Date published: 23 May, 2023
Date last updated: 26 May, 2023
Integrated care, Volunteering

A framework for addressing practical barriers to integration of VCSE organisations in integrated care systems

About this document

The framework supports leaders in integrated care systems (ICSs), NHS providers, local authorities, and voluntary, community and social enterprise (VCSE) organisations to recognise and address challenges and barriers that have an impact on their ability to integrate VCSE organisations as system partners.

The framework should be seen as a resource, rather than read cover to cover.

The framework is divided into three sections:

1. A list of challenges and barriers that are commonly experienced when trying to work in partnership with, and when integrating, VCSE and statutory provision and activities.

The barriers and challenges are organised in relation to three key areas of integration:

  • Commissioning and strategic planning, including the role of the VCSE sector in service design and delivery.
  • Sharing data, intelligence, and insight, including using VCSE data to inform population health management and social prescribing.
  • Funding, sustainability, and investment in the VCSE sector.

2. A list of ‘approaches’ that highlight what people have done to improve things together in relation to each of the above areas.

3. A series of case examples which provide more detail on the practical actions that people took within local systems when implementing approaches to integrating the VCSE sector and which take account of the overall journey and context. These cases provide clues as to what to think about and do in your own situation, which will be both similar and different.

Case examples are based on interviews carried out between April and August 2022.

Interviewees were identified through a series of workshops with VCSE, NHS and local authority stakeholders and through wider networks and were chosen based on their leadership in implementing different approaches to addressing challenges and barriers.

Each case is presented as a narrative of change from the perspective of the interviewee. Where possible, case examples were checked and verified for accuracy with interviewees.

This resource is supported by the report ‘Actions to support partnership: addressing barriers to working with the VCSE sector in integrated care systems’.

It outlines actions from across the case examples, that ICS and VCSE leaders, and those from national bodies and funders can take to support embedding VCSE organisations within the context of ICSs.

Commissioning and strategic planning: The role of the VCSE sector in service design and delivery

The commissioning and procurement processes

Common challenges and issues

  • Lack of transparency in procurement processes and the VCSE sector not having the capacity to respond.
  • Lack of support for the VCSE sector to engage with commissioning processes and limited VCSE sector infrastructure.
  • Lack of capacity to engage in tendering – particularly when tendering processes are disproportionate to the scale and funding available.
  • Ability to respond to bids from multiple sources requires dedicated capacity and resource that many VCSE organisations don’t have.
  • Commissioning ‘by habit’ with the same providers without considering whether services could be provided by VCSE sector.
  • Contracting requirements placing undue burden on VCSE organisations.

Possible solutions/mitigating approaches

  • Giving VCSE organisations advance notice/opportunity for involvement in planning service design and delivery.
  • Collaborative commissioning
  • Innovation partnership procurement
    • A model which allows commissioners to procure a provider(s) to work with it to research, design and develop a service that does not currently exist.
    • See case example: Somerset ICS
    • See additional resources: Scottish Government
  • Co-design of a grants scheme
  • VCSE commissioning framework
    • A commissioning framework outlines expectations and recommendations for working with the VCSE including an understanding of the needs of VCSE organisations, their value within the system, how they can be supported and approaches to investment. The framework is developed with VCSE organisations and agreed and signed up to by VCSE and system leaders.
    • See case examples: Greater Manchester ICS, Cheshire and Merseyside ICS.
  • Co-funding arrangements
    • An approach which considers where the assets are in the system, including what skills and resources different sectors and organisations can contribute, and what they may want, such as outcomes. Parties agree on how funding and resources are allocated based on local conditions.
  • National charities enabling local charities
    • Using the strengths and resources of national charities at a local level. Can include use of capacity, expertise, and knowledge to support and strengthen the VCSE ecosystem at a local level.
    • See case example: Somerset ICS.
  • Reviewing contracting relationships and building new relationships
    • Reviewing contracts, identifying which contracts go out to preferred or the same organisations and considering the possibility of bringing in new players and building relationships with them.
  • Developing procurement models
    • Working with groups of VCSE organisations or VCSE alliances to explore approaches to procurement which address issues such as sustainability.

Collaborative working

Common challenges and issues

  • Limitations of short-term grants to deliver a service versus ‘planning’ and collaborative working focused on community needs and outcomes.
  • VCSE sector organisations not engaged early enough in commissioning processes.
  • Being engaged in, rather than collaborating or partnering with statutory organisations.

Possible solutions/mitigating approaches

Engaging early, thinking about what each stakeholder has to offer.

  • Engaging with key stakeholders including the VCSE sector to identify gaps in services and consider how potential solutions might work as precursor to procurement.
  • Designing services as an ongoing process, focusing long-term on outcomes for people
    • Building in learning from VCSE organisations to develop an understanding of needs and how to meet them within service delivery.
  • Co-design with VCSE

Improving access to and uptake of VCSE services

Common challenges and issues

  • VCSE services are commissioned in isolation with no joined-up support to facilitate referrals, so activity and outcomes are sub-optimal.

Possible solutions/mitigating approaches

  • Creating a single point of access
    • a means by which services provided by multiple organisations including VCSE can be accessed. Examples include use of light touch triage service to reduce potential barriers to General Data Protection Regulation (GDPR).
    • See additional resources: NHS Confederation – Bristol Out-of-Hospital Care (p10).

Understanding the VCSE sector and its contribution

Commons challenges and issues

  • Priorities of different sectors/organisations not being aligned.
  • VCSE sector understanding of the issues and solutions may be better than statutory organisations, but not necessarily recognised.
  • Lack of understanding of what’s in the community and how it’s supported and deployed – resulting in failure to build on assets.
  • Challenges with seeing the VCSE sector as both a service provider and a system partner in different spaces.
  • What the VCSE sector provides isn’t easily captured by ‘outcomes’.

Possible solutions and mitigating approaches

  • Secondment/embedding the VCSE sector in statutory organisations.
    • VCSE leads seconded to the NHS or local authorities to strengthen connections and support different ways of working.
  • Joint training and workshops for workforce
    • Bringing individuals together from statutory and VCSE organisations, resulting in shared learning, changes to relationships and ways of working.
    • See additional resources: Health Education Yorkshire – GP training scheme.
  • Co-location
    • Building personal relationships between different organisations facilitates ways of working and shared learning, for example Plymouth ICS and local authority are in the same building.
  • Mentoring and buddying schemes
    • Established pattern of engagement and regular conversation with VCSE sector partners focused on getting to know each other.
    • See case example: Devon ICS.
  • Mapping VCSE sector provision
  • Co-producing key performance indicators (KPIs) and outcomes with VCSE organisations
    • Setting a contract up for a service but co-producing the KPIs and outcomes with the successful organisation through discussion and agreement on what they are trying to achieve.
  • Commissioning the VCSE alliance to explore specific needs to inform service design
    • Providing funding for VCSE alliance members to explore the needs of the population they support and what the community want as a precursor to service design.

Relevant case examples and approaches to change

Additional resources

Sharing data and intelligence and insight: using VCSE sector data and insight to inform population health management and social prescribing

Data-sharing: behaviours and systems

Common challenges and issues

  • A tendency not to share data – VCSE organisations are often competing for commissioned work and therefore, in a competitive environment, may be reluctant to share the data they hold without compensation.
  • Caution and perceived risks of sharing data – for example, concern that sharing information would be in breach of patient or client/service user confidentiality or General Data Protection Regulation (GDPR) rules.
  • Lack of legal framework or agreements to share data between the NHS and VCSE organisations.
  • Differences in data sharing processes between the NHS and VCSE sector.

Possible solutions and mitigating approaches

  • Co-ordinating work across networks to facilitate data-sharing
    • Bringing together VCSE organisations that work across a common geography or demography as part of a network. Co-ordination within the network can mediate between competitive behaviour and allow them to share data to understand how and when there are opportunities for collaboration.
    • See case example: North East London ICS
  • Developing a joint survey system
    • Co-designing surveys to capture patient insight across organisations. A survey jointly administered between the organisations, ensures that the data is consistent and organisations are able to overcome legal barriers to sharing data at an individual level.
    • See case example: North East London ICS.
  • Co-designing policies on data sharing
    • Ensuring that agreements to share data take account of, and address, the capacities and capabilities of the VCSE sector when sharing data with other organisations.
  • Developing data sharing agreements
    • Understanding the type of data and its flow and processing requirements to ensure that data-sharing agreements are practical and do not create undue burden or processes.
  • Developing a single data capture system with inbuilt security
    • A joint CRM system for statutory and VCSE partners to capture data. With in-built security, data can be stored securely while allowing different partners to capture, report and cross-refer information about individuals. This supports partners to overcome challenges related to data confidentiality and privacy that statutory partners have around data-sharing through using a third-party system. The system can enable easier analysis and demonstration of the impact and value of the approach.
    • See additional resources: Voluntary, Community and Social Enterprise Health and Wellbeing Alliance -Torbay Community Development Trust (p25).
  • Developing a shared care record using open access standards
    • Developing a platform for patient records that can be used to capture, report and share information between organisations including in the VCSE sector. The use of open-access standards ensures that software can be adopted more widely without costly subscriptions and maintenance.
  • Adopting a common platform for shared care records
  • Using honorary contracts and shared IT equipment
    • NHS organisations provide staff in the VCSE sector with honorary contracts and trust laptops with NHS smartcards to enable access to patient records and data sharing.
  • Patient-level data held by the patient/carer
    • key notes and paperwork held by the patient, or in their home.
    • Consecutive professionals update this on each visit. This approach has typically been used for maternity and end-of-life care.

Commissioning and data

Common challenges and issues

  • Lack of attention in commissioning processes to identifying the data that is available and missing to inform subsequent service design.
  • Scale and availability of data from the VCSE sector limits its use to inform decisions.
  • Commissioning is not consistent in the type of data collected and there is no consistent approach among contracts.

Possible solutions and mitigating approaches

  • Developing a system insight group
    • creating a group or network of different system partners with the aim of developing a culture of decision making which is insight-led and makes best use of, or links together, different sources of insight.
    • See additional resources: The King’s Fund – Joined Up Care Derbyshire (p21)
  • Adopting a balanced scorecard approach
    • The balanced scorecard brings together different sources of existing patient and user insight to inform system improvement management. It includes qualitative data such as real-time stories from people’s health journeys, written and video narratives, as well as data captured from other sources such as multi-agency and multidisciplinary team file audits and analysis of compliments and complaints.
    • See additional resources: The King’s Fund – Leeds Health and Care Partnership Executive Group (p20).
  • Developing a shared evidence base on needs
    • VSCE sector and local authority working together to develop the Joint Strategic Needs Assessment.

Types, uses and quality of data

Common challenges and issues

  • Challenges in being able to track people’s journeys across different parts of the system.
  • Ability to collect and use data at different geographical levels.
  • Issues with data quality and lack of common taxonomies in how data is categorised, which limit usability.
  • Scale of VCSE sector and data creates challenges for its relevance and usability more widely.
  • Lack of common language and understanding of terminology.
  • Timeliness of data to inform decisions – such as real-time data.
  • How qualitative and lived experience data fits and is received by the NHS – its value and potential use.
  • Being able to capture data on preventive actions.
  • Availability of data on specific groups, for example, marginalised groups, rare health conditions, small communities.

Possible solutions and mitigating approaches

  • Co-designing a data template
  • Using unstructured and structured data for population health management
    • ability to bring together different types of data, in particular being able to generate meaningful insights from the unstructured data (such as qualitative feedback) often collected by VCSE organisations.
  • Developing a community insights system
  • Using different data capture systems for qualitative/quantitative data
    • For instance, combining use of EMIS in primary care with Casebook for storing client data within a social prescribing pilot. This enables capture of wider range of data than EMIS alone. Sharing data can also help to demonstrate impact of referrals.
    • See additional resources: Voluntary, Community and Social Enterprise Health and Wellbeing Alliance – Wirral Social Prescribing Pilot (p24).
  • Obtaining data to support inclusion groups

Capacity and resources

Common challenges and issues

  • Lack of capacity to collect, analyse, interpret and make use of data.
  • Having systems and organisational support in place to collect and host data.
  • Short-term contracts limit impetus to develop capacity around data-sharing and use of data beyond funding.
  • Costs associated with data collection, collation, and analysis.

Possible solutions and mitigating approaches

  • Developing an open-source digital tool to capture data from VCSE and grassroots organisations.
  • Single point of access and shared data storage system
    • Shared database between VCSE organisations for example Charity Log holds all client data and enables reporting against KPIs. It allows outcomes to be captured as a whole (rather than by organisation), build wider intelligence, can be used to performance manage and address delivery issues within contracting.
    • See additional resources: Voluntary, Community and Social Enterprise Health and Wellbeing Alliance – Bromley Well (p23).
  • Co-designing data outcomes, including a bespoke data capture system
  • Working across organisational capacity
    • Data professionals working for their organisations provide support more widely and develop in-house data storage systems where data can be gathered and shared with others rather than being held for a single purpose.

Relevant case examples and approaches to change

Additional resources

Funding, sustainability and investment in VCSE sector: exploring different funding models

Recognition of costs

Common challenges and issues

  • Lack of payment (reimbursement) for VCSE sector time, for example, attending meetings.
  • Lack of full cost recovery in contracts.

Possible solutions and mitigating approaches

Timeframes

Common challenges and issues

  • Short timeframes for commissioning/bids and for service delivery which limit the ability to participate and ensure sustainability.
  • Ad hoc funding rather than sustainable thinking about the wider contribution of the VCSE sector.

Possible solutions and mitigating approaches

  • System-wide approach to social value
    • Developing a framework for commissioning that includes measures of social value which reflect the benefits of supporting and investing in the VCSE sector.
    • See additional resources: E3M.
  • Long-term contracting
    • Contracts lasting several years, enabling consistency of delivery, sustainability, and investment in development.

Commissioning approaches

Common challenges and issues

  • Insufficient ability to commission for outcomes, including investing and rewarding prevention.
  • Insufficient diversity in the commissioning models used.

Possible solutions and mitigating approaches

  • Developing a prevention workstream
    • Funding work on prevention, including VCSE sector led initiatives and building, sustainable partnership at place and ICS level. Investment may include salary backfill of VCSE staff to enable work to progress quickly and efficiently.
    • Also creating capacity to move from ideas to delivery.
    • See case example: West Yorkshire ICS.
    • See additional resources: NCVO – West Yorkshire and Harrogate ICS.
  • Use of social impact bonds
    • Social impact bonds are a form of outcome-based commissioning. Impact bonds incorporate the use of private funding from investors to cover the upfront capital required for a provider to deliver a service. The service sets out to achieve measurable outcomes and the investor is repaid if these outcomes are achieved.
    • See additional resources: The National Lottery Community Fund, Ways to Wellness.
  • Match funding and risk sharing
    • As part of a contract award, VCSE organisations are expected to provide a defined level of match funding. The result is that both parties own the contract, and the risk helps to support a greater partnership dialogue and increased motivation for the organisation to deliver as they ‘own’ the outcomes.
    • See additional resources: Suffolk County Council.
  • Participatory budgeting
  • Micro-commissioning for social prescribing
    • The process of identifying and addressing needs at an individual level through creating additional activities in local communities. Link workers and social prescribing services can micro-commission the ‘social prescription’. Micro-commissioning and small grants funding allows the VCSE sector to grow capacity and establish new provisions to fill gaps to meet needs.
    • See case example: Somerset ICS.

Relevant case examples and approaches to change

Additional resources

Working across the scale of the VCSE sector

Common challenges and issues

  • Ability to engage on an equal basis with a huge and diverse sector.
  • Availability and funding support for infrastructure organisations.

Possible solutions and mitigating approaches

  • VCSE Alliances
  • Creating networks to support different aspects of work and influence
    • For example, informal thematic networks focusing on operational work; organisations that attend meetings at a strategic level addressing community issues; representatives who sit in these partnerships.
    • See case example: Bedfordshire, Luton and Milton Keynes ICS.
  • Building on VCSE infrastructure
    • Developing a dedicated fund to provide cross-sector investment to develop the VCSE sector’s long-term capacity and resilience, and to help VCSE organisations to replenish and prepare for their ongoing role in supporting communities.
    • See additional resources: NHS Confederation – VCFSE Sector Resilience and Capacity Fund (p9).

Relevant case examples and approaches to change

Additional resources

Case examples

Bedfordshire, Luton and Milton Keynes Health and Care Partnership: Community Action: MK – collecting community insight

Overview

Community Action: MK is a local VCSE infrastructure organisation. As an organisation, in recent years it has been moving towards greater partnership working and supporting VCSE organisations to come together. One of the ways it achieves this is by facilitating, supporting or promoting ‘thematic networks’ across the city to bring people together around certain themes. These include a young people’s mental health network, an intercultural forum and an adult mental health alliance. Established networks Community Action: MK promote include a homelessness partnership and an Arts and Heritage Alliance network, which are led by other organisations in the city and Community Action: MK would like to support more networks to support on key issues and demographics – for example an LGBTQ+ network. There is a big focus on health and particularly mental health. Community Action: MK is made up of groups and organisations that support mental health and wellbeing across the city. Through this, Community Action: MK works closely with Central and North West London NHS Trust as part of a national programme to transform community mental health services. It includes funding that Community Action: MK has been tasked with disseminating to support smaller grassroots community groups that wouldn’t necessarily have been able to access funding or get involved in projects. Community Action: MK are developing an overarching VCSE alliance which will collect information from all the thematic networks in order to understand the broad needs of the sector and communities and use this to develop priorities and communicate this information more powerfully to decision-makers and service providers.

The following is their narrative of change, with key actions and challenges drawn out by The King’s Fund.

Key actions

Bringing together VCSE organisations working in similar areas or topics to map insight

‘As an infrastructure organisation we heard from lots of different groups and charities, that work with specific communities, about different issues that affected different demographic groups. No one sector or organisation had collated all this information. We wanted to try and map these issues and ensure that people weren’t falling through the gaps. We started up some geographical ‘collaborative action groups’ which were based around specific geographies and brought together any organisations and volunteers working in the area. This included COVID-19 mutual aid groups, church activities and local branches of national charities carrying out work in specific areas. This accelerated our common desire to capture the information we were hearing in a co-ordinated way. We could use the data to understand need and share it with service providers and decision-makers where it could make a difference’.

