The NHS won’t achieve the mental health revolution without the support of small charities

Claire Murdoch, NHS National Director for Mental Health, shares her vision for the future of mental health – a future in which the NHS and local partners work hand in hand to ensure people with mental health issues get the best care possible, as close to home as possible.

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Over 35 years I have had the privilege of working with so many impressive people and organisations dedicating their time and energy to making a difference to the lives of people with mental health issues. I have seen how small charities have been fighting against stigma, loneliness and lack of resources for decades. Today, I am so proud of the mental health revolution we are conducting together throughout England – a revolution that wouldn’t have happened without the support of our partners working tirelessly on the ground. On World Mental Health Day, I want to pay tribute to their dedication and thank them for their continued support.

It is an exciting time for our sector: the NHS Long Term Plan has committed a new ringfenced local investment fund worth at least £2.3 billion a year in real terms by 2023/24 to ensure that the NHS provides high quality, evidence-based mental health services to an additional two million people. We have been working in close partnership with stakeholders all over the country to decide what this extra money should be used for – and where it could make the most difference.

Last year we called on our partners for recommendations, and received contributions from more than 150 organisations, representing the voices of over 27,000 people. I was really impressed by the engagement of the sector, which supported us in developing ambitious plans for mental health. We published these plans over the summer and are now already working hard to make them a reality.

I often say that the NHS won’t achieve the mental health revolution by itself; we can’t deliver our plans without the support of the voluntary, community and social enterprise (VCSE) sector. We need to reinforce the links between charities and our services at the local level to achieve our ambitious objectives.

One of these objectives is to transform community mental health in the next five years. After decades of under-investment and increased pressures on our services, we want to ensure that people with moderate to severe mental health issues get the best care possible, as close to home as possible. We recently announced new funding to pilot integrated models of care with GP surgeries, mental health services and local partners working together to give personalised mental health care and advice to people who most need it.

In addition, funding has also been made available to all local health systems in the country to increase provision of non-medical, community-based alternatives to A&E and hospital for those experiencing mental health crisis. These services are often provided in partnership with the voluntary sector and help to ensure we can meet local need in an effective and timely manner.

I encourage local mental health and wellbeing charities to take part in these programmes to support the much-needed transformation of mental health outlined in the Long Term Plan.

I look forward to meeting representatives of small charities at Lloyds Bank Foundation on Friday 11 October, and to discussing our plans for the next five years. I am interested in hearing new ideas on how we can better coordinate our efforts with the VSCE sector to deliver meaningful change for people with mental health issues all over the country. I am also keen to understand how smaller charities can be supported to do more. Often run by local communities, they are one of the best ways to help challenge stigma and inequalities.

Fortitude, tenacity and consistency: celebrating seemingly unremarkable people and organisations doing remarkable things in the Voluntary Sector

Paul Streets, CEO at Lloyds Bank Foundation

As we mark 30 years of funding small and medium-sized charities, we’ve developed an Awards Programme that celebrates and showcases their important work. We recently announced our regional winners across six categories. The differences between these categories, programmes and pitches is both interesting and refreshing: it reflects the diversity and richness of what people do with the support we give them. Two categories that particularly shone for me were Unsung Heroes and Against The Odds. Each one remarkable.

The first a set of stories about individuals. Volunteers who have been the bedrock of organisations – sometimes as founders, sometimes just in being there to do whatever, whenever. People who been through their own personal hell, come out the other side and have then accomplished more than they might ever have achieved without adversity by choosing to use their own journeys to help others. Often people who have turned adversity into a personal asset which they have shared with others.

In July we had a reception at the Senedd where we announced the Welsh winners (pictured above). The ‘Unsung Hero’ for Wales, Sarah Baker from TOGs Centre talked so positively about how her son’s Angelman’s Syndrome had been such a positive driver for her. If you could paint a kind of aggregated pen picture of such volunteers it would be one of fortitude, tenacity, consistency – often over years and years – and massive optimism that people can come through whatever life throws at them. In some respects seemingly unremarkable people doing remarkable things.

If you could paint a kind of aggregated pen picture of such volunteers it would be one of fortitude, tenacity, consistency…seemingly unremarkable people doing remarkable things.

The second set of stories about organisations and what they’ve done to pull through …sometimes more than once – uncomplaining, often in the face of big cuts or losing big contracts – which they report without anger just as facts – to find a new way forward. Boards and CEs refreshed. New money sought. New purpose and direction found. The twinkles shine through the text. A pen picture that would echo collectively that of the individual Unsung Heroes.

I am struck by the juxtaposition between those stories and the vision George Osborne set out in the July Budget and in launching the Spending Review. The government has argued that even after five years of austerity, cuts of 25–40% in a whole range of key public services should still be possible. Things feel just about OK, so why not do more?  After all, it is argued crime is down – despite cuts to the Police they have managed. Allegedly the public report high satisfaction with public services.

