Where now for ‘Living Well’ in Cornwall

Peter Levin and Kath Maguire 13 August 2016 

This paper was researched and written by Dr Peter Levin and Dr Kath Maguire for West Cornwall HealthWatch¹ following discussions at meetings of the Governing Body of the Kernow Clinical Commissioning Group about the future funding for the Living Well programme. It has thrown up many questions which we feel need answering before a decision about funding can be made. These are listed in the Conclusions on pages 6-9. We hope for a response to these questions. 

1. What is 'Living Well'?

'Living Well' is the name that has been given to a health and social care programme that has been running in Penwith, in the far West of Cornwall, and in other parts of the Duchy. It is led by Age UK Cornwall.² Its main aim is to enable older people to live well with stable long-term conditions, avoiding unnecessary complications and acute crises. Other aims include: to reduce unplanned hospital admissions, to deliver care more efficiently, reduce loneliness and improve people's health and wellbeing.³ Paid staff and volunteers, working in conjunction, help people to manage their health conditions and to re-engage with their communities. The volunteers are an essential part of the system.

In Cornwall Penwith Pioneer was the second project to be set up under the Living Well programme, in 2014, following on from Newquay Pathfinder (established in 2010). Later in 2014 East Cornwall Living Well was added to the portfolio.  

2. Information on the operation of the Living Well projects

From a public perspective, detailed information about how the Living Well projects operate on the ground, who does what and how often etc. seems quite difficult to assess. Age UK Cornwall's Annual Review for 2014-15 informs us that in that year 1,227 people were referred to Living Well across the three Cornwall projects: they were supported by 67 volunteers and 15 staff co-ordinators.³ We are not told how many of the volunteers were still on the strength at the end of the year, nor how the volunteers and staff co-ordinators were spread across the three projects.

The charity Nesta commissioned a 'qualitative process evaluation' of how Living Well had been operationalized through the Penwith Pioneer programme, but the report on that study,⁴ published in June 2015, contained no quantitative information whatever about staffing (e.g. the ratio of staff co-ordinators to volunteers) and the use of human resources. It did say that volunteers 'tend to have 1-3 older people that they are responsible for' (p.11), which suggests that of the 1,227 people referred to Living Well across the three Cornwall projects in 2014-15 perhaps as few as 200 actually received support. 

The Nesta-commissioned researchers were told that volunteer numbers were a 'challenge' and that more were needed (p.19): they made a number of recommendations for stepping up recruitment, and noted that the majority of the volunteers who were interviewed were 'older, often recently retired individuals who are looking for new roles in their lives'. But their report had nothing to say on the drop-out rate of volunteers and put forward no ideas on how to retain them. Nor were the known problems of using volunteers, as opposed to paid staff, discussed. But they did make a total of 23 recommendations for improving the running of the programme.

3. Funding the Living Well programme

It has also proved difficult to gain complete clarity about how the Living Well programme has been funded so far, and indeed on which organizations – e.g. partners in the scheme – have received Living Well funding. The Age UK Cornwall Annual Review for 2014-15 cites support from Nesta and the Cabinet Office, through the Centre for Social Action Innovation Fund, and by a legacy left to Age UK for the benefit of people in Penwith.³ In the course of preparing this paper we sent an email to Cornwall Council, asking to be signposted to further information about the funding of Living Well. In response the NHS Kernow Engagement and Inclusion team sent us the following table of figures:   
Past funding

• £200k NHS England
• £150k Health Education England
• £100k Age UK local legacy
• £100k Age UK national
• £200k NESTA
• £100k CCG winter pressures
• Total: £850k*
• Of which activity: £660k Engagement and Inclusion Team NHS Kernow CCG 

We looked at these figures in the context of The Age UK Cornwall trustees' report for 2014-15, submitted to the Charity Commission, which show a total income during that year for East Cornwall Living Well, Newquay Pathfinder and Penwith Pioneer of £662,064 (see the Note in Table 20 of that document).⁵ In the light of this we sent a second email to the Engagement and Inclusion Team requesting clarification as to whether these figures represented the entire period of the programme. We were asked to contact a member of the team by telephone, which Dr Maguire did on 09/08/2016.  

