Feature

Should the voluntary sector be integral to public services?

In a speech last month, Alan Milburn called for the voluntary sector to ‘become part of the mainstream of public service delivery’.
But is he right? healthmatters asked key commentators for their views

Ed Mayo

Chief executive, National Consumer Council

What do Channel 4, the Lifeboats and hospices have in common? They are all non-profit organisations running highly effective public interest services.

The voluntary sector has always been integral to public service delivery. But its role has rarely been recognised.

There is no evidence to suggest that being a voluntary organisation necessarily means that you get better outcomes. But in those public services which can’t be reduced down to the wording on contracts, where the quality of care matters and where in turn that boils down to the relationship between carer and patient, there is a case for saying that values matter, and voluntary organisations tend to have the ethos and values of public service in spades.

One of the most important changes emerging in public services is the growing recognition and importance of the person using public services. It is no longer acceptable to treat people who use public services as passive recipients of someone else’s expertise.

Equally, there is a growing – though not yet universal – understanding of just how much healthcare depends on the co-operation of patients. Doctors complain that it is hard to get patients to change their lifestyles. Alcohol and drug rehabilitation programmes can’t work without the enthusiastic co-operation of the people involved, and a support group to go with it.

This kind of mutuality requires an organisational culture to support it. If there is a case for a wider role for the voluntary sector, it is this – that it could deliver a culture shock to public services that have lost sight of patients and users.

Margaret Cook

Author and retired haematologist

It is only natural that one’s first reaction to the government seeking to enlarge the role of the voluntary sector in health care provision, is one of cynicism. They always want Rolls Royce services for penny-pinching outlays. While that may be so, those of us who want practical solutions to intractable problems need to look at a bottomless well of goodwill and potential energy that is waiting to be tapped.

As the population age profile becomes more top heavy, there are many people over 50 who are time-rich and available. It is vital to keep these folk healthy and happy, for their own sakes as well as to consume less health resource. Initiatives such as 50+ clubs which get people involved, not only as consumers but as providers, are a good model. For instance, in Edinburgh an ‘Aging Well’ group, which aims to keep the older generation physically active, runs among other things a weekly walk which attracts some 40 attendees. These may go on to become volunteers or walk leaders. People use services more responsibly when they can give as well as take. Time banks are another highly successful community programme in which people can offer their time – as visitor, child minder, gardener, decorator, you name it – in order to qualify to receive someone else’s time when needed. A remarkable feature is that there are always more people wanting to give time than accept it.

A reciprocal arrangement promotes a person’s self-respect. People may discover skills lying dormant within, such as speaking and advocacy. Older people find in local forums that they are empowered by understanding rights and getting help to access services. Links with other people provide social networks, help to dispel involutional melancholia and keep mens sana in corpore sano. People feel good about themselves when they volunteer, and have less time to worry themselves into ill-health or iatrogenic disease.

Campbell Robb

Director of public policy, National Council for Voluntary Organisations

Partnerships between voluntary organisations and government at both a national and local level must be fair and equal. There will be many organisations in the sector who have absolutely no inclination to participate in the delivery of public services at all. However, when they do, voluntary organisations have a unique ability to involve users and communities, utilising their specialist skills and experience to secure a better deal for their beneficiaries.

It is vital that voluntary organisations only enter into partnerships with government when there is clear evidence that it will directly contribute to meeting their users’ needs. Talk of new initiatives that will enable the wholesale handover of large sections of services to the voluntary sector is dangerous. It represents a fundamental misunderstanding of the principal reason why the sector welcomes the current government’s efforts to lift the barriers to more service delivery by voluntary organisations. Namely, that it will provide opportunities for some, working in specialist areas, to widen their impact on the communities they exist to help, not fill gaps in service provision or replace the state. We must concentrate on building on existing initiatives such as the Compact, the Treasury review and Futurebuilders.

Peter Kenyon

Former NHS trust chair and advocate of election by universal franchise to NHS trust boards

In his enthusiasm for modernising public services, Alan Milburn seems to have forgotten about the workhouse, and the voluntary hospitals that preceded the NHS. There is nothing new in charities running public services. While he might be forgiven for lacking a historical perspective, his remarks about direct elections to foundation hospital beggar belief. It was he, as secretary of state for health, who embraced the illusion of mutuality when advancing the case for foundation hospitals.

What he and the so-called ‘modernisers’ need to recognise is that the missing element in improving public service provision is not switching providers from public to private, or private to voluntary sectors. Nor is it necessarily more money. The vital element is governance. It may not matter which sector provides a service funded by public money. Best value requires good, robust governance arrangements.

Modern society is plagued by the reluctance of professional people, irrespective of which sector they are employed in, to subject themselves freely to genuine accountability. This now includes national politicians. A national campaign for direct elections to every NHS quango in the land is needed to pave the way for better public services. Yes, we need nationally agreed frameworks for provision. But the audit responsibility has to be delegated to local directly elected bodies. For that we need new cadres of local politicians willing and able to stand up not just to Westminster but to their own chief executive, if necessary, to safeguard the public interest.

Margaret Mythen

Chief executive, New Health Network

As providers of care and important voices for local communities, voluntary sector organizations are already integral to health service delivery. But there is scope for even more involvement, while maintaining the flexibility and independence which is so beneficial to the public.

Sustained health service modernisation needs a range of players providing services that patients need – helping to increase capacity, extend choice and improve quality. And the wider public health agenda of preventing illness and tackling inequalities will flounder unless patient and community advocates are central to nurturing local engagement and new localism.

The issues are complex and individual organisations will each have to consider the implications and decide to what extent they want to get involved. Equally, public service bodies will also need to think through their relationships with organisations that are not just providers, but key players in local communities and the local economy. Proper governance, including probity and professionalism, will rightly be high on commissioners’ agendas, but risk-sharing should also be considered and longer term partnerships entered into, if the potential benefits of increased voluntary sector involvement are to be realised.

Martin McIvor

Director, Catalyst thinktank

In principle, the idea of the voluntary sector having a bigger input into public services is definitely an exciting one. Voluntary organisations can bring fresh ideas, a distinctive ethos and a special kind of relationship to the communities they serve. Public services must find ways to be open to these independent sources of social creativity and self-organisation if they are to renew themselves in response to changing social needs.

But there are good reasons to be cautious about handing over large chunks of the welfare state to the voluntary sector, and indeed to be suspicious about what is driving this agenda in the present context. The effect may be simply to cut costs at the expense of poorly paid public service workers (who generally fare worse in the voluntary sector), break up integrated, collaborative and redistributive systems of service provision, and open the way for more ‘contestability’ and competition for contracts from the private sector.

We should not be dogmatically blind to the achievements or potential of the voluntary sector, but our interest should be in how it can add value to the public sector, not in undercutting or replacing the public sector.