A new study published by LSE Consulting describes the 2020 pandemic as a “wake up call” for health policy planners in England. The paper by Dr Tony Hockley (LSE) and Prof Alison Leary (London South Bank University) details how charities have been filling major gaps in health and care services that are set to grow in the coming decades, and how policymakers have done little to involve these charities in planning their response to the pandemic. Given the challenges that lie ahead, the authors argue that this should serve as a “wake up call” to restore a culture of partnership.
In 1946, Aneurin Bevan described the fact that hospital services in England still relied upon charitable fundraising as “repugnant to a civilised community”. Bevan believed that “comprehensive” state provision should extinguish any need for charity. Yet the sector continues to make a significant and distinctive contribution to care some 75 years later. The Covid-19 pandemic has highlighted the importance of this contribution, not just in front-line care but also in professional leadership. It also accelerated the onset of some of the health and social care system’s biggest challenges, particularly in delivering high-quality care for ageing population and at the end-of-life. Charities have a huge amount to contribute in meeting these strategic challenges, but must first be brought back to the table as essential partners.
Our study was commissioned in the Spring of 2020 by the National Garden Scheme (NGS), which has raised £70m of funding for the Queen’s Nursing Institute (QNI) and other health and care charities since 1927. At first, we thought it would be a review of the routine work supported by this fundraising and its contribution to current public policy goals. This would build on earlier research by the King’s Fund. Instead we gained insights into the extraordinary work of the charities during a global pandemic, when needs exploded and fundraising activities all but stopped. We heard and read stories of a vital partnership with state-provided care under incredible stress. The gaps in care being filled by charities grew almost overnight. What had been forecast for the “future” was happening now. The individual stories of charities adapting quickly to the new and appalling circumstances bear testimony to exceptional motivation and professionalism.
We also found an historic partnership in apparent peril, with very limited proactive engagement from government. A culture of strategic partnership between the health and care system and major charities seems to have diminished over the past 20 years, with very little strategic engagement even in the areas of policy known to present the biggest future challenges. These areas have been highlighted by the pandemic: Improving wellbeing in the population, retaining and motivating the care workforce, tackling inequality, meeting the needs of an ageing population, and dealing with historically high numbers of deaths. These are all areas in which health charities have taken a lead, in “people, practice and policy”: Employing (and supporting) the people needed, particularly care professionals, quickly adapting front-line practice to changing needs, and giving policy leadership, developing and disseminating guidance on good practice in a changing environment.
We will probably never know whether some of the worst impacts of the pandemic could have been averted or reduced through better partnership planning. But the pandemic has served as a wake-up call for the major policy challenges that lie ahead.
Our study highlights ways in which charities sought to understand and respond to the impact of the pandemic on personal wellbeing, particularly through social isolation amongst those most in need of support, workforce stress, and untreated cancers. An ageing population demographic over the coming decades, the result of baby-boom births, will increase demand for more and better services from community nursing and from end-of-life care (forecasts suggest that within the next decade the number of deaths in a ‘normal’ year will exceed those in the 2020 pandemic): In all of these priority areas the charitable sector has been playing a major, much-valued and distinctive professional role. Without forward planning and an honest partnership, however, the charitable sector could not be relied upon to fill the growing gap between service provision and service need.
In the coming years, end-of-life care will become a major policy concern. More and more people will be living with cancer and dementia, needing specialist, personal support over periods of many years. The hospice sector will need to expand significantly whilst maintaining the very human touch that is the mark of this extraordinary voluntary movement. During the pandemic, however, charities working to meet these priority challenges were forced to lobby government in order to sustain their services in a situation of heightened demand and reduced fundraising. Their services and expertise appear to have been overlooked in government pandemic planning.
It was clear during our study of the activities of health charities during the pandemic that they are willing and able to contribute to policymaking, with exceptional motivation to deliver high quality services even in the most testing circumstances. It was also clear to us, however, that the NHS seems very willing to take what services charities make available at the local level, but not to engage in collaborative forward planning at the strategic level. This seems a grave misjudgement.
It is in the policymaking process that partnership seems to have become most weakened. It is perhaps a casualty of the boom years of NHS funding around 2003, when NHS self-sufficiency may briefly have seemed a viable option. But this is not normal and has never been a serious possibility. One of the last major health policy statements in which I was involved at the Department of Health was the November 1996 NHS white paper “A service with ambitions”. The then Secretary of State, Stephen Dorrell wrote that: “…the delivery of health objectives requires the NHS to work closely with other agencies, both voluntary and statutory”.
As a Special Adviser at the time it seemed perfectly sensible for me and for ministers to commit time to working with health charities and other partners in policymaking, whether tackling immediate crises or planning for future challenges and ambitions. Specialist charities were often my first call for advice when problems or opportunities arose. Today’s policy statements such as the “Long Term View” seem to be the legacy of a more self-sufficient view of the NHS, with the voluntary sector relegated to the status of a local service provider rather than a strategic partner. The contribution of charities to health and care is much more than an issue of the adequacy of state funding. Charity can be a valuable addition to what state agencies can do, with a unique motivational base. Today’s charities are much more than just a stop-gap for the failings of state provision, as Bevan once believed.
The case for renewed integration between the NHS and charities is not a new one: The 2016 “Untapped potential” report by NPC made a detailed case for a deeper partnership to deliver the health and care transformation of policymakers’ ambitions. The pandemic has added new urgency to this case. It has provided a foretaste of future challenges. Our study of charities’ pandemic response, when care needs exploded and fundraising collapsed, shows a charity sector that is professional, motivated and adaptable however trying the circumstances. In the paper we note that:
The charities covered in this paper not only rearranged their own services in response to the pandemic but often also helped guide NHS services through the coronavirus challenge. However, the initiative to do so came almost invariably from the charities themselves, with little or no forethought from the NHS, policymakers, or other public service leaders.
It would be a major mistake not to learn from the experience of the pandemic. The state alone cannot meet the challenges of the coming decades. Charity will have an important role to play in both the quantity of quality of provision, but there is an important conversation to be had if this is to be a sustainable and productive partnership. The severe wake-up call of 2020 should provoke a cultural shift. Charities need to be at the heart of future planning.