She was told that this table came from a presentation which aimed to demonstrate that the Living Well programme had attracted voluntary sector investment and would be likely to attract future social investors. These figures were intended to represent the funding of Living Well from the beginning of the programme. It was explained that the programme had grown ‘organically’ and that the figures we had been sent may not include all the sources of funding, but were indicative. Dr Maguire was assured that the per capita costing of Living Well being used in the business case to demonstrate cost effectiveness – £400 per client – was robust, although her question about whether all the funding for Living Well had been administered through Age UK Cornwall could not be answered. 

Dr Maguire further asked whether the £200k shown as coming from Nesta included the funds from the Cabinet Office mentioned in the Age UK Cornwall annual review3  and, if so, what proportion were charitable rather than public funds being administered by the charity. She was told that this was not known. She also asked about the £100k from ‘CCG winter pressures’ and was told that this may have funded the ‘Welcome Home’ hospital discharge service, although in the Age UK Cornwall accounts this service appears as a separate line, not part of  the three Living Well projects. It appears that some confusion may have arisen through a conflation of the core Living Well programme with other activities that are connected through the ‘Living Well approach’. This confusion is also apparent in the minutes of the NHS Kernow Governing Body meeting on July 5th 2016 which speak of a contract for falls prevention services being ‘incorporated into the Living Well approach’⁶, although again this contract is shown as a separate item in the Age UK Cornwall accounts. 

The following figures are shown in the Age UK Cornwall accounts against core Living Well programmes: 

• East Cornwall Living Well had income of £200,000 and expenditure of £200,000.
• Newquay Pathfinder had income of £85,792 and expenditure of £18,497, with £67,295 carried forward.
• Penwith Pioneer had income of £376,272 and expenditure of £186,048, with £157,026 carried forward and £33,198 described as 'transfer'.  

(In each case ‘income’ is from ‘restricted funds’, which are 'to be used for specified purposes as laid down by the donor. Expenditure which meets the criteria is identified to the fund, together with a fair allocation of overheads and support costs.’ Note 2.4, p.22) 

These figures give rise to a number of questions.

• How was it that East Cornwall's expenditure came to precisely the same round six-figure sum as its income?
• How was it that Newquay's expenditure was only around one-tenth of that for East Cornwall and Penwith?
• How was it that Penwith's expenditure amounted to only half its income?
• What happened to the £33,198 transferred away from the Penwith project?
• And has money been channelled to other bodies to spend as part of the Living Well programme?

In the interest of transparency it would have been helpful for an explanation to have been given.

Interestingly, the financial statements contain two tables (In Note 7, p.24, as well as Note 20) that both show income from restricted funds, together with expenditure. East Cornwall and Penwith appear in both, but Newquay in only one. The number and the list of items with restricted funds are significantly different in the two tables with some appearing in one but not the other. This is confusing. An explanation of why the items included in the restricted funds are presented differently in these two table would have afforded greater transparency and clarity. Similarly, income for the Penwith Pioneer appears in both tables as a single item, although the Age UK Cornwall Annual Review3 identifies two separate funding sources, a grant and a legacy. It would have been helpful for these to have been differentiated.

We recognise the complexity of managing a programme that includes multiple partners and interconnected elements. Yet it seems essential, if a cost effectiveness case is to be made for a model of public service delivery, for there to be clarity about what has been invested and how this equates to what has been achieved. 

4. Continuing the Living Well programme in Cornwall

In May 2016 NHS Kernow's Governing Body received a letter from Penwith GPs seeking a commitment to providing financial support for continuing the Living Well programme beyond September 2016.6 There was no accompanying document setting out a business case. At the Governing Body's July meeting it was reported that Age UK Cornwall was requesting a grant of £9.5 million (which would be spread over 5 years) to enable it to continue the Living Well programme. This bid for £9.5 million needs to be seen in the context of NHS Kernow's financial plan for 2016/17, which shows a forecast end-of-year deficit of £38.8 million, as well as identified risks that could amount to a further £20.28 million.⁷

The funding structure of Living Well was reportedly deliberately designed using the principles of social impact bonds7. This was intended to support the project’s readiness for commissioning by encouraging the Clinical Commissioning Group to adopt the social impact bond funding model. Social impact bonds invite private funders to invest over a fixed term. Returns on their investments would come through payments from the Commissioning Group. The Governing Body were given a detailed presentation about structure and implications of social impact bonds and it was suggested that there were significant financial risks inherent in this sort of scheme. They were advised by their Turnaround Director, that it would be unwise to adopt this funding arrangement at the present time.

