It is three years since Gordon Brown challenged the voluntary sector to get more involved in the delivery of healthcare services. Joe Lepper looks at what progress has been made - and what barriers still stand in the way.
In the Treasury's 2002 Cross Cutting Review, Chancellor Gordon Brown first laid down a firm challenge for charities to get more involved in the running of public and healthcare services. He has been reiterating the message ever since.
Acknowledging that cultural, contractual and financial barriers have traditionally stood in charities' way, he promised a raft of initiatives to help them meet the challenge.
A number are now up and running, the most significant being the National Strategic Partnership Forum, which was set up last year to monitor progress and provide a direct link between NHS employers, charities and government.
The Government has also just set up a taskforce, including charities such as Turning Point and Mencap, to identify problems and recommend solutions to ministers.
Clearly, progress has been made. But with charities still reporting difficulties and the uptake of many of the Government's schemes slow, it is clear the taskforce will have its work cut out.
"Speed can be a problem in the NHS," says Philippa Palmer, director of health programmes at the RNID, which is heavily involved in a number of NHS deals, including the nationwide roll out of digital hearing aids.
"Charities want everything 'now'. We move at a faster rate than the public sector."
Last year, Alternative Provider of Medical Services (APMS) contracts were introduced to make contracting between charities and Primary Care Trusts easier. Although private healthcare firms have now begun to sign APMS-style contracts with PCTs, a spokesman for the Department of Health says no charities have yet taken up this opportunity.
Similarly, few healthcare charities have secured funding from Futurebuilders, which has a £125m pot from which to offer grants and loans to develop charities' public service delivery role. The bulk of the cash handed out so far has been given to community and social care groups.
Sefton Carers is one of a handful of health sector charities to take up a Futurebuilders grant. The £16,000 award was made to develop plans for a hotel retreat for carers, where it is hoped future purchasers will include PCTs and local authorities across the UK.
Although the Futurebuilders grant is welcome, a question mark still remains over funding for the hotel itself. Meanwhile, successive reorganisations of local health trusts have eroded carefully cultivated relationships.
"It was better a few years ago," says Liz Williams, the charity's chief executive. "With the reorganisation, we have lost the relationship we built. Money, or lack of it, is still an issue.
"A while ago, we were in need of funding for a link worker project. But the PCT said there wasn't the funding - we were badly let down."
Not-for-profit organisation Get Well UK is another beneficiary of a Futurebuilders grant. It received £350,000 to expand its complementary health work, which has already been commissioned by PCTs in Haringey and Islington.
But Boo Armstrong, its managing director and a former director of the charity Women and Health, believes the key to Get Well UK's success within the NHS is that it is not a charity.
"It was important for us not to have the charity label," she says. "From my time in the voluntary sector, I learnt quite early that as a charity you were immediately disadvantaged when negotiating. The NHS looked at you differently, and I don't think that has changed."
Dr Gareth Morgan, director of the centre for voluntary sector research at Sheffield Hallam University, says a vital culture change is needed if public and voluntary sectors are to work together effectively.
"Full cost recovery is a big issue," he says. "Public sector bodies will meet the cost of a project, but that might not include overheads and other expenses. That needs to be sorted out." VAT is also an area of confusion, he adds, with those who are exempt unable to claim back on their expenses.
Jo Webber, deputy policy director at the NHS Confederation and a member of the National Strategic Partnership Forum, concedes that the public sector's attitude to charities needs to change, particularly at a PCT level.
"There have been issues about how things have been costed," she says.
"It's important that those issues are addressed. There also needs to be flexibility within contracting; in some cases, you are dealing with huge national organisations, and in others you are dealing with very small local groups."
She hopes further reform within the NHS should help this process of culture change. In particular, she says, proposals to merge PCTs and strip them of their service-provision role, as laid out in this year's Commissioning a Patient-led NHS report, should "focus the minds within PCTs".
Recent Government rhetoric has prompted many charities to do "a lot of soul searching", according to Morgan. "Are they a patients' organisation funded through donations, are they about NHS delivery or can they do both?" he says. "These are the questions charities need to be asking themselves."
This is particularly pertinent with PCTs handing over their provision of services, which offers a golden opportunity to charities to step in.
One charity looking at how it fits into this new vision for the NHS is Macmillan Cancer Relief.