And indeed that’s probably true for many people. The odd extra pot hole perhaps. For many of us we’ve still got secure jobs, homes, the dustbins get collected, my local library is still there, my trains have even improved and will do even further as I crawl past the billions being spent to improve London Bridge, and my parents have had fantastic care through the NHS.

Now of course there has long been a divide between those who “have” and are OK and those who “haven’t” and are far from. The welfare state, public services and the voluntary sector have always, separately and together, been part of helping to narrow the gap and help the “have nots”. But the money to do so will remain in short supply.

The recent NCVO Financial Sustainability Report projects a £4.6bn shortfall in voluntary sector income in the next few years – largely driven by a reduction in Government funding. At one level that’s only about 10%. Sounds doable. But if you read below the headline figures, there has been a significant redistribution of the sector’s spending power from smaller to larger organisations. In the last few years the small/medium-sized charities we fund have seen a 30% cut in Government funding. The next few will likely see something similar…so over about six to eight years they’ll likely see any government funding they receive roughly halve and the challenge of winning increasingly competitive public service contracts means what flows to them may well be even lower.

Charities have been positively likened to cockroaches in their ability to withstand a nuclear war and continue. But we want good charities to not just survive but thrive.

Charities have been positively likened to cockroaches in their ability to withstand a nuclear war and continue. But we want good charities to not just survive but thrive – Our Against The Odds category demonstrates that. But these are the best, alongside the other 121 charities which won or were highly commended at a regional level. There are 36,000 small/medium charities working in health and social care alone – around 160,000 in total.

Foundations have a vital role to play here as the level of grants we provide now matches that from Government – leaving us as one of the few remaining sources of vital unrestricted funding. Whether we like it or not as Foundations that gives us extra responsibilities – to think about the accessibility and distribution of our grants across the country and against need.

But we also need to find a way to speak these truths about the sector to power. Maybe Central Government has no money anymore, but it can recognise the vital role of the sector in reaching those who are not seeing any light at the end of their tunnels.

Maybe Central Government has no money anymore, but it can recognise the vital role of the sector in reaching those who are not seeing any light at the end of their tunnels.

It does have the power to seek for the money left to reach the right places through the right ways. But for that to happen it needs a narrative for the sector which is sadly absent.

Too often the voluntary sector is allowing its story, purpose and achievements to be told, or indeed mis-told by others. It is striking that no-one is telling a positive story about the sector and in particular what small and local charities are doing day-in day-out to help the people who need it most to get back on their feet and rebuild their lives. But these charities cannot have a voice if they don’t exist.

These charities cannot have a voice if they don’t exist.

If I sound angry I am. But anger has always been a big personal motivator in my work on different ‘lost’ causes through the years.

And all hope is not lost.

If we honestly believed this Government didn’t care – as some in the sector have said to me – then perhaps it would be.

But David Cameron has been noted as a person driven by a motivation for social reform. George Osborne’s commitment to a higher minimum wage is a clear sign that this government can take ideas from across the political spectrum and be influenced by evidence and effective campaigning (Living Wage Foundation and all who have supported and worked with it take a bow).

Yes, we need to hold the Government to account… but most of all we need to work with them to find a way to ‘socially reform’ which can work for those who know better than they ever will: our Unsung Heroes battling Against the Odds.

It is them we betray if we keep quiet and continue to wring our hands because it’s oh so difficult…

…if they had  done the same and not responded to the call to help their fellow citizens we’d have no charities and no-one to give Awards to.

Paul Streets Asks Three Wishes of the VCSE Government Review

By Paul Streets, CEO at the Lloyds Bank Foundation

Let’s ask for three wishes of this Government review. If England’s Public Health Services and their local friends in Clinical Commissioning Groups, Local Authorities and Local Health and Wellbeing Boards were Genies, and we were in Aladdin’s cave – what might our three wishes be?

The NHS remains the darling of the public. Health is never far from the top of our personal or Political agendas.

But we need to redefine what ‘health’ means for the needs of the 21st century. And whilst the centre calls for this ever more stridently and often: from The NHS Plan (2000) to Derek Wanless (2002) to the Five Year Forward View (2014) – the VCSE sector quietly gets on doing it.

We saw this in the 1990s with the shift in the focus of effective chronic disease management. This began with Arthritis Care bringing ideas from the USA to introduce self management. When I was at Diabetes UK we plagiarised this and models in Germany to create DAFNE, the patient education programme centred on supported peer learning. Then came Asthma, Osteoporosis – the list goes on. This thinking is now widespread across chronic disease management with an understanding of the expert patient. And now even cancer with the focus on survivorship and the work of Macmillan. It has even begun to flip over into elective care through the growing interest in shared decision making – which reduces elective care demand through a focus on patient over clinical preference.

There are many more examples. End of life care has been transformed through the hospice movement. Alzheimer’s Society has led to thinking on dementia friendly communities and dementia friends: still in its infancy but creeping up as mainstream thinking. The list is almost endless.

