Exploring lessons from Covid‐19 for the role of the voluntary sector in integrated care systems

Abstract Integrated care systems (ICS) in England are partnerships between different health and social care organisations, to co‐ordinate care and therefore provide more effective health and social care provision. The objective of this article is to explore the role of the ‘Voluntary, Community and Social Enterprise’ (VCSE) sector in integrated care systems. In particular, the paper aims to examine recent experiences of the voluntary sector in responding to the Covid‐19 pandemic, and the lessons that can be learnt for integrated care provision. The article focuses on the case of Oxfordshire (UK), using a mixed methods approach that included a series of semi‐structured interviews with key informants in health and the VCSE sector as well as online surveys of GPs and organisations in the VCSE sector. These were complemented by two contrasting geographical case studies of community responses to Covid‐19 (one urban, one rural). Data were collected between April and June 2021. Interviewees were recruited through professional and community networks and snowball sampling, with a total of 30 semi‐structured interviews being completed. Survey participants were recruited through sector‐specific networks and the research arm of doctors.net.uk, with a total of 57 survey respondents in all. The research demonstrated the critical role of social prescribing link workers and locality officers in forging connections between the health and VCSE sectors at the hyper‐local level, particularly in the urban case study. In the rural case study, the potential role of the Parish Council in bringing the two sectors together was highlighted, to support community health and well‐being through stronger integrated working between the two sectors. The article concludes that enhanced connections between health and the VCSE sector will strengthen the outcomes of ICS.

ICS are partnerships between different stakeholders, including the NHS, local councils and the 'Voluntary, Community and Social Enterprise' (VCSE) sector working within the ICS boundary, to provide more effective health and social care to local communities (Charles et al., 2018). A total of 42 ICSs have been introduced in England, organised through integrated care boards and integrated care partnerships. NHS Trusts are also joining together, to form 'Provider Collaboratives', new partnerships bringing together different aspects of health and social care, such as hospitals, mental health services and community services. ICSs are made up of a number of local authority areas, but a key characteristic of ICS policy is that commissioners and providers work over smaller geographies (at the so-called 'place' level, such as the local authority), with teams delivering services within even smaller footprints (at the so-called 'neighbourhood' level, such as the primary care network). One of the aims is to encourage closer working between different sectors, including health and the voluntary sector.
Recent research has highlighted some of the opportunities and challenges of closer integration between the health and VCSE sectors. The King's Fund notes that partnership working between health and the voluntary sector can contribute to people living longer in better health (King's Fund, 2021a), with impacts on reduced hospitalisation. However, the Institute for Voluntary Action Research (IVAR) has demonstrated the need for greater understanding, including a common language to talk about improvements to health and well-being at the local level. They also emphasise the importance of co-designed, integrated and asset-based approaches to health and well-being that provide locally relevant solutions, co-designed between the health and VCSE sectors (IVAR, 2014;IVAR, 2016). Croft and Currie (2020) highlight the importance of VCSE involvement in delivering integrated care, through workforce capacity development and specific coordinating roles. However, they also warn against the potential for exploitation of VCSE organisations, whereby they become replacements for health and social care provision, rather than a complementary service within an integrated team.
The need for strong and mature relationships in co-production between the VCSE and health sectors is also highlighted by the King's Fund (2018). These themes were picked up by the NHS's VCSE Health and Wellbeing Programme, launched in April 2017, to promote co-production in the creation of person-centred, community-based health and care, to support more effective and equal health outcomes. One strand of this work was the 'Leadership Programme', where funding and facilitation support were available to develop place-based VCSE Alliances within ICSs. Building on research by the National Council for Voluntary Organisations (Pedro & Baylin, 2020), a series of VCSE Alliances have been funded, to establish networks of VCSE and health stakeholders in ICS areas. One such Alliance in Derbyshire has produced a good practice schema ( Figure 1) of how the VCSE Alliance in their area can be embedded within the three different components of the ICS: system, place and neighbourhood. It illustrates the importance of integrating a network of VCSE voices at all three levels. However, there is currently a lack of research on how VCSE partners can work more effectively in partnership within the new ICS structures for better health outcomes (King's Fund, 2021b).
During the Covid-19 pandemic, one of the key features of the societal response to the crisis has been the rise in mutual aid organisations and related activity through the VCSE sector, particularly in supporting vulnerable and older populations (NLGN, 2020