Developing a mechanism for collecting insight systematically from communities

‘The original tool that we used for a number of years was the QuickChat app. This was a phone-based app that our team of community development workers used through our Community Mobiliser programme. They used the app to record the information they received in the 12 most deprived neighbourhoods where they worked. This was used to inform the projects they were supporting the community to deliver, and to help community members to come up with solutions to issues. These insights were fedback to our commissioners and other organisations who may be able to use the information to influence service provision. Using the Quickchat app, the community development workers input the conversations they heard and added tags related to particular themes and categorised the dialogue under ideas, issues and impacts. The information could then be analysed, quantified and communicated more easily. The QuickChat app was too expensive to maintain, but via the Catalyst programme, Community Action: MK were able to work with developers and VCSE organisations to co-design a digital tool which is low-cost to run and ‘fed’ by information collected directly from Milton Keynes VCSE groups – this is called the MK Community Data tool’.

Aligning work to key systems issues, to capitalise on funding and contribute towards solutions

‘At the time of the Community Mobiliser programme, we received funding from specific areas of the council, including environment and education. We were able to create reports from the Quickchat app relating to the areas each commissioner was interested in. We were also able to create reports at an estate level to share with local schools, children’s centres and parish councils. For example, at one point there were a lot of issues around fly tipping on an estate. We were able to highlight the issue to the environmental team – along with ideas the community had for addressing it. In this way we were able to log the journey from an issue to an idea having a positive impact by supporting the community to make the changes they wanted to see. We also shared the insights we were collecting with other organisations such as local Healthwatch, so it could reach key decision-makers. We were also commissioned to undertake some targeted community engagement work using the app. For instance, Thames Valley police asked us to undertake a piece of focused research on antisocial behaviour, and we did some work to inform the 50-year plan for Milton Keynes Council’.

Being prepared to iterate and adapt based on learning

‘In developing a new tool, we wanted it to be sustainable, something simple that we can maintain ourselves and that groups across the city can contribute to, not just team members from one organisation. A key aim for having a platform that everyone can feed into was to strengthen the voice of the VCSE sector by drawing together insights from different organisations. We were able to present the information in a way that gave weight, clarity and meaning to the data and so it could be communicated not just through text, but charts and graphs to quantify some of the vital information the VCSE sector holds’.

Use of innovation grants and expertise to support progress

‘We accessed some funding through the Catalyst programme and The National Lottery Community Fund COVID-19 Digital Response Discovery programme fund which aimed to help charities find solutions to COVID-19 related issues using technology. The programme supported charities to prototype and build their digital projects. The programme included an initial discovery phase during which we conducted some interviews with key groups that we’d been working with through COVID-19 to understand what would help them overcome some of the issues they were facing if they used a digital tool to capture and share insight. The charity was then matched with a digital partner to develop the solution. Community Action: MK were involved in the matching process. Their choice was a provider (Mosaic Digital) who offered to co-produce the tool with the VCSE sector rather than approaching us with an existing tool or having a fixed idea of what they thought was needed. This provided the opportunity to co-produce the tool with other VCSE organisations. The tool is owned by them, rather than being owned by the infrastructure body’.

Co-designing tools to capture and use data

‘The whole project was carried out with an ethos of open learning. It’s important to recognise that you need to test things, accept that things might not work out as expected and go back to the drawing board if that happens. The tool will be open source enabling other people to have the opportunity to learn from and build on it. We wanted to be able to bring the data together, adding tags and structuring it into themes so it could be analysed and searched and used to create reports that could be shared and meaningfully used to inform decision-making. We held a series of focus groups to try and help us understand the themes and keywords we needed to tag data and discover areas that we might be missing, and how to group themes and keywords so that they are useful’.

Supporting uptake and implementation

‘It takes quite a lot of resources to drive uptake of the tool as everyone is busy and using the tool is not everyone’s top priority. Therefore, the tool must be promoted, and people supported to input data. We are hoping to build on the thematic networks across the city to engage organisations in each network in inputting data so we can capture and focus on their area of work. We can use the information gained from the tool to support each network to identify their priorities on a rolling basis. We can create a feedback loop, where organisations are able to see how the information, they input alongside others is able to build a picture that helps them with their own work. The information can feed into the overall VCSE Alliance, which can use the information to influence at a strategic level. The networks are also important in making sure we capture data on important themes across a range of communities in Milton Keynes’.

Embedding insight tools into wider ICS programmes

‘There is a lot of interest in how organisations in the health sector can use the tool to understand the lived experience of communities, design services, and work with grassroots. Funding is coming through the mental health alliance network to projects on the ground. This has allowed us to put in place agreements for those organisations to input data into the tool on a regular basis as part of their funded projects. We are hoping this will start to demonstrate how the tool can be used and encourage others to get involved in inputting data. In addition, funding from the NHS to address winter pressures is enabling us to establish stronger links with primary care networks (PCNs) to explore how they could use the insights we are collating, including the information we have around local support groups and volunteers which patients could access, We want to  develop a better understanding of how we can complement each other in the work we do’.

Challenges and learning

‘A key limitation of using the QuickChat app was that it was dependent on our community workers inputting information. Withdrawal of the funding for the community development work meant there was no route to collect the information. The app itself was also very expensive to maintain. Additional changes to the app and hosting incurred additional costs. This made it too expensive to be sustainable’.

‘At the moment, the digital tool only allows Community Action: MK to see the raw data. In the future we would like to develop ways of sharing this data with organisations to support them in demonstrating needs and accessing funding to support those needs’.

‘We’ve had some conversations about potential use of the digital insight tool across the ICS for which there is a lot of interest. However, we recognise it would take a lot of resources and has funding implications. At the moment we probably don’t have the capacity without additional funding’.

Cheshire and Merseyside Health and Care Partnership: Voluntary Sector North West – embedding the VCSE within the context of place

Overview

In Cheshire and Merseyside, the local infrastructure body, Voluntary Sector North West (VSNW), provide support to VCSE partnerships to engage in the health system. In addition, the policy and research manager for VSNW is the interim representative on the integrated care partnership (ICP) and the participant representative on the integrated care board (ICB).

Although VSNW covers both the Greater Manchester and Cheshire and Merseyside Health and Care Partnership ICSs, the two ICSs are distinct in nature. Cheshire and Merseyside are comprised of geographical areas which are distinct in nature, and the ICS geography is not well aligned with the traditional regions. As a result, there are number of different partnerships within the area. In Liverpool City region, a voluntary sector partnership called VS6 covers six boroughs of the Liverpool City region and covers a large part of the ICS.

Cheshire and Warrington have set up an equivalent partnership, the Cheshire and Warrington infrastructure partnership (CWIP), which covers three unitary authorities. To bridge these partnerships, and to support accountability and connectivity they set up the Cheshire and Merseyside Voluntary, Community, Faith and Social Enterprise (VCFSE) Health and Care Leadership group. The group consists of VCSE place representatives and local infrastructure organisations (mostly CVSs). Within the group there is a representative from each of the nine boroughs in Cheshire and Merseyside. In addition, they have providers and representation from networks of organisations working with groups at risk of marginalisation, and  thematic leads such as local Healthwatch and Citizen’s Advice. The group comprises around 80 organisations in total. This is the mechanism to manage accountability, feedback and engagement.

The Cheshire and Merseyside ICS reflects two areas coming together, therefore there is representation from each area on the ICB. The ethos is that in coming together to develop a new system, the priority is place. This is in line with the accountability and connectivity model they are using for the VCSE sector.

The following is their narrative of change, with key actions and challenges drawn out by The King’s Fund.

Key actions

Developing a commissioning framework for the VCSE sector

‘Cheshire and Merseyside took the Greater Manchester VCSE commissioning framework and is integrating it as part of a place model. An example of this is work on transformation in Sefton which includes elements of the commissioning framework at a place level. The framework is informing our work on place-based assurance frameworks and models of driving innovation and relationships with the VCSE sector. This includes recommendations on what good partnership and a good VCSE ecosystem at place level look like’.

Developing a dedicated programme for developing VCSE involvement in the ICS

 ‘The VCSE alliance is part of the VCFSE health and care transformation programme. Our accountability body is the health and social care partnerships transformation board, alongside the other ICS programmes. This is a better place in terms of who we are reporting to and how we are accountable. A key part of achieving that has been the use of secondees, one from Cheshire and Warrington and one from Liverpool City region for one day a week. The secondees were also a big part of how we co-ordinated a response to the COVID-19 pandemic, for example, achieving simple things like getting PPE (personal protective equipment]) to VCSE providers, and getting engaged in hospital discharge conversations and driving some of the work in this area.

Integrating work led by the VCSE sector into wider programmes

‘The VCFSE health and care transformation programme still lead some individual pieces of work such as a carer’s strategy and some pieces around workforce, but we are trying to integrate those into proposals. The aim would be that once the ICS structures are established (in light of recent legislative changes) will be to go for formal investment as one of the programmes’.

The role of the VCSE Alliance

‘Cheshire and Merseyside was in cohort 1 of NHS England VCSE Leadership Programme. Funding as part of the programme was used to get some matched funding from the local system. This small investment provided capacity to set up some of the structures early on and include representatives. A unified, transparent voice has been a key part of the alliance. Going to meetings, having sector representatives, and having the capacity to deliver has also helped. It’s hard work, and it’s been about slowly proving ourselves, and it’s about being able to support some of the accountability mechanisms (Liverpool City Region partnership and Cheshire and Warrington partnership, and the ICS leadership group, and the communications that connects them) and engagement streams that the ICS needs. It’s being part of that world’.

Evidencing the role of the VCSE as a system partner, identifying gaps and investing to maximise contribution

‘The VCFSE health and care transformation programme includes research into how you evidence the role of the VCSE sector, how you build in integrated working, how you connect volunteers, and how you demonstrate cash savings to a health system. We’ve got a place-based programme that is looking at driving forward a place-based assurance framework where we’re building an evidence base around what good partnership working with the sector looks like. As part of that £20,000 per borough has been invested to support proposals from local places to identify where their weaknesses are, using the commissioning framework, and, in comparison to other areas, to identify how they want to use the investment to strengthen their partnership. Some areas are looking to do this at place level and others are doing this at neighbourhood level. It’s a larger programme of investment aimed at driving change aligned with the health system and organisations rather than being a separate entity’.

Using transformation funding to invest in VCSE-led solutions and projects

‘The majority of investment so far has been to support pilot projects. Although it’s not large scale we are hoping to use the pilots to drive forward more investment and activity’.

  • One of the trailblazer projects has been around hospital discharge in Horton and Warrington hospital where we are looking at mobilising as many community groups as possible. We have used investment from NHS charities to take this forward. This was a useful part of the drawdown of additional investment to actually drive service delivery rather than just supporting representation and engagement. It’s not coming from the system. We’ve also had funding through the Liverpool Women’s Hospital. They ran a one-year pilot, with each of the nine places in Cheshire and Merseyside, with small pots of grant investment, £20,000 per borough, to mobilise VCSE organisations to deliver some of the activities which support maternal wellbeing. We are currently pulling together a report on the project for the commissioners.
  • There is a piece of work in Cheshire East around engaging diverse communities where we are mapping access to services. By taking this forward and working with VCSE partners, we identified immigrant populations in Crewe who had no access to services. This has been a collaboration between a local infrastructure organisation and CARITAS who are building a community centre in Crewe to support this need. This is not tied into how we engage with the health and care partnership but links into the place’.

Increasing the scale of investment and moving towards systematic approaches to investment

‘Conversations around top slicing CCG (clinical commissioning group) funding to support VCSE involvement has raised some tensions but as it progresses, the CCG are seeing its value. There is a challenge from CCGs to us, to drive transformation at place level. The work is still in early stages but investment in the VCSE sector in 2022 was around £438,000, which goes way beyond any involvement of the VCSE being seen as a tick-box exercise’.

Building an understanding of what the VCSE sector can achieve

‘We were able to apply pressure around the work we were doing and provide regular reports to key boards. This has been really helpful for the commissioner. The quality of what we are doing has impressed the boards and the Sefton transformation report gave them a much clearer understanding of what the sector could achieve’.

Widening involvement among VCSE organisations

‘The principle we try to use in the model is ensuring representation from VCSE service providers, equalities organisations and local infrastructure bodies. What has been important within this is building a common vision about what we are trying to do. It’s not necessarily about responding to the health system but being able to articulate what we need. In the past we have held 24-hour lock-ins with VCSE leaders where they have had to come up with their vision. That was fundamental to some of the work we did. Currently there is recognition from the ICS that they need to get all their partners on board’.

Challenges and learning

‘Initially funding for sector engagement and delivery was agreed on an annual basis. Reporting was made to the main boards and executive rather than a unified programme. This resulted in the work being somewhat on the fringe rather than embedded into system’.

‘In the past our work to embed the VCSE has been positioned as a pilot or a project of a commissioner rather than a mainstream mechanism to partner and engage with the ICS. What’s been important is making the transition from commissioners identifying individuals, to seeing the VCSE sector as part of the system. This has resulted in far greater investment in the sector in the past year’.

Devon ICS: Devon Mental Health Alliance – commissioning for co-design

Overview

In September 2020, NHS England issued the Community Mental Health Framework and invited submission of plans to secure funding at a local level to support implementation. Core to the framework was that the transformation should be a system response, with an expectation that NHS providers would work collectively with VCSE organisations.

When Devon ICS submitted their proposal to NHS England they stated in the document (which was approved by Devon CCG) that they would work with the VCSE sector as an equal partner. In the plan they outlined that a fair proportion of the funding would be invested in the VCSE sector.

The following is their narrative of change, with key actions and challenges drawn out by The King’s Fund.

Key actions

Ensuring VCSE organisations are engaged early in the process

‘The CCG mental health commissioning lead ensured key organisations were kept aware and informed of all the developments at those early stages. We knew about the commitment and the submission of the bid and were open to and consulted. We clearly knew the direction of travel and were on board. As a result we started talking to VCSE organisations, including Mind and a network of wider partners, and we started to align our thinking about how we might respond further down the line’.

Co-designing service delivery with the VCSE sector

‘As soon as the CCG was told that we had been given the go ahead and the funding by NHS England they started working with the VCSE sector as equal partners, co-designing the approach, and working to the strengths of the organisations. All the partners got round the table including:

  • The CCG
  • Devon Partnership NHS Trust and LiveWell (the two main mental health service providers)
  • Key partners in the VCSE sector
  • People with lived experience and carers

To share the approach, we were taking that was in the bid to NHSE. The CCG wanted our overall community mental health framework design to be collaborative and inclusive.

The CCG went out publicly to say that they want to have an open conversation about how the VCSE and independent sector work collaboratively to best support people’s mental health needs in the community. There was an initial vision document and five to six pages of high-level service descriptions that outlined the key areas of focus. As NHS commissioners we took the position that it was not our role to say who organisations worked with or how they delivered services. The aim was to have conversations with interested parties who had shared common aims and interests and ask, ‘How do you see yourselves addressing that in the tender?’ We wanted an open conversation about how this would be put into place. We had a vision of where we wanted to go, but collectively we worked together to shape what the final masterpiece would look like’.

Creating opportunities for involvement at different levels

‘We held a series of open engagement sessions with the VCSE sector, the mental health trust, primary care, social care and people with lived experience and carers. From these sectors people developed sessions with us. We talked to over 135 organisations across Devon, asking, ‘How would you go about this?’ Although we cover a big geographical area, we want to be locally responsive. How do we do that collectively and how do we assure ourselves of the delivery of that? These questions helped us to start the conversation about what is possible and to develop relationships between the sectors. We asked the VCSE organisations how they wanted to collaborate:

  • Do you want to be a strategic partner?
  • A delivery partner?
  • Are you an interested observer?
  • Is this not for you?

This resulted in some organisations saying they didn’t want to be a strategic partner, but they’d be interested in what they could do as a secondary care option. We then held specific meetings with each of the cohorts. Twelve organisations expressed an interest in becoming strategic partners of which six formed a formal collaboration. Known as the Devon Mental Health Alliance, they comprise three national charities with local services including Devon Mind, Rethink and Step One and three local place-based charities – Co-lab based in Exeter, Improving Lives in Plymouth, and Shekinah in Torbay’.

Setting a clear vision, approach, and timescales, but being flexible in implementation

‘The CCG was very ambitious around timescales. We all work to deadlines, and some of the timescales were very ambitious. In March/April 2021, the CCG announced that it would put the contract out that year. This led to a very busy summer, lots of virtual workshops, with hundreds of organisations. We were clear from the outset – this is what we want to achieve, and by when. Is everyone up for it? We then asked what are the steps that we need to take to get there and from there we could work back. We set ourselves clear goals that were time specific and we continue to do this. We said we would get these things up and running, and we have plans around what each part of the operational implementation looks like. It’s ambitious but they are clear-cut. we all hold ourselves to account by asking, ‘does that still feel right?’ People did take a deep breath; the ambition to transform community mental health was years in the making. For the VCSE sector, the pace of the past three months (as a result the amount of resource available) was really challenging and raised questions in the VCSE alliance about whether they could commit and had the resilience to take it forward. In other places the pace may be dependent on the capacity and capabilities of the local VCSE sector’.

Talking to other people doing similar work

‘We did discuss this with other organisations and other areas that have experience such as the other early implementer sites involved in the community mental health transformation and asked how they have moved forward. We also had discussions within the ICS footprint, where there has been other pieces of work such as the development of a VCSE alliance in Plymouth to deliver a 10-year contract to support people with complex needs’.

Adapting procurement processes to support equal partnership

‘The reality is that we continued to have quite traditional procurement policies in the NHS, and they don’t fit with the way that other partners work or even our aspirations for this. We spent the summer challenging ourselves to maintain that commitment to equal partnership. We asked ourselves what reasonable adjustments we can take in the process which keeps us within the legal framework we are required to work within but doesn’t undermine the principles?’

