Work at our level don’t ask us to work at yours

Giles Piercy as part of his involvement in Power to Change’s Community of Practice recently wrote this blog for Power to Change’s website you can read here

Imagine if almost £100bn of England’s health and social care budget was controlled by communities of less than 8,000 people.

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.

When you’re going to spend a lot of our money in our community can we please be asked how best to spend it?

The debate around whether public services should be run by the private sector or the public sector, is one that is often driven by dogma rather than any dispassionate assessment about what will actually be best for people and their communities.  One significant absence is the failure to ask: “could the community not do this better than either the public or the private sector?” It is a question that is not always uppermost in commissioners’ minds when determining service strategy.  I want to highlight this through two recent examples.

The first relates to an NHS building which was formerly a rural community hospital and has recently been turned into a community health and wellbeing centre.  As a result of a recent project, I visited it and was impressed by the quality of the building (it had recently been refurbished at significant expense) but the place seemed virtually empty.  There is a cavernous, vacant, waiting area and many of the rooms, though excellently kitted out, were not used.   I heard from a worker there that one of the tenants had just moved out because the rent was too high.  I spoke to the local GP practice to understand why they were not located in the building – they could not reach a sensible deal about letting space in the building from the landlord (NHS Property Services).  Despite all this empty space there was nothing in terms of promotional material to suggest that there was space for hire.  So I decided to investigate and asked whose responsibility was it to “sweat this asset”?  I was directed to NHS Property Services, whom I contacted and asked how the letting of space worked.  The helpful member of staff told me they set a “market rate” and if existing tenants or prospective tenants don’t like it then tough.  I challenged him by saying that surely the “market rate” is what the person who has just terminated her contract with you is now paying for similar space in town (i.e. significantly cheaper)?  So why would NHS Property Services behave in such an uncommercial way?  The answer was startling, and in fact worrying, given the state of NHS funding.  This is the way it works – if there are “voids” then the local Clinical Commissioning Group (CCG) picks up the cost.  So effectively NHS Property Services are incentivised to keep the place empty – that way they get the same rent but don’t have to bother with any pesky tenants.  NHS Property Services charge the local CCG almost £500,000 pa for being in the building – given that the local community spends (via the CCG) in total c. £1m on non-elective hospital admissions, £0.5m is a staggering amount of money to be spanking on property (a big chunk of which is empty).   Amongst this £500,000 were cost items such as £16,800 for “income generation” – would be good to see that itemised!  Corporate overhead and Management fees amounted to £37,000 pa.  The list goes on.  Also attached to this building is a small birthing unit which has one or two midwifes at different times offering pre-natal and post-natal services.  Mainly though the space is set aside for births.  Unfortunately, last year they only had five births – the unit was charged £50,000 by NHS Property Services for the space, that’s in addition to the £500,000!  As the midwife said to me they’d do better paying people to go to the Portland Hospital in London and putting the immediate family up in the Ritz.

The point of all this is why is the community not given a chance to do this better?  If they put the marketing or running of this facility into the hands of a local group it is almost impossible to conceive of them making more of a hash of it than currently being achieved by NHS Property Services – and there could be a great incentive for the community – lift the use, bring in some “real” revenue and we will share the upside with you.

My other example relates to a community centre in an urban area in the north of England. Recently the contractor who has the contract for housing repairs and maintenance of the council’s community centres started work doing “planned maintenance” to the Community Centre.  Next door to the community centre is another building.  This in the past was a venue for older members of the community to meet and socialise.  Sadly, it has been unoccupied for a long time because it is in a poor state of repair.  The community, through local people and local charities, have been trying to get the council to fix the dilapidated building but there is no money and the repairs are way down a priority list.   What would have happened if the community had been properly approached and been involved in a discussion about how best to use the budget that was set aside for the community centre’s planned maintenance (well into six figures)?  They might well have had a conversation that asked: “Do we need to do all of this work – what is really essential to us?  If we got some volunteers together would that help the budget go further?  There’s a couple of local developers we’re in touch with that might help fund the refurb of the dilapidated building if there was some recognition for them.  If we could do that could we direct some of the money, earmarked for the community centre maintenance, to bringing the dilapidated building back into use so that we can make it available for much needed community use.  Maybe even, as a result, we’d reduce loneliness and isolation among our older population with all the benefits that would bring?”   This conversation never really happened though and ultimately that’s not a criticism of the contractor or the council but a plea to the “system” that – “when you’re going to spend a lot of our money in our community can we please be asked how best to spend it?”.

Eight characteristics of councils that are building stronger more resilient communities

We were commissioned recently to carry out research to try and uncover which upper tier local authorities in England were making genuine progress in terms of building stronger more resilient communities.  Through both desk based research and structured interviews what emerged was a set of characteristics of councils who are serious about getting communities to play a more active role in: designing, commissioning, delivering or critically preventing demand for public services.  We’ve set them out below:

  1. They have very clear INTENT
  • Community empowerment is embedded in strategic plans.
  • Beyond principles they have a defined approach – a way of doing things.
  • They see community empowerment as a part of budget and demand management approaches.
  • They recognise that people can get trapped in a service delivery world.
  1. They have a defined and consistently applied APPROACH for building stronger more resilient communities.
  • They have approaches that support communities to place less demand on public services.
  • They are actively looking to encourage greater co-production of public services. By this we mean involving communities, at the earliest possible time, in defining requirements and designing how these will be addressed (or their need prevented) and being involved in the delivery of services or demand management activity.
  • They are working with elected members to get them to be more involved in their local communities.
  • In Unitary councils they are creating and funding Ward Forums.
  • They have dedicated staff teams to undertake community work and co-ordinate activity across the council.
  • They try to understand which staff live and work in their communities.
  • They are devolving meaningful budgets to community control.
  1. They have KNOWLEDGE about their communities and processes to maintain this knowledge
  • Have a defined way of understanding and mapping community assets (people, organisations and physical assets).
  • Are able to define and calculate public sector spend at a community level.
  • Have some way of measuring community capacity across all their communities.
  1. They COMMISSION from an asset basis which is underpinned by the aim of fostering greater community delivery (i.e. greater involvement of the community and voluntary sector from design through to delivery).
  • Commissioners engage with communities at the earliest possible stage.
  • Commissioners test, as part of any procurement exercise, whether the community is capable of delivering the required service or aspects of it.
  • They have processes in place to measure the impact of community empowerment on budgets, service delivery and service demand.
  • They understand the principles of social impact investment and are looking to apply them to community development work.
  1. They have effective GOVERNANCE in place.
  • They have a director with specific responsibility for supporting demand management work in communities.
  • They have an elected member with specific responsibility for supporting demand management work in communities.
  • Political patience – i.e. an acceptance that it will take time to measure impact upon public services.
  • They recognise, and are dealing with, the challenge that may come from encouraging greater involvement of community groups and how this may clash with the responsibilities and mandate of elected members.
  1. They are changing the CULTURE within their organisations.
  • They have programmes in place to help support and train staff.
  • Their aspirations around community empowerment are enshrined in staff appraisals and team targets.
  1. They have effective PARTNERSHIP working at a locality level.
  • They have processes in place to allow joint working at a locality level.
  • They are starting conversations with partners where they say “if we can reduce demand for your service in this area will you commit to realignment of budget”.
  • There is meaningful activity around shared budgets at a locality level between different statutory providers
  1. They are able to MEASURE the impact they are having.
  • They have specific goals both around strengthening communities and reducing public service demand.
  • They are able to assess whether interventions are improving services or what specific difference they are making.
  • They have systems in place to measure the impact they are having on:
  • Community resilience,
  • Service demand and service costs.