What this paper adds
• Social prescribing link workers, together with locality officers, play a critical role in bridging knowledge gaps between the two sectors of health and the voluntary sector, particularly in an urban context. Stronger links between the two can support health and well-being in the community.
• Outside urban areas, the Parish Council is well placed to play the role as intermediary between health and the voluntary sector in a rural setting.
The overall aim of the research was to identify key components that have facilitated partnership working between the VCSE and health sectors and to provide recommendations for the ICS on how the two sectors can work together more effectively, to the benefit of population health and well-being. The specific research questions addressed were: How have local communities responded to the pandemic through VCSE initiatives? How effective have these initiatives been in reaching older and more vulnerable people, and in addressing isolation, mental health concerns and well-being? And what is the potential for policy learning from these experiences, to strengthen voluntary sector involvement in the local BOB ICS health system? 2 | ME THODS

| Study design and setting
This was a mixed-methods study, using primary and secondary sources to examine the role of VCSE organisations in the county of Oxfordshire (UK) in supporting older and more vulnerable people, and the potential for closer voluntary sector involvement in health provision within the BOB ICS (Buckinghamshire, Oxfordshire and Berkshire West). The methods included semi-structured in-depth interviews and online surveys at the regional level, complemented by two place-based case studies, one urban and one rural, drawing on the experiences of three stakeholder groups: health providers, the voluntary sector and local residents.
The study was constructed using a three-stage methodology. Building on an initial literature review, a series of in-depth semi-structured interviews was conducted in the first stage of the research, with key informants in both the health and VCSE sectors.
A qualitative approach was used to gain an in-depth understanding about experiences of, and responses to, the pandemic from different actor perspectives (VCSE, health and communities). A total of 15 people were interviewed virtually on Zoom in this first stage (13 from the VCSE sector, one from health and one in social prescribing, that combines VCSE and health perspectives), to explore their different experiences of the pandemic, and how health and the VCSE sector could be more closely integrated.
The second stage involved distributing two online surveys to GPs and the VCSE sector, focusing on cross-sector collaboration and support to older and vulnerable groups during the pandemic.
The GP surveys were circulated through the research arm of Docto rs.net.uk (M3) focusing on Oxfordshire and the wider South East.
The VCSE survey was distributed through the volunteer organisation 'Oxfordshire Community and Voluntary Action' (OCVA) via its members' newsletter. A copy of the survey for GPs can be found in Appendix S1, while a copy of the survey for voluntary and community groups can be found in Appendix S2.
The third stage involved case studies in two contrasting localities: Case A, a neighbourhood of Oxford, and Case B, a rural village in Oxfordshire. These two cases were selected in consultation with the project Advisory Board, as examples of strong community responses to the pandemic, to explore those elements that worked well, as well as aspects that worked less well, and the reasons why that might have been. The two areas were also interesting to explore, given their different socio-economic profiles. Case A is a mixed-tenure urban housing estate originally built in the 1940s as social housing and located on the edge of the Oxford city. According to the 'Indices of Deprivation' data for 2019, the neighbourhood falls within the F I G U R E 1 A good practice model of VCSE engagement at a system, place and neighbourhood level. Source: "Joined Up Care Derbyshire". https://joine dupca reder byshi re.co.uk/get-invol ved/volun tary-commu nity-and-socia l-enter prise -leade rship -progr amme most deprived quintile nationally (Oxford City Council, 2019). Case B, on the other hand, is a relatively well-off rural village and civil parish of under 400 residents, located outside Oxford. The village has no amenities, shops or a pub, and residents are dependent on private transport, due to a very limited public transport service.
For the two case studies, a total of 15 semi-structured interviews were carried out. In Case A, nine interviews were completed: three involving the VCSE sector, two in health, and four residents (1 who received support and 3 who provided support). In Case B, a total of six semi-structured interviews were completed: three in the VCSE sector and three residents (all of whom received support).
Interviews were carried out either by Zoom or telephone.
The table below (Table 1) summarises the characteristics of the interview participants, including the type of organisation that stakeholders were engaged with, to illustrate the spread of views included, from national and regional perspectives, through to local and hyper-local levels.
The research was also supported by an Advisory Board with six members across the health, VCSE, local authority and academic sectors, who met virtually three times during the study in February, April and June 2021. Consent from survey participants was obtained using the survey tool.

