Tower Hamlets VCS Health & Wellbeing Strategy (2016 – 18)
This strategy makes a case for the role of the Voluntary and Community sectors (henceforward VCS) in relation to the health & wellbeing challenges we face in Tower Hamlets. It highlights priority areas for a VCS contribution and flags key activities for taking our contribution forwards.
The strategy has been prepared with input from Tower Hamlets VCS Health & Wellbeing Forum. The Forum meets quarterly. Its leadership is provided by a core group, elected annually:
Jennifer Fear (Step Forwards): Chair
Steve Worrall (Positive East): Deputy Chair
Suzanne Firth (Green Candle)
Myra Garrett (Citizens advocate)
Jack Gilbert (Rainbow Hamlets)
Mike Smith (Real)
Runa Khalique (Docklands Outreach)
Mel Steel (Praxis)
Abidirashid Gulaid (Mind)
Ibrahim Hussain (Somali Senior Citizens)
Kirsty Cornell (THCVS)
Alex Nelson (The Volunteer Centre)
Diane Barham (Healthwatch)
We aim to review and update the Strategy annually over the next 3 years to ensure it remains current.
P 3. The Voluntary Sector in Tower Hamlets: An Overview.
P 4. Our View of Health & Wellbeing.
P6. Need in Tower Hamlets.
P6. The VCS Offer.
P 7. Key Challenges.
P 9. Our Change Model.
P 9. 4 Key Planks to our Strategy.
P 13. Appendix A: Cormac Russell’s “5 Painful Shifts”.
The Voluntary Sector in Tower Hamlets: An Overview
According to 2013 NCVOstats there are 1461 registered VCS organisations in Tower Hamlets. These organisations have a combined income of £352m, and employ 5219 permanent staff. We estimate there are 84,000 volunteers in Tower Hamlets if the number conforms to the national average of 29% volunteering population.
The current voluntary sector contribution is very diverse. VCS organisations in Tower Hamlets span the whole range from large, formalised charities, social enterprises able to compete with the private sector in commissioning markets, to very small community groups such as gardening projects and lunch clubs. We need to recognise and value the different strengths of this diversity and not seek to apply a single template or set of aspirations to the whole of the VCS.
In 2010, the Marmot Review highlighted the importance of the ‘social determinants of health’ in reducing health inequalities across England, arguing that links between social conditions and health ‘should become the main focus’. Although not all of the organisations working in Tower Hamlets see themselves as primarily contributing to health and wellbeing, the thrust of the Marmot Review and its impact on thinking within the Health Sector means that all VCS organisations have a health impact.
Following on from this, in 2015 NHS England set out its challenges for the future in “The Five Year Forward View” (2015), arguing that we must do more to “harness the potential energy within communities”. Our strategy is based on the belief that the VCS – and citizens themselves – needs to be considered a part of the wider health & wellbeing workforce in order to reach these communities.
This strategy is timely. Tower Hamlets is an NHS Vanguard “New Models of Care Pilot” which opens up lots of opportunity for the VCS, and many developments currently underway depend on VCS contribution. For example, plans to roll out a borough-wide Social Prescribing project (where GPs and health professionals prescribe patients to non-clinical services to improve their health and wellbeing) will need to harness capacity within the VCS in order to provide better, and more appropriate, support. Another example is the plan to develop a Tower Hamlets Health Hub, where capacity from the VCS will be key to reducing demand on statutory health services. Such initiatives are also key to meeting the challenge of “affordability” highlighted by the Five Year Forward View.
In addition, personal health & social care budgets give individuals more control over some aspects of their clinical and non-clinical care, and open up markets within the VCS for individually procured services.
And yet there remains much to do. The fact that current approaches arefailing to get to grips with horrendous health inequalitiesin Tower Hamletsis the elephant in the room in meetings and forums set up to look at health and wellbeing in the borough. We know thatinequality can only be reduced by real sharing of power with communities – and we recognise that in many instances our organisations are part of the problem: we play a role within a commissioningsystem that too frequently reduces people to the status of service recipients rather than helping people take power and build community. This strategy is ultimately for the people and communities of Tower Hamlets, not a self interested strategy. There is much we need to do as a sector to change our role within the system, and to change the system. Yet voluntary and community organisations are often at the forefront of innovation in this area and this is why our strategy and the work that will flow from it is particularly important.