What all of these have in common is a subtle but clear paradigm shift in thinking: usually centred on listening hard to those on the receiving end and driving innovation up through the eyes of consumers, rather than down through providers. DAFNE is the example par excellence. It turned conventional thinking on its head with the strapline ‘eat what you like, like what you eat’ : an anathema to (then) current diabetes management.

But because none of these were initiated or planned from the centre and have often been achieved quietly without the brouhaha of the next miracle drug cure we rarely reflect back on the profound impact.

A powerful VCS national advocate or movement has often been critical. Prepared to be tenacious against the grain of current thinking with independent funding to put their money where their mouth is and create leverage.

But the 21st Century challenges health faces often don’t have organised and independent advocacy.

If we look at many of the avoidable health costs we see drivers that often don’t sit in ‘health’ at all and which affect the most disenfranchised in our society: drugs, alcohol, mental health, social isolation in older people, domestic violence, and homelessness. These are the bread and butter of A&E.

But they are also the bread and butter of the VCSE.

Usually this is local. And often small scale with a focus on good relationships as a central philosophy: outwards between the VCSE and its community, and inwards in the relationship formed with those it serves: a physical manifestation of Think Local/Act Personal rather than a strategic wishlist.

But whilst many of the large national charities which drove innovation in self management are independently funded – most local VCSE services whether provided by small charities – or national branches of larger charities – rely on a degree of public funding to survive, albeit often alongside funding from people like us at the Foundation.

NCVO data shows that public funding is both rapidly declining and shifting from a focus on holistic support of complex needs to one of contracting, scale and single outcome.

This is particularly problematic when the ‘spread’ model that works for chronic disease – VCSE pilots/proof of principle to an NHS which picks up the tab – doesn’t cut it for these issues. Success here is often founded on trust based relationships with people who have little faith or trust in public institutions which have often affected their lives so adversely. Effective reach will always require trusted independent agents – the VCSE will always be central.

At the Foundation we are becoming very concerned that these critical organisations are under real threat. Many of the larger foundations like us rely on what we have called the ‘fruitcake’ model. As we can only afford to be the icing and marzipan we often rely on public funded fruitcake. Both are critical but they are symbiotic: without one the other will not thrive.  Recent ESRC research demonstrates that this ecology is especially fragile where the need is greatest. What we have called triple jeopardy: the inverse relationship between need and VCSE capacity; and the direct relationship between areas with high public sector investment in the VCSE, high benefit dependency and high needs. NCVO data shows that at a macro level between and within regions. We see it ourselves: looking at London with the concentration of good VCSE’s in the centre, and near The City, and the scarcity in the outer suburbs where the need is greatest, or in the North East between Durham City one of the wealthiest areas, and Redcar – one of the poorest.

The implication is those most at risk are often supported by a VCSE infrastructure which is also most at risk. It is not hard to extrapolate what that might mean for health and social costs right across the Board and where the greatest impact will be felt if it continues.

So this really matters.

If we are brave the review is an opportunity to turn the tide. And a new electoral cycle the right time to ask for our three wishes.

So here are the 3 wishes to the DH/PHE/NHSE and their local partners in CCGs, Local Authorities and LHWBs: each in order.

The first wish: a more rounded view of where ‘health’ begins and ends. To the NHS it may end in A&E, the elective surgery table, long term care or blocking beds but it starts with people, the lives they lead and the communities they live in.

The second wish: match the recognition of the strategic value of the VCSE intended in this review with the need for well placed national and local funding to those best equipped to tackle these issues. This is hard at a time of fiscal constraint with little new money. It will mean diverting funds from what isn’t working, or from where we are funding the costs of failure, to funding community based prevention and support.

The third wish: take a more flexible approach towards how that support is provided with a determined focus on purpose centred on people as they present with their complex lives and wishes – rather than the service silos we pigeon hole them into. This probably means a radically different approach to how to achieve ‘scale’ and a big rethink of whether contracts are fit for purpose.

If you agree let us know.

Then: once our wishes are granted – we need to hear:

  • examples of how the VCSE is the answer to some of these intractable health problems so we can make a robust case for a strategic and central role, and
  • practical suggestions about what DH, NHSE and PHE and their local system partners need to change – or do – to enable that to happen.

This is not an easy ask and there are no easy answers. We need scale – and yet part of the solution lies in retaining the essential ‘localness’ of many small/local organisations. We will need to turn current orthodoxy of reach through scale up on its head – to create a presumption of achieving reach through replication, collaboration across boundaries and ‘spread’. So this time we need paradigm shifts on how to deliver, how to ‘commission’ and what constitutes ‘scale’.

Tough stuff.

But – as with self management 20 years ago – the answers will come ‘bottom up’ from us and those we serve: turning existing orthodoxy on its head.

So … give us a hand and, like Aladdin, we might even live happily (or at least purposefully) ever after.