| Data collection
The researchers conducted the semi-structured interviews and distributed the online survey over a 3-month period, between April and June 2021. Due to the pandemic, all methods were designed to be online to avoid face-to-face interaction, using zoom, telephone and the online survey tool Qualtrics.
Semi-structured interviews lasted approximately 60 min. The topic guides for the interviews were informed by the literature review, with advice from the Advisory Board. The three topic guides, one for each group (health, the voluntary sector and residents) were tailored to each specific category, but broadly covered their experiences during the pandemic, and the links between the health sector and community provision of support. In each case, respondents were asked to reflect on aspects of support that had worked well, those that had worked less well, and the lessons that could be drawn for future cross-sector working.
The online surveys were designed to access a wider range of views, from both VCSE organisations, and from GPs about their experiences of working with the VCSE sector, before the pandemic, during the health crisis, and their views on how cross-sector working could be enhanced in the future. The online survey was completed by a total of 50 GPs and seven VCSE organisations. A total of 12/50 of the GP surveys were completed from Oxfordshire, with a further 26/50 from elsewhere in the South East. The remaining 12/50 came from London, East and West Midlands and the East of England. All seven of the VCSE organisations were located in Oxfordshire.

| Data analysis
All 30 semi-structured interviews were recorded, transcribed by researchers and analysed using thematic analysis (Braun & Clarke, 2006). The coding frame was developed by three of the researchers (J.C., B.S., T.M.D.S.) who read and re-read the transcripts and compared codes to ensure reliability and validity of the analysis.
The coding frame was divided into three main codes: perspectives on how the health and VCSE sectors have worked together during the pandemic, lessons learnt for integrated working in the future and differences between responses from interviewees in the urban and rural case studies. Data from the online surveys were integrated into the interview analysis through descriptive statistics.

| Terminology
There are a number of different ways of referring to the 'communityrelated' sector, for example, 'civil society', 'mutual aid organisations', the 'Third Sector', the 'Voluntary and Community Sector (VCS)' and the 'Voluntary, Community and Social Enterprise' sector (VCSE).
In this research, we have adopted the term VCSE, to include any organisation (incorporated or not) working in the 'communityrelated' sector. Where possible, in light of the research data, we make the distinction between small community-based neighbourhood groups, such as local street-based WhatsApp groups that have sprung up during the pandemic, in contrast to large, registered charities, such as Age UK and Mind that operate locally, regionally, nationally or even internationally. In the research, we use the general term VCSE to cover these different types of organisation, although we recognise that there are significant differences between them, and that particular comments in this paper may not be relevant to all organisations covered by this term.
We also recognise that the 'health sector' and the 'VCSE sector' do not represent single voices, but many voices within each

Number of interviewees
National organisations 1 Regional offices of national organisations 3 Regional/county level organisations 5 City level organisations 7 Local and hyper-local organisations 7 Local residents 7 Total 30 sector, and referring to these broad umbrella terms will inevitably involve grouping together a range of disparate cultures and perspectives. However, we felt that this would be the most effective approach to access a range of perspectives in a short period of time, without excluding certain voices in the broad sectors of health and VCSE. Within the 'health sector', we have included 'social prescribing link workers', who straddle both the health and VCSE sectors.

| RE SULTS
The results are divided into three main themes: Community responses to the pandemic; Effectiveness of community initiatives during the pandemic; and Potential for policy learning for ICSs.
Points are illustrated with verbatim quotes from participants.

