Work package 2: national provider and commissioner surveys

Context of work package 2

Three national surveys were undertaken in parallel, to allow ‘mapping’ of VSS service provision across England and describe service commissioning for victim-survivors of SV. Surveys focused on: (1) NHS statutory providers supporting victim-survivors of SV within SARCs; (2) commissioners from LAs, CCGs, Office of the Police and Crime Commissioner (OPCC), the NHS and Health and Justice who commission/co-commission therapeutic services for victim-survivors of SV that may be provided by VSS services and (3) senior staff working in VSS services. Initially, there were to be two online surveys; however, during survey development, it became apparent that separate surveys would be required for the voluntary specialist SV sector and SARCs due to differences in their operation and configuration. As a result, we designed and administered three separate online surveys for (1) commissioners of services for victim–victim-survivors, (2) specialist voluntary sector SV service providers and (3) SARCs. The surveys were designed to enable comparison between the three participant groups on a number of key themes (e.g. views of funding and commissioning, the strengths of specialist services, under-representation of victim–survivor groups).

Methods

Development and design

Survey content was informed by the relevant academic and policy literature, and by qualitative data collected from service providers, commissioners, policy leads and victim-survivors in WP1. Surveys covered the following topics:

1. Principles underpinning VSS service provision.
2. What services are commissioned and provided, how, by whom and to whom?
3. Criteria for accessing VSS services.
4. Referral patterns and pathways; relationships and partnerships between organisations.
5. Sources of funding and trends over time, including innovative responses to evolving commissioning and funding ‘landscapes’.
6. Commissioning approaches/models, including perceived effectiveness, facilitators and challenges.

Surveys included both closed questions (tick-boxes or Likert scales) and open questions (free-text responses) and were piloted within the West Midlands with staff from VSS services (provider survey) and commissioners (commissioner survey) for clarity of wording and relevance of questions to their intended audience(s). Surveys were disseminated electronically using the JISC Online Survey Tool and each took up to 25 minutes to complete.

Eligibility and recruitment

Potential participants accessed surveys via a weblink embedded within a brief invitation e-mail. The research team sent invitations directly to named SARC, VSS provider and commissioner contacts, for forwarding to the appropriate person within each organisation. Weblinks were also disseminated by members of the study Steering Group representing umbrella organisation networks (e.g. The Victim-survivors’ Trust); included in articles within professional press communications (e.g. Association of Directors of Adult Social Services newsletter) and publicised on the PROSPER website and social media accounts. Written informed consent was not obtained, but respondents could not progress into the survey without seeing detailed participant information and selecting a consent box embedded on the entry page. All surveys were anonymous, and participants were not asked for any personal information except sociodemographic data (age, sex, ethnicity) and some brief information about their job (e.g. role, time in current post). The surveys remained open from 13 January to 20 June 2021 and non-responders received up to two e-mail or telephone reminders. Table 1 summarises the inclusion and exclusion criteria.

Sample size

There were no formal sample size requirements for the PROSPER surveys. For statutory and VSS providers, we sought one response per organisation, as surveys focused on respondents’ experiences of service provision, funding and commissioning at the organisational rather than individual level. Duplicate responses from the same organisation were deleted and only the first response received (chronologically) was retained. For the commissioner survey, it was recognised that there may be multiple individuals involved in VSS commissioning with different remits within an organisation (e.g. adult services vs. services for children and young people (CYP)). Here, we aimed to obtain as many responses as appropriate from each organisation, to capture service provision and/or commissioning practices as fully as possible.

Analysis

Data were analysed descriptively using Microsoft Excel, to characterise specialist SV service provision, statutory services and commissioning across England, and response counts/percentages are described and presented graphically as appropriate. Respondent views about service quality, possible improvements and how commissioning was perceived to work were also analysed descriptively to identify differences and commonalities by stakeholder group. The small number of responses prohibited subgroup analysis. Free-text comments were analysed thematically.

Results

Responses

Twelve surveys were returned from SARCs, 54 from VSS providers and 34 from commissioners. Table 2 outlines the personal (sociodemographic) and professional (role-related) characteristics of respondents.

