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1. The British Red Cross welcomes the opportunity to respond to the Government’s Health White Paper Equity and Excellence: Liberating the NHS. 2. The British Red Cross works in the UK and internationally to support people through crisis situations and build their resilience. Our key areas of work in the UK are providing emergency response, first aid education, health and social care, and refugee and asylum seeker services delivered by trained, skilled volunteers and supported by our staff. 3. We have over twenty years experience of working in the health and social care sector throughout the UK. We have almost 5,000 volunteers helping us to provide tailored support services to vulnerable people at times of crisis to address their practical and emotional needs, and enable them to live independently and with dignity in the community. While most of our beneficiaries are older people, we also work with those with other vulnerabilities including mental health and substance misuse issues, and have specific services working with HIV positive people, and with Gypsy and Traveller communities.
4. We currently hold 248 contracts, primarily with the NHS and Local Authorities, to provide Care in the Home, Transport and short term equipment loan services designed around local need, and a national Skin Camouflage offer. We also hold contracts with Practice Based Commissioning (PBC) consortia, including in Nottingham where we have established an innovative Crisis Intervention Community Support Service supporting vulnerable people in the community to prevent hospital admission, and producing an estimated saving of £200,000 within a year1. However,
Pulse Magazine, How our third-sector provider goes that extra mile, 22nd March 2010, http://www.pulsetoday.co.uk/story.asp?sectioncode=40&storycode=4125530
our experience of PBC in other areas has been less successful in terms of GP interest and engagement. 5. Our services have consistently demonstrated that intensive time-limited support can be beneficial in promoting reablement, reducing the need for hospital or residential care and improving the patient experience. They have been recognised by the Department of Health’s QIPP programme as achieving cost savings of up to £1million per commissioner per annum2. 6. Our response to the White Paper is based on this expertise and rooted in our experience of delivering health and care services to vulnerable people.
7. The White Paper proposes a radical restructure of the NHS. This response will not address the full range of areas addressed in the White Paper, but will comment briefly on the overall strategic vision. The response will subsequently focus on two areas which are of specific relevance to our beneficiaries and our service delivery:
the challenges and opportunities presented by the commissioning transition ensuring that the needs of vulnerable people are identified and addressed
8. The British Red Cross welcomes the White Paper’s vision for the NHS, and particularly the ambition to develop a patient-centred approach, which mirrors our own approach to developing flexible, beneficiary focused services. 9. We welcome the focus on improving quality and healthcare outcomes, but would highlight the importance of looking beyond short term outcomes, to the medium and long term outcomes which are critical to assessing the quality and effectiveness of intervention. We will be responding to the consultation on the NHS outcomes framework separately. 10. We also welcome the commitment to ensuring that services work better across health and social care boundaries and focus on prevention, and the ambition that NICE quality standards will play a role in highlighting the need for joined up care pathways.
Department of Health Quality Improvement and Productivity Programme (QIPP), www.evidence.nhs.uk/quality andproductivity
However, given the White Paper’s stated intention to ensure better integration, we note with concern that the publication and consultation period for this White Paper was not co-ordinated with the forthcoming White Papers on Public Health and Social Care. We would like to see more detail on what mechanisms, in terms of duties and financial arrangements, are likely to be implemented across the services. Similarly, we would like to see more detail on how the proposed outcomes frameworks in each service will fit together to deliver integrated care pathways. Without such detail it is difficult to comment meaningfully at this stage. 11. We would also like to see recognition of the key role voluntary sector organisations play in the delivery of holistic services across health and social care, and would hope that there will be a role for the sector to play within the proposed Health and Wellbeing Boards.
12. The British Red Cross welcomes the creation of the Public Health Service but would like to see more detail in relation to its powers, and the anticipated role of the NHS Commissioning Board and other relevant bodies, specifically as they relate to building resilience in communities and mobilisation during an emergency. We believe that the Health and Wellbeing boards may provide a key opportunity to better integrate services between health and emergency planning. However, we would hope to hear more about the mechanisms envisaged for the Public Health Service to engage with the voluntary sector, together with clear recognition of the role the voluntary sector play in supporting the statutory sector to deal with public health emergencies, such as the recent Flu Pandemic.