  • ‘In the pre-procurement or market engagement process we thought about how we did the workshops, who we included in them and the types of conversations we had. Even in the competitive component there were some reasonable adaptations that we made to maintain that principle about the equal partnership: no surprises, co-design and respect each other’s worlds. This led to a better outcome and a better relationship for us as a system. Throughout the process we took advice from our commissioning support unit and procurement teams around what we could do. On each occasion that we tested what we could do, we got colleagues from the VCSE sector around the table to describe what we were doing and why – so there were no surprises’.
  • ‘In a traditional procurement, there comes a point where you have a preferred bidder and you need some way of assuring yourself and feeling confident that that bidder can take on the service that you want to commission. The way in which this is often executed, can make it feel like the commissioner is the expert and you are inviting others to show how they are going to meet that specification to which you apply some judgement.You give us your documents, we mark your homework and tell you where we need more. This doesn’t feel equal and who are we in the NHS to say how the VCSE sector works best? Once we learnt that there was an emerging alliance of organisations who were aiming to create a formal partnership to engage in the work, we had to test how we do that due diligence together. This required the alliance to submit a suite of documents that provide confidence for the CCG to be allowed to issue a contract, but how do we develop that together and how do we ask the questions of ourselves collectively, what does that look like and how do we co-design that in such a way that respects the equal partnership? The commissioners worked within the parameters of what they need to do, but with acceptance that none of them are experts in what this future would look like’.
  • ‘The VCSE organisations that came together were keen to have a fully developed alliance contract model. They found this was not available in its planned format within the NHS system, as contracts in public procurement tend to be a bilateral agreement between the commissioner and the provider. A similar example of an alliance contract in Plymouth, to deliver a 10-year contract to support people with multiple complex needs, provided key learning for us. That contract is held by a single organisation but is supported by a series of memorandum of understanding’s (MOUs) with other partner organisations, operating as an alliance. One of the strengths is that it supports people to work together, getting people in the room who wouldn’t normally be there, and enables an MDT approach by joining up agencies and organisations. Plymouth’s experience has highlighted the value of building an alliance based on collaboration as opposed to taking a more structured approach in which the contract and each MOU defines what each partner delivers in the alliance. Deviation from this can result in removal from the alliance and can result in people thinking they can’t do the things that they think need to be done’.

Identifying solutions or workarounds which fulfil the principles of equal partnership

‘The CCG commissioners set up a contract with a single organisation within the VCSE alliance. Within that they stated that the lead organisation has contracts with the other five partners with the principles of alliance working embedded in every single contract. We have taken the principle of what an alliance contract is and built it into individual bilateral MOUs so when you read them, as a whole, it emphasises joint responsibility and joint ownership. This is also reflected in the way we undertake what would be considered contact management meetings. We have an alliance leadership team which consists of the six contracted organisations, plus the commissioners and colleagues from the two main mental health providers. This means we have joint ownership and joint responsibility for delivery and decision-making, and any barriers or challenges that are faced in achieving our outcomes are discussed collectively. The way we undertake contract management is very different; we act as an alliance of public sector and VCSE organisations that work together to achieve shared outcomes. Initially the expectation was that this would be a temporary solution until we could develop something further down the line, but if this proves to work and keeps on working, we might not change it’.

Developing a strategic partnership rather than a service specification

‘We had to use service specifications to demonstrate how we could all work together. Ultimately this is a strategic partnership that will work together, it will expand and incorporate ideas around long-term sustainability and business development outside of this core funding. We can tap into and leverage all of the resources locally, regionally and nationally. This is more than a narrow specification. If people ask how the money is spent, there is a clear articulation of what difference will be made and what impact will be made. We are not commissioning specific NHS services. There are roles, responsibilities and outcomes and we know how the money will be spent to achieve that. It’s more than that, it’s a strategic partnership that aims to develop a community response and future opportunities. The proof of all this is in the next phase. We will face challenges in the implementation, but how we tackle those, what risks we take and what choices we make will be a test of the aspirations we set ourselves. We are on a point of that journey’.

Allocating a proportion of transformation funding for the VCSE sector

‘Approximately 25 per cent of the funding Devon has received from NHS England to deliver the community transformation framework will be invested in the VCSE sector over three years. At the time we did not know if this funding would be sustainable, but it covered three years and was a shift from the traditional annual cycle of commissioning or use of short-term grants that many VCSE organisations were subject to. Now we have confirmation of the future of that transformation fund, and it provides more solid ground for sustainable relationships with the VCSE sector. The funding model is currently a three plus two-year contract’.

Considering long-term sustainability and expansion of approach to VCSE sector involvement

‘At the end of the contract it will depend on what our existing funding streams are regarding mental health and whether what we have commissioned proves to be successful enough to be able to change and adapt what we have. The ICS will make that easier because of the pooled budgets. It should also theoretically be easier to devolve budgets to a local level. It would not be surprising if we had five VCSE mental health alliances covering the five local care partnerships. In addition, there are services and contracts that have been commissioned traditionally and delivered by the NHS. They were built into the development of this strategic partnership to look at how we create a broader holistic system response for mental health. So, there is additional funding available on top of the 25 per cent.

Challenges and learning

Flexibility was built into all stages to allow for timescales and approaches to be modified while still working towards a clear deadline. Some changes that were necessary included: ensuring more time and more meetings were scheduled with emerging alliances, development of an overarching plan with each stage informed by the previous, and use of a competitive process with the option to stop competition built in to keep communication open between all parties involved. The benefits of this ensured a meaningful relationship was developed between commissioners and the VCSE sector. This was characterised by continuous open dialogue, testing, and challenging views, and taking into account the perspectives of all involved in order to shape the commissioning approach. Importantly it set the foundations for an equal relationship and removed traditional commissioner/provider barriers.

Ensuring responsive, robust, system-wide governance arrangements were in place to support effective decision-making was essential to the commissioning process. While planning the commissioning of a VCSE sector alliance, Devon considered the future landscape of strategic planning and oversight, and organisational commissioning and contracting governance.

Devon ICS: developing mechanisms to support partnership working

Overview

Devon ICS has good relationships across the county and leaders who wanted to be open and transparent about partnership working. In addition, the ICS Chair was described as really good at identifying what the NHS was good at and what it wasn’t good at and opening up dialogue through her outreach. The Chair was approached by a couple of VCSE leaders who highlighted that they had better relationships with the local authority than NHS. Rather than just being seen as service providers they were seen as a partnership that the local authority used to seek advice. There was transparency around the use of the advice. Those relationships were different to the relationship between the NHS and the VCSE sector, where the latter could be perceived primarily as a workforce from which the NHS can commission services and activity. There wasn’t an understanding of what the VCSE sector is, the pressures it’s under and there wasn’t a culture of championing the sector.

In response, Devon ICS created a role with the specific remit of liaison with the VCSE sector particularly around social prescribing. The individual they recruited had previously worked in a similar role within the local authority and had a history of working with the VCSE sector. Now, the remit of the role is as champion of the VCSE sector, critical friend and negotiator within the wider sector.

The following is their narrative of change, with key actions and challenges drawn out by The King’s Fund.

Key actions

Having a role that acts as an intermediary between the system and VCSE sector

‘The role includes representation on the executive group, and as a co-chair alongside a VCSE lead for the VCSE network. The network meets every six weeks and has a newsletter that goes out to registered VCSE organisations across the ICS who are unable to attend. Having a focal point for the system and for the sector has been really positive. It’s helped speed up partnership working and encouraged greater transparency. The role provides a bridge, reflecting the role and value of the VCSE particularly in relation to key decisions within the ICS. It’s also served as a direct way of bringing ideas from the VCSE into thinking at ICS level. Both have resulted in decisions to support investment in the VCSE sector. For example, the role led to the negotiation of PPE for VCSE organisations during COVID-19, and the gathering of VCSE sector views on issues for the ICS’.

Developing mechanisms to engage with the sector

‘We are currently writing a bid for support for the VCSE assembly. This is expected to enable engagement with the VCSE sector at the ICS level. The bid, factors in costs that reflect the time spent for people from VCSE organisations to attend meetings’.

A cultural shift around risk, accepting the NHS cannot support or deliver for communities on its own

‘During COVID-19 the ICS realised it needed communities to be able to support people. Funding was available, and they were able to turn around decisions quickly. The response of the community was creative. The NHS gave them the support they needed including. funding, ‘kit’ and/or information. The ICS observed and learned but did not seek to direct. We had to rely on each community responding in the way that was best for them, as opposed to making it a uniform offer. We hope this is a positive legacy of the pandemic’.

Buddying between the VCSE sector and ICS system leaders

‘The scheme came about from recognition of the value and impact of conversations between leaders in statutory and VCSE sectors. This led to an agreement to discuss potential opportunities to support this more widely. The result was a buddying system. When the idea was presented to the ICS executive group to see who might be interested, 16 people said they’d like to take part. Participants came from across the ICS including acute trust leaders, local authority leaders, heads of social care and the CCG executive. They took the same proposal to the VCSE reference group who were equally keen to participate. The scheme was then designed with the VCSE sector, to identify what would work, the design included a 12-month relationship, with 10 contacts in the year. Pre-pandemic meetings were held face to face but changed to virtual meetings during the pandemic. Currently the statutory buddies include all the executives in the CCGs, the CEOs of all 4 acute trusts, 3 adults social care directors, and directors from the mental health trust and other key organisations. The VCSE buddies include CVS leaders, county-wide charities, and some of the larger charities within the county. The buddying system is overseen by the ICS VCSE lead and comprises of check-in meetings every 2 months with each of the buddying partnership to see how it’s going and collect feedback. Most of the time it’s just a check in, but every so often partners share some of the outcomes of their buddying in terms of new ideas for working. After a year, the scheme was revisited to assess impact. Some of the buddying relationships worked well, and others have been less successful. Some people were keen to continue with the same relationship, and others have been keen to build new relationships and explore other opportunities’.

  • ‘Buddying has brought greater awareness of the pressures and motives of others. The motives are the same, but they are approached from different angles. It has created a sense of empathy and brought a greater understanding of opportunities for the future. It has also challenged the boundaries between commissioners and providers and resulted in a more collaborative procurement process where commissioners are able to talk about what is needed. The sector can identify who is best placed to put forward a collaborative offer. Buddying has created friendships, now people can pick up the phone, this didn’t happen before’.
  • ‘It’s hard to know the actual impact but we believe it has contributed to some decision-making. For instance, priorities were established through the buddying relationships and the sector was able to provide solutions as a group. VCSE leaders are now on senior leader recruitment panels as a matter of course. It’s not just going out to a single VCSE leader but asking the sector who might be most relevant to interview a post for example, the post of digital lead’.
  • ‘Key points of learning include that the agenda is not too prescriptive, it’s a simple and low-cost practical way of building relationships. You can’t build relationships instantly there is always a bit of toing and froing. We are working in a system that hasn’t worked on a personal basis before. Sticking with it is means building on a more honest and open understanding of each other, with an appreciation of the pressures that keep everyone awake at night. One of the VCSE leaders said this was one of the first conversations where the ICS had listened to the problems that they were dealing with. The human relationships have enabled the system to be more emotionally intelligent’.

Using transformation funding to invest in the VCS as part of a system response

‘An example of the work between the ICS and VCSE sector has been the use of winter pressure money to address delayed discharges from acute hospitals. A conversation between the VCSE lead in the ICS and a VCSE leader in the café of one of the small community hospitals revealed how a member of staff from the VCSE organisation, walks the wards and has conversation with every person who is ready to be discharged to find out what they need. This in turn led to the idea of a discharge navigator. Devon ICS received £5m from NHS England to support timely discharge from acute hospitals. The idea was pitched to the executive team to provide wrap around support in the community, to be delivered by the VCSE sector to reduce readmission to hospital. This would involve VCSE sector-based discharge connectors working on the wards with the hospital discharge teams. The executive group agreed to invest £2 million of the funding in VCSE support for discharge.

Co-designing VCSE solutions to system problems

‘Once funding was agreed, the ICS used VCSE sector networks to reach out and ask for expressions of interest to support with hospital discharge. We were inundated with interest. The ICS brought VCSE organisations that had expressed an interest and ICS leaders together to develop a system of support which would allow acute trusts to be able to discharge patients safely home with the appropriate support. Key elements were a relationship with acute hospitals, the ability to link into a type of social prescribing model, connections with wider community groups who can support the wrap around support and an individual or organisation to act as coordinator. There was already some short-term support for up to 7 days post-discharge, but this was insufficient for some people and led to readmission. Therefore, it was key to ensure support for a longer period of time’.

Understanding and working with the needs of the NHS and system partners

‘Our acute care trusts are hugely supportive. Without confidence in where patients were being sent, their duty of care meant they were not discharging people as quickly as they would have liked. One of the hospitals then highlighted that they were vastly underusing their discharge grants. This would enable them to provide a package of care, along with funding for an individual if that would then allow them to be safe at home. Conversations with the other acute hospitals highlighted similar situations. We worked directly which each acute hospital and spoke to their discharge teams to ask what they needed to make it happen. We then went out to the VCSE sector – some already had existing relationships albeit not well developed and not at ward level. We now have the VCSE sector working in the hospital with a more robust handover – more like an extension of care’.

  • ‘Each hospital trust has their own VCSE partner. The discharge navigators are employed by 4 organisations, most of which are CVS’s because they have the connections into the community. A role profile for the discharge coordinator was written jointly with the VCSE sector and brought together ideas about how it would work – something that had not been done before. Across all 4 hospitals there are 10 discharge navigators, working with the ward on a case-by-case basis, to identify what will get people home sooner and to provide extended support in the community for up to 6 weeks. The opportunity for the discharge grant then goes to the smaller organisations who are likely to be providing specific parts of support. One of the indicators of success is that our discharge figures are improving, people report feeling secure when they go home, and there are reduced readmissions. The scheme is now funded for 2 years’.

Challenges and learning

‘There are still huge challenges – for instance reaching out to over 7,000 VCSE organisations. Devon ICS is reliant on the VCSE sector to reach out to the small community groups, which are almost impossible for us to reach at ICS level.

Devon ICS is now considering whether the buddying scheme can be extended to managers within organisations for example making buddying part of the induction for new senior leaders in the ICS. The scale and numbers make this a challenge, but there are also potential opportunities around talent management’.

Greater Manchester Integrated Care Partnership: Voluntary Sector North West – a commissioning framework for the VCSE sector

Overview

Voluntary Sector North West (VSNW) is the regional voluntary sector network for the North West of England. In 2014 the organisations were working with Greater Manchester, Liverpool City region and Lancashire to think about devolution and the role of the voluntary and community sector.

The following is their narrative of change, with key actions and challenges drawn out by The King’s Fund.

Key actions

Developing a common vision

‘At the start there was limited understanding of the devolution agenda, so we looked at what was being done in Scotland. We developed a presentation that covered what devolution is and what it could be using the example in Scotland. We then asked three questions:

  • What would be your vision for your community in 20 years (ie a generation)?
  • What’s the biggest barrier?
  • What will your role be?

In a 12-month period, VSNW ran 104 workshops with over 2,000 people from the VCSE sector. Out of that emerged some of the partnerships that we have in the North West. Having that common vision helped create trust’.

Going beyond your own organisational aims to influence

‘One of the big wins early on was VCSE providers using their resource to engage with commissioners to convince them they had something to gain in being able to articulate a larger vision that didn’t just include their own organisation. This matches with the ethos of development more generally within the Greater Manchester area, put people before organisations’.

Developing a commissioning framework for the VCSE

‘The partnership in Greater Manchester has been operating since 2015 and has had significant investment since as part of the health devolution deal. In Greater Manchester they developed a VCSE commissioning framework. Greater Manchester has a centralised commissioning team, and they seconded 2 people in from VCSE organisations to help develop and have conversations around what that framework could look like. A lead at a local CVS ran a series of roadshows across the 10 boroughs of Greater Manchester to meet with the CCG and local authority commissioners. We also had roadshows for the VCSE sector in each of the 10 boroughs to talk about the key issues. We crowdsourced a strategy to find out what were the key issues around sector investment, commissioning, and procurement. How do you do the market mobilisation of the sector, so it suits large, medium providers and grassroots groups. Finally, ow do you make the most of the 17,000 groups across Greater Manchester, rather than the 10 that might get the ear of the commissioner on the day that they have some funding available?’

‘The Greater Manchester VCSE commissioning framework was signed off by the health and social care partnership and it has recently been re-adopted by the combined authority who have signed up to it as part of the 5-year accord. The new accord will be signed off by the ICP. The framework outlines 7 high level areas of activity that we see as fundamental in supporting the sector, concessions around commissioning and procurement and market mobilisation’.

‘Below each high-level area there are several specifics. For example, it calls for a 1% levy on £1m+ contracts as part of the procurement process. This approach was informed by work that has been done in Bristol where the VCSE sector has agreed with the community provider for a defined percentage to be invested in VCSE provision. This was orientated around social value, so they had had a number of measures of social value embedded in their procurement processes, but it had not resulted in changes in practice in tendering. In the end, they agreed to top slice their council budget and then formed a grant programme to support sector activity. They found this to be far more effective’.

Co-designing grant funding programmes

‘CCG funding was passed to Salford CVS, (a local infrastructure organisation) to run a market mobilisation grant programme that linked to the local place strategy and also to the ‘5 ways to wellbeing’. There was a set of 17 indicators related to wellbeing which included a broad range of issues such as employment and wider determinants of health. Grassroots groups were then able to use the indicators to identify activities or support which would be beneficial to the communities they work with and submit a grant application for funding. This programme is part of a wider Third Sector Fund in Salford which seeks to deliver funding and investment to the VCSE sector. As part of the Greater Manchester STP, all 10 areas were invited to name one flagship project which would be included in the STP strategy and for Salford it was their Third Sector Fund. Over the last 7 years the fund has led to over £10m in grant investment in VCSE organisations and grassroots groups. During COVID it was repurposed to support groups working directly with communities as part of the local response. As a result, emergency cash supported organisations and people within 10 days of it being supplied by government. The Third Sector Fun has been very good at mobilising the VCSE sector and allowed them to think about how they drive change in their community in partnership with CVS, the health system and the council’.

Having mechanisms to develop ways of engaging the VCSE sector in the ICS

‘Greater Manchester has a VCSE leadership group which includes a mental health leadership group chaired by the CEO of 42nd Street. The Chair has worked with a secondee from Mind to develop ways of working which enable VCSE organisations to be embedded in decision-making processes at a system level. Trying to backfill each meeting with representatives from the VCSE sector proved burdensome and ineffective in influencing change. Instead, they adopted a model developed by the Mental Health VCSE leaders’ group in which they would go through a recruitment process to identify one lead for each borough. Each lead would receive £12,000 and it was their responsibility to represent the interests of the VCSE in their borough. In addition, there would be thematic leads. In total there were 22 people appointed to drive forward the work. The leads then fed into the wider partners within the VCSE sector. Key to that approach was having a dedicated role, such as the secondee from Mind, and the early investment from the leadership group which was pump-primed for around £12,000’.

