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13 July 2007

There may be answers, but what’s the question?

What is the Department of Health hoping to get out of the third sector and social entrepreneurs?

By Cliff Prior

They say there is nothing new under the sun. Certainly, there is nothing new about charity or social enterprise providing health services. Before 1948 they formed the mainstream in the UK. Nationalisation was introduced to deal with the problems of the time: inequity of access and fragmentation, and there are salutary lessons there. But even before the government’s strategy to extend the role of the third sector in health services has had time to bite, over 10 per cent of mental healthcare and most care for people with learning disabilities is delivered in this way. In case anyone thinks that the third-sector role is limited to the lower tech and non-medical services, remember Macmillan in cancer care, St Andrews Hospital in children’s mental health, the hospice movement, and Wellcome on research.

The Department of Health (DoH) now has a Social Enterprise Unit, and a delivery board on third sector and social enterprise provision. A pathfinder fund of £1m last year has been followed by a new programme of over £70m. Serious work is going into expansion of the sector.

But it is not easy to get a clear answer to the question: why? Is the DoH looking for better managers of existing provision, or choice for patients and service users? Or perhaps the goals are innovation, or reaching the hard to reach, building community capacity, or user- and carer led services to help engage people in their own health. All of these are worthy goals, but different ones, and amenable to different solutions. The DoH may well want to achieve several of them, which would be fine, but would still require distinct programmes. