Surviving and thriving as a small health and wellbeing charity

Natasha Thomas, Chief Executive of GSK IMPACT Award-winning charity Health Action Local Engagement, reflects on what she has learnt as a charity leader over the past 14 years.

I have been the CEO of HALE – Health Action Local Engagement – in Bradford, West Yorkshire for the past 14 years, and a lot has changed over this time. Our project has evolved from being a healthy living centre fully funded by the Big Lottery with five staff employed by the NHS, to becoming an independent charity employing 28 part-time staff.

The scale of this change presented real challenges for the organisation – and to me personally as a leader – but through being adaptable and open to opportunities we’ve been able to successfully grow and develop. We were lucky enough to win GSK IMPACT Awards in 2010 and 2012, and our charity is a member of the GSK IMPACT Awards Network which has enabled us to continue our learning and development alongside other charities. I have also been a consultant on the Cascading Leadership programme. This experience has given me some real insight into the unique challenges faced by small charities and what’s most important when it comes to surviving and thriving.

GSK Impact Award

A few years ago I attended The King’s Fund’s Top Manager Programme, which really helped me to reflect on communication and culture. I realised that as an organisation we had tended to play a role that is expected (often unconsciously); so for instance I would feel grateful if I was invited to clinical commissioning group board meetings or working groups, and although not shy at coming forward I would often have low expectations of my ability to influence change. Since this training and continued support from the IMPACT Network, I have started to understand and recognise our strength as a sector, distinct from statutory services; that we need to express that strength and that we don’t need to feel grateful for having a place at the table – we should be there. The temptation has been for us to try to mould ourselves into mini-systems that respond to what commissioners want, rather than to be assertive about the improvements our approach and our view might bring to services.

Third sector organisations are typically set up either to fill a gap in services or as a response to an identified need – often working with and on behalf of those people and communities who are most vulnerable and have complex needs. Leading an organisation that works in an area of significant health inequalities, I have constantly asked myself: how can we make things better? How can we provide a link between our communities – local people with chaotic lifestyles – and appropriate services?  To coin a phrase, how can we ensure the right service is in the right place at the right time? Additionally, because we start small we are very agile and able to find solutions quickly, which allows for a person-centred service. We also need to be innovative in relation to funding; contracts often don’t give us enough to cover our overheads so we need to look for additional funds.

As funding has got tighter and harder to secure, and more and more services are contracted out, I believe as third sector organisations we need to avoid the temptation to replicate existing services, but instead keep to our mission as individual organisations. We are able to engage local communities because we speak their language; the challenge that I have tried to reflect on and respond to is how I share my understanding of need, and of ways of doing things differently with my colleagues in primary care, in the care trust, in the local authority and with those in education, the police. I believe the answer is in the small steps of behaviour change. It made me smile the other day when I was writing a report about how we might bring about some changes among local GPs, and I found it was exactly the same as what I might write for bringing about change in a community – community and peer support, offering small incentives and case studies. We all are working within systems that in one shape or another will reflect the expectations of others. As third sector leaders, we need to work with the system to make our voices heard – this might mean learning the foreign language that is spoken, but not that we lose sight of who we are and why we do what we do.

We have to address the faultline between social care and the NHS

One is heavily rationed and means-tested, the other free at the point of use and tax-funded. And when assets are involved, the issue becomes politically toxic.

In his first speech to the Labour party conference as Prime Minister in 1997, Tony Blair declared that he did not want his children to be brought up in a country ‘where the only way pensioners can get long-term care is by selling their home’. Twenty years later this remains a politically toxic issue – even though many people with care needs might wish they had a home to sell. The events of the past few days illustrate why the bold promises of successive governments to reform the way social care is funded have come to so little.

The Dilnot commission’s proposed cap on the lifetime costs of care was accepted by the coalition government in 2011 – albeit with the cap set at £72,000 rather than the £35,000 to £50,000 range proposed by Dilnot. It even made it on to the statute book as part of the Care Act 2014, and was generally welcomed as providing protection from the ‘catastrophic’ costs faced by the one in 10 who need care costing at least £100,000. Implementing the cap was a Conservative manifesto pledge in the 2015 election but, barely 10 weeks later, the government announced this would be postponed until 2020 as the circumstances were ‘too difficult’.

While the cap was a notable absentee from last week’s Conservative manifesto, proposals that did make it included the replacement of the current means-testing thresholds with a new single limit that would allow people to retain £100,000 of their savings and assets – but, more controversially, it proposed to include the value of property in working out how much people should pay towards care at home, as is currently the case for residential care.

Social Care

Following the criticism that greeted these proposals, Theresa May today promised that, if re-elected, her government will publish a green paper with proposals for an ‘upper limit’ on now much people should pay. This about-turn reflects the difficulties faced by all governments in addressing the hard choices and trade-offs involved in resolving this thorny issue. But while the reinstatement of the pledge to introduce a cap is welcome and could help to achieve a fairer balance in how costs are shared between the individual and the state, its impact will depend on the level at which it is set: the higher the cap, the fewer people will benefit; the lower the cap, the more it will cost the taxpayer. The detail in the proposals will require carefully scrutiny.

But reforming means-testing alone does not address the deeper challenges facing the social care system. Many thousands of older and disabled people have not been able to acquire property, savings or pension pots, and instead are wholly dependent on local authority-funded care budgets that have been cut by £5.5 billion over the last six years. The Conservative manifesto is silent on how much they would invest in the local authority system over and above the additional £2 billion announced in the Spring Budget. The proposal to means-test winter fuel payments for pensioners will bring more money into the system, although it is unlikely to be enough to bridge a looming £2.1 billion funding gap in 2019/20.

Nor do the proposals address the deeper inequities in entitlements between the NHS and social care. Although all three main parties are committed to further integration of health and social care, none of their proposals will remove the historical faultline between the NHS – free at point of use and funded through taxation – and social care – which is heavily rationed and means-tested. As the Barker Commission concluded, this is neither sustainable or equitable: develop cancer or heart disease but not dementia, and your house and savings will be intact.

The Conservatives are right to say that reforming social care is not just about money. Big changes are also needed in the way services are delivered to offer better outcomes for people and to tackle the mounting workforce problems facing the sector. However, none of the manifestos offer any new or imaginative thinking that address the scale of these challenges. A green paper early in the term of a new government would be an opportunity to put that right.

Source: Richard Humphries a senior fellow at the King’s Fund