The meeting was also told by a representative of Age UK Cornwall that current staff contracts would expire at the end of September 2016. But the Governing Body were clear that it would be inappropriate for the Clinical Commissioning Group to commission any service before a clear business case had been put forward. It was announced that the South West Academic Health Science Network have been asked to explore the business case for Living Well.⁷

The normal NHS cycle for the procurement of services would begin with the Clinical Commissioning Group (CCG) being alerted to a need, consulting with stakeholders, drawing up a business case, then issuing an invitation to tender with clear evaluation criteria⁸. Suitable suppliers from the private sector as well as the voluntary sector would then be able to compete for the contract. It would then be for the CCG to receive bids, assess them, and then to make a choice. This procedure implies a clear boundary between the commissioning body and those that submit bids. We recognise that this boundary may sometimes be difficult to maintain while simultaneously supporting effective partnership working on the co-production of complex health and social care interventions. We do, however see it as a vital element of NHS Kernow’s leadership role to demonstrate their commitment to good procurement practice and effective governance. This is not made clear where the NHS Kernow Director of Integration is simultaneously the Chief Executive of a voluntary sector organization seeking substantial funding to deliver an integrated service.⁹

In discussions about commissioning Living Well, emphasis has been laid on potential cost savings to acute services in hospitals and on social and psychological benefits in terms of enhanced well-being of recipients of the service. These are important issues, however at this point it is vital to be able to clarify whether these benefits are delivered by the ‘Living Well’ programme or whether learning from the ‘Living Well approach’ could support these outcomes being better delivered within the NHS. 

An important pre-condition which needs to be met by any potential service provider, whether a single organization or a partnership, is that of 'organizational capability'. For example, there must be a clear structure, not necessarily hierarchical, but one that is appropriate to the tasks taken on. Also – and this is absolutely crucial where the programme is innovative – the provider must be committed to effective monitoring, evaluation and learning. This requires that what is invested, what is done and what this achieves are observed, recorded, and, importantly, that this information is shared. People with appropriate skills must take responsibility for collating, interrogating and analysing this information, drawing inferences and learning lessons, further developing policies and practice, and ensuring that all members of the partnership – and its clients where feasible – can take part in this process. 

5. Attitudes among Living Well managers

On attitudes among Living Well managers, we have evidence from a document entitled Cultures of Volunteering in Cornwall,¹⁰ produced by the University of Exeter's Volunteers in Communities group, based in the University's Penryn campus. The authors describe themselves as social and cultural geographers. The document contains quotations from interviews with the Directors of Age UK Cornwall and Volunteer Cornwall, Living Well Team Leaders and others. Here is an extract: 

The Director of Volunteer Cornwall explained in the East you have a culture of selfreliance; they organise themselves and go on after any funding pot has run out. In fact the East has had less money than the West but they have done more on their own whereas in the West there is a culture of external dependence where we are having to do a lot more, but achieved less; they have had more money over the last decade but when the money stops they stop'. [p.3]

Particularly noteworthy are repeated references in this document to a ‘culture of dependence’, a term which is used by the authors without qualification. As is well known, this term is used by right-wing politicians and commentators in a pejorative, stigmatizing sense: it features in their vocabulary along with ‘feckless’, ‘shirkers’, ‘skivers’ as a term that denotes the undeserving poor. So it is not value-free.   

As to the evidence of the existence of such a culture in West Cornwall, the views cited above can hardly be described as objective. They describe how the inhabitants of West Cornwall fail to carry on with initiatives imposed on them by external funders and co-ordinators when the money from outside runs out, and in effect blame them for this.  
Although this document is entitled Cultures of Volunteering in Cornwall, it makes no mention of the work of the Penwith Volunteer Bureau, an independent charity managed by Penwith Community Development Trust, based in Penzance, which is a local volunteer development agency. The Bureau assists the Trust in delivering services and support to community projects by promoting and developing local volunteer support. No-one from the Bureau or Trust appears in the list of people interviewed by the authors.

One could put forward an alternative hypothesis. West Cornwall has been hard hit by the closure and run-down of traditional industries, and the resultant need to rely on tourism for (seasonal, low-paid) employment, coupled with the loss of housing stock to holiday homes, has emphasized the wealth and income gap between local people and incomers. We should not be surprised that locals have learned to look with a jaundiced eye at time-limited initiatives that charitably-inclined outsiders have seen fit to bring to them.

