Emma Wilkinson asks the experts some burning questions about how PBC can tap into this sector.
Lord Victor Abedowale
(VA) Chief executive, Turning Point social care organisation
Dr Mike Dixon
(MD) NHS Alliance chair
(SiG) Director, Upstream UK healthy living project
Dr Shane Gordon
(SG) Associate medical director, NHS East of England, chief executive, Colchester PBC Group, and national co-lead, PBC Federation
How important is it to engage with the third sector?
MD The third sector is always an afterthought, but clearly it's a massively important way of tapping into experience and funding. It's something that hasn't really evolved with PBC but will become more important. Actually I think PBC – in terms of local know-how and value for money – will probably use the third sector more than PCTs have used it once they get their feet under the table properly.
There are three factors that will drive better working with the third sector: pressure on budgets; commissioning to meet local needs; and greater patient involvement in design of services.
SG Real budgets and the possibility of a Tory government mean that PBC clusters will increasingly be looking at effective and low-cost opportunities to improve the health of the local population, especially in the areas of wellbeing and prevention. The third sector is particularly well placed to support that agenda. It is already happening, it'sa matter of building on the relationships and capabilities.
SiG I'm delighted there are some GPs who value the third sector but they are in the minority. At the moment GPs are not making the best use of what's on offer – some because they haven't got to grips with how money would flow through, some because they are not convinced of quality or value. But the third sector has a huge amount to contribute in terms of initiative, ideas, energy and drive.
What advantages are there in working with the third sector?
SG There are third-sector organisations now that are very much able to deliver and demonstrate value for money. They are incredibly lean organisations because they have to work with low overheads. They are often very aware of clients' specific needs and how to research and address those needs. Quite often these are small groups of patients and it can be difficult for GPs to meet those individualised needs.
SiG The third sector is good at connecting with communities, very often with people who have found it more difficult to connect with statutory services, either because they are isolated or find the bureaucracy too much. The third sector is also very good at putting together partnerships between organisations and between the third sector and statutory sector. I think the third sector is very economical, it's good at dealing with small budgets because it's always had to do that.
VA There are potentially huge benefits. We are great value for money, we have proven ability and reach those at the sharp end of the inverse care law. We also have the ability to bring together funding, provide a bespoke service for individuals and deliver broad types of programme. We can also help GPs understand the nature of the environment they are commissioning services for. And we share many of the values that underpin the NHS – more so than the private sector.
What are the barriers to effective partnerships?
MD The focus on PBC has been trying to get things right between PCTs and practices, so there has not been a focus on working with the third sector and they feel left out of it. But it is starting to come to the fore now.
SG There is a difference between some of the large national third-sector organisations and some of the smaller local ones who may be less equipped to demonstrate outcomes. It can be more difficult to work with them – although not impossible. They might need more support with collecting data and demonstrating outcomes. There are also issues of robustness with organisations that are very small. If you have a key member of staff who leaves or is off sick or on maternity leave, that can have a large impact on the service and that needs to be accounted for in the contract.
SiG The third sector has a problem because a small local organisation isn't big enough to take on major contracts.
For big local authority contracts or even government contracts there is too much competition from the private sector. We have been working on putting together consortia of third-sector organisations with a greater range of skills and greater credibility for making bigger bids. For example, in the South West three or four organisations have formed a consortium called Well UK.
VA It has been a real struggle for the third sector to engage with the NHS. There has been a view that providing NHS services is not something charities should be doing. Also the NHS has had a blind spot when it comes to the third sector. GPs see charities, voluntary organisations and social enterprises as a luxury, not part and parcel of what they can provide. The other problem is with the definition of commissioning itself – commissioning should be the means by which you understand the needs of the individual or community and then build a framework for procurement. This means commissioners need to be held more accountable for understanding the requirements of the community.
Are there examples where partnership between the NHS and third sector has worked particularly well?
MD There are many – diabetes associations, asthma charities and mental health (see case study on page 33). But the NHS does need to be more inventive about how it works with the third sector.
SG One example would be the health trainers programme in London, run by the Terrence Higgins Trust. That was born out of the Trust's work promoting healthy lifestyles for people with HIV. The Trust was then commissioned to deliver those services to a more general population.
A lot of the Improving Access to Psychological Therapies Programme commissioning has gone to third-sector organisations, for example our local one is a joint programme between Mind and the mental health trust. We also have services delivered by Age Concern and the Alzheimer's Society.
VA Partnerships have worked well in mental health, learning disabilities, substance misuse – but there isn't an area that shouldn't be open to third-sector involvement. One example is the substance misuse services in Somerset, where commissioners took a real risk by going against a lot of commercial interests to have a thorough commissioning process with provider involvement in the design process. As a result we had a strong partnership and a real focus on the customers and outcomes.
Should you work with one organisation or many, and what type of contracts?
MD Contracts shouldn't be different from those with anyone else. But if you have small projects and small contracts you wouldn't have to go through the whole tendering process, especially if they have already proved their merit. In the current economic climate, tendering needs to be reserved for your major services or very poor services.
SiG As I mentioned, more collaboration is needed between third sector organisations. On a national level there is a new consortium called 3SC, of which Well UK is one of the eight managing partners. The 3SC people are making bids to Government departments for very big contracts – over £10m – with the aim of boosting the profile of the third sector. That work will filter down to frontline delivery.
Just as GPs are working collaboratively to commission services with economies of scale, the third sector needs to respond in the same way. If they don't get involved in consortia bidding, they may not get the work. They need to offer services that cover an area. On the other hand, diversity is needed. In terms of contracts, they need to be planned at the beginning so the services can be flexible and inventive. Organisations also need to be absolutely clear what they want out of the commissioning process – who it is targeted at and what needs to be delivered. Then when the work starts there is no disagreement about what is needed. Very often in contracts between the third sector and statutory sector, the statutory sector tries to adjust what they want as they go along and that affects their ability to deliver the service. The private sector has always been more savvy about conditions and modifications.
VA Turning Point is a not-for-profit social business and we are very clear about what we can deliver. But some aren't as clear – there aren't that many large operations doing this. However, size isn't everything – quality, safety and appropriateness are the issues the commissioner should be looking for. An organisation doesn't necessarily have to be large to deliver the service the community needs. You also have to remember that it costs money to compete in procurement processes and commissioners should be focusing on quality of design. When it comes to procurement, the commissioner can say if you're a large organisation your chances will be improved if you can show us how you're working with smaller organisations in these communities.
What is your vision for the future?
MD Working with the third sector is something we all ought to be involved in and I'm considering introducing a third sector adviser at the NHS Alliance. It is going to become more important.
SG We ran a workshop, led by the PBC group and in conjunction with social services and the PCT. We invited all the local charities and third sector organisations to work through how the third sector can position themselves to carry out this work and how we can fund them. It was extremely well attended. And we have had experience with the third sector facilitating redesign of pathways. It's a really good opportunity.
Emma Wilkinson is a freelance journalist