Having intermediaries in the ICS and VCSE sector who advocate for and enable partnership working

‘Alongside the mechanisms for VCSE engagement described above was having someone like the Chair of the Greater Manchester Association of CCGs, who was the public sector lead on mental health, committed to work with the VCSE sector. It was reliant on him having the vision for the VCSE role in the system. It always needed someone on the ICS side recognising the potential, and it needs someone on the VCSE side being able to promote, evidence and do the influencing alongside them and bring the mechanisms into play so they can justify their position in relation to their own accountability structures’.

Building on opportunities to embed and invest in the VCSE sector

‘There is a feeling that the role and influence of the VCSE is ‘snowballing’. An evaluation on the Greater Manchester work after 5 years highlighted two big examples of work with the VCSE sector around mental health and homelessness. VSNW co-chairs some of the mental health work in Greater Manchester. They have just rolled out a £750,000 fund for diverse grassroots groups to support mental health as part of the national community mental health transformation programme funding. We had a secondee manage the process and they monitored the investment being made and held providers to account on the funding they had allocated in line with their stated commitments. There was also a pilot during COVID with Black, Asian and minority ethnic groups delivering mental wellbeing support, which has acted as a forerunner for this larger programme. This sees the beginning of large chunks of investment coming into the VCSE sector’.

Consideration of VCSE alliances in the context of provider collaboratives

‘In Greater Manchester there is a £200,000 workforce programme for the VCSE sector, and there is a £200,000 investment in thinking through the VCSE role with PCNs. There are several other workstreams as well. One of the things we have set up in Greater Manchester is the alternative provider federation, this allows us to be a provider collaborative alongside public sector partners. The alternative provider federation was conceptualised as a next step within the commissioning framework’.

Challenges and learning

‘Spreading the Third Sector Fund model across different places has been more challenging as what worked in Salford won’t necessarily work in other areas. There are now a number of grant programmes (not yet on the same scale) that have set the bar and give a sense of how a place might work with a market development lead agency to drive forward wider outcomes and address the wider determinants of health’.

‘The Greater Manchester leadership group were constantly asked for representatives from the 40 boards in the health and social care partnership. They allowed us two representatives from the VCSE sector on each board, and each of those boards had sub-boards. The door was always open but just having representatives wasn’t driving change’.

Humber and North Yorkshire Health and Care Partnership – developing a VCSE provider collaborative

Overview

Following investment from NHS England as part of the second wave of the VCSE Leadership programme, Humber and North Yorkshire ICS developed a VCSE leadership group. The leadership group has evolved in recent years to form a VCSE collaborative. The collaborative comprises representatives from the NHS, a dedicated VCSE programme director and representatives from VCSE sector infrastructure organisations from each of the geographical areas of the ICS. These representatives act as place leads. The collaborative is also recruiting for a project manager and business support manager.

The VCSE collaborative sits within the governance of the ICS, alongside other provider collaboratives in mental health, primary care, acute and community. They have a terms of reference which outline their objectives and responsibilities as a group, and how they work together. The group meets on a monthly basis to discuss how the VCSE sector engages strategically with the ICS.

The following is their narrative of change, with key actions and challenges drawn out by The King’s Fund.

Key actions

Developing an understanding of the VCSE and sector its contribution

‘The VCSE collaborative started by concentrating on how the VCSE sector could engage at ICS level, by working with the ICS as a health entity in the area and getting in front of key system leads. The programme director plays a key role in talking to people in the ICS and explains what the VCSE sector is and what they can do. The programme director demonstrates the value and contribution of the work the VCSE sector is currently undertaking and advocates for continuous investment into the sector. The programme director is honest about the challenges including being able to speak as one voice, and funding. The programme director was able to do this through building relationships with the ICS chief executive officer (CEO) and executive colleagues, which enabled conversations with senior leads in the ICS. The programme director has created opportunities for ICS leaders to meet with and learn about the VCSE sector. For instance, he arranged for the CEO of the ICS to visit Hull and meet with VCSE organisations who were able to outline their roles, it also gave them the opportunity to ask each other questions. The programme director also took the CEO to one of the more deprived areas of Hull to meet 3 VCSE organisations working in the area, this helped the CEO to build an understanding of how the VCSE sector is structured and managed. After the visit to Hull, the CEO asked if the programme director could facilitate visits to the other 5 places, showing a commitment to the VCSE sector’.

Having an intermediary to navigate between the priorities and challenges of the ICS and the capacity and capabilities of the VCSE sector

‘The VCSE sector needs to understand the challenges and priorities of the ICS and how they can contribute. The programme director has made many presentations to various boards and networks to give an overview of the VCSE collaborative and the sector, how they connect, and their progress. The presentations are used to create conversations around how best to place the VCSE sector within the system to deliver upon ICS priorities. The programme director has gone to meetings for workstreams where it was felt VCSE engagement would add value. Most of these discussions were around the current situation and explored what could happen and how. The programme director role is key in ensuring that the sector doesn’t sit beside the ICS but is part of the direction of travel and the plans to move forward (as it is now)’.

Investing in developing and sharing a sector-wide voice to support wider investment

‘The VCSE collaborative has an annual budget for a programme of work. The collaborative used funding to allocate investment for place leads across the ICS footprint, supporting them to be able to ‘speak as a sector’. The first step of this programme of work was identifying and increasing investment to the wider VCSE sector as a priority. The collaborative made this a key strategic objective. The collaborative noted the language used in conversations around funding and are working towards more simplified and meaningful language. The collaborative aim to include a wide range of stakeholders and not just NHS organisations. Additionally, they proposed a move away from language such as ‘grants’, noting the need to shift the type of language to ‘investment’ which promotes more longer-term development in the VCSE sector. They advocate for strong language, strength, and depth of those conversations with the system around long-term investment’.

Codesigning VCSE solutions to system problems

‘The VCSE programme director and system leaders had conversations in autumn to discuss the relationship between the VCSE sector and ICS and the sector’s contributions in general to help relieve the pressures on the NHS during winter. The programme director was asked to put a proposal and business case together, in a week, outlining what the sector could do, rather than it being a pot of money organisations could bid for. The programme director was able to speak to the 6 infrastructure organisations within the VCSE collaborative and discuss the challenges, their potential responses to it, and identify a range of organisations that would be able to contribute. They chose 4 areas that they could lead on:

  • A social prescribing/community navigation type model specifically for winter.
  • Home from hospital services to help support hospital discharge.
  • Mental health home from hospital service (working with Mind and other VCSE organisations that provide step down services).
  • Increasing volunteering and the roles that volunteers can provide outside of acute care settings with the idea of helping to free up hospital space.

As part of the systems functions, the VCSE sector was able to articulate where they could help deliver some of their requirements and services. The programme director had the time, the capacity, and the existing relationships to create the business proposal. The proposal was submitted a couple of weeks after those conversations and ultimately led to over £1million of investment into the VCSE sector’.

Using VCSE networks to identify opportunities for investment and delivery

‘Two of the infrastructure organisations which were part of the collaborative delivered some of the services already, so they received some of the winter pressures funding. In other areas, this wasn’t the case and so the collaborative went to external organisations through the connections made by the 6 place leads. Instead of the programme director using up capacity and duplicating databases, he was able to use the networks of VCSE organisations and the 6 infrastructure organisations. It was a case of who they knew were delivering the services already. For example, in Hull the collaborative knew the British Red Cross and Hull churches were delivering ‘home from hospital’ services, so they went directly to them and asked if they were able to increase and extend their service provision if they got additional money. Due to the short timescales, they went to organisations they knew were already delivering some of this work and worked with them to extend their services’.

Working with finance directors to facilitate investment

‘The ICS accepted the business proposal for over £1 million. The programme director spoke to the six CCGs (at the time) and the finance leads to discuss implementing the plans. Together they decided whether they were going to amend existing contracts or create new grant agreements to deliver the services to help ease winter pressures. For many services, new grant agreements were put in place with the remainder services receiving variations of current contracts. The grant agreements were drawn up between the programme director and relevant CCG. Once signed off by all parties the delivery of services commenced’.

Developing a memorandum of understanding (MoU) to support effective investment

‘The Collaborative have developed their MOU to include principles around engaging with and managing relations with the VCSE sector, for example  the effective management of investment, such as providing investment in a timely fashion once agreed. The MOU comprises commitments towards understanding and supporting how the VCSE sector operates including:

  • Finance, the sector requires funding to deliver, this may need to be upfront and managed efficiently.
  • Capacity, organisations have limited capacity and cannot provide resource that is not planned and costed appropriately.
  • Reach and trust, the sector regularly engages and supports specific communities and trust has been built over time.
  • The partnership should work with and through these organisations to reach our communities.
  • Sustainability, longer term commitment to investing in the VCSE through different commissioning models.’

Planning for VCSE input as part of a system approach

‘Successful discussions resulted in over £1m investment in the VCSE sector to support the NHS with tackling winter pressures. While the infrastructure organisations could think of many things they could do in small areas, members of the VCSE collaborative were very cognisant of it being a system-wide pressure. It needed to be a system-wide approach taken within the short timescales. It would have been easy to think the £1m was a brilliant win, but the conversation wasn’t just about the money for the previous winter, it was that winter pressures occur every year and so will the challenges. The collaborative members noted that they shouldn’t be talking about how they can come back to the system each year offering their help and asking for the funding, rather it should be planned as early as possible with the VCSE sector’s input accounted for. It should be that the VCSE sector has an allocated budget to deliver services to help ease winter pressures each year’.

Developing approaches to working at scale across the VCSE sector

‘With ongoing investment for the programme, the VCSE Collaborative are now thinking about how the benefits of the arrangement can expand beyond the 6 organisations within the collaborative to benefit the wider sector. Since this investment, the VCSE Collaborative have created VCSE place-based assemblies. These are networks of VCSE organisations operating at place, which will make future engagement easier. The VCSE place-based assemblies will provide a mechanism to approach problems, challenges and opportunities that come from the system. They would be able to ask the places if their VCSE assembly can be involved in a more transparent way, rather than going to an organisation they know are delivering the service’.

Challenges and learning

‘A continuing challenge is the delay between securing an agreement to deliver a service and receiving the funding to reflect that delivery. The grant agreements had started to be developed, however there was a delay in working across six finance teams (as it was) to finally agree them. As a result, there was a period, for some areas, where VCSE organisations received funding several months after the agreement. In this instance, they started delivery without the funding, but this was only possible because the organisations involved were confident the money would be coming, and they had sufficient cash flow to bankroll it’.

‘Learning from securing funding from NHS winter pressures funding has highlighted the importance of having those conversations as early as possible. The sustainability of the investment doesn’t come from talking about winter on an annual basis; it comes from delivering the winter pressures money and engaging in various conversations around embedding the VCSE sector in ICS. There will be other pressures and challenges that the VCSE collaborative will support the system on, and it stems from having those regular conversations’.

North East London Health and Care Partnership: Local Voice – developing a community insights system

Overview

Both the statutory and voluntary sector gather lots of feedback about patient care. For instance, a VCSE organisation might do a survey or run focus groups with the community they serve. It could be a small local group, or a national charity which is collecting information from local branches. The data is often unstructured, and not very comparable but it has inherent value and provides an opportunity for rich learning. Feedback is also collected through statutory bodies through national websites such as NHS.co.uk and free text comments on the NHS Friends and Family Test. Currently, this data is collected separately.

The community insights system started out as a tool used by between 3 to 4 local Healthwatch organisations that were using it in the ICS footprint to support the work of local Healthwatch. It was conceived and created by a staff member at a Local Involvement Network/Healthwatch office back in 2010, and the same individual has continued to develop it in partnership with the North East London Healthwatch and the ICS. The system allows patient feedback and insight to be collated. The application of a coding matrix to each piece of insight provides a means of grouping feedback – for instance, type of care, location, health condition, or sentiment (i.e. positive, negative or neutral). Demographic data such as GP practice or geographical location can also be included. This information can be used to look at the sum of feedback on issues, or over time. For instance, you could look at the sentiment of feedback about primary care. You could also look at the more detailed feedback behind that. Data on the wider determinants of health such as the physical environment, employment and economic factors can also be incorporated. This enables broader pieces of analysis around the place-based partnership such as preventative health.

The following is their narrative of change, with key actions and challenges drawn out by The King’s Fund.

Key actions

Presenting data in a way that is meaningful to the work of other organisations

‘As soon as we started to use the Community Insight System, we realised we started to get better engagement from across NHS organisations and providers. We were able present the insights in a way that gained traction with them – for instance, by presenting graphs and/or amalgamated insights which were evidence not just of the local Healthwatch, but of the wider populations they hear from. This enabled them to use it more meaningfully in their commissioning. We also started to produce quarterly reports on general practice, overall integrated care and our hospital systems. As a result, NHS organisations and providers started to see how this could be used as a tool on a regular basis and as part of their quality improvement programmes’.

Identifying the benefits of sharing data in the context of organisational roles

‘When COVID occurred, the ICS decided to commission a piece of community insight work to support rapid insight gathering, making the best use of all the intelligence sources. One of the challenges the ICS had was how to coordinate something across multiple local Healthwatch organisations. The ICS approached Healthwatch England to support and facilitate collaboration across the 8 local Healthwatch organisations. This included building an understanding around the purpose of sharing data and recognising that the unique strength of each local Healthwatch was not the data itself, but the relationships and links each organisation has in its local community which enables them to gather this insight. This has been important in building relationships across the local Healthwatch organisations’.

Expanding what’s working more widely

‘The ICS identified £50,000 which the 8 local Healthwatch organisations were successful in bidding for. The initial set up funding paid for the local Healthwatch organisations that weren’t already using the system to get it. This capitalised on a system that was working in one place, that could be replicated across the ICS because of an identified need. This meant that they did not have to develop new technology from scratch. In addition, the underlying software for the tool, MS Access, is affordable and widely available across VCSE and NHS organisations’.

Funding to support capacity and development

‘The funding also covers local Healthwatch organisations to generate quarterly reports, it also funded time for training people in how to use the system, time for an analyst and time for a dedicated lead. There is also funding to support new business proposals as new projects are identified. The local Healthwatch also get to generate their own reports’.

Paying attention to data processing

‘Data is entered by both staff and volunteers. Depending on each local Healthwatch, between once a week and once a month we run a ‘people’s experience panel’ where a group of volunteers go through some of the feedback comments and code them as a group. A staff member with experience of the coding system attends the panel helping the volunteers to learn on the job. This helps reduce individual bias in coding. The ‘people’s experience panel’ allows us to train a group of resident representatives and they get to understand what the issues are as they code them. The result is we have a knowledgeable group of people we can call on to do other activities such as codesign. It’s also been good for engaging people across different equalities groups because it builds confidence, they are knowledgeable, and they build relationships with other people and then take on other roles. Now the cost of managing the volunteers is largely met by the local Healthwatch’.

Routine engagement with system leads to share insight

‘As a partnership we meet every 2 weeks with the local Healthwatch and the ICS communications and engagement team who are our main links within the ICS. We generate quarterly reports which are ICS and borough wide and cover services such as outpatients, and conditions such as diabetes. The system now has almost 80,000 comments from local people, this equates to approximately 270,000 separately coded issues that can be used to rapidly generate reports. Our reports feed into the Integrated Care Strategy and across the governance structures of the ICS including quality assurance, primary care commissioning and population health improvement including tackling inequalities’.

Developing data sharing processes and agreements

‘Each of the organisations involved have data sharing agreements in place so that they can share data with each other and the ICSs (including the NHS mental health trust and NHS acute providers) in a way that is compliant with GDPR. Most of the data is publicly available – for example community insights, google reviews, comments on the NHS choices website, surveys undertaken by local Healthwatch, insights collected from local Healthwatch outreach, PALS and complaints from some hospital trusts. The tool uses data collected through existing processes, so each organisation has a process in place to remove confidential and personal information before data is shared. This places some limitations on how the information can be used, for instance it cannot be used to follow up on individual complaints. Occasionally, we are asked about individual comments, but generally the reported data is fairly high level. If we share individual comments, we ensure it is not identifiable’.

Agreeing a clear and shared purpose for sharing data

‘The argument for sharing data in this way has been based on one that is data driven and in support of quality improvement. There was an initial bit of push back – with questions about whether numbers were statistically significant and concerns that local Healthwatch organisations might use data supplied by NHS trusts to challenge and hold them to account. Each time new data is gathered/shared there is considerable investment in developing a shared understanding that the aim of sharing data is to support quality improvement. This approach has also been agreed with the CEO of the ICS. What we have been able to do is highlight areas that work well and not so well and why. For instance, when we presented insights to GPs, we were able to say that their patients really like the GPs and clinicians, but patients also say that they can’t get through on the phone. This highlighted that the issue was not with receptionists, so taking them out for a day’s training was unlikely to address the issue on customer service as the issue was about getting through in the first place. This insight served as a tool to pinpoint what they should be focusing on if they want to improve patient experience and minimising the amount of resources spent. Timeliness and availability of the data also allows organisations to see if their interventions are having an impact, rather than waiting a year for the next GP patient survey’.

Using community insights data alongside systems data

‘The holy grail is when the community insights data that local Healthwatch collect is shared alongside other sources of internal data. We are currently working with the quality improvement team in primary care drawing on PCN level data about GP services. The PCNs get a report on activity according to equalities group, alongside patient experience data, this means they can look at where the activity is and evaluate some of the patient experience data which might tell you why that activity is happening. For instance, why a higher number of children from the Bangladeshi community end up in A&E – what does the patient experience tell us about why that is happening? Our data can be aligned with their data and presented to health professionals in a way that they find useful’.

Using analysis and presentation to create insights from data

‘We find it helpful to bring all the data into the community insights system, and then export the qualitative data and use analysis software to carry out thematic coding. The data is then brought back together. We’ve also been using a lot of infographics to present the data – with 3 to4-page reports showing the patient journey, patient stories, quotes and graphs. These infographics gets used across the ICS and within ICS internal reporting because it gets the message across quickly in busy meetings’.