| Responses to the pandemic
In line with experiences elsewhere ( Therefore, the responses to the pandemic linking the health and VCSE sectors differed in the two case study areas. In the urban case study, there were already strong links between the GP practice and the local community. This relationship had been built up over a number of years through a partnership between the social prescrib link worker (Polley et al., 2017), and a dedicated locality officer on the ground, who promoted asset-based community development (ABCD) (Kretzmann & McKnight, 1993, 1997 Since there were very few links between local health services and the village's community support networks, a system of prescription collection was established. This was an informal arrangement between the organisers of the village's pandemic response and two local pharmacists, with named volunteers assigned to collect particular prescriptions. There were no links with more formal NHS health services or any local social prescribers in relation to activities run by village residents. Such links were seen as potentially problematic, given the nature of more ad hoc or voluntary activities, which by their nature are not necessarily regular.
Nonetheless, it was suggested that a more formal contact point within the village serving as a hub for signposting information about local initiatives and community assets that could potentially be relevant for social prescribing purposes would be useful, particularly for older residents.

| Effectiveness of the pandemic responses
Survey responses from VCSE organisations indicated that the hyperlocal support offered to local vulnerable groups during the pandemic was seen as a vital initiative, particularly for older people who were at risk of social isolation during lockdown. Phone buddying allowed for safe contact, while delivering services such as shopping or food parcels to those self-isolating was also seen as a valuable way of checking that vulnerable individuals had regular socially distanced contact. A summary of the survey results from the VCSE sector can be found in Appendix S4.
While community responses to the pandemic were largely seen as a significant success, it was recognised that the role of effective partnerships between the health and VCSE sectors was key to this. Investment in social prescribing link workers (Tierney et al., 2020) within PCNs was welcomed but some interviewees thought that more was required to maximise the benefits from this, including providing infrastructure to support their work, as well as networking and training opportunities for the link workers.

A very strong and recurring theme of the interviews in Case
Through the survey, many GPs also reported on the benefits of working with the VCSE sector during the pandemic. In particular, they cited increased community cohesion at a time when close family, perhaps living at a distance, were unable to help vulnerable members of the local community. Volunteers became a point of referral and support, helping people with both practical and social aspects of need.
The most common benefits reported were support for the isolated elderly, support for mental health and supporting the vaccination centres. GPs felt volunteers were enthusiastic, flexible, helpful and good team players. They felt that working collaboratively improved communication and helped relieve the pressure from GPs, at such a busy time.
However, working with the voluntary sector was also reported to be challenging. As well as reduced funding and staffing of voluntary groups, and the loss of face-to-face interactions, there was also concern around confidentiality and volunteer safety checks.
One GP referred to the challenge as 'crossing boundaries', between the health and VCSE sectors. Others reported concerns around the level of knowledge that the volunteers had, and the perceived lack of training of volunteers with appropriate skills. Furthermore, some GPs reported that they were unsure which voluntary organisations to contact, and felt the voluntary organisations did not promote awareness of their services effectively within healthcare services.
Over 70% of those GPs who responded to the survey linked with just one VCSE organisation, with a further 18% only linking to two organisations. This suggests the need for more comprehensive signposting of local VCSE organisations and the services that they provide that could be useful for social prescribing. These moves to engage more fully and transparently with the VCSE sector were welcomed by respondents. But as many interviewees recognised, it will take time to put systems and structures in place, to embed the VCSE sector within BOB, and to shift mindsets to embrace the VCSE sector in decision-making around the table.

