Labour's offer this week of 'NHS preferred provider' status to voluntary sector organisations raises some fundamental questions about their role in today's world.
Charities will be ‘preferred providers’ of NHS services if Labour wins the election, shadow health secretary Andy Burnham told charity bosses this week. He promised the Association of Charity Chief Executives (ACEVO) that charities and other voluntary/third sector groups would get favourable terms and longer contracts to take over running NHS services if Labour wins the election.
But should they?
Voluntary organisations occupy a space within civil society that is distinct from the State and the private sector; a space in which citizens come together freely to exercise self-determining collective action.
Voluntary services exist to do the things a government cannot or will not or should not do; and to act as commentator and critic of state services and state action. In this, voluntary action is part of the ‘ungoverned political space’ of civil society.
The severe cuts to services and living standards have affected the poorest communities most harshly; the very people that charities and voluntary groups exist to serve. One would expect that this would have galvanised anger and resistance in the sector.
Yet a new report from the National Coalition for Independent Action (NCIA) shows how the reverse is true - many third sector groups have responded to these pressures of co-option in complicit and supine ways, failing to defend their autonomy or show active solidarity with their users and communities.
Instead, the corporate third sector has acted as a willing accomplice in the privatisation ‘arms race’.
The complicity takes a number of routes - as providers, sub-contractors, and ‘co-designers’.
As ‘providers’, large organisations like BUPA, the Nuffield and addiction ‘social enterprise’ Turning Point have professional bid teams, ‘contract ready’ and adept at winning bids against global corporations, the NHS, and smaller locally rooted charities alike.
Both New Labour and the Coalition have blurred the role of the voluntary sector by promoting the vague concept of ‘social mission’ and encouraging the rise of ‘social enterprises’ and ‘social investment’ (a new form of indebtedness for voluntary organisations).
Charities are also facilitating privatisation as sub-contractors. Private sector ‘prime contractors’ can cut their costs and spread the risk in their contracts - and make the privatisation more politically palatable - by sub-contracting to third sector groups, often using them to dump the clients reckoned to be most intractable or difficult to deal with. We’ve already seen this in the deeply unpopular ‘work programme’, where charities were extensively sub-contracted to by the for-profit providers such as A4E, and it’s the model being followed in the privatisation of probation now, too.
And shamefully, some charity ‘leaders’ are working actively with state bodies to ‘co-design’ outsourcing programmes.
These three tendencies come together in what has been described as the most reckless - health privatisation yet – the £700m contract for NHS Cancer Care in Staffordshire and Stoke-on-Trent and £500m contract for End of Life Care in the same region.
MacMillan Cancer Support (already a contracted service provider to the NHS) have been taken on as “facilitators and advisors” to the outsourcing. The group has shortlisted mostly private firms bidding for the work and anticipates that the new service will be one that sub-contracts bits of the service to private and voluntary sector groups.
The organisation that Burnham addressed this week, the Association of Chief Executives of Voluntary Organisations (ACEVO), calls such arrangements ‘alliance contracting’, saying it is "an efficient way for health and care commissioners to bring in a wide range of service providers.” (whilst now rather unconvincingly claiming this is ‘not competition’).
ACEVO have consistently pushed the case for voluntary groups to take over public services. Its chief executive, Sir Stephen Bubb, pops up regularly to assert the superiority of the third sector over the public sector.
Bubb is entitled to his own opinion - though it’s not one backed up by any evidence, certainly not across the board.
More shamefully, Bubb has been exposed for secretive dealings in with the ‘NHS Partners Network’, a private healthcare trade and lobby group. In 2011, Bubb was Chair of the ‘Choice and Competition Sub Group’, set up as part of the ‘listening exercise’ designed to deflect opposition to the (then) Health & Social Care Bill. Social Investigations published an internal document which showed that Bubb had agreed with the NHS Partners “….the approach he would take, what the key issues are, and how he would handle the politics”, and that “…he (Bubb) has not deviated from this for a moment throughout the period.”
And in 2013 Bubb was again exposed as having lobbied Jeremy Hunt on behalf of the same group, not to water down the regulations opening the NHS up to full competition.
The co-option, incorporation and, indeed, corruption of independent voluntary services groups goes far beyond the specific arenas of health and social care. The NCIA's report Fight or Flight sets out the grisly tale of how voluntary services have been progressively re-engineered by successive governments as delivery vans for their own neo-liberal ideologies, policies and programmes. Outsourcing is key to this agenda - and what has happened to voluntary services groups can be seen as an ancillary consequence.