Duleep Allirajah, senior policy analyst at Macmillan, says: "We are starting to look at strategy, and there is talk of service delivery contracts.
But our initial instinct is that we don't want to depend on contract funding and let the NHS decide our terms."
The Government has pledged to boost investment in the sector and link its specialist care into the payment-by-results system - where the money follows the patient - by 2008/09.
Claire Newton, finance director at Marie Curie Care, says if the funding needed for its community nurse and hospice services is met in three years' time, it would have a huge effect. "This would be a positive for us," she says. "We could then use our funding to give us greater scope to pursue innovation rather than the running of the services."
But Hannah Lynes, policy and public affairs manager at Help the Hospices, fears that, despite Government promises, money will still be in short supply - it is estimated that at least an additional £100m is needed.
"The sector has always been underfunded," says Lynes. "There is a long way to go before we know how this will work out."
The proposed reorganisation of PCTs could also scupper the plans, she says. "If this means that commissioning is done at a lower level and the hospice has a number of contracts, it could get very complicated," she explains.
Melinda Letts, chair of the NSPF, agrees that "significant barriers" remain, but she is upbeat for the future. She says the newly created taskforce will be the key to improving the situation, because it will gather specific examples of problems facing charities within the NHS and give ministers a clearer picture of where further reform and additional schemes are needed.
"We are not saying there is a compulsion to sign contracts," she says.
"But for those that want to and believe that it fits in well with their core mission, there are real opportunities out there."
Nick Aldridge, director of strategy at Acevo, welcomes the taskforce but says it is long overdue. "Too little attention has been given to improving procurement and putting together contracts that actually work," he says. "We want to see the same attention given to contracts with the third sector as government has given to working with the private sector over the past 15 years."
From the Coram Family's contract in the mid-18th century to provide childcare services in London to the creation of the NHS and the outsourcing drive under Margaret Thatcher's Conservative Government, charities have been no stranger to answering a call from government to run healthcare services and fill in the gaps in state provision.
What makes this latest policy drive different is that, for the first time, a Government appears to want charities to be at the very heart of service provision, and has placed a priority on cutting down the barriers that stand in their way. Whether those barriers eventually crumble remains to be seen.
REFUSING THE CHALLENGE
Medecins du Monde UK is launching an initiative in the east end of London in January 2006 to help vulnerable migrants, homeless people and street sex workers. Project London will include treatment by volunteer GPs and nurses, advice and support.
But rather than answering the Government's challenge to enter into contracts and service-level agreements with NHS bodies, the charity is to carry out the work through its own funding and partnerships with specialist charities.
Michelle Hawkins, the charity's communications and fundraising officer, says working for a central government organisation such as the NHS goes against the ethos of the charity.
"Historically, we are a global non-governmental organisation working in developing countries," she says. "We locate a problem, find local groups on the ground and work together with them to solve the problem. What we do in east London is no different from how we would run a project in Tanzania.
"That is our most effective way of working. Government contracts are not part of how we work - and not how we intend to."
She adds that the charity will also use case studies from the project for its advocacy work, something that could be constrained if working directly for the NHS.
The charity was formed 25 years ago as an off-shoot of Medecins Sans Frontieres. Project London is its first major UK project.
ANSWERING THE CHALLENGE
The Terrence Higgins Trust has a long track record of direct public service provision. A third of Primary Care Trusts, eight central government bodies, including the Department of Health, and 30 local government bodies already commission services from the charity, either through full or part funding.
"NHS contracting is the best way for us to deliver our services," says Peta Wilkinson, executive director of service delivery and development.
"We are providing services for those groups that are traditionally hard to reach and that trusts can't provide themselves. The NHS has targets for areas of sexual health, so we can also help with that."
Wilkinson welcomes government initiatives to improve the role of the voluntary sector in healthcare delivery - she is a member of a steering group of trust, charity and private providers looking into setting up APMS contracts within the NHS. Terrence Higgins is tipped to be one of the first charities to sign one of these new contracts.
She sees the planned reorganisation of PCTs as a "real opportunity" for the charity sector to get more involved in healthcare provision, but adds that problems still remain. "It is still not a level playing field," she says. "Some in the public sector still think charities will do certain things at a lower cost, and full cost recovery is a huge issue."
She is also scathing about the Futurebuilders initiative, which she says is "more about one-off costs and loans than about recurrent costs."