Written evidence from the National Association
for Voluntary and Community Action (COM 54)
NAVCA is the national voice of local support
and development organisations in England. We champion voluntary
and community action by supporting our members in their work with
over 160,000 local charities and community groups. NAVCA believes
that voluntary and community action is vital for vibrant and caring
communities.
We provide our members with networking opportunities,
specialist advice, support, policy information and training. NAVCA
is a vital bridge between local groups and national government.
Our specialist teams take a lead on the issues
that matter most to local support and development organisations.
We influence national and local government policy to strengthen
local voluntary and community action.
NAVCA's work is guided by the values of equality
of opportunity, participation, co-operation and democratic involvement.
In supporting the local voluntary and community sector we help
to combat poverty, disadvantage and discrimination, and improve
the quality of life for communities, groups and individuals.
INTRODUCTION
1. NAVCA welcomes the opportunity to submit
written evidence to the Health Committee inquiry into Commissioning.
In our response we focus on the issues that are most relevant
for our members, for local voluntary organisations and community
groups and for excluded communities and individuals. These include:
— wider outcomes and social value;
— the voluntary and community sectors role
in commissioning;
— commissioners' skills and understanding
of the sector; and
— integration of health and social care.
2. We welcome ambitions that seek to make
services more accountable to patients and the public, to provide
meaningful choice, and to reduce bureaucracy and top-down control.
What is less clear is how the reforms proposed in the White Paper
`Equity and Excellence: Liberating the NHS' will make these ambitions
a reality.
WIDER OUTCOMES
AND HEALTH
INEQUALITIES
3. We agree that health commissioning is
too remote from patients and the public. We welcome an increased
role for those with clinical expertise in the commissioning process,
particularly where this will improve clinical pathways and the
commissioning of acute services. However, we believe there is
a risk that moving from PCT commissioning to GP consortia could
swing too far in favour of a clinical model.
4. It is essential that health commissioning
incorporates wider social outcomes and reduces health inequalities:
it should not just focus on clinical interventions. Commissioning
needs to focus both on geographical communities and communities
of interest, as well as on individual patients. It is critical
that there is continued investment in prevention and early intervention.
5. In a challenging financial climate, radical
approaches are needed to support more innovative, cost effective
interventions across agencies. Commissioning for improved health
and well-being needs to be based on a total place approach, creating
incentives and opportunities for local authorities and their partners
to break down service silos, join up budgets, reduce costs and
deliver better outcomes for local people. A joint approach is
needed, looking across services, such as education, employment
and housing, to commission for the improved health and well-being
of local populations. However, the challenges of implementing
this approach should not be underestimated, particularly where
resources are already overstretched.
6. In order for Health and Wellbeing Boards
to be effective in joining up the commissioning of local NHS services,
social care, health improvement and the wider local authority
agenda, they will need to have statutory powers to hold GP Consortia
to account in this area.
7. The full value of what is being delivered
in a contract needs to be evaluated and needs to be considered
at the early stages of the commissioning cycle. NAVCA believes
this demands a better understanding of social value in commissioning
and procurement. Social value is the additional benefit to a wide
community over and above the direct purchasing of services. We
would welcome government support for the Private Member's "Public
Services (Social Enterprise and Social Value) Bill" introduced
to parliament by Chris White MP.
8. Wider outcomes and community benefits
should not be seen as the responsibility of the proposed Public
Health Service alone but must be integrated into commissioning
practice across the public sector. We are concerned that in seeking
to increase clinical expertise in the commissioning of health
services, a lack of commissioning skills and the need to achieve
extreme productivity savings could lead to a focus on clinical
interventions, acute care and short term savings at the expense
of preventative services and cross community benefits.
What voluntary organisations and community groups
can contribute to commissioning and engagement with the sector?
9. Voluntary organisations, charities and
community groups have a much wider role in the commissioning of
public services than just being contracted to deliver those services.
They also have a key role in helping to identify needs, particularly
for marginalised groups, and in shaping service design. Intelligent
commissioning needs to involve both patients and the wider community
at the early stages of the commissioning cycle and ensure the
needs of the most excluded are taken into account. Recently developed
National Occupational Standards for Commissioners cover a range
of skills including engaging with community partners. Our concern
is that GPs have limited experience of working in a culture of
public participation. In some areas our members have reported
great difficulty in trying to engage with practice based commissioning.