Across each group, most respondents were female, of white ethnicity and most likely to be aged over 50 years. Professionally, nearly all SARC respondents managed their organisation and most (83.3%) had spent ˂ 5 years in their current post. Commissioner respondents had typically spent fewer than 5 years in their current post (64.7%), with none in the post longer than 15 years. Around a third of commissioners reported that between 10% and 30% of their role involved SV commissioning (n = 12; predominantly in local authorities); eight spent < 10% of their time on SV (23%), and seven (21%) spent > 50%. In VSS services, many were highly experienced, with 18.5% having worked in VSSSVs for > 21 years.

Organisational and service characteristics

Geographically, only Cumbria and Berkshire did not return any surveys. Thirteen areas made a single response. Sixteen areas returned both commissioner and VSS surveys, and seven areas returned at least one survey from each of the three stakeholder groups (Figure 2).

FIGURE 2 Geographical spread of survey respondents. (Figure not reproduced here; see the original article.)

Sexual Assault Referral Centres were predominantly private (n = 8) and offered services to CYP (n = 1), adults (n = 5) or both (n = 6). All SARCs offered forensic medical examination, crisis workers, emergency contraception and prophylactic medication. Most (10/12) had dedicated helplines. Less frequent services were sexual health screening (n = 7), children’s ISVA (ChISVA) (n = 5), ISVA (n = 4) and counselling (n = 4), either in-house or via onward referral. Most VSS providers (41/54) described themselves as specialist organisations, and 34/54 offered services to adults and CYP. All but seven reported an affiliation with umbrella bodies such as Rape Crisis England and Wales. One-to-one specialist counselling/psychotherapy was the most widely offered VSS service, alongside a range of other therapeutic support (Figure 3), usually for around 26 weeks’ duration. Extra support was offered to specific groups for example, males, sex workers by 25/54 VSS providers; 30/54 also offered well-being/holistic services, and 28/54 provided activism-focused support.

FIGURE 3 Support offered by VSS services. CBT, cognitive–behavioural therapy. (Figure not reproduced here; see the original article.)

Service funding

As statutory providers, SARCs are funded directly by National Health Service England (NHSE) for initial support services, with additional therapeutic services usually funded by OPCC. In contrast, VSS respondents reported a complex system of reliance on multiple and varied funding sources, most commonly from charitable trusts (45/54) and fundraising/donations (45/54) (Figure 4). VSS providers reported using a mean of 4.8 funding sources (range 1–9) for their services.

FIGURE 4 Voluntary sector specialist provider funding sources. VAWG, Violence against women and girls. (Figure not reproduced here; see the original article.)

Service commissioning

Most SARC services (45%) were commissioned by a single body (usually NHSE), although joint commissioning by OPCC and NHSE was common, particularly for forensic and crisis worker services (Figure 5). CCGs and local authorities had minimal involvement in SARC commissioning (Figure 6).

FIGURE 5 Commissioning of SARC services. Green cells represent number of respondents reporting each commissioner/combination. (Figure not reproduced here; see the original article.)

FIGURE 6 Commissioners of SARC services. (Figure not reproduced here; see the original article.)

Voluntary sector specialist providers described a complex commissioning landscape. Eighty-three services (65%) were single-commissioned, usually by OPCC (56/83); 29 were dual-commissioned (23%), typically by OPCC + NHSE or OPCC + LA, and 16 were triple-commissioned (13%). The greatest variability in commissioning was for one-to-one adult and CYP services (Figures 7 and 8).

FIGURE 7 Specialist SV commissioning. (Figure not reproduced here; see the original article.)

FIGURE 8 Commissioners of specialist services. (Figure not reproduced here; see the original article.)

Satisfaction with commissioning

Providers rated their satisfaction with commissioning arrangements for services (and commissioners rated satisfaction with commissioning arrangements in their area) (Figure 9). See Appendix 1 which describes scoring.

FIGURE 9 Satisfaction with commissioning. (Figure not reproduced here; see the original article.)

Generally, SARC providers were most likely to be satisfied with commissioning overall and for each commissioning body. Commissioner and VSS providers’ levels of satisfaction were lower, and for all commissioners except CCGs, VSS providers reported the lowest rates of satisfaction with commissioning, with over 40% of respondents either dissatisfied or ambivalent (Figure 10). The general trend across all respondent groups was that OPCC and NHSE commissioners were rated highest, followed by local authorities and CCGs.

FIGURE 10 Voluntary sector specialist provider satisfaction with commissioning. (Figure not reproduced here; see the original article.)