This strategy sets out our commitment as partners to work alongside our NHS and other colleagues to step up to these shared challenges. It also flags areas where we see the potential to scaleand grow the VCS contribution. However our contribution, whilst it presents excellent marginal benefit and value for money, is not costless –both in terms of resources required and the need for partners to work differently. The strategy therefore identifies some of the key dependablesand support needs of the sectorin order to maximisetheVCScontribution.
Our View of Health & Wellbeing
“The more favoured people are, socially and economically, the better their health” – Marmot Review: Fair Society, Healthy Lives
Many people in Tower Hamlets live under complex and often chaotic life circumstances, which impact on their health. Our health system as a whole has not got to grips with the ‘wider determinants’, nor the impact of disempowerment on a person's health chances. Hazel Stuteley, a health innovator and former nurse who spoke at the recent Tower Hamlets Health Inequalities Summit, says: “What my long career as a nurse with a special interest in health inequalities has taught me is that it’s not smoking, alcohol, obesity or substance misuse which are the greatest determinants of poor health in low-income communities, but rather powerlessness, hopelessness, disconnectedness and passivity. The former are merely ways of coping with the latter, with catastrophic health consequences” (‘Handbook of Research Methods in Complexity Science and their Application’, to be published in 2016 by Edward Elgar Publishing.)
Our strategy draws fromprinciples set out by Cormac Russell in his article Making ‘health’ healthier in 5 painful shifts (9th September 2015). Cormac is a practitioner of Asset Based Community Development, the philosophy that sees people and places as possessing assets, strengths, and the solutions to their problems even under difficult circumstances. The 5 shifts are included in full as Appendix 2.
Cormac says that“Health is not a product of health systems but of humanness interacting with itself, its environment and its economy.”
He goes on to say:
Action towards health improvement must lead away from an almost total dependency on professional interventions and tools, toward community-building and citizen action.” And
Resources need to flow towards the domain of greatest health producing competence: citizens organised in communities. In essence, this means that even if a small portion of medical system budgets were reinvested in community building and away from medical intervention, huge savings should result and significant harm to social capital averted.”
The Health System as a whole – including the role of VCS organisations within it – currently does much to contribute towards inequalities in life experiences and health outcomes in Tower Hamlets. This is not the whole picture – obviously – but is an understated and important part. The very fact that many of us work within organisations gives us status and power over the people we work with – who are reduced to the status of clients, patients or service users. We all need to become more aware of the intrinsic privilege that comes from being on the ‘provider’ rather than the ‘client’ end of this relationship.
The opposite is always to find real ways of sharing powerwith people, and removing the barriers that keep us safe from really connecting with our fellow citizens. This often poses a threat and causes discomfort to people not used to sharing power. This is not an acceptable reason for not doing it. If we are to get to grips with health inequalities in Tower Hamlets we all need to change. Initiating a dialogue and meeting through our differences is a part of this change. The creation of community is healing, and is directly linked to the creation of health. This is the essence of the argument for Health Creation that has a strong place in this strategy and is currently the focus of an NHS Alliance project
In Tower HamletsVCS services and ‘community building’ projects are for the most part commissioned separately from provision of mainstream health services, so the medical systemis rarely confronted with the impact of the way it organises on people and communities. We haven’t yet seen ashift in investment from medical to community settings, nor a proper integration of the understanding that the medical system can have a disempowering impact.Cormac’s shifts are “painful” because they require us to look at the impact we have as part of a system and to initiate real systemic change.
A system that understands health as a product of “humanness interacting with itself, its environment and its economy” willdo more to prioritise the creation of community.
Need in Tower Hamlets
Health needs in Tower Hamlets are complex, and there are a number of interconnected factors that affect Tower Hamlets residents’ ability to live well.
Despite improvements, Tower Hamlets is the 7th most deprived borough in the country, and 70% of the population live in the 20% most deprived areas in England. 39% of children live in poverty, the highest rate in the country. Green space is limited, and as with much of Inner London, Tower Hamlets suffers from poor air quality which contributes to around 100 deaths per year.
The population is young, with 51% aged between 20 and 39. 69% of the population are from minority ethnic groups, with a significant Bangladeshi population (32%). Life expectancy has improved, but healthy life expectancy – the number of years people can be expected to live in good health – remains low (55 years for men and 63 years for women). The difference in years between Tower Hamlets residents and the rest of the country is as much as 9 years for men (Tower Hamlets has the lowest rank in the country), and 7 years for women (145th of 150 local authorities in England). Life expectancy also varies hugely across different wards in the borough, varying by as much as 10 years for men and up to 15 years for women (broadly correlating with levels of deprivation).