| DISCUSS ION
The research demonstrates, through stakeholder interviews, online surveys and the two case studies, that the pandemic mobilised different organisations and local volunteers to support vulnerable community members in their neighbourhoods. In both areas, the pandemic responses were seen as effective in supporting well-being through volunteer engagement. However, there were differences between the two cases. In urban Case A, this led to a strengthening of the existing ties between the health and VCSE sectors in the area and demonstrated the key role of social prescribers in forging links between health and the VCSE sectors at the neighbourhood level, with clear policy implications for the ICS agenda to support local integrated approaches to health and well-being. In rural Case B, community mobilisation was not connected to local health services due to the village's relative isolation, the physical distance to GP practices and absence of local formal health and well-being services.
There was an absence of contact between the VCSE sector and health agencies and sectors, which led to limited health-related support in the rural setting.
The NHS Long-Term Plan set a target that by 2023/2024, every GP practice in England will have access to a social prescribing link worker and by then, a target of 900,000 people has been set for those referred by a social prescriber (King's Fund, 2020). Social prescribing is already embedded in health practice (Costa et al., 2021;Pescheny et al., 2020), and is seen as being key to the delivery of an integrated health service in the future (Bickerdike et al., 2017;Drinkwater et al., 2019). The urban Case A supports the case for a strong role for social prescribers in linking health and the VCSE sectors. However, one of the challenges relating to social prescribing is the volatility of the availability of local services and activities to which to refer patients. The fleeting nature of some activities and initiatives means that social prescribers have to be continuously up-to-date with what is offered locally. This is directly linked to the ability of these small organisations to secure and maintain funding, as well as their access to volunteers and specialised personnel.
Funding cuts in recent years and the current financial climate have created volatility and undermined the ability of the sector to meet local needs, which is destabilising for social prescribers. However, as Knapp et al. (2013)  As a result of this instability, social prescribers very often link to more formal or substantial VCSE groups that are well-known and well-established in an area. This is due to the challenges of working with smaller providers related to the sustainability of opportunities, as well as those associated with whether the true value of small providers is fully understood by commissioners (Dayson & Batty, 2020). The research showed that in many cases, the more informal community-based networks and support, that are so vital to neighbourhood cohesion, are 'off the radar' in relation to social prescribing. Dayson and Batty (2020)   of Japanese municipalities had implemented the salons in their localities. Studies have shown that participation in these salons is associated with a halved incidence in long-term care needs, and around a third reduction in the risk of dementia onset. Lessons from this integrated approach could usefully inform how the VCSE and health sectors in England could work more closely together to fulfil the aims of ICSs going forward, with a shift towards prevention and self-care.

| Strengths and limitations
One of the key strengths of this study is the inter-sectoral focus, exploring the links between the health and community sectors.
Further added value was provided through drawing lessons from the pandemic, which provided a unique context to study these critical linkages. However, the research also had a number of limitations.
Restricting the study to Oxfordshire meant that it was limited in its scope, although the urban and rural cases provided interesting contrasts.
Although the survey link was sent to a range of different organisations to cascade through their networks, the response rate was limited and non-representative. Similarly, the number of participants interviewed was limited, with only one each from the health and social prescribing sectors, despite approaches to a wide group of potential interviewees. This reflects the severe pressures that the health service is currently under, more broadly due to underfunding, but in particular recently due to the pandemic. Additional research would endeavour to engage with a wider group of respondents.
The research also focused primarily on health and the voluntary and community sectors, rather than social care. Therefore, it did not address issues of the gap between health and social care, joining up these two dimensions, or other issues related to local authority involvement and their contribution to health and well-being. These issues would benefit from further research.

| CON CLUS IONS
Closer working with partners in the VCSE sector will be crucial for integrated working in the newly created ICSs. The VCSE sector is uniquely placed to provide a link between health services and local communities, to support population health. The research revealed a number of opportunities and barriers to joint working between the health and VCSE sectors which were highlighted by the experiences during the pandemic. In relation to opportunities, the pandemic brought different organisations together in crisis mode, and relationship building that can generally be time-consuming and complex, materialised relatively quickly and with minimal friction.
New partnerships formed that can be built upon in the future.
However, there were also a number of barriers to joint working, including different cultures and mindsets in the health and VCSE sectors, leading to a lack of understanding between the two groups, and hindered by their different languages. It was also evident that financial constraints in the VCSE sector, both now and particularly in the future, will limit the capacity of VCSE organisations to reach out beyond their core mission, to invest in collaborative work in ICSs. These are all issues that need to be considered when strategising around the partnership working with the voluntary sector in ICS in the future. Future research could be usefully focused on how to address the barriers to closer integration, in particular exploring the most effective way of forging partnerships with local and hyper-local grassroots organisations, through the intermediary of locality officers and social prescribing link workers.