Having an intermediary in the ICS who can make the right connections

‘The lead for the community insights system also has a role internally in the ICS. The lead provides a key link, in knowing enough of the system and the people involved to ensure it reaches the right people and groups to have impact. Working within the ICS and with the communications and engagement team ensures that it reaches senior teams as well as at practice level. For instance, the ICS asked us to look at drivers for A&E use. We took out all the insights that we had about people who had tried to get a GP appointment but couldn’t and how they ended up in A&E. We analysed it, themed it and showed them a flow chart of the journeys of different groups of people and their route to A&E. This data went to the regional urgent care meeting. That led them to consider new ways of communicating and engaging, targeting the right people, and thinking about what they could do at different access points. That report then went to the health and wellbeing Boards across the ICS. (It needs to reach a wide number of teams to make a difference)’.

Commissioning insight as part of the core work of ICS

‘We continue to get our core funding for the community insights system through the communications and engagement team in the ICS, we are also commissioned by different teams to undertake specific engagement projects. Now we are running a survey for them with care homes, and a survey and coproduction around inequalities and maternity. The funding for these pieces of work comes from each team’s budget. This is important because the insight is seen not purely as a communications and engagement project but is becoming embedded in their core working. The expectation is that local Healthwatch also work with local VCSE organisations in their network. We are also expanding out to some other VCSE organisations, including Age UK and several CVS organisations to bring in wider sources of insight’.

Challenges and learning

‘When we started looking more regionally across the STP we started working in groups of three borough local Healthwatch. Because some of us were already using the system it would make sense if we could try to join up those insights. The 3 local Healthwatch organisations asked the STP if they could start to fund the community insights system. The first time they declined as it was perceived to be too expensive’.

North West London Integrated Care System: Harlington Hospice – developing mechanisms for data sharing

Overview

Harlington Hospice is based in North West London, providing end of life care support for people in the London Borough of Hillingdon. The hospice has been involved in a few projects which aim to share data across organisations for the purposes of joined up care delivery and as part of service planning and population health management.

One of these projects has been Coordinate My Care (CMC), a single care plan across London for people who require end of life care. It allows organisations involved in end-of-life care, including the London Ambulance Service, GPs, and community services teams to input into a single system. The approach that has been taken by the CMC Urgent Care plan is the first time the hospice has experienced this level of consistency across different services. Attention to all the organisations that form part of the end-of-life care pathway and therefore who need to contribute to CMC, including hospices and private sector care homes who may have an NHS patient, means that everyone is at the same level in terms of the design and planning processes.

Harlington Hospice has access to the clinical records system of the local community health services, and is engaged in work to incorporate their data into the local Whole Systems Integrated Care (WSIC) data warehouse to enable the delivery and planning of care.

The following is their narrative of change, with key actions and challenges drawn out by The King’s Fund.

Key actions

Having the right governance in place

‘The governance for CMC ensures that all the different organisations within London that support end of life care have the correct information sharing agreement and a data protection impact assessment is carried out. VCSE organisations involved, such as hospices, have access to the system, and can input updates which are then shared automatically with other organisations and teams dealing with that patient. This provides a greater confidence in the system’.

Understanding how shared records systems are accessed and the infrastructure required

‘CMC is accessible through EMIS, SystmOne, and the London Care Record. A web portal means that the relevant parties, including the hospice, can access CMC through their organisational systems. CMC (and the new platform Better Care) requires a dedicated Health and Social Care Network (HSCN) line. This is a secure physical connection to NHS records and systems. The HSCN line requires a separate router and firewall and, as a result, access to CMC and other NHS systems is only through local devices, therefore, you must be on site to access it, and on a computer that has the correct routing’.

Having someone with the right technical knowledge to support the work

‘Within the hospice this work has been led by the data compliance manager who manages system implementation and data flow including information governance and provides internal IT helpdesk support. The data compliance manager is supported by a colleague who reports on data analytics’.

Ensuring both clinical and technical leadership in designing shared records systems

‘The CMC system started as a pilot project in North London but is now led by South West London ICS as a project for the whole of London. CMC is being decommissioned and the data is being migrated to Better Care. Through the tendering process a new company won the contract. The new provider has built on the CMC platform to develop greater usability. The new provider has been influenced by strong clinical leadership who have defined what data needs to be collected, the provider has ensured that it works to support clinical care across the different organisations, as well as technically working for different organisations’.

Working with VCSE organisations to understand and develop processes for data flow

‘A key part of ensuring the system works for different organisations is attention to how the data flows. This includes the format of the data when entered into the system, how often data is required, what the process is and how it can be extracted. We often see the product and the reporting dashboard, but to contribute we need to understand how the data flows at an operational level’.

Leadership on the development of information governance processes

‘South West London ICS has led on all of the information governance. They undertook a thorough data protection impact assessment (DPIA) which is required by the Information Commissioner’s Office for any data flow. It is a legal document which risk assesses how the data flows for any project. Firstly, we undertake a DPIA to make sure that we’re in agreement with the legal basis for the data, how it’s going to flow, who the processor is, who the controller is, what are the risks of losing the data to the organisation etc. A DPIA ensures you evaluate all these questions before making decisions’.

Seeing VCSE data as integral to decision-making

‘The WISC dashboard is a shared database across North-West London ICS. The database is effectively a data warehouse in which anonymised data is collated. The outputs are all based on Tableau (data visualisation software) which is a very dynamic reporting system. Outputs include heatmaps of service use throughout that area which can then be used to inform planning of services in the wider sector. It gives a good story of different areas and the data they have and how it is used. Commissioners have identified it would be beneficial to extend access to hospices and the data they have would be useful as part of the wider mapping. We don’t need to pay for access to WSIC because having our data at a wider level is seen as beneficial to make better decisions’.

Challenges and learning

‘The HSCN line and associated technical infrastructure for NHS clinical records systems are managed at a national rather than local level. They provide a list of approved suppliers for the line, each of which has a different cost. With different organisations purchasing access to the line on different bases – it can be challenging to argue for organisations such as commissioners to extend their access to smaller organisations such as the hospice when it might be cheaper to purchase from a different approved supplier.

‘The decision to put the line in has to be approved through the hospice’s own governance systems. The cost of the line has been borne by the organisation. We have been able to fund the line through our associated charity which seeks to raise funding for the hospice. In addition, the line has a monthly access cost. For some smaller VCSE organisations the cost is prohibitive and not viable for the charity to invest in’.

‘One of the challenges we have in the VCSE sector is that we don’t have much capacity. As much as we say we need to be part of all the meetings, it’s hard to find the time or people to attend! What has helped is that all the documentation and videos of meetings are shared. This has helped us to keep up to speed with how the system is developing and absorb information in our own time’.

‘The hospice has access to the local community and mental health trust records system – TPP’s SystmOne community modules. However, access is read-only, so for any care the hospice provides, they have to inform the community team so they can update the patient’s record. It’s an extra step in the process’.

‘Access to SystmOne was initially agreed with the head of information governance at the NHS trust. However, when it comes to implementation at an operational level, the trusts’ teams have specific governance processes and protocols that they need to follow. For instance, there is often a stipulation in many contracts to only use NHS email. This causes difficulty because, as we are not employed by an NHS organisation it can take weeks to obtain an NHS email address. Previously we have been able to obtain an NHS email address through the (then) CCG who made us a sub-organisation to create emails. We now have an agreement with the local Community and MH trust. They have a requirement that all requests must be filled in by an active service manager, however the hospice lead is not a manager, and the service manager already manages a clinical team, so obtaining email requests for the 150 staff that work at the hospice creates a significant additional burden’.

‘One of the challenges of adopting organisational platforms, is that the different organisations have different platforms. For instance, the EMIS platform is primarily used by hospitals and GPs in their area, while the community and mental health trust which provides district nurses, end of life teams and palliative care teams use SystmOne. Traditionally, decisions about which system to use have been made at an organisational level but they haven’t considered the impact at an operational level, particularly when care is provided across different organisations. In practice this means work-flow processes and how data will flow to the various different systems without duplication is not considered.

‘One of the key challenges for VCSE organisations is identifying the right person to speak to. Initial conversations with the CCG on access to the WSIC data warehouse began 3 years ago. However, changes in local health organisations (including a merger of CCGs) and changes in personnel have contributed to delays. The person who built the WSIC database no longer works for the CCG and when people leave the relationship breaks down. Recently we have been contacted by the operational lead in the CCG for this work, but it’s not clear where they sit in the organisation. It is important to know if there are changes in personnel. The CCG now has an application process to get access to WSIC which may help to centralise conversations’.

North West London Integrated Care System: H4All – partnership working through place-based VCSE alliances

Overview

Hillingdon has had a third sector collaboration called H4All in place since 2013 to engage VCSE organisations in service transformation processes. H4All comprises 5 local charities:

  • Harlington Hospice
  • Age UK Hillingdon Harrow and Brent
  • Carers Trust Hillingdon
  • Hillingdon Mind
  • DASH – a local disability organisation

The CEOs of these organisations come together on regular basis, (at one point this was weekly). Together the group provides a talent pool that no one third sector partner has, because each CEO has slightly different skills. CEO’s take a lead on different things making best use of those skills.

Unexpectedly, going through the process of working and learning together has also benefited the CEOs and their organisations individually. H4All doesn’t employ staff but seconds them from the partner organisations to support policy development alongside managing the H4All services collectively. Through this collaborative process, they have learnt more about each other and about what is possible.

Hillingdon Health and Care Partners was set up in 2014 and now forms the local place-based partnership as part of the ICS. It comprises:

  • the local acute hospital
  • district general hospital
  • community and mental health provider
  • GP federations
  • CCG

As a third sector collaboration, H4All has a seat on the board, is involved in decision-making and governance and attends programme groups.

The following is their narrative of change, with key actions and challenges drawn out by The King’s Fund.

Key actions

Building relationships and understanding a systems overview

‘We always ensured that the Hillingdon Health and Care Partners board was attended by two of the executive group from H4All. This enabled us to build up relationships with the CEOs of the CCG and the NHS trusts. There were several groups, including:

  • a strategic finance group
  • a group that dealt with developing the alliance agreement
  • a group that dealt with developing business cases
  • a strategic leadership team (since it has moved into operations).

There are 3 of us out of the 5 organisations that are involved in H4All, but because we go to most of the meetings, we had a better understanding than the NHS providers as they have different staff going to different meetings. This gave us a systems overview which enabled us to identify where the gaps were and potential business cases. Without that information we would not have known where to start’.

Understanding ICS finances and expectations of delivery

‘As we started to learn how finances worked, we were able to identify what the metrics are that VCSE organisations need to meet. As third sector organisations we were under much higher scrutiny than the NHS providers were. Anything we did we had to have proof of its impact, and then we only got money to do proof of concept. This gave us an understanding of the evidence needed to meet NHS requirements, what the targets would be, and we had to be confident in meeting those targets. In practice we under promised and over delivered’.

Sharing risk as equal partners in a system

‘Hillingdon Health and Care Partners has a degree of pooled budgeting. We are part of the risk and gain share with the CCG. The CCG took 50% risk and gain share, the two smaller providers, H4All and the GP Federation took 5% of the risk and then the rest of the risk was split between the two NHS trusts. This year H4All has a risk of £32,000 and we have ringfenced that in our budget. We have now set up H4All as a charity, which acts as an incorporated vehicle that holds the contract. Building the reserves up has been challenging for us. We currently have a reserve of £250,000 – £300,000 with a turnover of £2m. For us risk is important. In a board meeting, it enables H4All to highlight how they are taking part in this risk and enables us to ask how others are contributing’.

Identifying additional funding expertise to develop business practices

‘Each of the leaders in H4All were doing this work in addition to running our organisations and the whole system work. This had given us the information, but we didn’t have the resources to take it forward. At this point we went out to find funding. We had some conversations with The National Lottery Community Fund, but they didn’t have any relevant schemes at that time. We identified that the Big Potential programme had funding which could support access to consultancy support. The programme required organisations to shortlist which consultancy support would support their proposal, and one of the organisations said they would be keen to do this. We submitted a bid and were successful and received £72,000 in funding. The programme aimed to improve the sustainability, and capacity and scale of VCSE organisations in order that they may deliver greater social impact. The programme provided access to consultancy support to support sites to raise awareness of the social investment market and support VCSE organisations to prepare themselves for social investment or win contracts. They helped us look at our financial modelling and forecasting’.

Identifying system pressures and approaches to addressing them

‘Attending meetings meant that we were able to identify where the pressure points were, and that our system was reactive to these issues rather than proactive. One of the key areas was pressure on hospital beds. Two contributing factors were many people who were admitted could be kept at home and being able to discharge people. Then we looked at models for how we can prevent this. We identified models that worked elsewhere including a model to address the needs of high intensity service users and active case management for people with long term conditions as these groups are most at risk of admission to hospital. We already had a couple of projects running in these areas and we knew that if there were opportunities to invest in preventative approaches, we could reduce the number of admissions to hospital. As part of the support provided by the Big Potential programme the consultants helped us to develop 5 business cases and we received funding for 4 of them’.

Obtaining the relevant information by being in the room

‘Because we sat on all of the boards and all of the meetings within the local partnership, we had the information. Without that information we wouldn’t have been able to put the cases together’.

Addressing system issues with VCSE solutions

‘We also came up with business cases that the commissioners would not have ordinarily commissioned, as they were all non-medical, and based around addressing the wider determinants of health. For instance, the service that we proposed to support high intensity users, although the commissioners knew about it, they had not thought about commissioning such a service. Our approach was to identify the problem, identify some potential solutions to prevent admission and then develop them for our local market. These services have now been running for 3 years. Each has been evaluated and each achieved their targets in terms of savings. The plan outlined a return on investment of 1-1.5% to 2-3%. The evaluation looked at patients that came into the system in the first 10 months of the project and compared data from 6 months prior to engagement of the service and 6 months post engagement. There was a significant drop in acute care attendances alone’.

Investing in business development capacity

‘H4All has since invested in a business development director who is employed to produce the business cases. This came out of the learning from the Big Potential investment. The business development manager was initially funded by three of the charities for a year. We have since got half of that funding from other projects, and the other half has been split 3 ways. We are now operating on work at ICS level. Although the business development director is funded by the umbrella, they are not a member of any of the individual organisations. This has been valuable in creating a bridge between the group and the ICS, particularly as the group is supported to develop infrastructure for engagement across the ICS as part of their role in 3ST, an ICS level VCSE alliance’.

Allocating funding to support transformation projects

‘The acute hospital received just under £5m increase to deal with the increase in demand on A&E and non-elective admissions, so it is baseline funding. We agreed as a partnership to use half of that money to run transformation projects with an aim of reducing admissions. The money was put into an escrow account which was held by the acute trust but separated from their budgeting processes. Individual partners then developed business cases. We were able to develop business cases using the data that we obtained from the ICP and we put those forward as part of the transformation funding that was available. In Hillingdon we got about £1.5 m in funding out of a pot of £2.5 m for services, as part of the place-based model. Of the services and models that were funded, some were successful in creating savings, while others were not. The VCS business cases that were put forward created savings, which in part was because we were very careful and commercially minded’.

Challenges and learning

‘Hillingdon does not have a CVS or infrastructure body. As part of a commitment to place-based working, H4All have supported the development of a health and wellbeing alliance. The alliance comprises a wider group of 60 smaller local charities and faith groups who are interested in health inequalities and supporting residents with their health. In addition, H4All has developed a community development arm. These functions are supported by outside grant funding. Although these activities make an important contribution to insight and expertise at a place and strategic level, H4All do not receive any investment for them from the wider system’.

‘Although H4All is fully embedded as a partner in the local place-based partnership and contribute financially through a risk-share agreement, each of the organisations involved in H4All has been required to retender for their service-delivery contracts. This contrasts with other NHS partners for whom the requirement for competition has been removed. The reality is that without those core contracts, it would make our role within the Hillingdon Health and Care Partnership, and the ICS through 3ST very difficult. The ICS sees this as a procurement issue, but it has strategic implications. Each of the organisations in H4All contributes at a wider strategic level because it is the right thing to do, but it’s largely over and above the day job and for which we do not access any additional funding. Underlying this is a lack of understanding for how VCSE organisations work and are governed. Our core business is to support local residents. If our funding is reduced, then our wider role in the system would not be justifiable. The instability caused by something at place-level could impact more widely on the strategic contribution we are making at ICS and place level. It’s more of a precarious position for the VCSE than those on the statutory side realise’.

North West London Integrated Care System – embedding the VCSE sector at scale

Overview

From previous experience, we (NW London ICS) recognised the need to involve the VCSE sector in developing strategy and driving programmes of work that we wanted to focus on. Securing that level of representation was challenging.

The programme lead for self-management and prevention for the strategy and transformation department in the collaboration of NW London CCGs (as were) identified two key experiences demonstrating how place-based approaches to representation could work:

  • A VCSE alliance in Hillingdon (H4All – see previous case example)
  • Kensington and Chelsea Social Council who had been consistently supported by the CCG to work together as a third sector group including providing a social prescribing service for older people.

However, the challenge was to build on that to operate across the eight boroughs that the ICS covered. It was agreed to start with those two organisations as representatives on the board on the condition that they would start to bring other parties in. That was the beginning of what became Third Sector Together (3ST). Both organisations took their learning then started to bring other partners in.

3ST is structured with a leadership group; a strategy group with representation from the eight boroughs in NW London (operating like a reference group); and borough-based groups which link in with the work at neighbourhood level. Thus, they are developing an infrastructure which mirrors that of the ICS.

The leadership team has done most of the work in getting everything up and running. They have also increased representation on their governance with four representatives from each of the boroughs, each of which is elected by the boroughs. One of the elected representatives in each borough is a CVS or infrastructure organisation which means the ICS can tap into those overarching umbrella organisations.

The following is their narrative of change, with key actions and challenges drawn out by The King’s Fund.

Key actions

Developing governing structures and contract management models to support the wider sector

Because H4All is already established, we are in the process of moving it from a borough-based vehicle to a NW London vehicle. We are doing a lot of work around governance structures and contract management models. We have been working on this for the past three years.

It is much harder to take a bigger group of people, with approximately 10,000 third sector and community groups, across the area. So, there are dual running activities of pulling VCSE organisations in and together and engaging with a system that is still developing its direction.

Considering how VCSE alliances and activities align with the context of place

3ST has two main elements: 1) engagement and influencing, and 2) informing. It does this through groups at three levels:

  • borough-based leadership teams
  • a strategic group which includes representatives from each of the borough teams that supports each leadership group, conducts borough-level strategic activity and ensures wider engagement with all interested third sector groups and organisations at a neighbourhood level
  • an executive leadership group which is responsible for sub-regional strategic and income generation activity and with oversight of borough and neighbourhood

Any member of the CVS organisations is part of those partnerships and we have over 25 larger VCSE provider organisations involved as well.

