The role of the voluntary and community sector in service delivery

In this section, the role of the VCS in public service delivery in rural areas is analysed using four interlinked themes: demography and ageing, rurality, volunteerism and the VCS and social policy interventions. As previously noted, demographic change is more advanced in rural than in urban England, in part the result of rural in-migration (HMG, 2009), making ‘rural England the pioneer in terms of the nation's population ageing’ (Atterton, Reference Atterton2008: 20). One fifth of England's population live in rural areas, that is settlements of 10,000 or less (Champion and Shepherd, Reference Champion, Shepherd, Lowe and Speakman2006). The perceived quality of the rural environment is one of the most important factors in the appeal of rural areas as places to live, especially when an older person is relatively fit, partnered and able to play an active part in village life (Milne et al., Reference Milne, Hatzidimitriadou and Wiseman2007). But rural life can become more difficult in later old age when physical and mental capacities are more likely to decline, when informal social networks and support structures may weaken and when partners die (Le Mesurier, Reference Le Mesurier2003, Reference Le Mesurier, Lowe and Speakman2006; Milne et al., Reference Milne, Hatzidimitriadou and Wiseman2007).

The idyllic representation of rural life centres around close-knit communities that have a strong culture of self-sufficiency, alongside an assumption that the VCS can be relied upon to plug any service gaps (Sherwood and Lewis, Reference Sherwood and Lewis2000). The VCS in rural areas is distinctive from the VCS in urban areas. For example, organisations tend to be smaller, more heavily dependent on volunteers and enjoy fewer opportunities for economies of scale as geographical dispersion can mean that providing services in rural areas can cost more (Alcock et al., Reference Alcock, Brannelly and Ross2004; DEFRA, 2003; NCVO, 2002). Managing these additional costs (the ‘rural premium’) inherent in delivering rural services to dispersed populations of older users is a constant challenge for the VCS (Craig and Manthorpe, Reference Craig and Manthorpe2000; Manthorpe and Stevens, Reference Manthorpe and Stevens2009). Moreover, rural communities get significantly less funding per head than their urban counterparts. For example, Asthana et al. (Reference Asthana, Halliday and Gibson2009) argue that the National Health Service (NHS) funding formula underestimates the healthcare needs of rural communities. Likewise, an Audit Commission (2006) study of adult social services noted that the proportion of over 65s who are helped to live at home is 40 per cent higher in the London boroughs than in rural counties.

Currently the majority of service provision for senior citizens is focused on the frailest older people with the highest needs, with financial support mainly sourced from health and social care budgets. In the context of services for older people, the VCS typically offer so-called ‘low-level services’ that fill in gaps between specialist and universal public services (Manthorpe et al., Reference Manthorpe, Malin and Stubbs2004). Small-scale local services can be innovative, especially in responding creatively to the importance older people attach to support to care for themselves, rather than being recipients of care (Clark et al., Reference Clark, Dyer and Horwood1998). Indeed, many older people perceive the services as ‘help’ rather than ‘care’ (ibid.). But the demand for these services is increasing as a result of the noted divergent demographic profiles of urban and rural areas. The ‘ageing countryside’ is posing enormous challenges for policy-makers and practitioners (Champion and Shepherd, Reference Champion, Shepherd, Lowe and Speakman2006; Manthorpe and Stevens, Reference Manthorpe and Stevens2009).

In Opportunity Age, the Government placed a particular emphasis on encouraging and supporting the development of a new vision for social care in England, with independence and choice as key messages (HMG, 2005), and a framework for cross-sector reform was set out in Putting People First: A shared vision and commitment to the transformation of Adult Social Care, a ‘Ministerial Concordat’ (Department of Health, 2007). One method of delivering independence and choice in social care is via personal budgets, originally piloted as individual budgets (IBs) (Manthorpe and Stevens, Reference Manthorpe and Stevens2009). These resources can be used flexibly according to an individual's priorities and desired outcomes (HMG, 2005). IBs were piloted from 2005–7, and were largely used to pay for personal care, domestic help and social, leisure and educational services (Glendinning et al., Reference Glendinning, Challis, Fernandez, Jacobs, Jones, Knapp, Manthorpe, Moran, Netten, Stevens and Wilberforce2008).

The analysis of these pilots revealed that they were welcomed by users because they gave them more control over their lives, as well as producing better outcomes for the costs incurred (ibid.). However, the staff involved in piloting them encountered challenges, including devising processes for determining levels of IBs (ibid.). There may also be opportunities for the VCS to assume new roles and responsibilities in terms of case management and support planning for IBs as well as becoming more adaptable and flexible in the services offered (ibid.). But Manthorpe and Stevens (Reference Manthorpe and Stevens2009), in their study of the possible impact of the personalisation of social care services in rural England, highlighted that personalisation potentially generates a new set of challenges in terms of the loss of income for the VCS, as well as pointing out that it will be the VCS that is called upon to provide much-needed information and advice on the personalisation agenda. Although IBs will benefit those eligible for social care support, increasing numbers are excluded by tightening eligibility criteria and means testing (Age Concern/Help the Aged, 2009).