The number of people living in social housing and the level of overcrowding in Tower Hamlets are both significantly higher than the rest of London (40%/24% and 35%/22% respectively). Changes to the welfare system following the Welfare Reform Act are having significant impacts on Tower Hamlets residents, including those affected by the introduction of Universal Credit, and loss of Housing Benefit and other benefits entitlements. Unemployment is relatively high, and skills levels among residents are relatively low compared to the rest of London. There are also relatively high numbers of Tower Hamlets providing unpaid care – around 8% of all residents – with around half providing more than 20 hours of unpaid care a week.
The VCS Offer
Responding to need calls for the contribution of many different parts of our sector – from the more formally constituted organisations that deliver commissioned services to the contribution of small groups, community organising, and local networks.Our strategy encompasses the importance of all of these contributions.
VCS capacity to deliver change derives from:
- Reach and access into communities that statutory organisations don’t have
- We have more flexibility relative to the statutory sector in our capacity to tailor interventions to the needs and circumstances of individuals.
- We have capacity and experience of working in ways that involve and empower citizens and communities – we are better able to enlist citizens in actions that create the enabling conditions for better health.
- We have understanding of what citizens and communities need – based on our people-led ethos and closeness to those we work to support and empower.
- We have capacity to leverage non-statutory funding into the borough.
- We have capacity to plan and develop interventions over the longer term. We are not bound by public sector spending or political cycles.
- We have capacity to innovate – to try out new things. Many of the most significant social innovations, such as personal budgeting originated in the VCS.
There are a number of current challenges which need to be addressed in order to support the VCS contribution:
The VCS in Tower Hamlets is still too often seen by partners as a ‘free resource’. Currently, conversations and decisions around funding and commissioning the VCS happen at a distance from the value that we deliver to our health partners. This means that the costs involved in delivering a service are not factored in by those who gain most from our services, and potentially funding is not going to those parts of the sector that stand to deliver the most. An example of this is social prescribing, where the non-clinical services patients are referred into are seen as a free resource from the point of view of GPs, without due consideration of the costs involves with delivering them. Moreover because funding the VCS happens at a distance from the commissioning decisions of most medical services, the value we deliver is not readily comparable against other parts of the health system, with the probability that NHS colleagues are poorly incentivised when it comes to allocating resources most efficiently across the health ‘system’.
In future it is important that funding/commissioning decisions and agencies benefitting are brought closer together.
One way we will ensure this is by continuing to engage with the CCG and partners on the Capitation project. Under ‘capitation’,separate NHS budgets for the highest users of health services will be brought together into a single pot, and money will be allocated across the system according to where it has most impact. This may for example incentivise transfer of resources from hospital settings to primary and community care.
If we believe that prevention saves the NHS money, then there must be advantage to statutory partners under a Capitated Budget scheme in ensuring that VCS provision at least continues to exist and possibly increases in scale and scope.
We will explore ways to measure the tangible contribution of VCS work for other health partners,such as conversations we are beginning to have with hospital discharge teams.
Developing leadership within the VCS is important so that the sector can be proactive in finding ways to contribute to health & wellbeing initiatives like social prescribing, personalisation, local wellbeing hubs, and Vanguard Population Health aspirations.
Currently the Steering Group of the Health & Wellbeing Forum represents the VCS on the Health & Wellbeing Board and subsidiary committees. As of April 2016 we have not beeninvolved at a similarly strategic level with Tower Hamlets Together (THT), which is leading the Vanguard project,although this looks set to change.
In future we aim to work towards full membership of THT, possibly by (re)developing a VCS consortium as a commercial vehicle (similar to the GP Care Group) that will equip us to engage.
The Health & Wellbeing Forum with THCVS (Tower Hamlets Council for Voluntary Services) will continue to prioritise leadership development within the health sector, and will apply for CEPN (Community Education Providers Network) and other funding to deliver leadership training.
In addition we will look to bring people from all sectors together in “communities of practice” around some of our key health challenges. These will be examples of building community within and across sectors that have potential to provide support, challenge and the opportunity for building better understanding across different roles.
- System Transformation
The requisite changes cannot come about only through more activity within the VCS – as an add-on to existing NHS activity.
Viewing the local health economy as a “system”, we understand that change in one part of the system can only come about if there is also change in other parts. We believe that beneficial change will come through developing more and stronger relationships and an improved understanding between different parts of the system.