Prioritising investment in VCSE infrastructure where required

Although three boroughs have more well-developed engagement, the other five haven’t and therefore we are seeking to invest in those areas. This is important particularly if we are to serve as an engagement channel and feed information back from community groups at a neighbourhood and borough level into planning.

We used £40,000 in funding from the NHS England Voluntary Partnerships team to develop our governance model and requested funding from the ICB to enable us to get the infrastructure in place in these areas.

Developing a VCSE provider collaborative

We are in the process of developing a third sector provider collaborative which is about the third sector as a provider. In NW London, the provider collaboratives are split horizontally so the acute trusts are all working together, the community trusts are working as a collaboration, the GP funding has come in as separate, as has mental health; this is where the funding is. To get ready for this, 3ST has negotiated with the ICB to become the recognised third sector collaborative.

Having a lead within the ICS as an intermediary with the VCSE sector

The ICS programme lead for strategy and transformation has since changed role to lead a programme focused on volunteering and the voluntary sector. Part of that remit is to ensure the voluntary sector are around the table as part of the ICS and have a role in developing the ICS going forward.

Developing a set of expectations between the ICS and VCSE sector

We have set up a programme board to enable 3ST to have a running agenda, particularly in how they are engaged at a NW London level and how we support them with that. The ICS developed a set of expectations, setting out what the ICS will do for 3ST and vice versa. This enables a consistent approach no matter who turns up to a meeting and an understanding that they are not representing their own organisations, they are representing 3ST and the collaboration more widely.

Embedding VCSE development as part of ICS programmes

Part of the role is also working with the programme leads across all the areas in the ICS and at a partnership board level to ensure we have representation from the third sector on all groups. It’s also not about setting up a programme board about VCSE development and saying that VCSE development is ‘done over there’.

What we do is make sure it is ingrained across all the programme’s work. So whenever there are discussions around strategy or funding, the third sector is there to ask questions and support the development of the strategy. In particular, how they can support with some of the issues and challenges that the ICS is facing.

In reality, what happens is people ask to have a seat at the table and what the NHS does is create lots and lots of tables and lots of meetings. It’s then recognising that we always ask for the third sector to be engaged but we don’t expect them to be on every single meeting. So they have a seat on every programme board that we have set up, they have a seat on the partnership board and then they have a seat on some of the working groups where they feel they can add value and they will benefit from that relationship.

The aim has been to embed VCSE organisations at every level and every programme board, and the programme lead now only steps in when there are problems or if any new groups are formed and they need to identify a VCSE lead. For instance, a group has been set up to focus on homelessness, and a representative has been identified on that board. That process took a couple of weeks, which is fairly streamlined.

Developing an understanding of the role and value of VCSE representation

The initial response from boards to the question of VCSE representation is often ‘who are they?’ and ‘who do they represent?’ We recommend that whenever a VCSE representative attends the board for the first time, the expectation document is presented back to the group so there is clarity about the role of the VCSE representative, as a representative of 3ST and what 3ST is.

3ST has since developed their website so it outlines what the collaboration is and how it operates. Ultimately the strength of this should be that people see the benefits of it. It should be recognised that having the VCSE sector involved will enrich the approach to a developing programme of work, rather than being a tick-box exercise. This is about winning over hearts and minds, and this takes time. Progress has been made; there is a spread of representation.

Part of the role of the volunteering and voluntary sector programme board is to provide challenge back to the 3ST to make sure they are representing NW London, that is making sure that membership is strong in each borough and they are representing the diversity of the third sector and what they deliver. Many small local charities and groups don’t want to be on a programme board, but they want their voices heard.

Broadening representation of the VCSE sector

Part of the challenge raised by the ICS was the potential over-representation of VCSE organisations working with older people. So, we’ve challenged 3ST to develop representation of charities supporting young people. They also identified that they did not have any organisations supporting autistic people, so they have since engaged with an organisation and they have included them in the membership, and they have a membership place at a North West London level.

There is recognition that some of the organisations they are working with might not align with an individual borough but instead operate across the North West London area. In addition, making sure that a mix of local and national organisations are involved. They are developing an associate model for membership of national organisations We were keen not to support the development of a closed shop organisation; it needs to be inclusive and open to all third sector organisations.

Developing work through ICS programmes that is owned and co-designed by the VCSE sector

The ICS is developing a piece of work with Helpforce around the Back to health campaign which is a model that has been developed in North Warwickshire. We are driving that through the volunteer and voluntary sector programme board and part of that is about making sure that it’s co-owned by the VCSE sector and 3ST, developing a volunteer model and VCSE model that looks at how we can support our patients in their journey into and out of hospital. That’s about developing a model so it is owned and taken forward by the third sector.

Developing a VCSE infrastructure funding proposal to enable engagement

We have to recognise that if we want 3ST to engage with us in developing our strategy, it takes time and it costs them money to do that. Kensington and Chelsea Social council secured funding from their bi-borough place-based partnership to engage with the ICS and to take part in 3ST. The rest of the organisations are engaging in addition to the role they play within their organisation. The feedback from members of 3ST is that part of their remit as individual organisations doesn’t include engagement at a system level to develop strategy. So when they are trying to justify funding and resource to their trustees it can be a difficult conversation.

Using the programme board we have developed an infrastructure funding proposal: it outlines what the ICS gets from engagement in this way. It is not delivery of service but supporting VCSE leaders to engage at the programme boards, supporting development of the strategy. The proposal also recognises that there are some boroughs which have received funding to develop their infrastructure from borough-based partnerships while others have not received any funding and therefore prioritising funding to support their engagement at the same level.

Sharing information and data from ICS programmes with the VCSE sector

The engagement of 3ST at all of the programme boards provides them with access to a lot of the data that is being produced from that. They also receive all the papers from each of the programme boards.

An example of this was a piece of work undertaken as part of the acute care programme board: looking at patterns of not attending hospital appointments in relation to deprivation and ethnicity. Data analysis conducted for the acute care board found a clear correlation between higher rates of ‘did not attend’ (DNA) for people from high deprivation compared with low deprivation. They then looked at deprivation across the ICS and developed a heat map with an aim of focusing any work on DNAs at PCN level. That analysis was shared with the third sector.

The board set up a task and finish group to explore what they can do to address these issues, involving 3ST are involved. There is a meeting between the acute care team and 3ST to discuss some of the ideas they have about reducing DNAs and supporting hospital discharge and whether there is an opportunity to pilot some of those approaches.

Joint working between the ICS leadership and VCSE sector

The programme lead for volunteering and the voluntary sector meets with 3ST on a weekly basis and attends all their strategy and leadership meetings. A lot of it is listening to them, and if there are issues, taking ownership of them within the ICS and supporting them through that. In addition, the role is about providing challenge back to them as a critical friend and acting as a bridge, articulating back to the group what he is hearing from others in the system.

ICS ownership of third sector development

From an ICS perspective, we have owned third sector development as part of our programmes. Our senior responsible officer is the CEO of West London Health Trust. It needs to have a home to drive that forward, and ownership. Otherwise, it can feel like the third sector is on the sidelines, shouting to come in.

Being a core part of the ICS programme means that leadership and some of the shouting can come from the established programme lead role for volunteering and the voluntary sector within the ICS from the VCSE perspective. Once you have the ownership within the structure of the ICS, the aim is that it spreads across the ICS, rather than being a discrete programme.

Understanding that embedding the VCSE sector in ICS is a developmental process

At a system level there is a need to recognise that some areas are going to be more developed and take this on more than others. You should not expect perfection on day one and accept that initially it may be those who are in a position to get involved, or those with strong voices who lead.

One of the challenges has been people expecting a ready-made NW London group that represents all the boroughs and all the disciplines. It will initially prioritise specific voices, but this is where investment in the infrastructure will be important in bringing other areas to that same level.

In the first year, there was a lot of challenge around the more vocal and engaged organisations being primarily from two of the eight boroughs where there were well-established infrastructure organisations. However, investment in infrastructure and the development of 3ST means that is no longer the case, with four representatives per borough with each areas infrastructure body and representation from other areas. Although the ICS has been facilitative of this, achieving it has been the role of the VCSE sector.

Challenges and learning

We are developing our ICS strategy and the individual leading on that strategy is working with 3ST to identify how to work together and what areas they think need focusing on. The third sector have highlighted how data sharing needs to be part of this. Our finance director, who is also engaged with 3ST has also had that conversation and offered to support with access to data.

Because we have a whole systems data warehouse in NW London it is an easier approach to provide access to some of the activity data. Working with our evaluation partner, Imperial College Health Partners, on this piece of work provides them with access to this data. Ideally, we want 3ST members to access the data themselves. It’s not been solved yet, but there is a clear direction for how to do that.

Somerset Integrated Care System: Open Mental Health alliance – commissioning the VCSE sector at scale

Overview

Somerset ICS (then CCG) was awarded funding from NHS England (then NHS England and NHS Improvement) to be one of 12 early implementer sites for a programme to transform community mental health care. Rethink Mental Illness and local VCSE organisations and worked with the ICS and NHS mental health trust to put the bid together.

Part of this reflected leadership from the trust and the ICS on the need for a fundamental shift in provision and working more closely with communities and the VCSE sector. The local authority was brought into discussions early on. On receipt of the funding, the ICS put out a £1 million a year tender for an innovation partner formed by an alliance of the VCSE sector.

Several organisations contributed to bringing VCSE organisations together and alliance building. Rethink Mental Illness already had good working relationships with local commissioners and the NHS England mental health team. Therefore, they were able to identify how commissioning plans aligned with the proposals outlined in the community mental health framework and the ambition to embed VCSE provision within associated funding.

The local authority played a key role in reaching out to VCSE organisations, as did the local VCSE infrastructure organisation which was seen as a trusted organisation among local VCSE organisations.

The following is their narrative of change, with key actions and challenges drawn out by The King’s Fund.

Key actions

Adopting an innovation partnership approach to commissioning

This approach means there wasn’t a pre-defined specification from the outset that the alliance of VCSE organisations was going to be bidding for, but instead the ICS, local authority and NHS mental health trust invited the VCSE sector to come together and shared a broad view on what they wanted to do together focusing on the outcomes it aimed to achieve.

Those statutory organisations then ‘left the room’, allowing the VCSE organisations to decide how they would want to do that, the structure and governance for taking their work forward and how they would manage the contract, as opposed to working to a pre-defined plan of the NHS.

Using a democratic process to identify alliance leadership

The local VCSE infrastructure organisation led a democratic vote on who would become lead accountable body for the alliance. Organisations then put themselves forward for being the lead and a vote was held. This was key to building trust and it being VCSE-led.

Establishing organisational roles and responsibilities as part of alliance governance

The role of Rethink Mental Illness was to support co-production and project management as well as communications. As the contract holders they are also responsible for risk management and reporting to commissioners. Given the variation in size of the partner organisations, it also provided a sense of assurance to NHS providers and commissioners.

Rethink Mental Illness also made commitments to open book accounting to ensure transparency across the alliance, that all decisions would be made within the partnership organisations governance structures. However, as the contract holder they retained the right to raise anything they saw as questionable use of public money at partnership board and the trust. Finally, they agreed that they would not take on any of the contracted work themselves unless the partners voted that they wanted Rethink Mental Illness to do that due to a gap in provision.

The Open Mental Health alliance initially comprised:

  • Somerset NHS Foundation Trust
  • Somerset County Council
  • Somerset CCG (now ICS)
  • The mental health charities:
    • Rethink Mental Illness
    • Mind in Somerset
    • Second Step
    • Balsam Centre
    • Chard Watch CiC
    • Age UK Somerset
    • Citizens Advice
    • Somerset and Wessex Eating Disorders Association (SWEDA)
    • Spark Somerset.

There are now a wider range of charity partners involved that focus on the wider determinants of health including:

  • Diversity Voice
  • Somerset Activity Sports Partnership
  • Fuse Performance
  • Young Somerset
  • Conquest Centre
  • Minehead Eye
  • 2BU

Recently the alliance has expanded to include a local substance misuse provider.

As a big national charity, Rethink Mental Illness recognised a national programme to transform community mental health services as an important opportunity to improve the lives of those they support, but that it requires a whole community response. As a national leader on severe mental illness, Rethink Mental Illness has the policy knowledge, relative financial stability, IT and communications capacity. It sees see its role in this as one of ‘intelligent partnering’ – that is, shifting from service delivery to being more focused on enabling and working in a symbiotic way with smaller VCSE providers, communities, institutions, and individuals within communities.

The organisation has since embedded this way of working and a commitment to partnership as part of its strategic plan. This means helping to build capacity in smaller organisations and building on what already exists in local communities to support that. This includes sharing resources, such as expertise from our IT team, to support organisational development among smaller charities.

Paying attention to governance, vision and aims and values

The governance of the alliance has developed iteratively. The alliance partnership board has a term of reference, and all partners sign a partnership agreement, outlining our vision, mission, values, ways of working, roles, responsibilities and accountabilities, and our governance structure.

Each VCSE provider is sub-contracted by Rethink Mental Illness, as the Lead Accountable Body, but with oversight of the contract delegated to the board. The alliance members have also spent time and energy on coproducing their vision, mission and values, including bringing in different VCSE voices which has been important to tackling cultural barriers and embedding relationships which ensure sustainability.

Co-production at the heart of the work

Co-production is core to the alliance’s ways of working: having everyone in the room and with different perspectives being equally valid. This includes representatives from the community and people who are experts by experience of mental illness. The conversations were externally facilitated and focused on what we want to do, what the barriers were and the problems in community mental health support and where we might want to go.

Some of the ‘lightbulb moments’ for commissioners and other people in the room came from hearing people who need or use mental health services about the things that are important to them. As an alliance we then put a bid into the ICS for the contract.

‘The alliance was awarded a contract of £1m in January 2020 for 3 years and is now about £4m. In the initial months, the alliance continued a coproduction approach to developing the model of delivery and agreeing which organisation would deliver what.

However, the impact of COVID led to fast forwarding plans, adapting the model in the context of COVID, to meet an expected increase in demand for support. Many of the things implemented early on have since become part of the longer-term model.

For instance, introducing a 24/7 VCSE-led mental health helpline with close links to the NHS MH home treatment team and other NHS services. That was enabled by the relationship-building between those VCSE partners and the NHS in the work that we had been doing up until then.

Allocating time and resource for activities to develop and maintain relationships

It has been important that we have put dedicated time and resource into activities such as strategy awaydays and planning. The commissioning relationships allow us to allocate resource to do that. One of the strengths of the alliance structure has been the shift of power and the amplification of voice of different sizes of VCSE organisations. The alliance has also sought to continue to expand, extending to other areas and organisations so that it’s not a closed shop.

Developing a discrete working group that meets on regular basis

During the pandemic, the Somerset system set up a ‘strategic cell’ for mental health and learning disabilities across Somerset. This has equal representation from the VCSE sector, the NHS mental health trust, ICS, local authority and public health to hold the strategic level decision making and system-level thinking.

This group is relatively small and has met on a weekly basis. This has enabled the development of a high level of trust and good relationships which have made it easy to make timely decisions. The group have a governance system, but they have also developed a set of principles that they agreed together and are then shared across the VCSE alliance and local statutory organisations.

Recognising the costs of working collaboratively with the VCSE sector

To date, the cost of commissioning through an alliance is higher. There are additional costs in alliance working in terms of convening and money flowing through multiple organisations. If the overheads on a typical direct contract were around 12%, for an alliance they are probably in the range of 15-17%.

However, the value that can be leveraged from collaborative working builds over time – such that, over time, organisations get to know each other and their capacity and are able to recognise the strengths and opportunities each bring and look beyond their own organisations to the assets of the alliance. This also brings efficiencies in terms of collaborative rather than competitive behaviours. However, this comes from building an ecosystem based on trust, and requires ongoing investment, rather than transactional and repeated contracting rounds.

Co-designing an integrated care record

The local shared care record is based on Black Pear’s core care record software. In theory, the system lets services streamline their existing information and share it with each other, rather than creating a unified dataset from scratch. This should reduce the need for infrastructure and time needed to connect disparate record-based systems.

As equal partners, staff in the VCSE sector should not only have read/write access but be able to initiate a new entry. This would support the ICS system approach of ‘no wrong door’. The platform supports the collection of outcomes that were co-produced by the Open Mental Health Alliance.

However, the alliance has experienced significant challenges in implementing this due to data governance requirements and the number and different sizes of organisations involved. Data governance has now been resolved, but some technical challenges remain. A way forward has been identified. It has been essential to stick with this, as without it, the ‘no wrong door’ approach would have to be compromised.

Use of technical expertise and capacity of a national charity to enable local charities

For organisations to gain access, they need to ensure they are compliant with NHS information governance requirements and completion of the NHS Data Security and Protection toolkit as part of that. As the lead accountable body for the Open Mental Health Alliance, Rethink Mental Illness acted to support and bridge gaps in technical capacity and expertise to be able to complete the toolkit and gain access to the digital platform.

Development of a capacity and attendance payment

As part of the Open Mental Health work in Somerset, a capacity and attendance payment has been developed – which provides support to small charities and community groups to attend and contribute to planning and development meetings. In practice, this means paying smaller organisations for the time they spend engaged in these activities.

Development of a microgrants scheme for community groups and small charities

This provides a route for small organisations which don’t want to go through the organisational development that is implicit in working as part of an alliance model. This forms part of the approach to involving organisations in the planning, as well as in the delivery model.

For instance, another Rethink Mental Illness programme in North West London that is an alliance focused on suicide prevention includes a microgrant scheme to support small charities and voluntary groups. The alliance provides infrastructure for coproduction of where to target money, as well as being able to hold the risk for funding relatively small organisations and interventions.

Suffolk and North East Essex Integrated Care System: Voluntary, Community, Faith and Social Enterprise Assembly – developing system insight

Overview

During COVID, a group of 40 VCSE leaders in Suffolk and North East Essex met with the head of transformation in the ICS as the ‘eyes and ears’ of things that were happening on the ground and, in turn, this resulted in the NHS allocating some resources to addressing some of the issues that were arising.

The national programme supporting progression from sustainability and transformation partnerships to ICS provided an opportunity to form a smaller group and then look at a higher-level strategy for moving this conversation on from the issues individual agencies were experiencing to the wider VCSE sector.