In the 2008 consultation, The Case for Change, the Department of Health describes the social care system as: ‘the activities, services and relationships that help people to be independent, active and healthy – as well as able to participate in and contribute to society – throughout their lives’ (Department of Health, 2008: 13). This description goes beyond ‘care’ and ‘services’; it implies delivering support and care that older and disabled people need to live fulfilling lives (Yeandle, Reference Yeandle2009). The message of the need for reform of the care and support system appeared in Shaping the Future of Care Together, the Government's Green Paper published on 14 July 2009 (Department of Health, 2009). It highlighted the challenges faced by the current system and emphasised the need for radical reform, including cost containment and making more use of telecare (see also Yeandle, Reference Yeandle2009). However, such policy prescriptions pay minimal attention to the challenges faced by local providers who deliver community-based services and activities for older people in rural areas.

In summary, as the scale of demographic change is more advanced in rural than urban England, the pressure on services that help and support older people to remain in their homes is particularly pronounced. In recent years, the VCS has been playing an increasingly prominent role in delivering these public services under contract. But such services are more costly to deliver in rural areas, in part because of the distances involved in serving a dispersed population (the ‘rural premium’), and also because of the problems inherent in recruiting volunteers and paid staff in rural locations. In the following section we briefly describe the methods employed in our recent study of community-based services and activities which support older people in remote rural England.

Methods employed

A charity active across England delivering help to older adults commissioned research to identify and evaluate existing effective practice in delivering services to older people aged 70 plus in remote rural communities. Fieldwork was carried out in a variety of appropriate rural locations across three English regions: the East and West Midlands and the East of England, which represent 37 per cent of the land area of England and 30 per cent of the population (Hardill et al., Reference Hardill, Benneworth, Baker and Budd2006). Local branches of the national charity which funded the research were invited to put forward services for inclusion in the study. Subsequently, six services, two in each of the three regions, were chosen. Projects 1, 2, 4 and 6 aimed to alleviate the social isolation of older rural people in various ways. Projects 3 and 5 offered information/advice and practical help in accessing welfare benefits and services (see Table 1).

TABLE 1.

Village services

The projects represent a small part of the range of services provided by the charity. The staff that manage and administer them routinely have a wide portfolio of services for which they are responsible. All the paid staff directly involved in day-to-day service delivery worked part-time on fixed-term contracts. Five projects used volunteers for service delivery (Project 1 is the exception). The information and advice projects (Projects 3 and 5) are about expanding the number of older citizens accessing their rights to benefits, and thereby enhancing economic inclusion (Craig, Reference Craig2004). The remaining four projects focus on overcoming social isolation (Projects 1, 2, 4 and 6). One project (Project 4) had some service users who did not fit the criteria for the service (in terms of their dementia), while another (Project 3) had requests for help from people who did not reside in the geographical area in which the charity was contracted to deliver the service.

TABLE 2.

Study participants

A total of 69 participants were interviewed in the course of the fieldwork. Of these, 25 were key informants and 44 were older people who made use of one of the six services under consideration. Within the sample of key informants interviewed, 19 worked for the charity, six were managers/chief executives responsible for the service overall and seven were paid workers involved in the day-to-day delivery of services to service users. A further six were volunteer workers involved in delivering rural services to older people. The remaining six key informants interviewed had specific insights into the funding arrangements of services. Of the 44 service users interviewed, 32 were women and 12 were men, reflecting the fact that more service users were women. They were between 58 and 93 years of age. Four users within the sample were aged below 70 years, and while these four respondents were chronologically younger than their fellow participants, they had much in common with certain older users. All four had physical impairments that had developed with the passage of time, and the two who were living alone clearly valued the companionship that the service they used offered. These participants illustrate that chronological age is but one aspect of the ageing process and that ill health and social isolation may ‘age’ people in other ways.

Interviews were tape-recorded, transcribed verbatim and analysed using grid analysis and thematic code and retrieve methods (Ritchie et al., Reference Ritchie, Spencer, O'Connor, Ritchie and Lewis2003). Following an initial reading of all transcripts, an overview grid that provided a descriptive summary of the key informant interviews was produced. This enabled a range of broad common key themes (such as ‘financial matters’, ‘service delivery’) within the data to be identified. Relevant sections of data were then assigned to appropriate thematic codes, and more refined sub-categories identified and allocated to appropriate text within the transcripts. A QSR Nudist 6 package was used to help facilitate this process of classifying and ordering the data. This approach helped to ensure that analysis was both systematic and grounded directly in the concerns of respondents.