There is actually a good deal of evidence as to the prevailing culture in West Cornwall. Here is a taste of it:

• Every town and village has its annual special event, be it a festival, feast day, charter day, gala, steam fair or ploughing competition. Week-long Lafrowda in St Just and Golowan in Penzance are just two examples where it’s all by local people and for local people. 
• The great majority of locally-owned shops in central Penzance close at 5pm. Only branches of national chains close at 5.30 or later.
• The Open Studios Cornwall exhibition in 2016 featured 79 artistic/creative studios welcoming visitors in West Cornwall. In East Cornwall there were 15.¹¹ 

One may hypothesize that what we have in West Cornwall is actually a culture of individuality, cussedness, resourcefulness and self-sufficiency. In a word, a culture of independence – the exact opposite of what the directors and team leaders of Living Well in Cornwall have diagnosed.

To send in managers, co-ordinators and team leaders is to assign to local people the role of being managed, co-ordinated and led, and given the prevailing culture of independence we should surely not be surprised if this does not go down well with local people in Penwith. We would suggest that for a volunteering project to succeed it is necessary to 'work with the grain’, and that on the evidence in Culture of Volunteering in Cornwall, some Living Well managers and the authors of the report have strikingly failed to comprehend and appreciate the grain in West Cornwall.  

6. Conclusions: Is the current organizational structure appropriate for a Living Well programme?

West Cornwall HealthWatch agrees with the view that integrated multidisciplinary working and person centred services are the right approach for the future of local care provision. And there is extensive evidence of the health and social benefits that volunteering can deliver.¹² The question remains whether it should be delivered by an organization or partnership outside the NHS, thereby incurring external overheads and running costs. There is also a question about the sustainability of using volunteers, many of whom may already be acting as unpaid carers to relatives and friends. The decision of the NHS Kernow Governing Body to reject the model of social impact bond funding was welcomed by West Cornwall HealthWatch as was their insistence on a robust business case.

Funding which goes to Age UK and its voluntary sector partners will not be available for provision of NHS community services. From the perspective of West Cornwall HealthWatch it is vital for NHS Kernow, Age UK Cornwall and its partners to address four fundamental questions about the current organizational capability to run a Cornwall-wide Living Well programme before any service can be commissioned:

1. Has the accounting of Living Well been robust and transparent, and is the partnership able to spend all the money that is dedicated to Living Well?
2. Is Living Well able to recruit and retain the necessary volunteer force, and operate efficiently?
3. Does the partnership possess the organizational capability to undertake the tasks that the Living Well programme requires?
4. Do senior staff within the partnership have the attitudes and sensitivity required for work in West Cornwall communities?  

Each of these over-arching questions gives rise to more detailed questions.

(1) Has the accounting of Living Well been robust and transparent, and is the partnership able to spend all the money that is dedicated to Living Well?

The evidence from NHS Kernow and from Age UK Cornwall's annual accounts has already been examined here. As we saw, there are detailed questions to answer:

• At the end of 2014-15 both Newquay Pathfinder and Penwith Pioneer had substantial sums to carry forward. Was this intentional or were the allocated funds not spent?
• How was it that East Cornwall's expenditure came to precisely the same round six-figure sum as its income? 
• How was it that expenditure in Newquay, the original project, was only around one-tenth of that in East Cornwall and Penwith?
• How was it that Penwith's expenditure amounted to only half its income?
• Where was the £33,198 from the Penwith project transferred to? 
• Why do tables 7 and 20, which both show income from restricted funds, together with expenditure, contain different lists of items? 
• What have been the sources of funding for Living Well, and what has been the overall investment from the public purse? 
• How much of those funds were found by re-deploying resources already within the community, how much was additional money from external grants?  
• Which bodies have actually spent those funds? 
• How has the per capita client cost of £400 been calculated? 
• Why was there not an evaluation by Health Economists built into the programme to ensure a business case could be presented in a timely manner? 

(2) Is the Living Well partnership able to recruit and retain the necessary volunteer force, and operate efficiently?  