Leaders from VCSE organisations put in expressions of interest, a chair and vice chair was nominated, and we made a universal agreement to move beyond our 12 individual organisations to try and take the sector forwards. We set about looking at the issues in the sector and across the sector and we created a process with an aim to look at:

  • Ourselves as organisations
  • Developing a MOU with the ICS,
  • How the sector is perceived with a view to developing a corporate view for the sector
  • Attending ICS meetings to understand what was happening and the relevance to the sector, and in some cases bringing people back out into the wider group of 40 VCSE organisations to engage with the sector around certain issues

The following is their narrative of change, with key actions and challenges drawn out by The King’s Fund.

Key actions

Working with the ICS to lead a wider conversation on working with the VCSE sector

The system held a series of ‘thinking differently together’ events which brought together 80-100 people online to work through issues in the sector. We became more involved in some of the leadership of those events and in generating ideas. This was one of the key points of getting traction with the system.

Senior sponsorship for embedding the VCSE sector within the ICS

Key to this was having sponsorship from the ICS CEO and the ICS programme director who were committed to seeing change in their system and taking the VCSE sector forward as part of it. They provided strong messaging through the system in support of the work the VCSE group were doing. In addition, they built a strong sense of belonging, including challenging behaviours outside of meetings which did not reflect the commitment to equal partnership with the VCSE sector, as well as the VCSE leaders also providing that challenge.

Being clear about what the VCSE sector does and its approach to engagement

As a group of VCSE organisations we were also mindful of presenting ourselves in a coherent and professional fashion, addressing behaviours such as explicit competition between charities, which could undermine their ability to be seen as equal partners. The group took the opportunity to develop a strategy that described what they were doing and the approach they were taking which they were able to share with the ICS as a means of engagement.

Developing a paper outlining some of the challenges the VCSE sector faces

The big test of the relationship with the ICS was the development of a paper: The VCSE Charter for Action: the case for resilience and sustainable investment.

The local authority and NHS commissioners shared their commissioning intentions and approach to commissioning and the group identified some of the proposals were incompatible with the aims of equal partnership working. The group surveyed other VCSE organisations and drafted a paper which outlined key issues when being commissioned which undermine the resilience of the sector. The Charter has since been adopted by the ICS and the systems executive group have committed to exploring how it can be put into practice locally.

Identifying solutions to barriers and challenges

Part of the approach is where there are objections or barriers, such as procurement rules, we try to find examples from others that have got around them, to demonstrate how many of the issues raised in the resilience paper could be addressed. As a result of the work the group has done, the spending on the VCSE sector has gone up from 0.5% to 1%, and there is a commitment to go to 2-3% of the NHS spend.

Looking at system issues in the context of the VCSE sector

The evolution of our approach to working with the ICS is now taking us into discussions about workforce. To date this has been focused on the scale and complexity of the NHS, but we have managed to secure £20,000 to do a workforce review of the VCSE sector to start the conversation around this agenda and reflecting our role as an equal partner in the system. We’ve tendered for an organisation to map paid and volunteer roles to be able to get better local statistics.

The VCSE sector in Suffolk and North East Essex has a combined value of £275m a year. The value of volunteering across our sector is £360m a year. We employ around 14,000-16,000 people while the largest NHS trust employs 10,000 (at the time the work was carried out). Our argument is the opportunity to align the capacity of the VCSE sector and NHS towards the same goals to improve population health. In changing the conversation and drawing attention to our strengths and opportunities to contribute, we’ve managed to get traction.

Working with the NHS trust data analytics team on VCSE sector data use

Age Well East has been working on a solution to capture data on the care that is provided by the VCSE sector as a means to understand the needs of people as well as gaps in provision across the ICS. They have built a relationship with the data analytics team at East Suffolk and North Essex NHS Trust who are providing support to create a ‘black box’ through which data from the charity’s Salesforce for charities platform can be anonymised.

Power BI is then used to support ways of visualising their data including mapping. This has included the provision of some coaching support for a graduate volunteering with the charity to lead this work.

Our ICS programme director made the introduction to the Digital Programme Director in the ICS to understand the issues around data from the perspective of the VCSE sector. This led to attending a director’s data awayday where we highlighted that without data from the VCSE sector they were making decisions with only two-thirds of the insight available, and how the VCSE data could support greater real-time insight.

We gained further support from the shared record programme manager for the ICS and the ICS digital programme director identified some funding to support developing the ability to better gather insight from the VCSE sector.

Developing ways of using VCSE sector data through a ‘ground up’ approach

We’ve formed a small project group and got data sharing agreements in place between those organisations. Some organisations already use a CRM system to capture data, but the team working with the shared record programme manager are also developing a solution which enables those without a CRM to be able to enter data so that it comes through in a structured way.

The ICS team is leading the project management and how we spread out to and engage organisations across the ICS. The main issue we’ve encountered is data governance, so we’ve agreed to initially focus on volunteering which allows us to largely work with data which is not personally identifiable. In capturing where their volunteers are and what type of support they provide, Age Well East are able to map where they have support services and where they don’t.

This is the first project which is starting from the ground up, and we don’t know where we’ll get to, but it’s about having courage to try something. Part of the value of a ground up approach is that the sector is very fragmented and complex, so in working with organisations we are able to identify and document the challenges we have along each step and the ability to engage people and build momentum along the way. At the same time, we’ve chosen a simple project to start off with, focusing on one type of data that the VCSE sector has.

Combining VCSE sector insight with system data

The local authority and NHS trust are already working to develop a single data warehouse which will include their own volunteers. If we are able to capture and integrate data from volunteering in the VCSE sector, we would be able to look at the landscape for volunteering across the whole ICS. Some of the envisaged benefits would be more informed commissioning decisions, for instance, understanding if volunteers from the different organisations they are commissioning are providing similar support, and where there may be gaps in support.

Working with the ICS to manage data governance issues

One of the advantages for the ICS is that the VCSE sector is less restricted by processes and ways of working that apply to statutory agencies. This allows for more flexibility. For instance, approaches to map need or provision in the NHS often start from the point of patient-level data and use of an NHS number.

Data governance requirements around use of patient-level data can constrain the ability of the VCSE to contribute. However, mapping volunteering provides a means of developing insight on provision and need, without that level of identification.

The team are still working on what level of detail is required so that the data is meaningful, but at the same time minimises risk of identification of recipients of support. Working with the ICS has been really valuable in identifying issues such as personally identifiable data and how that is handled.

Challenges and learning

To understand investment in the VCSE sector, we are asking the NHS finance spend to reflect the VCSE sector spend, in the same way it does for the large providers. However, this would require NHS England to change the data spine to ensure there is a coding that would enable that to be pulled out by individual systems.

West Yorkshire Health and Care Partnership: Calderdale – developing an alliance for commissioning 

Overview

Since 2018, Calderdale has maintained an innovative and unique VCSE commissioning alliance. ‘Voluntary sector infrastructure support services’, is made up of providers and commissioners to support the sector, jointly funded by Calderdale Council and Calderdale CCG. The aim of the alliance is to support organisations to work together more closely.

The alliance comprises a local infrastructure body Voluntary Action Calderdale, Forum, Locality, West Yorkshire Community Accountancy Services, Calderdale Council and Calderdale CCG. The alliance partners were identified through an open procurement process. The annual budget for the alliance is £240,000 with the local authority contributing £145,000 drawn from adult health and social care and children and young people’s services commissioning budgets and the CCG contributing the rest. The contract for running the alliance is managed by Calderdale Council through the Alliance Leadership team and is guided by a set of alliance principles to ensure the best outcomes for the Calderdale VCS.

The following is their narrative of change, with key actions and challenges drawn out by The King’s Fund.

Key actions

Building relationships at place level

One of the benefits of operating at a place-level is that the organisations are frequently in touch with each other. As well as discussing commissioning, people get to know about each other and what each other’s motivations are. In particular, commissioners and VCSE leaders having those conversations together gave a sense of partnership.

Senior leadership on the value of embedding the VCSE sector

The CCG has been represented on the alliance by the Director of Improvement. They have been important in that they have adopted the principle that the VCSE sector fundamentally adds value, so how do we get that to work in practice. The alliance have a delivery plan which is reviewed annually to reflect emerging priorities for the sector and support a resilient third sector.

Reviewing the support provided for the VCSE sector

In 2021 a review was commissioned into the support for the VCSE sector, including the VCSE commissioning programme. The review made a number of recommendations, including the value of working in partnership with the VCSE sector, the need for good quality infrastructure and to review the length of contracting, so that rather than having a standard contract length for any service, it is tailored to the type of service being delivered and how this is monitored.

A report commissioned to understand the value of the VCS in Calderdale was valuable in identifying the need for a common goal. The benefit of the report was that its findings were all very relatable and all of the VCSE sector people who were involved in the consultation process felt that they’d been listened to. That was very powerful, because it then influences their approach, as opposed to feeling that VCSE organisations are never listened to. This has been important in shifting to new ways of working in partnership.

Setting up a procurement vehicle for the VCSE sector

In Calderdale they set up Calipso, a Charitable Incorporated Organisation comprising a consortium of VCSE providers and organisations. It can tender for any managed public sector contracts on behalf of a consortia of local VCSE organisations. Prior to this, commissioners used the contracting process to provide assurance, leading to annual decisions about whether services would be re-contracted and resulting in ongoing insecurity for VCSE providers.

The benefit to the commissioners was that it was overseen by the local infrastructure organisations, so there was a level between the commissioning and the delivery, which provided better oversight and monitoring. It also reflects the aim of local commissioners to have fewer contracts or have single contracts with a consortia or a supply chain of providers. Anyone can be a member of Calipso and can jointly bid for available tenders. 

One of the contracts this was piloted was on mental health provision. The team leading a programme of transformation of mental health care didn’t have the time to oversee the delivery of this service which was VCSE led but the infrastructure organisation did and was able to provide the assurance and agile response to issues. They moved to a two-year cycle of commissioning and the service was successfully recommissioned because the commissioners were happy with the oversight and connection.

Asking the VCSE sector to codesign solutions to system problems

The urgent and community response was the next phase of that which was a response to the codesign of services. The NHS emergency response team identified a need, and a gap in support but were not sure what would work and asked the VCSE sector what it could provide that might help.

The initial response was ‘what is the spec?’ and ‘what is the money available?’. But the approach they took was one of ‘we will fund things that we think will work, do you think you have something that can fit in one of the gaps we’ve identified’. This was a marked change for the VCSE sector, that they were not bidding for a defined service tender but instead asked to outline how they could add value to address issues identified by the commissioner. Some of the things that emerged were things that were working at a neighbourhood level, with the aim of building on those principles. 

Facilitating VCSE representation on wider system programmes

Calderdale forms one of the place-based partnerships in the West Yorkshire Health ICS. The VCSE sector has two spaces on the place-based partnership board, and the infrastructure organisation was a signatory to the agreement. In establishing a set of shared principles there has been a commitment to at least one coming from the VCSE sector and not necessarily being in something ‘obvious’.

There have also been notable changes in that the local infrastructure body were asked to sit on the clinical and professional forum which sat under the place-based partnership, so places that VCSE organisations would not traditionally expect to be, but it was about joining up the pieces.

West Yorkshire Health and Care Partnership: Bradford and Airedale – developing mechanisms to support investment

Overview

During the period in which CCGs were being set up, a Bradford-based charity called Project 6 was a member of a local strategic group that supports transformation and integration. While the group expressed an ambition to invest in the VCSE sector and in prevention, and getting resource and power closer to communities, translation of this into practice was limited, with many of the activities in this space being seen as the remit of public health. The VCSE organisations involved started to talk about how to make some of the changes happen.

The following is their narrative of change, with key actions and challenges drawn out by The King’s Fund.

Key actions

Getting a team of really good VCSE leaders working together

VCSE leaders need to be supportive of each other and collaborative. In practice, that looks like organisation leaders representing each other at meetings, being ‘on the same page’ and doing what we say we’ll do. When an opportunity comes up, organisations should say ‘yes’, and be positive.

The next step is asking each other key questions, such as, we know we need to invest in prevention and community health creation, how are we going to do it? Have we got some ideas? It’s about getting a group of people who are passionate about those things and doing the groundwork to create those relationships. In some places you are pushing at an open door, in others it’s going to be harder.

Creating an alliance between the VCSE sector and health and care system

Project 6, along with a group of other VCSE leaders, established the VCS Alliance, a charity which works to create partnerships between community organisations and the health and care system to achieve transformation within Bradford District, and Craven. To deliver this, they have come together with the local acute trust, care trust, local authority and two CCGs to form the Bradford Provider Alliance. Underpinned by a signed a legal agreement, the provider alliance governs integrated multi-party solutions for health, care and support across the geographical area covered by the two Bradford CCGs.

The VCS Alliance also manages VCSE representation on different Partnership groups, ensuring they have a seat at the table in the health and care system, with a role to reflect the voice of the VCSE sector by holding a place at the table, to achieve investment, to try and get a level playing field. Technically the VCS alliance signs up to things like the ICS strategic partnership agreement, but we are there to say that the VCSE sector has a role to play and we can deliver some of this. How can we get some people together to coproduce and co-design a solution that includes VCSE organisations and local communities?

Being part of the VCS alliance has provided access and a level of privilege to other leaders in health and care system which can be important in gaining knowledge, expertise and influence. One of the roles of VCS alliance members is to use that privilege to hold the door open for other organisations and help others to come through it, reflecting systems thinking and collaborative and generous leadership. If we can’t do something, we know an organisation that can and make the introduction.

Setting a clear ambition for investment in the VCSE sector

Some of the VCSE leaders came together and decided to make a pitch and ask for a specific amount of money which was seen as important in focusing people. The ‘left shift’ was a concept which described how we ‘shake’ money out of acute care to the community, from community to primary care, from primary care to the VCSE sector and (within the VCSE sector) from larger charities to smaller grassroots organisations. How do we give as much power and resource to communities for health creation? That was the principle, we then asked for 1% of the budget.

The VCS Alliance did a lot of tactical work to influence and make a pitch and the partnership agreed to it in principle. Then COVID happened and it became harder and more important at the same time. For about a year it was the Chair of the alliance constantly putting it on the agenda. Then after a year, we started to hear other people talking about it and it felt like it was getting somewhere. At that point it would mean 10 different things to 10 different people, but it was starting to get people thinking.

Setting up a task and finish group to identify routes to investment

We then went to the ‘partnership leadership executive’ where all the CEOs for our CCG area come together. We raised the 1% principle and which parts of the system had offered a commitment to it and the question of how we were going to take it forward as a group – rather than just being led by the VCS Alliance Chair. We set up a task and finish group with people from across the system. We talked loosely about what we were going to do and about how we were going to do it and then developed some mechanisms.

The task and finish group comprised, the Chair of VCS Alliance, Locality (a national membership organisation for communities that had been involved in Keep it Local pilots about how local authorities could review procurement to invest locally); the strategic director of partnerships who works between the local authority and health care at a place level; the head of strategy for the CCG; and the head of access to care from the acute trust (which is one of the 1% principle workstreams – focusing on keeping people out of hospital).

Working with people open to the principles underpinning working with the VCSE sector

One of the critical people was the director of finance from the care trust. The finance director was really innovative and really got the notion of spending to save and shifting where you have to spend. That was different from simply balancing the spreadsheets – instead thinking about what you can free up, what to stop doing and where to invest. You need a systems thinker and someone who understands prevention.

One of the challenges was everyone talks about systems, but when the money is tight everyone retreats back to old patterns of behaviour and ways of working around managing risk. Another key player was the Director of Adult Social Care who was leading work to review commissioning of the VCSE sector in the local authority.

Developing a community investment standard

The first mechanism was about how we assess any new money that comes into the system and developing a set of principles so that more will be invested in the community than the acute trusts. Funding from the community investment standard goes into our community partnerships which are the building blocks of our places. These are the clusters of GP practices and they operate at a more grassroots level.

These were local people who knew about local issues and the level of need in the population. For instance, in one inner city area, one of the issues was the prevalence of diabetes and the way to tackle that was getting people active. In other areas, there were lots of issues around mental health and alcohol use so the needs and support were different. Some initial investment would support capacity building so they were able to receive further funding, and then they could make decisions on what their area needed.

Seeking co-designed VCSE solutions to system issues

Although somewhat opportunistically, one of the first successes has been securing £1.9m of investment from NHS funding to support winter pressures. With pressure to address demand for acute and primary care, and workforce shortages, the ICS approached the VCS Alliance with a request to see how VCSE organisations might be able to help.

The VCS alliance co-designed solutions including a series of six wellbeing hubs in a wellbeing network that worked with primary care to keep people out of GP practices. Within each hub we’ve commissioned physical and mental health support, support with welfare benefits, substance use, domestic abuse, older people’s services – a ‘one-stop shop’ for many issues. Each hub had a grant programme for local people and that helped to improve the health of communities.

For example, in one area we worked with several providers that support south Asian communities (around 43% of the local community), but into which our reach is quite low. The grants have helped to improve reach and accessibility for those communities.

Reviewing and developing a commissioning strategy for the VCSE sector

The second mechanism was considering how a review of the commissioning strategy and the Sheffield Compact being conducted by Director of Adult Social Care could reset the relationship with the VCSE sector. This included what the VCSE sector can expect from commissioning – for example, is there always a need to go out to tender? How do we keep it local? And developing a new compact about commissioning in the future.

Often traditional commissioning approaches either serve to maintain the status quo (recommissioning the current provider) or are about changing provider. An alternative approach would be to start with the question of whether the service could be provided in the community, or by the VCSE sector. There are TUPE implications with transferring services, but the local authority has been helpful in mitigating those risks in the past.

As the ICS forms, the lead for commissioning at place level (who leads this work) will be joined by commissioners from health and this provides a further opportunity to try to socialise them to new ways of commissioning under the compact.

Adopting an approach of co-design of services with the VCSE sector

The third mechanism is about how the VCS Alliance supports the co-design of solutions. In traditional commissioning, often the commissioner sets out what they want and you have to agree to it even though you know it’s something else that is really needed. Then, once the tender has been won, you spend time influencing so that it moves towards what was needed in the first place, which gets commissioned on the next round.

