Andrew Lansley’s reforms of the health system (in 2012) created the commissioner/provider spilt, effectively putting providers such as hospital trusts into a position where their primary focus was to treat patients when “commissioned” to do so.   In effect, hospital trusts, one of the most significant components of our health and care system, were deliberately distanced from thinking about how to prevent demand on themselves.  In fact, they were paid to treat patients and the more patients they treated the more they got paid, albeit they are public rather than private enterprises.  At one level, given such structures and incentives in place it is unsurprising that they regularly became overwhelmed with demand.  Until recently, though, that remained largely the concern of commissioners not the hospitals themselves, or at least not until demand reached crisis point.

Recent changes that have come into place in the health and care system since July 2022 have thankfully largely dismantled this commissioner/provider split.  Finally, hospitals, as partners in Integrated Care Systems (ICSs) and Place Based Partnerships, are now forced to think about their role in building stronger healthier places, places that ultimately will put less pressure on the health and care system.  As critical local institutions, hospitals are being asked to play an “Anchor Role” in their local communities.  The Health Foundation describes “anchor institutions” as large organisations whose long-term sustainability is tied to the wellbeing of the populations they serve.  Extraordinary really that this needs to be set out now (as if this wouldn’t have been at the heart of what all hospitals were trying to do). It does reveal how far many hospitals have strayed from where they were before the NHS was established.

So, at a time of unrelenting pressure on the health system, how do Hospital Trusts find the time and capacity to play that role in their local communities? Our experience through working with different Trusts has been that they are generally too busy to be able to devote resources and time to preventative, health creating, community building activity.  However perverse that may sound.  Through having worked alongside Helpforce with several Acute (Hospital) Trusts we believe that volunteering may be a route for enabling Trusts to become meaningful contributors in building stronger, healthier, communities.

Trusts are now being asked to think about what they can do to support patients at all stages in their journey through the health system.  How do they ensure patients are prepared for their hospital visit or appointment, how do they ensure their experience in hospital is as good as possible, how do they ensure people recover as quickly as possible once back home and how do they contribute to building healthier communities? Getting these things right will, amongst others, have significant impact on:

• Reducing health inequalities
• Reducing time in hospital
• Reducing missed appointments
• Reducing re-admission rates
• Speeding up diagnosis
• Encouraging greater take up of vaccination, immunisation and screening services – particularly from marginalised communities.

So where do volunteers come in?

Almost uniquely amongst statutory health and care providers, hospitals have a long and successful tradition of working with volunteers.  Almost every hospital in the country will be supported by volunteers in different ways.  They carry out all kinds of tasks from running cafes, to collecting prescriptions for patients, to being meal time companions, and so on.  Many hospitals have 100s of volunteers on their books providing invaluable support. We believe this experience of working with volunteers and the presence of this volunteer work force in all Trusts can be the catalyst for Trusts effectively reaching out into their local communities to drive improvement in health outcomes and deliver on their obligations to be anchor organisations.

So much of the demand that faces the health system is only in part driven by ill health. So often the root cause (or wider determinant) of the issue is something that a volunteer could have helped to fix. 

• Women from ethnic minority groups are nervous about attending cervical cancer screening leading to delayed diagnosis.
• People miss appointments because they can’t get transport or can’t understand the letters that are sent to them.
• People’s loneliness drives them to seek medical support when in fact they need support to be better connected to their local communities.
• People don’t attend community events because they are anxious or need accompanying.
• People can’t be discharged from hospital because they’ve no one to help them once at home.
• People visit A&E because they are unaware of other services, they can make use of.
• And so on

So many people are willing to help their neighbours but are unsure how.  Because of our work alongside partners in health and care systems, we are certain hospitals have a significant role to play in building stronger more resilient communities where volunteering is much more widely practiced.  We believe the starting point for this should be looking at the touch points between patients being at home and being in the hospital, and looking to identify and support volunteering that can substantially ease the pressure on health systems by identifying and supporting roles for volunteers where they are supporting people before, during and after they visit hospital.

If you would like to find out more about our work in this area, please contact gilespiercy@localitymatters.co.uk.

That is a reality in the Faroe Islands.  Almost 35% of the Faroe Islands’ health and social care budget is controlled by local councils covering populations ranging from 2,000 to 7,000.  Give or take, the Faroes spend a bit more per head on health and social care than we do in England.

