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Matters of size

Dr Charlotte Augst

Charlotte reflects this week on being Chief Executive of National Voices for one year.

  • Health inequalities

Matters of size

It is a year this week that I started as Chief Executive of National Voices. I have spoken to many leaders of other small charities since, as I’ve tried to work out how to do this job, and here is the thing: It is nigh impossible to run a small charity well.

The demise of the core grant, in combination with higher expectations for what a well run organisation needs to look like makes this a precarious and somewhat scary space to inhabit. Do we have an employee assistance programme? Not really. Do we pay maternity pay? Not beyond statutory. Have we got professional GDPR advice? Not sure we can afford it. Do I know what I am doing when purchasing IT support or indemnity insurance? Hardly.

But these back office concerns are not what running National Voices should be about. We need to stay focused on our real job which is about making life better for everyone who uses or needs health and care services, who lives with ill health and its impacts on life. And we need to find a sensible way of doing so, with our six full time equivalent staff.

Size matters

So what have I learned about making change happen, then? Size matters. When I started, National Voices was simply too small, too under resourced. It is growing now, fast, but that brings its own problems, because we need to make things work across a wide range of partnerships and projects – all of them important and exciting, but showing up very clearly where our processes aren’t up to scratch, where we need to professionalise and become more effective.

My main focus can’t be on our policies on procedures though. It needs to be on our relationships and conversations with external partners, who are all much larger than us.

A sense of size

One thing that has become even clearer to me in this year is that the NHS doesn’t have a sense of how massive it is. I often talk to leaders of teams inside NHS England that have over 100 staff and cover only SOME of the issues National Voices care about. The same is true at local level. The NHS is big, compared even to public health, to councils, to the largest charities, and increasingly also compared to all other public services. So when the NHS partners up with anyone, with a council or a community, it must not forget how large its footprint is. These are never equal partnerships. And this puts an extra onus on the larger party to treat the time, resource and enthusiasm of its much, much smaller partners with respect and care.

Doing things at (the right) scale

But size also matters in a less obvious way. The challenges we collectively face are absolutely enormous: obesity, mental distress in children and young people, lives shortened and blighted by ill health in ways that are very unfairly distributed. But to change these things, lots and lots of sometimes very small things need to happen. And maybe sometimes the smaller players are better placed to act. As Andy Burnham said at the launch of the Marmot report last week: In local administrations you can know the names, rather than the numbers of your rough sleepers, your children facing exclusion, your families in bed and breakfasts.

There are no silver bullets to any of our enormous challenges, just combinations of many small changes that stay close to where and how people work and live. Making health and care responsive to what goes on for people, and addressing disadvantage and individual circumstances, requires listening, empathy, kindness and trust.

Relatable size

Centralised, command and control, one size fits all approaches won’t tackle the challenges we face. And as Richard Darlington points out in this very worthwhile read, even getting politicians to take responsibility for the most burning national problems requires a personal connection.

No amount of hard evidence will convince Government to address social care, health inequalities or climate change, if it can be dismissed as only being relevant to metropolitan policy bubbles, no matter how professional they are. It will require people, people ministers and MPs recognise as their actual voters, to demand better. And this in turn requires better story telling, community led campaigning and the core skill of making your argument relatable.

Big won’t deliver the change we need if scale puts distance between yourself and the places where people live and work, where health or illness are created and where the stories of change are imagined and told. Size matters, but in matters of size it also turns out that small can be beautiful.