We have particular concerns that GPs are not involved in and often
unaware of the neighbourhood level preventative work which is
carried out by many small local voluntary sector organisations.
10. The voluntary and community sector has
a long history of successfully engaging with the most excluded
groups, communities and marginalised individuals. Success in this
area is a result of being rooted in the local community, as well
as having particular skills around engagement, involvement, partnerships
and representation. Many of the most vulnerable citizens are not
registered with a GP: it is the voluntary and community sector
which often works with these people.
11. NAVCA's members support and champion
local voluntary organisations and community groups. We call them
support and development organisations, locally they are often
known as CVS or Voluntary Action. These organisations are well
placed to take a greater role in engaging with local communities
and identifying their needs. They already have many of the skills
required to identify gaps in the provision of community services,
to develop service specifications or to contribute to training
GP Consortia in public participation and working in partnership
with the voluntary and community sector.
12. Local support and development organisations
also have skills and experience in bringing together commissioners
and local groups. This is evidenced in the directories research
project which looked at the use and development of supplier directories
in the voluntary and community sector, see Third Sector Directories
Research (North West Region-wide) July 20101
13. Bringing commissioning closer to local
communities should result in increased opportunities for the voluntary
and community sector to engage in sharing their expertise on local
health priorities, setting outcomes and designing services to
meet need. If meaningful engagement is to continue, local support
and development organisations will have an essential role to play,
developing links and building bridges between local groups, communities
and GP Consortia. At present, our members often receive funding
for this work from PCTs. This may be through grant aid, enabling
a specialist health partnership officer to be employed, grants
for specific projects or contracts to deliver services around
partnership working, engagement and representation. With commissioning
structures changing, it is essential that this wide-ranging engagement
work continues to ensure that the benefits of working with the
voluntary sector are realised and that commissioning is effective
in reducing health inequalities.
14. Health and Wellbeing Boards are seen
as the vehicle for aligning health commissioning with wider outcomes,
therefore it is essential that they have appropriate voluntary
and community sector representation. GP Consortia will need to
fully engage with and integrate into these boards and other local
strategic partnerships.
15. One of the proposed functions of the
Health and Wellbeing Boards is to undertake a scrutiny role for
major service re-design. However, scrutiny functions need to be
separate from the original decision making bodies and appropriate
checks and balances are needed across the system to ensure accountability
for decisions, to ensure that local politics do not inappropriately
influence decision-making and that decisions are taken at the
right level.
16. We value the intention to strengthen
the patient and public voice through local HealthWatch and to
increase accountability to patients and local communities. We
believe that in order for this to be successful HealthWatch should
be commissioned and delivered at a local level by organisations
that are based within and understand local communities. Independent
research undertaken by Warwick Business School, published in January
2010,[82]
indicates that where the contracts for LINks host organisations
are held by local organisations, the LINk has been better able
to represent the core values of the local community and engage
with disadvantaged people. HealthWatch should focus not only on
strengthening the involvement of individual patients, but provide
an increased role for the engagement of communities in both operational
and strategic commissioning.
17. We are concerned that reorganising commissioning
structures, as proposed in the White Paper, will incur significant
additional costs and risk at a time when public finances are under
great pressure and resources are desperately needed for service
delivery.
18. We are concerned that the process of
transferring commissioning from PCTs to GP consortia could in
effect become a very expensive rebranding exercise. It is difficult
to see how this reconfiguration will reduce overhead costs. In
addition to the financial cost of buying in commissioning support
services, there is a risk that commissioning could take a step
backwards and revert to overly bureaucratic and disproportionate
practices, particularly in regards to procurement.
19. The previous Health Committee report
on commissioning suggested that commissioning weaknesses remained
20 years after the introduction of the purchaser/provider split.
However, improvements in commissioning have been made. GP commissioning
consortia will have fewer skills and less experience in commissioning
than PCTs. It is likely that they will need to buy these skills
in. In addition to needing access to wide ranging commissioning
skills, GP consortia will be bound by other public duties such
as equalities duties. We expect that this is another area where
they will need to buy in outside specialist support.