Interview transcripts were anonymised and identifying locations removed. Respondents subsequently received a copy of their transcript and were invited to feed back any further responses/reflections to the research team. This article draws specifically on the qualitative data generated in semi-structured interviews with key informants (that is, paid staff, volunteers and funders) to consider the challenges facing the VCS when delivering community-based services to older people living in remote rural settings in England.

Making ends meet: Managing money and people when delivering community-based services for older people in rural England

The majority of current funding agreements for service delivery held by the VCS are for one year only, and very few charities delivering public services achieve full cost recovery. In addition, only one in eight charities delivering public services achieved full cost recovery all of the time (Charity Commission, 2007). Government policy since the 1990 NHS and Community Care Act has assumed that the VCS will use unpaid volunteers to deliver services at little additional cost (Wardell et al., Reference Wardell, Lishman and Whalley2000). These two key dimensions – the funding of services and ongoing issues related to the terms and conditions of the personnel (that is, paid staff and volunteers) used to deliver them – were consistent concerns of our respondents. We first examine the funding of the services and then turn to explore workforce matters.

The six projects considered here had quite different funding arrangements. For example, Project 6 was financed by a fixed-term grant, while Project 2 was funded by an annual contract alongside service-level agreements with the statutory sector. Another (Project 1) relied on annual contracts with multiple funders (the statutory sector and charitable trusts) and some had had a range of funding sources since they were established (for example, Project 4). The diverse mechanisms used to support the six services are illustrative of a wider complex jigsaw of funding sources on which charities often have to rely to support and deliver services (Alcock et al., Reference Alcock, Brannelly and Ross2004). The short-term nature of much funding had a profound impact as service managers tried to maintain their services to older adults in rural locations. The six projects faced an annual funding dilemma, demanding entrepreneurial behaviour on the part of managerial staff.

Those respondents delivering services with annually negotiated service-level agreements acknowledged that the statutory sector also faced recurrent annual budget problems as they juggled competing priorities while trying to maintain services which supported critical cases of serious, ongoing need. However, the routine reality of delivery of services for older people in the countryside was one of annual cutbacks in budgets and/or the freezing of funding at the previous year's level due to increasing competition for scarce resources. For one project the level of funding has remained the same for the last four years, while another project has experienced annual cutbacks of 10 per cent for three years.

As grant income to run services is for a finite period, it also creates problems as demand for the service endures beyond the period of the grant. The manager of Project 1 (KI1) related how the maximum term of six years allowed by the grant funding body had elapsed, and that the service was potentially in jeopardy unless a new long-term funder could be found. In the short term, the charity was allocating £12,000 of its own money to keep the service going. Unfortunately, he indicated that the funding shortfall would also mean that the contribution from older users of the service would also have to increase substantially from £4.50 per person per visit to £7.50. Other respondents also indicated that future funding for their services was uncertain and this necessitated drawing on the charity's core funds to maintain current levels of provision as initial, time-limited funding came to an end.

Although aware of the costs of delivering a service, project managers were routinely unable to achieve full cost recovery (cf. Charity Commission, 2007). Funding arrangements were underpinned by an inherent assumption that allocated money should be used to establish and maintain frontline service provision. Consequently, several projects received little or no money to cover project administration/management costs:

Voluntary sector performance can be hard to define and measure (AVECO, 2008); also, charities are increasingly required to gather quantitative and qualitative evidence to present to funders looking for evidence of service impact. Therefore, managing and delivering projects often brought additional administrative burdens for hard-pressed service providers. This included regular surveys of service users to gather qualitative and more holistic feedback on what the service meant to them and, in some cases, other household members. As they receive funding from a number of sources, they are likely to be subject to a number of regulatory regimes, with different approaches to performance management and reporting. The administrative burden of such record-keeping was consistently noted by respondents:

In short, while the six projects had different funding arrangements, they all failed to receive funds to cover full administration and management costs. Moreover, projects routinely had to draw on their own financial reserves to maintain much-valued services as grant funding ended or rising costs were not met by annual increases (see Dwyer and Hardill, Reference Dwyer and Hardill2008).

We now look at the added costs of delivering services in rural areas, the ‘rural premium’. All the key informants commented on the ‘rural premium’ (that is, the extra overheads incurred in delivering services in rural areas), with meeting transport costs a central and consistent concern.

The above quotes summarise the major concerns highlighted by key informants. Delivering services to a dispersed population of service users with often limited mobility was a constant challenge (see also Alcock et al., Reference Alcock, Brannelly and Ross2004). For the four projects where services were provided directly to service users in their homes (Projects 1, 3, 4 and 5), the financial costs of transport, combined with staff travelling time, in effect limited the number of service users whose needs could be met.