As noted above, the Nesta-commissioned 'qualitative process evaluation' study reported that there were not enough volunteers in the project and that recruitment was slow, that the majority of the volunteers who were interviewed were 'older, often recently retired individuals who are looking for new roles in their lives', and that there was a 'tendency' for volunteers to be allocated to 1-3 people each. So we need to ask:

• In 2014-15, how many people actually received support from the Living Well programme? (With a maximum of 67 volunteers through the year, working with 1-3 people each, that suggests a maximum of 200 recipients, rather fewer than the 1,227 people 'referred' to the programme.) 
• What steps have Age UK Cornwall and its partners taken to implement the 23 recommendations for the recruitment and management of volunteers made in the Nestacommissioned report?
• What was the justification for employing in 2014-15 as many as 15 staff co-ordinators to 67 volunteers? (Note the implication that if there were 1,000 recipients of the service across Cornwall, there would need to be around 500 volunteers and (at a ratio of 4½ to 1) more than 100 staff co-ordinators, plus all the organizational superstructure that that would entail.) 

(3) Does the partnership possess the organizational capability to undertake the tasks that the Living Well programme requires? 

Here we need to ask: 

• What has been done up to now to define, observe, record and analyse Living Well activities?
• What has been done to use that information to develop and amend the programme's policies and practices? • Is there a clear boundary between commissioning and bidding bodies? 

 (4) Do senior staff within the partnership have the attitudes and sensitivity required for work in West Cornwall communities?  

• What steps will the partnership take to disabuse its staff of prejudices towards the culture of independence that prevails in West Cornwall, and to understand the need to attune service provision to local cultures more fully and sensitively? 

Notes  

1. West Cornwall HealthWatch is a voluntary, independent campaigning health watchdog that has been serving West Cornwall since 1997.  It exists to monitor developments and campaign to safeguard and improve existing services provided in West Cornwall by the National Health Service. 
2. 'Age UK Cornwall & the Isles of Scilly' is the trading name of the charity 'Age Concern in Cornwall and the Isles of Scilly'. For the sake of brevity it is referred to here as 'Age UK Cornwall'. 
3. http://www.ageuk.org.uk/cornwall/about-age-uk-cornwall-and-the-isles-of-scilly/annual-review-2014-15/living-well/  (Accessed 22/07/2016) 
4. How does change happen? A qualitative process evaluation, by C.Leyshon, M.Leyshon & K.Kaeshage, https://volunteersincommunities.files.wordpress.com/2015/09/nesta-final-report-30th-june-2015.pdf (Accessed 22/07/2016)  
5. Age Concern in Cornwall and the Isles of Scilly (Limited by Guarantee), Trading as Age UK Cornwall & the Isles of Scilly, Trustees' annual report and financial statements,  http://apps.charitycommission.gov.uk/Accounts/Ends42/0000900542_AC_20150331_E_C.pdf (Accessed 22/07/2016)  
6. Letter from GPs re Living Well http://policies.kernowccg.nhs.uk/DocumentsLibrary/KernowCCG/OurOrganisation/GoverningBodyMeetings/1617/201605/GB2016017LetterFromGPMembersReLivingWell.pdf  
7. Minutes of July meeting of Kernow CCG Governing Body  http://policies.kernowccg.nhs.uk/DocumentsLibrary/KernowCCG/OurOrganisation/GoverningBodyMeetings/1617/201608/GB2016056MinutesAndActionGridMeeting5thJuly2016.pdf  (Accessed 22/07/2016)  
8. Greater Manchester Academic Health Science Network (2014)  The NHS Procurement Cycle https://www.intohealth.org/documents/17188/0/Procurement+Fact+Sheet+2b.pdf/20f4a2e5-16ed-4cb2-94fe-48f4da0aaf47 (Accessed 12/08/16)   
 9. Cornwall and the Isles of Scilly Pioneer Programme – Profile, by Tracey Roose, Chief Executive Age UK Cornwall and the Isles of Scilly, Director of Integration NHS Kernow  http://www.local.gov.uk/documents/10180/6927502/Appendix++Pioneer+Profiles+and+Case+Studies/1f7b8968-c949-4116-af33-339d40286cea [pp27-32] (Accessed 22/07/2016) The website is that of the Local Government Association. 
10. C.Leyshon et al, Cultures of Volunteering in Cornwall,  https://volunteersincommunities.files.wordpress.com/2015/09/cultures-of-volunteering-in-cornwall-a-working-paper.pdf (Accessed 22/07/2016) 
11. See http://www.openstudioscornwall.co.uk (Accessed 22/07/2016) 
12. C. Naylor et al, Volunteering in Health and Care, http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/volunteering-in-health-and-social-care-kingsfund-mar13.pdf (Accessed 22/07/2016)