20. Inexperienced Commissioners result in
bureaucratic and risk adverse procurement processes being followed
when they do not need to be. For example full Part A processes
are often followed for Part B or below threshold contracts. This
increases procurement costs and therefore reduces the funding
available to frontline services. With PCTs, NAVCA members have
started to see some improvements in this practice. We believe
improvements are due to the increasing skill and confidence of
commissioners, who are seeking more innovative and cost effective
ways to secure services and who are not letting themselves be
overly-controlled by procurement departments. We need to ensure
that the move to GP commissioning consortia does not create a
return to overly bureaucratic, inefficient procurement practice,
owing to a lack of commissioning skills within the consortia.
Where these skills are bought in there is a risk that expensive,
risk adverse practices could once again dominate.
21. We are also concerned that risk adverse
practice and a lack of understanding around procurement regulations
could result in reduced use of grant funding. A number of recent
guidance documents published by both the Department of Health
and other government departments have made it clear that contracting
should not inappropriately replace grant funding. There continues
to be a place for grants in a mixed economy of funding. Competitive
tendering and outcomes based, payment by results contracting is
not the most appropriate or efficient delivery mechanism for all
services. Local community based organisations, relying on volunteer
effort, can deliver very cost effective preventative support,
which can reduce the need for costly health and social care interventions,
such as emergency hospital admissions. If we are to see a growth
in innovation and increased choice for patients, grants are also
an important mechanism in stimulating the market.
22. We are also concerned that some GP Commissioning
Consortia may seek to simplify their commissioning role by awarding
larger contracts to a reduced number of suppliers. We would argue
that a number of services, especially community based provision,
are more effectively delivered by local organisations. If only
larger contracts are tendered, many valuable and cost effective
voluntary and community sector services would be lost, thus reducing
patient choice. GP Consortia will need to have the skills to recognise
where outcomes can be better achieved by procuring services in
smaller scale contracts or lots.
23. If large contracts are to be awarded
to prime-contractors, then we would expect some form of protection
to be developed for smaller sub-contractors, including recognition
that it is often more time consuming and expensive to work with
marginalised communities or with those with multiple or complex
needs. Protection of sub-contractors needs to be incorporated
into contracts as well as a framework to guide good practice,
like the DWP's Merlin Standard. If these safeguards are not put
in place, an unfair proportion of risk could be borne by those
further down the supply chain, and the most vulnerable patients
could be excluded from services.
Difficulties of working with GP consortia that
are not aligned to local authority boundaries
24. It will be difficult to align health
and social care commissioning where GP Consortia cover different
boundaries to those covered by local authorities. Whilst in some
areas this has continued to be an issue for PCT and Local Authority
joint commissioning, many areas currently enjoy coterminous boundaries.
We are concerned that joint commissioning will be made more difficult
and inefficient if GP consortia have no prescribed geographical
coverage. This will also present problems and inefficiencies for
the voluntary and community sector in engaging in partnership
working. The reasons why PCTs were reduced in number and aligned
more closely to local authority boundaries should not be ignored.
Where will challenges be directed?
25. From what we understand under the proposed
changes Monitor and the NHS Commissioning Board would be responsible
for ensuring transparency and fairness in commissioning decisions.
We are concerned that, if these bodies are insufficiently resourced
to operate effectively at a regional or local level, poor practice
could go unchecked and providers could have difficulty in challenging
bad practice at a local level. Dispute resolution procedures in
the form of Co-operation and Competition panels currently exist
at PCT and SHA level, as well as at national level, ensuring accessibility
for local providers.
CONCLUSION
26. Whilst we support the stated aims of
the White Paper, of putting patients and the public first, improving
accountability and healthcare outcomes and increasing efficiency,
we have many concerns about the practical implications of the
proposals. Not least, we are concerned that over recent years
the NHS has suffered from too many reorganisations, that the proposed
rate of change may be too rapid and that the increased risks and
costs involved in implementing these fundamental reforms, are
too high. We are particularly concerned to ensure that there are
no unintended negative consequences from the reforms, that the
progress which has been made with respect to the role of the voluntary
and community sector is built on, and that the health inequalities
for most disadvantaged groups in our communities do not increase.
October 2010
82 Local Involvement Networks (LINks) Local Authorities
Research Consortium Research Project Report Jan 2010. Back
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