The Faroes are, to all intents and purposes, a separate county.  The islands are under the protectorate of Denmark but they have total autonomy over their own tax and spending plans, including those covering health and social care.  I was recently there on holiday and lots about the place left a deep impression on me.  One of the most astonishing facts about the Faroes is that almost the whole archipelago is connected by tunnels.  They go under the sea and through mountains and make journeys across the 18 main islands a breeze.  How they pay for this is a mystery.

I was curious to find out how their health and social care system worked.  The total population of the Faroes is around 50,000 people. I’ve not done a detailed analysis of the health demands and prevalent long-term conditions that exist on the islands, but I suspect they are not going to be that different to much of England.  Although, because a large percentage of the population are descended from the same small group, there are some special genetic diseases that are off the charts in the Faroes.  For example, Carnitine Transport Deficiency (CDT) which 1:500 people have in the Faroes compares with the world average of 1:500,000.  Obesity is not a big issue in the Faroes. Nevertheless, heart disease and cancer are, like almost everywhere else, significant killers.

In broad terms, the way they have set up their health system is like ours in England. Primary Care, covering local GPs (of which there are c. 20) prescriptions and community nursing, is run by central government.  Secondary care, covering the three hospitals on the islands as well as c.20% of specialist treatments, which they buy in from abroad (i.e. by sending patients overseas) are all, again, covered by central government.  What we would describe as social care – covering costs of domiciliary and residential care is organised, delivered and paid for by local government.

However, that’s where the similarities start to break down.  Of the overall budget of c.£150m a year nearly 33% is controlled by local government.  What’s extraordinary though is that when we think of local government in England, and its influence on health and social care, we are talking about population sizes of well over 100,000, and in some cases above a million people when looking at some county areas.

When I described my local situation to Símun Hansen, from the Faroe Islands’ Government and how the budgets are separated in most local areas in the UK he said “when you talk it sounds like a crazy budget!”.

Comparing the two:  In the White City (West London), a community where I am involved, across a population of 13,000 people we consume about £35m – £40m per annum of health and social care spend.  The local community, through local charities, our neighbourhood forum and other groups has direct control over effectively zero per cent of this budget.  We must get to an administration covering 190,000 people (London Borough of Hammersmith and Fulham) before one can, through the ballot box, influence spend.  At that level, the council nominally controls around 25% of the spend, although there’s a strong argument to challenge the degree of control they actually have, versus central government pulling the strings.  The tables below try to show how small the individual’s voice is in my community (White City, West London) compared with Símun’s voice in his community, Runavíkar Kommuna in the Faroes.

Local Government

Location	Approx. spend per head	Of which controlled by local government	Population covered by local government	Value of one person’s voice
Runavíkar Kommuna, Faroe Islands	£3,000	£1,000	4,000	25p
White City, London	£3,000	£750	190,000	0.4p

National Government 

Location	Approx. spend per head	Population	Value of one person’s voice
Faroe Islands	£3,000	50,000	6p
England	£3,000	50m	0.006p

 

So, on the basis of the above if you live in Runavíkar Kommuna, in the Faroe islands, your voice is over sixty times louder someone’s in the White City, when trying to influence local government and 1,000 times louder when trying to influence national government.

This is not an argument about economies of scale or comparing different health and social care demands.  We could easily get bogged down in trying to unravel the different systems and the pressures they are under and doubtless someone could set out a compelling justification for how efficient the NHS and our attendant health and social care systems are.  There would be room to question that argument and put the case that significant diseconomies of scale exist and flourish in our health and social care systems.  That though is the subject for a different piece.

That would also be missing the point of this piece which is that if essentially, I have virtually no control about how my money (raised through tax) is spent in my community, why would I bother to get involved?  However, in Runavíkar Kommuna as one of 4,000 people who live there, I can have a big say in what our priorities, as a small community, should be.  What do we need?  A place to worship?  A new harbour? A new care home?  An extension to our school?  Maybe even another tunnel?   If that degree of control and empowerment were available to local communities in the UK it would transform our communities into stronger and more resilient places.  Places where people are heard – because for many of us, if we felt we had a meaningful say in how our money was spent, we would be keen to make sure our voice was heard.