Challenges and opportunities presented by the commissioning transition
13. While welcoming the principles behind the transition from PCT to GP commissioning, the British Red Cross shares the concerns of other organisations about the speed of the proposed reforms and the lack of detail regarding how the transition will be managed. 14. The British Red Cross is also concerned that the White Paper contains no explicit recognition of the role of voluntary sector organisations such as ours in addressing the health and social care needs of vulnerable people and ‘filling gaps’ in service provision which would not be addressed without our offer. We have serious concerns
about the challenges that organisations with limited resources are likely to face in engaging with and responding to the proposed commissioning environment in terms of an understanding of their added value, operating in an increasingly competitive environment, engaging with the choice agenda and marketing their niche offer. We also believe that loss of such organisations will be detrimental to the health and wellbeing of the vulnerable people they support, and would be likely to increase inequalities in health outcomes. 15. Without a clear commitment to managing existing relationships with voluntary sector providers – and clear responsibilities for effectively handing over these contacts to the relevant professionals within GP consortia – much of the work that organisations such as ours contribute to the health and social care sector may be lost. In particular: i. British Red Cross services have started reporting instances where PCT Commissioners have already left their posts and no new contact has yet been identified. This leads to difficulties for organisations in forward planning and further developing existing services in the absence of interested strategic input from existing contract managers and commissioners leading to a shrinkage of activity ii. There will be loss of knowledge and understanding of our services which have been externally assessed as bringing adding value to beneficiaries – in terms of practical and emotional needs3 – and the health service – in terms of supporting independence, promoting reablement and reducing use of statutory health services4. We would welcome the identification of a voluntary sector lead within PCTs and the Department of Health to better manage this process and support the transfer of knowledge and skills built up within existing organisations, and would highlight the risk that providers like ours may be unable to maintain their services without such support. We would also caution that loss of services during this transition period will make it much more difficult for organisations to develop similar services in the future, particularly given that closure of services is likely to lead to a loss of goodwill and commitment from our dedicated volunteers. Furthermore, loss of services such as
Dr Fiona Zinvieff & Dr Catherine A. Robinson, The Role of the Voluntary Sector in Delayed Transfer of care/Hospital Discharge and Prevention of Readmission, Bangor University, October 2009. 4 QIPP
ours will lead to smaller provider market for both beneficiaries and commissioners to engage with and as such would be likely to threaten the underlying principles of the emerging choice agenda.
16. We note the intention that the Secretary of State will agree a mandate with the NHS Commissioning Board to be updated annually, while GP consortia will develop and review yearly implementation plans. While we welcome the acknowledgement of changing local need and the importance of responding to this on an ongoing basis, we have concerns that the implications of this will lead to further uncertainty which may make it increasingly difficult for organisation such as ours to operate. We also note that this is at odds with the Government’s recent stated intention to offer longer term contracts for the sector and highlight that very short term funding is likely to stifle development and work against the kind of innovation sought by the White Paper.
Ensuring that the needs of vulnerable people are identified and addressed
17. Our overriding interest is ensuring that people get the help they need in a crisis, so we welcome the focus in the White Paper on putting patients and public first, and believe that the proposed model of GP consortia has the advantage of bringing commissioning closer to the patient. However, we would hope to see more statutory safeguards for ensuring that the voice of the most vulnerable is adequately fed into the proposed joint strategic needs assessments and commissioning processes. 18. In particular, our experience of working with more vulnerable groups of beneficiaries, including Gypsy and Traveller communities and refugee and asylum seekers highlights that these groups often struggle to access primary health care and may face prejudice from practices who frequently refuse to register them. It is vital that the healthcare needs of these groups are not overlooked in the commissioning process, and we believe specific measures may be necessary to safeguard against this. 19. We note with interest the role for the NHS Commissioning Board in championing patient and carer involvement, promoting quality and tackling inequalities in access to healthcare, and the duty of public and patient involvement placed on GP consortia to
engage patients and the public in the commissioning process, but would like to see more detailed proposals in these areas. 20. Furthermore, we are concerned that the proposed duty for Local HealthWatch to ensure that patients views are integral to local commissioning is likely to be executed with varying degrees of success across different areas,. We also note that the White Paper proposes a very wide remit for Local and National HealthWatch, from advocacy to audit and across both health and social care, though the resources they will have at their disposal have yet to be detailed. Our experience of working with existing LINks varies widely between areas and while some are highly effective, we have concerns that others may not be fit for their current purpose, and would therefore be ill equipped to effectively play the proposed role in lobbying GP consortia and holding them to account when they become local HealthWatch. We believe Local HealthWatch would benefit from stronger organisational frameworks and guidance, that better links should be established between local groups to facilitate the sharing of learning, and that the resources which will be made available to them must be clarified at the earliest opportunity. 21. We would welcome recognition of the vital role the voluntary sector often play in supporting and empowering the voice of the most vulnerable and would hope to see a statutory requirement for the voluntary sector to be appropriately represented on the proposed Health and Wellbeing boards. 22. Finally, the British Red Cross welcomes the White Paper’s vision of the NHS as part of the Big Society and believes that our services, based on volunteering and a framework of interdependent benefit for the beneficiary, the volunteer, and the taxpayer, are already modelling this approach. Promoting independence for our beneficiaries is also a critical part of our ethos, and we know this is a key part of what inspires our volunteers. However, we would highlight that vulnerable people in crisis are not always able to take on greater responsibilities. It is vital that this should not preclude or curtail their access to the care they need.
For further information, please contact: Natasha Kutchinsky, Public Policy Advisor email@example.com; 0207 877 7309