Fight or Flight: Voluntary Services in 2015 is a summary of 17 separate research papers that show to an alarming degree the extent to which voluntary groups involved in delivering services have become servants of the state and the corporate private sector.
Cuts to contract and services budgets drive a race to the bottom. In social care, it is barely possible now to offer a basic service, never mind a quality one.
Along the way, the voluntary sector has become a heavy user of zero-hours contracts. It has ditched solidarity for managerialism. Some third sector social care providers have been named and shamed for paying below the minimum wage, even as they boast of their ‘not for profit’ ethos. And volunteers, too, are now seen and managed as unpaid workers - and, with the rise in charities participation in workfare and similar schemes, may no longer always even be voluntary.
Last month three charities – Age UK, The Red Cross and Royal Voluntary Service – were given a £1.2M Cabinet Office grant to provide 700 volunteers who will help 10,000 patients over a 12 week period to “…help the 29 A&E Departments under the greatest pressure”. This was hailed as a triumph of good sense by the ubiquitous Bubb, who apparently brokered the deal.
According to press reports Bubb and colleagues were given 3 days to come up with a plan which once agreed was to be immediately implemented as of the 5th February.
We were promised that these volunteers would “support older people and prevent unnecessary admissions to hospital”, that in casualty departments they would “support medical teams to secure early discharge of patients who do not need admission on medical grounds, but are prevented from returning home for social care reasons”, and in wards they would “secure early discharge of patients who do not need a bed for medical reasons”.
But what will this look like in practice?
A month into the scheme, there is no publicly available detail of how its running (unlike state providers, charities are not required to publish minutes of meetings or respond to Freedom of Information Requests).
So it’s unclear where the promised 700 new, “fully trained” volunteers, able to start work immediately, will come from. From existing volunteers - pulled away from whatever (presumably useful) work they were doing before? From existing volunteers already working to support older people in the community, merely re-badged as a new government initiative without any actual additional people on the ground?
If charities have difficulty recruiting hordes of genuinely new volunteers, might they be tempted yet again to turn to compulsory ‘workfare’ type schemes, as too many have shamefully done already?
And what exactly will these volunteers - whether genuinely voluntary or not - be doing? Hospitals already have discharge teams. “Someone very senior said hospitals did not need do-gooders wandering around casualty getting in the way of doctors”, Bubb admitted in the Guardian.
Bubb suggested “As for after emergency treatment, volunteers will help patients return home safely and make sure there is food in the fridge”.
So, give them a lift home and make sure there’s a bite to eat. Hardly an adequate solution to the crisis in home care and its knock on effects on patient discharge.
All of this raises questions about volunteering and the place of volunteers in the provision of health and social care services – is it acceptable for them to substitute for properly funded services and, if they do, can we expect then to be truly useful?
One of the most dangerous consequences of the changes to the sector is that the sector's critical voice is being silenced - and not just through obvious routes like the Lobbying Act. NCIA's research has found that the local and national dependency on securing contracts through commissioning and procurement (instead of the old grant regime) tends to make even the mildest forms of informed criticism of cuts and privatisation, unacceptable. This is perhaps the number one vital role of voluntary action - advocacy, campaigning, opposing excesses, abuses and injustices, holding powerful interests to account - but it is inconvenient to neoliberalism, and it is being killed off.
It is hard to avoid the conclusion that a significant part of the voluntary sector has sown the seeds of its own demise. History will be especially damming of the so-called ‘leadership’ bodies within the sector. Figures like Bubb at ACEVO, and his counterpart Sir Stuart Etherington at the National Council for Voluntary Organisations (NCVO) – and not excluding many other ‘second tier’ groups in the sector – have failed to defend communities against the cuts or help voluntary groups stay true to the radical roots of voluntary action. In contrast, their recurrent message has been for the government to create a ‘level playing field’ enabling voluntary groups to pick up a larger share of the contracts.
Is all yet lost? We hope not. Radical action and alternatives to the market will be found in informal groups and networks operating on the basis of mutual aid, reciprocity, activism and conviviality. But to do so, we need to renew our understanding of the historical role of voluntary action and its values as set against the tenets of neo-liberalism. We need to challenge the assumptions that public expenditure cuts are inevitable and privatisation the way forward. We need to reassert ideas of ‘public good’, moral obligation and collective social responsibility. We need to pay greater attention to people’s voices in designing and providing services. We need to rethink how voluntary organisations should behave and be run. And we need to build alliances that support the pursuit of social and economic justice.
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