Working with commissioners

Respondents rated agreement with a series of statements characterising perceived facilitators of, and barriers to, working effectively with commissioners (Table 3). Facilitators of working with commissioners showed similarly high levels of agreement across groups. Good relationships with individual commissioners, commissioners who understand SV and the voluntary sector, and communication with named commissioners were considered the most important enabling factors. The largest disparity related to the perceived importance of partnerships with other services, to which 97% of SARC respondents agreed, compared with 78% of VSS providers.

Few factors were considered substantial barriers by SARC respondents, with 4/12 citing clashes between health and criminal justice priorities and 4/12 highlighting time-intensive contract management/reporting as the greatest barriers. VSS providers highlighted failure to consult with services (61%) and unrealistic timelines to respond to briefs/tenders (61%) as the most important barriers; the latter was noted as important by only 6% of commissioners. Other barriers reported by VSS respondents were perceived limited ability to shape service provision (47%), time-intensive contract management/reporting (45%) and unrealistic contracts and expectations (42%).

Commissioner views about working with providers

Commissioners were asked whether any potential barriers (from a pre-specified list) had hampered their ability to work with providers (Figure 11).

FIGURE 11 Barriers to commissioners’ ability to work effectively with providers. (Figure not reproduced here; see the original article.)

The perceived lack of currently available funding was the most likely to be cited as hampering commissioners’ ability to work effectively with specialist providers (38%). Having some service components still subject to national commissioning and the impact of austerity measures on the sector over the last 10 years were reported as important by 11 commissioners (32%). The least important factors, each selected by one individual, were perceived issues with subcontracting arrangements, commissioners’ lack of access to data about local SV rates and a lack of time to develop good relationships with providers and other organisations. Commissioners also reported undertaking specific activities to support VSS providers to engage with the commissioning process. These related to consultation and discussions about commissioning (77%), provision of pilot funding for VSS organisations to develop partnerships or joint working (41%) and training support about the commissioning process (35%). Seven commissioners (21%) reported offering all these engagement opportunities.

Commissioner perceptions of voluntary sector specialist services

Commissioners were asked about their perceptions of the strengths and limitations of VSS services, and to select statements they agreed with from a pre-specified list (Table 4).

The factors considered the greatest strengths of VSS organisations were their perceived expertise and knowledge of SV (91%), centrality of the victim-survivor voice to services (88%), holistic approach (76%) and commitment to making service users feel believed (76%). Less frequently cited strengths (although still widely agreed) related to the context of gender inequality (29%), embeddedness in local communities (47%) and balance between bureaucracy and innovation (50%). Limitations of VSS organisations were reported far less frequently. The most cited weakness was the impact of short-term funding/commissioning on service longevity (71%). Others related to the potential for exclusion of male victim-survivors (29%), lack of data collection infrastructure (27%) and potential resistance to change (27%).

Consequences of funding/commissioning arrangements

Voluntary sector providers and commissioners were asked to select from a list of statements, those that they agreed were consequences of SV commissioning/funding arrangements over the past 5 years within their region. VSS respondents were most likely to perceive an increased need for partnership working (61%), an increase in short-term funding (59%), positive relationships between commissioners/funders/providers (50%) and greater competition between VSS providers (50%) (Figure 12). Least reported were an increase in mid-long-term funding (17%), money leaving the region (13%) and closure of specialist SV services (7%).

FIGURE 12 Perceptions of regional commissioning/funding changes. (Figure not reproduced here; see the original article.)

Commissioners were most likely to report positive relationships between commissioners/funders/providers (53%), different commissioners working together (50%) and greater need for partnership working (41%). Two issues showed notable disparities in perceptions. First, only 12% of commissioners believed there had been an increase in short-term funding (vs. 59% of VSS providers), and 6% of commissioners perceived a growing prioritisation of support work over therapeutic provision (vs. 35% of VSS providers).

Not all statements were common to each survey.

Voluntary sector specialist providers were also asked about perceived consequences for their organisation over the past 5 years (Figure 13). While job cuts were reported least (13%), around a quarter of respondents reported that there was underinvestment in services for specific groups, there had been changes/scaling back of VS work and that they were increasingly required to work with partners with a different ethos. Most likely to be reported were attempts to diversify funding sources (69%), staff stress/anxiety (67%) and greater use of paid, short-term staff positions. Around half of respondents reported that there had been opportunities to innovate in service design, and to develop new partnerships, although the same number also reported victim-survivors’ stress/anxiety.