Co-designing VCSE services and solutions from the outset can avoid this. With any funding that goes through the VCS alliance, the aim is that the solution will be defined at place level. So the health system identifies what the need is, and the VCS alliance bring together expertise of the local communities to create place-based solutions.

An example of this has been work led by Project 6, The Cellar Trust and Carers Resource to codesign support to reduce demand in A&E. The solution we came up with was a multi-agency support team in the emergency department (ED) working with people affected by alcohol, mental health problems and older people and their carers. We screen people in the ED and support them, providing either a brief intervention, or taking them on as part of a caseload and supporting people in the community to engage with the appropriate statutory services.

The work has identified some gaps that they have needed to fill, and it’s taken a while to become socialised and accepted as part of the ED provision. That team is now embedded, working with hundreds of people and the support is resulting in low readmission rates for them. The team were a regional winner at the parliamentary awards and at the HSJ awards. The work was codesigned and this is about how the VCSE sector can overcome some of the challenges and barriers the NHS has. That team has data on activity, patient level outcomes.

They work with the data teams in the hospital to look at readmission rates. They have committed to funding the service for five years. It is about proving we can have impact by being trusted to codesign solutions. We are currently developing our processes and resources on how to do this.

Building data sharing governance from the ground up

As part of the contract to support people attending A&E, the VCSE sector has had to develop data sharing processes. The VCSE providers involved started by developing basic principles around what their information sharing agreements were between themselves and with each other.

They then went for the NHS level 3 data sharing qualification which provides assurance to statutory systems that their data can be managed securely. Our staff delivering the service had honorary contracts from the hospital and set up NHS emails and got access to SystmOne, because sharing data outside of NHS systems can be very tricky.

Then we developed a data sharing agreement with the hospital that incorporated all of that and provided assurance. Our access to SystmOne is via social care, rather than the NHS, as social care supported us to do this. This process has been led by the operations director in the charity. One of the advantages of our organisation being established for some time was we were well known and have good relationships with others. We had a lot of people who wanted it to happen.

Seeing different investment opportunities as ways to embed the VCSE sector

The aim of investing 1% of the core budget in VCSE organisations would amount to £10m. So far, we’ve achieved around £4 million. The money is coming from various places, but it doesn’t need to be from just one place. This has included about £1.9 million of winter pressures money, nearly £1m of grants and roughly £700,000 from other sources.

One of the lessons was, when the opportunity comes, you need to say yes and then work out how you’ll take it forward. The funding secured so far was relatively easy because it was new funding to support transformation and managing demand.

Flexible funding opportunities

New funding, particularly during the COVID period, provided flexibility and an opportunity to do things differently. If we can prove collectively what we’ve done with the new money, so we can demonstrate that by working with the VCSE sector to codesign creates better solutions.

We hope this will make the argument easier for carving up the existing core budgets differently which can be a difficult conversation. We believe it is ultimately what we need to do to keep people in the community and at home.

Expanding the conversation to a broader set of people

It’s gone from being the Chair talking about it, to having a task and finish group, to it starting to be embedded in the way we are thinking. The trick now is not to let that fall off the radar and to keep the momentum going with a broader set of people. It’s difficult because people go off in different directions. but, if everyone is committed to it and saying ‘how is the VCSE sector involved’ then it becomes organic and cultural – this is what we do.

The task and finish group will transform into a steering group. The aim is to keep up momentum, for instance if the compact is finalised, that can be handed over to the infrastructure organisations to make sure that is taken forward. The VCS alliance is continuing to grow and develop systems and processes and it’s place within the wider VCSE. There is a way to go to embedding it and the challenge for the VCSE sector is how to maintain this commitment in difficult times.

West Yorkshire Health and Care Partnership: A strategic approach to embedding the VCSE sector

Overview

Harnessing the Power of Communities (HPoC) is a dedicated programme responsible for strengthening the position of the VCSE sector across the health and care system. The programme influences the governance and decision-making processes of the Partnership including funding and commissioning, shaping services and being an equal partner across the system. It also operates at all levels, from system level through to place and neighbourhood level.

It’s not a programme that delivers projects. It is a catalyst for change and improvement. HPoC is the function within the Partnership which, brings together the VCSE perspective and voice, and is positioned strategically within the system in order to engage across all the programmes and different levels of the Partnership Board and NHS West Yorkshire Integrated Care Board. HPoC identifies opportunities or creates opportunities to strengthen the understanding and involvement of the VCSE sector across the Partnership.

The programme has a team of three, an Associate Director, a Programme Manager and a Programme Support and Communications Officer. At the start, the HPoC lead was employed in the VCSE which was important early on to establish credibility within the sector and to be able to honestly represent them within the Partnership and understand their issues.

Getting to this point has been a process of evolution – starting from an ambition to have a strong VCSE voice in shaping how the partnership moved forward and then advocating for a paid role when it became clear that this needed capacity to make it happen. At the outset the aim of the programme lead has been to turn the work of the VCSE alliance into a strategic approach, to extend the reach, and to position the sector in a way that would attract more sustainable investment, to ensure the sector had an equal voice and was firmly positioned in the governance and decision-making processes. HPoC is the lynchpin that grounds everything and pulls it together within the Partnership working alongside VCSE sector colleagues at place.

The HPoC programme is supported by a VCSE alliance (known as the HPoC Board) which comprises all the VCSE infrastructure leaders for each place plus others representing distinct communities, such as ethnic minority communities and mental health where there is a high priority need. This group shapes the work of the programme and is directly connected into the VCSE. The VCSE alliance were integral in positioning the VCSE and HPoC within the emerging integrated care system – working alongside partnership leaders.

With a Programme Lead in place, HPoC sought to build on that to embed the programme and VCSE sector involvement into the system. The journey towards achieving this was important and key to enabling colleagues in the health and care sector to building understanding of the unique nature of the VCSE sector, the difference it can make to health and care outcomes and its role in tackling health inequalities. This helped to build recognition that the VCSE sector is not just an add on but a critical aspect of the system.

The following is their narrative of change, with key actions and challenges drawn out by The King’s Fund.

Key actions

Socialising the VCSE sector with ICS programmes and building allies

In practice, we invited ourselves to every programme board. It didn’t matter which board, whether it was maternity services, cancer services, population health, Primary Care, or workforce. What was important was to understand what each Board did and where the VCSE could add value. In the first few meetings we were seeking to listen and understand. As this evolved, we were able to make informed decisions about who would be best to sit on each Board – if indeed it was useful for someone from HPoC or a VCSE colleague who might bring specific expertise to do so.

Currently, HPOC programme team members attend some of these, particularly corporate functions such as finance, quality and workforce and so on. Others (ie Maternity Services, Stroke Network, Diabetes, Digital etc) are attended by VCSE leads whose organisations have specific or relevant expertise. In earlier conversations with staff from across the ICS, it was about introducing the VCSE sector, not expecting anything to come out of the meetings but these conversations set in place the foundations for us to build on. Because then when you go to the formal meeting, you have got your allies and people who have a little bit more understanding of the sector.

Some boards were extremely open and immediately recognised the value of connecting this and building on the value of what they were already doing. For instance, Macmillan Cancer Care is already an integral part of cancer care. Other boards did not understand the value of the VCSE, but the ask was to let us come along and listen to meetings to understand what they were doing and to see if there are any areas that the VCSE sector could add value to what they are doing.

Once we started to comment and add value, we were invited to become a part of the board. It took time, but those relationships and connections remain strong and have been the foundations on which we have built collaboration around funding, service design and development, and innovation.

Understanding system issues and identifying opportunities for the VCSE sector to contribute to solutions

The Planned Care Board holds oversight of hospital waiting lists and it is quite a clinical space. It took six months of attending the meetings to understand where the VCSE sector could add value and where it should position itself. In particular, it was about building understanding to identify where the potential wins were for the population, for colleagues in health and care, as well as for the VCSE sector.

It took patience and it was important not to step in too quickly and suggest things that weren’t needed or impactful. Through that process we heard about pressures on waiting lists, and people who were managing long term conditions who were repeatedly turning up at accident and emergency departments or their GP.

We identified a real need for VCSE organisations to help people manage their pain, become more active, and to help make social connections so their mental health did not deteriorate while they were waiting. This led to funding being allocated to develop health and care pathways so that the VCSE sector became part of the journey for a patient, and not just through social prescribing, but being built into lots of different referral points along that journey.

The aim is to add value through volunteers or VCSE staff who will listen and respond to the needs of patients. As this work goes on we were able to demonstrate how some of this work has made a tangible difference, for instance in reducing the number of people presenting in general practice, enabling people to manage their pain better and to have connections with others experiencing similar conditions.

Working with the wider VCSE sector to identify priorities and shape the focus of the VCSE sector in the system

Most of the work of the HPoC programme, working alongside the VCSE infrastructure leads at place, is based on applying shared decision-making processes. HPoC doesn’t work in isolation but alongside the sector in all its work. Moving forwards, further strategic VCS groups have been established, including a group which brings together the VCSE place leads, and one where the focus is on how we shape approaches to diversity and inclusion across all of our work.

The HPoC programme is way of listening to the wider voice of the sector and we are guided by their priorities at any one time. For example, after COVID, staff and volunteer health and wellbeing was identified as a priority. The sector was key in supporting very vulnerable people, but this had an impact on their staff and volunteers delivering services and support on the frontline.

One of the programme’s roles has been to ensure that VCSE staff and volunteers can access our full Mental Health and Wellbeing Hub offer that is available to health and care staff. It is the job of the programme to lobby for equity of access and value in these instances.

System leadership which understands and is an advocate for VCSE organisations

A key ingredient for success is the leadership of the Integrated Care Board. Both the Chair and CEO are advocates for the VCSE sector. We do not underestimate how valuable this has been in embedding the VCSE across our system. In the early days, to help build understanding and knowledge, we had a lot of infographics produced to help with communications done around understanding the value of the VCSE sector.

They are very simple, they explain what the sector contributes, how it contributes and why they are an important partner. They start to open the conversation and challenge people’s thinking. This has been a useful tool in building understanding of the sector.

Using data to inform decisions which evidences the role of the VCSE sector

Making this happen is about taking one step at a time, starting with building relationships by being in the room, establishing your position and understanding of the sector. Then using evidence, data and real examples of what works and why. That means communicating in terms that colleagues in health and care will relate to.

Early on, working with South Yorkshire ICB and North Yorkshire and Humber ICB, we commissioned research to better understand the VCSE across Yorkshire. This gave us robust data around the shape and size of the sector and its economic value which we were able to use to inform West Yorkshire strategies and plans.

Developing a business case for investing in prevention

The shift towards prevention began 2 years ago. The theory is if we shifted some of the money that went into acute services into prevention then we would have much less demand at the acute care end and improved health and well-being of our population. The conversation was initiated by building a business case about why that would be important, which was evidence-based.

The paper was discussed by the ICS leadership and went to the Partnership Board to ask for a commitment from statutory bodies (NHS and local authorities) and at all levels of the system to making this ‘left shift’ happen. We recognise that this is a long-term piece of work, which requires winning over different people and long-term budget planning because there are existing commitments, and you are proposing significant changes to how things work.

The aim is that over time more resource will be shifted to the prevention agenda which often happens in local communities because it’s about maintaining good health through a healthier lifestyle and healthier choices. Mostly it is VCSE organisations which support people in these activities and in making these changes. This also includes working with communities of interest to improve access to health services including screening when earlier intervention and treatment can be lifesaving.

Building VCSE representation and involvement at strategic level

We now have a VCSE member on our integrated care board who is a full voting member and also the Senior Responsible Officer for the HPoC programme. This means all our work at West Yorkshire level is connected and via HPoC we have a mechanism to connect the VCSE Board Member to the wider sector. This will help ensure that it is a sector voice rather than an individual one. We also have 3 VCSE members on our Partnership Board and we have VCSE members on every ICB Place Committee. This has provided us with a stronger strategic structure to act as an enabler and turn ambitions into actions.

Principles around allocation of new funding for the VCSE sector

At a system level we have tried to influence programmes in two ways. Firstly, to ensure that when there are large amounts of funding, for example winter pressures funding or health inequalities funding, that there are principles around the amount or percentage that should be going to the VCSE sector based on the value and importance of the VCSE contribution.

When the funding goes down to place level via our distributed leadership model, place-based leaders are, in turn, committed to ensure that a fair amount goes out to VCSE organisations. Each individual place makes the decisions about what that looks like and relevance for their place.

Secondly, we work alongside colleagues to ensure the VCSE is built into all finance strategies and plans, and that consideration is given to joining up funding and simplifying processes including for application and monitoring requirements.

Reviewing commissioning processes with a focus on creating greater inclusivity

Within the NHS there are a lot of traditional commissioning processes and funding often goes to the larger providers which are known to the NHS. Many of those organisations do great work, but many have been commissioned on contracts which have been repeatedly renewed over a number of years, and there are likely to be many local organisations which could add value in today’s context.

We are asking each area of the partnership, as part of the transition to the ICB arrangements and with the dissolution of the clinical commissioning groups, to review how we commission and if/why we continue to commission particular VCSE organisations, and to create a more inclusive process. We have identified some principles for commissioning around being more inclusive, such as investing in local organisations and those working at grass roots level with communities.

Making a commitment to VCSE sector investment

Project 6 in Keighley (see previous case example) has been one of the lead partners in delivering a system-wide commitment to investment in the VCSE sector and making it happen. They have had a grant from The National Lottery Community Fund to start that process. This seed funding enables testing ways of making this happen and seeing what difference it will make.

However, we couldn’t adopt that across West Yorkshire because there was a challenge in that some local authorities already contribute more than 1% to the VCSE, it can be up to 3-4%. We would not want to see a reduction in investment by trying to encourage some parts of the system to invest more. In addition, a larger target would be over-ambitious when some places are not investing at the lower level. At system level, the decision was made to frame it as a commitment to move towards a greater investment in prevention as a direction of travel.

Adopting a reimbursement framework for VCSE sector involvement

For involving members of the VCSE sector in shaping decision-making we have a reimbursement framework so that we make sure that organisations can attend meetings. This framework for involvement is something we have encouraged all programmes to sign up to. We’ve deliberately not made it a policy yet. We want to give this framework a couple of years to bed in and for programmes to budget for it and then we’ll make it a formal ICS policy. This is about supporting and enabling people on a journey, rather than pushing and shoving.

Adapting and optimising commissioning processes

HPOC are often consulted on commissioning the VCSE sector at an early stage. Throughout we act as a critical friend, offering challenge to commissioners, understanding their limitations and caution as ultimately, they are accountable for the funding, but supporting them to take small steps which start a journey. Some of the areas we are working on include:

  • Simplifying and streamlining funding application processes
    • We have things we ask for people to put in their application forms, and we check the wording of application forms to ensure it’s simple.
    • We challenge funders on why they use particular questions and why they request certain information.
    • This is about challenging the processes that we use to ensure that they are simplified and accessible.
  • Working with other funders to align processes to maximise funding opportunities.
    • We regularly liaise with our regional National Lottery Community Fund team, the Community Foundations and some other local funders.
    • We’ve tried to align our application forms as far as possible to make things simpler for applicants. One of the questions we’ve added into application forms is ‘Do you mind if we share this application form with other funders?’ For example, when there isn’t enough money to do something locally, HPOC have passed the application form onto The National Lottery Community Fund (TNLCF) and they have funded it.
    • We are trying to streamline processes. We each have our limits, but we are also exploring the flexibilities that we have. We also share who we are investing in so that we can try and collaborate. For instance, when the TNLCF or NHS Charities fund something in West Yorkshire, the HPOC programme is available to talk about what connections they can make into health and care in order to secure more sustainable long-term funding.

We have encouraged commissioning using a partnership model, as this is a much more inclusive model. Collaboration not competition!

Trying and testing different approaches and evaluating the impact

It’s not one approach fits all! Different things cut across the different levels of the system/neighbourhood/place, across the different functions or health conditions, and then across commissioning which is at different levels as well. We have tried and tested a whole range of approaches and seen the difference it has made.

In addition to these different models that we are looking to transfer across, either PCN or programme level, we are starting to demonstrate the effectiveness of all this work. This is now reflected in a new MOU with the VCSE, and a conversation with the Chair and the CEO of the ICB with our VCSE leaders around how we make sure this is real and translates into action across every place. Within this HPoC acts as an enabler, supporting others to have the conversations.

Challenges and learning

One of the challenges to making commissioning more inclusive is that the system does not want to directly commission lots of small organisations because it is a lot of work for a little bit of money. So what we need to consider is whether we can give that money to a VCSE infrastructure organisation, or Community Foundation or similar that can then distribute it to those smaller groups with a clear framework about what that needs to look like and the anticipated outcomes.

Alternatively, we need to encourage the VCSE sector to work in partnership where one of the larger organisations leads a partnership in which we have a principle around inclusivity in relation to the different size and type of organisation. We have both models working in tandem because there isn’t one size fits all.

Getting the principles for inclusive commissioning into CCG processes hasn’t been easy, and as we go through change processes again, we are trying to get something more consistent. Consistency across place is a key challenge because they all have different relationships and understanding of their VCSE sector.

For instance, in Leeds, the area is well developed in terms of its engagement with the VCSE sector, and there is an infrastructure body solely focused on health. In other areas there has been less investment in the infrastructure organisation and less capacity, and where the local authority has traditionally taken on more of the convening and relational role themselves. There is a need to work with what exists at place level but also considering how to level up areas and make sure the VCSE sector is properly supported and represented.

We are currently in a process of change, around programmes, and the structure of the system and of course the staffing changes that will come with that– we are taking our time because we need the right people in place to build relationships and make commitments. Then there will be a bedding in period where everyone will be getting to know their new roles and ways of working. Our aim is to embed the new arrangements over the next 12 months, but it might take longer. Also, if some of the core processes change because of the ICB, then HPOC might need to adapt how it does things.

Publication reference: PR1075

This resource has been published by NHS England. It was commissioned as an independent resource from The King’s Fund. The team members at The King’s Fund who contributed are Shilpa Ross, Helen Gilburt, Clair Thorstensen-Woll and Nick Downes.

The King’s Fund is an independent charity working to improve health and care in England. We help to shape policy and practice through research and analysis; develop individuals, teams and organisations; promote understanding of the health and social care system; and bring people together to learn, share knowledge and debate.

Their vision is that the best possible care is available to all. www.kingsfund.org.uk @thekingsfund

Date published: 23 May, 2023
Date last updated: 26 May, 2023