our branding and marketing is getting slicker, even as the budgets for our front-line services are being cut like never before. We talk about quality, excellence and the need to ‘professionalise’, whilst many charities have to employ people on minimum wage to make ends meet while some senior salaries continue to rise.
Some not-for-profits have been so successful in competing with the private sector on that sector’s own terms that it is getting hard to distinguish them from their profit-making counterparts. Others have found themselves, like some private sector organisations, at loggerheads with their own workers, local branches or ‘beneficiaries’.
It is time to consider not how not-for-profits can emulate the public or private sectors, but what makes our sector uniquely valuable to people who need support.
There are always gains to be made from becoming more efficient, but the challenges facing providers of public services that are genuinely values-led are now far beyond solving through leaner processes or smaller back offices. They are existential. It is time to consider not how charities can emulate the public or private sectors, but what makes our sector uniquely valuable to people who need support, and how we can work with those people to ensure that our public service system values that contribution.
At their best, VCSEs get alongside people to help improve their lives
As the independent chair of the Joint Review of the role of the Voluntary, Community and Social Enterprise (VCSE) sector in health and care, I heard a strong consensus from government, sector and citizens on the unique value and roles that the VCSE sector can and should have. We all believe that the future of health and care services lies closer to our communities, and in offering support that is more carefully shaped around and in support of our individual needs, goals and capabilities. In the words of the charity Nesta and NHS England, our public services should be ‘people-powered’.
However, neither the statutory nor the private sectors have a track record of getting alongside people who make most use of services, of hearing their insights into what works and what does not, and enabling them to input that expertise in service design. Some VCSE organisations do have that track record, particularly when it comes to groups and communities that are commonly seen as ‘hard to reach’ by bureaucracies reluctant to reach far beyond their headquarters. So a distinct role for the VCSE sector is to enable citizens to codesign the health and care system we need, and to challenge the one we have.
When our public service systems are codesigned in this way, the support provision role of our best VCSE organisations also becomes one that has a unique business case to make. This is primarily because, when ordinary people are involved in defining what we should value and aim for, they steer us towards services that are embedded in our communities, easy to access without having to wait for a crisis, and willing to see the world from the point of view of individuals.
Again, it is VCSE organisations that have the strongest track record of developing services that fit comfortably with people’s lives, homes and neighbourhoods, particularly when it comes to those communities currently least well-reached and served. So a people-designed health and care system is likely to include organisations that reach us early and that help people, families and communities to develop their capacity, confidence and resilience. We are unlikely to address the social determinants of health nor the many inequalities in our health and care systems without a wide range of large and small VCSE organisations designed and led by the communities in which they work.
Non-profits are best placed to deliver services that are both complex and human
The role of non-profit organisations is not limited to early or light-touch interventions, however. Some VCSE organisations are providing the most complex and technical support. Here the unique value of great VCSE organisations is that they deliver technical or medical care, whilst continuing to think socially and holistically about the people they support. They manage challenging risks but do not let those risks obscure people’s potential. They personalise their support to individuals, whilst drawing upon whole communities for volunteering and social action—which addresses service-resistant problems like loneliness and stigma—and for the expertise of lived experience in coproducing their support.
But the current climate is one in which commissioners are increasingly focused on short-term cost cutting, leading them to offer larger, narrower and shorter-term contracts for the cheapest possible price. So how can the not-for-profit sector maintain and improve its uniquely cost-effective codesign and codelivery offers?
It is possible to draw on the assets more commonly associated with community and civil society alongside the assets usually held by public.
The final report of the Joint Review of the Voluntary, Community and Social Enterprise Sector set out a number of recommendations intended to bridge the gap between vision and day-to-day reality. This includes an outline of how the health and care system as a whole could define its goals in more human terms (through the concept of well-being, which is already embedded into social care legislation), and then measure, pay for, inspect and demand well-being at all times. There are some underused levers in the system, such as the Social Value Act, which can put a real monetary value upon the goods that the VCSE sector is best able to produce.