FIGURE 13 Voluntary sector specialist providers’ views about changes in their organisation. (Figure not reproduced here; see the original article.)

Partnership working

Both provider groups were asked about services or partnerships they had developed jointly with other statutory providers [(e.g. IAPT or Child and Adolescent Mental Health Services (CAMHS)] or voluntary sector organisations (e.g. RC or Victim-survivors’ Trust affiliated organisations) (Table 5).

Nine SARCs (75%) reported at least 1 partnership with another statutory provider, compared with 26 VSS providers (48%), although for those with at least 1, SARC respondents reported a mean of 1.6 statutory partnerships compared with 1.8 for VSS providers. The nature of joint working with statutory organisations was more varied for SARCs than VSS organisations, with the exception of having a co-located worker/service (8% vs. 11%). For both groups, the most frequent type of joint working with statutory organisations was the development of joint referral pathways (67% vs. 41%).

With regard to partnerships with voluntary organisations, SARCs were more likely to have developed these compared with VSS providers (83% vs. 65%), although again, the mean number of partnerships reported with voluntary sector providers was greater for VSS providers than SARCs (2.4 vs. 1.8). VSS providers were more likely than SARCs to have established a co-funded worker/service within the voluntary sector (19% vs. 8%), or to have a co-located worker/service (24% vs. 8%). For both groups again, development of a joint referral pathway was the most reported form of partnership working (75% of SARCs, 46% of VSS providers).

Perceived under-representation of specific groups

Voluntary sector specialist providers were asked to indicate which (if any) groups of adult and CYP victim-survivors were under-represented in their services. Similarly, commissioners were asked their view on under-representation of these groups in their area (Figure 14 for adults, Figure 15 for CYP).

FIGURE 14 Voluntary sector specialist and commissioner’ perceptions about under-represented adult victim-survivors. LGBT, lesbian, gay, bisexual and transgender. (Figure not reproduced here; see the original article.)

FIGURE 15 Voluntary sector specialist and commissioner’ perceptions about under-represented CYP victim-survivors. (Figure not reproduced here; see the original article.)

Adults from ethnic minority backgrounds were considered to be the most under-represented by both providers and commissioners. Commissioners reported that older adults, adults with learning disabilities and lesbian, gay, bisexual and transgender (LGBT) + adults were more under-represented than those working in services, but proportions were similar. The largest disparities came in relation to refugees and asylum seekers (thought by VSS respondents to be more under-represented than commissioners), people with disabilities and adult men. The latter groups were thought to be far more under-represented in specialist services by commissioners than the staff in those services thought.

The view on under-representation of CYP in VSS services was again fairly uniform across VSS and commissioner respondents. The largest disparities came in perceptions about the under-representation of ethnic minority CYP, which commissioners reported was more pronounced than VSS respondents did. Similarly, commissioners perceived that there was greater under-representation of LGBT + CYP, and in particular boys, which 21% of VSS respondents considered were under-represented, compared with 54% of commissioners.

Innovative practice to engage with under-represented groups

Fifty-four per cent of VSS providers reported (via free-text comment) at least one way they had tried to engage with under-represented victim-survivors, representing a wide-ranging variety of services (Table 6).

Key messages from work package 2

• Huge variety of service scope, organisation, funding, delivery.
• Complex patchwork of services often working closely with each other to support victim-survivors.
• Service configurations may reflect a legacy of historical funding and commissioning arrangements but evidence of effective, needs-led practice.
• Many VSS service providers offer support that no other services do, and often to under-represented groups, for example, sex workers.
• Most services work with a variety of commissioners, with varying satisfaction with these arrangements.
• Complex funding landscape: most services rely on multiple funders, but a dynamic and evolving picture.
• Providers competing for same funding, an inconsistent/unstable funding picture.
• Substantial unmet need which restricts responsiveness to client need, waiting lists growing over time.
• Service users with complex trauma, restricted duration of support, worries about not meeting victim-survivors’ needs, in some areas a need to expand support for under-represented groups.
• Difficulties due to funding competition, problems with referral processes, good links support certain under-represented groups, enhanced working with NHS and statutory services.
• Need for greater capacity and efficiency.
• High turnover, stressful, difficulties funding specialist team staff members.
• Need for more holistic support, increasing provision of wraparound projects that add value to core services.