By Paul Streets, CEO at the Lloyds Bank Foundation
After decades of (relatively) safe London cycling….a three minute ride to my local choir in a sleepy East Sussex village and a wet manhole cover, did it for me. The full Casualty – even on a Wednesday Night! Blue lights, A&E, multiple scans, fractured skull, scapula, clavicle etc. And spectacular facial cuts and bruises …worthy of Halloween.
Enforced confinement gave me the opportunity to ponder the nature of big and small organisations – having contributed singlehandedly to the NHS overspend through the array of treatments.
Well. Everything that the Localities ‘Diseconomies of scale report’ last year tells me is right. Large organisations pass you from pillar and post (six specialists so far and still counting two months later) and, as part of that, consider you as an exercise in anatomy and different organs, rather than a whole person. Work gets missed because no-one knows who is responsible for what or assumes someone else has done it (spinal scan four hours after I’d been laid out without a neck brace – it was fine!); duplicate effort (everyone in the NHS knows my name, rank and number by heart); repeat communications (no specialist seems to have spoken to any other so I become the means of transmission) and systems that make the easiest things the hardest and most stressful.
Earlier in the year, I reread the seminal work by E F. Schumacher ‘Small is Beautiful’. He perfectly describes this. Writing in 1973 he states ‘Even today, we are generally told that gigantic organisations are an inescapable necessity: but when we look closely we can notice that as soon as great size has been created there is often a strenuous attempt to attain smallness with bigness’. This is exactly true of the organisation of professional teams within the NHS.
But there’s an important rub….it may be chaotic, disconnected and disembodied but it works. Albeit like a set of organs on the dissection table rather than a whole person. Specialists do their thing and you’re grateful they know what they’re talking about and are expert because we have a professional education and regulation system that ensures standards. You do get referred to the right places – eventually.
Whilst you’re laid up they take over by checking, feeding, medicating/checking, feeding; medicating/checking. And reassuring you by telling you what you’re experiencing is normal.
Interestingly, as Shumacher suggests, what’s most impressive is the small team work. Ambulance team – utterly amazing, compassionate and professional. A&E team – ‘we can fix you – you may think you look terrible – we’ve seen worse’. Surgical assessment….lull you into a calm sense of routine which is what you need. The small teams visibly work in spite, or ignorant of, the dysfunctional system of which they are a part. Schumacher wouldn’t be surprised.
So as a Foundation which has put at the core of its new strategy supporting small and medium sized (sub £1m) charities does it mean anything? It tells me we need to be clear when small is beautiful and why?
What ‘small’ might have done is treat me as a whole person with a one stop shop that meant I didn’t have to navigate my own very complex and confusing journey. Or it might have become the translator, mediator and advocate if I needed that. It might have considered my mental and longer term health post hospital needs….as well as my acute needs at crisis. And stuck with me beyond the critical few days by making the connections needed to make things happen. Offering the post acute basic needs that mean so much when you’re vulnerable: a decent meal, comfy bed, peace and quiet, rest and no pressure – that rely on family and friends. The voluntary effort rather than the professional.
In the context of our strategy it would probably have dealt with my ‘transition’ far more effectively. These are the things that we need to argue for when we make the case for small charities and their worth. They feel exactly right for people who are vulnerable – often without networks and support.
But we should also be clear when the specialist and large service has its place. Much as the NHS shares the dysfunction of all large entities, I’m sure as hell I wouldn’t have wanted to live this experience through a collection of a dozen different small charities.
Now, I am told that a head injury causes some strange effects so I am going to use my ‘concussion syndrome’ to give license to some personal opinions which may not be shared. In my view, for too long a part of the voluntary sector – and some of its leaders – have argued for level ‘playing fields’ with the inference almost that the sector should take over the state. Their arguments have fallen into the favour of politicians of left and right with dubious motive – or dangerous naivety. Naivety which has done those we wish to reach no favours…because the ‘level playing field’ argument has been far more effectively deployed by the private sector at immense cost to individuals. This was borne out on a visit earlier in the year to a South Devon CAB where we were supporting appeal work (almost always successful) against a large private sector work programme provider assessing whether disabled people could go back to work (bitter sweet for those affected perhaps but they subsequently lost their contract. Even the Daily Mail got angry about the impact on disabled people).
Much as I like the analysis in Locality’s report there is a danger of them also falling into the same trap. With their excellent critique of state provision for people with complex needs they potentially risk not recognising the ‘horses for courses’ argument about when the state and scale can work. Personally I don’t believe the (current) voluntary sector will ever achieve scale and standardisation when it’s really needed as the best option – even the very largest charities in Britain are minnows compared to the size of the public sector – except perhaps in real niche areas.
The voluntary sector at its best is the defender of individuals when scale services fail them (like the South Devon CAB) or ignore them or ‘standardise’ them. We may do worse than look back at some of the things that Schumacher says as a start point. He talks about the need for both freedom and order and states ‘the centre can easily look after order: it is not so easy to look after freedom and creativity’. If we use my analogy – my effective treatment needed order and standards. No thank you ‘creative and free’ medical staff. Creative and free was what I needed when the ‘order’ was done with me!
I believe we urgently need a new (post Big Society?) dialogue about why and when the Voluntary Sector works. But equally importantly when it doesn’t.
With our historic work and reach as a Foundation (30 years; 42,000 small charities; £350m) and our new strategy (promoting practical approaches to lasting change) we are perhaps uniquely placed to contribute to that. As part of our new strategy we aim to develop our national impact to influence policy and practice by looking to generate, challenge and provoke debate around this crucial issue. Making the case for the VCS – and in particular for the small and local VCS – as key tools in tackling disadvantage. That case will be all the stronger if it recognises that small isn’t always beautiful.
As we develop our programmes, thinking and actions further I hope this blog will be the first of many. I hope they provoke thought and debate that you’ll engage with us. We all need to be open to new ideas and ways of working and thinking as we grapple with the shared challenges of most effectively tackling disadvantage against a background of austerity and ever greater complexity in the social issues we face together.