The best new models out there are smart, values-led, people-powered
The charity I work for, Shared Lives Plus, is the UK network for Shared Lives and for Homeshare. Both models are examples which are values-led and people-powered. Shared Lives creates savings for commissioners alongside the type of value that can only be measured in more human terms. 150 independent Shared Lives providers recruit and spend three to six months approving people from all kinds of backgrounds to become Shared Lives carers. They then match Shared Lives carers with adults who need support, with whom they share family and community life. Half of the 13,500 UK people using Shared Lives live with their Shared Lives carer as part of a supportive household; half visit their Shared Lives carer for day support or overnight breaks. Some go on to get their own place, others are looking for a home where they can settle and feel they belong.
Most people who use Shared Lives have learning disabilities, but it is also used by people with mental health problems, older people, care leavers, young disabled adults, parents with learning disabilities and their children, and others. It is being developed as a home from hospital service, an acute mental health service and a form of short breaks for family carers.
Take James, for example, who lived in a residential hospital for people with learning disability and mental health problems for many years and after discharge could not live with his family. He was matched with Phil and has lived with him for some time now. The health outcomes are significant: he has fewer psychotic episodes, uses hospital less frequently and for shorter periods. But the most important gains for James are living an ordinary life: sharing with Phil a love of greyhound racing and fishing, going on holiday, exploring supported employment and travelling independently.
Shared Lives illustrates that it is possible to draw on the assets more commonly associated with community and civil society—such as people’s own capacity for independence and the support of family and community—alongside the assets usually held by services but that are often inaccessible within bureaucracies. Each local Shared Lives scheme is regulated and inspected by the Care Quality Commission, which consistently rates it as the highest performing and safest form of regulated care.
Shared Lives carers are trained and paid and there is back-up from the local organisation if the match breaks down. But Shared Lives carers and their families typically say that the person who lives with them is ‘just one of the family’. They will say, ‘we love them’. Because Shared Lives draws both on service resources (money, knowledge, infrastructure) and on family and community resources (friendship, fun, love), rather than costing more, the model is on average £26,000 a year lower cost for individuals with learning disabilities and £8,000 for people with mental health needs. Additional savings can often be identified from reduced use of the NHS and crisis services.
These models connect and empower people. They are co-designed with the people who use them to shape their interventions around people’s lives.
A recent report identified six innovations that are amongst a growing movement around a similar ethos. These include Homeshare, in which isolated older people are matched with young adults who move in and help out a little, rather than paying rent. The older person gets low level support, while helping a younger person get a start in life. Community Catalysts have brought their creativity, resources and social networks together to build hundreds of supportive small community enterprises, including 170 tiny home care providers in rural Somerset.
This model also includes Well-being Teams, which combine home-care with a range of community and relational forms of support. These can include Community Circles, a structured way for friends, family and chosen professionals to form long lasting circles of support around someone with long-term support needs. Local Area Coordinators get to know people in a defined neighbourhood, such as those at risk of needing support, and help them to connect or reconnect with their neighbours and the wider community. This means people who might otherwise become isolated and dependent on services can live well in their own homes.
These models connect and empower people. They are codesigned with the people who use them to shape their interventions around people’s lives, their families and their informal support networks. Some of these models, such as Shared Lives, are open to any VCSE organisation to pursue. And all VCSE organisations that seek to deliver—and ideally help to shape—the health and care system we need, could embed the values that these models share. All non-profit support providers can ask:
- Do we support the communities we serve to design and redesign what we do?
- Do we aim for good lives, not just good services, helping people to build and sustain well-being?
- Can we show that our long-term support services connect the people we support and avoid disconnecting them?
- Are our services delivered in a way that empowers people and builds resilience, confidence through sharing our knowledge, networks and resources?
- Do we create added social value such as drawing in volunteers and employing local experts by experience?
In some areas of public services, commissioners are struggling to see beyond immediate budget constraints. But the VCSE sector and the communities from which most VCSE organisations are born have a strong history of innovation. That pioneering spirit is needed now more than ever.
About the author
Alex Fox OBE is CEO of Shared Lives Plus, the UK network for Shared Lives and Homeshare. He chairs the NHS England, Department of Health and Public Health England Joint Review of the Voluntary, Community and Social Enterprise Sector and sits on the boards of the Think Local, Act Personal partnership and NHS England’s Integrated Personal Commissioning programme. He is a trustee of the Social Care Institute for Excellence, a Director of the Local Area Coordination Network and an advisor for Altogether Better. He blogs at alexfoxblog.wordpress.com.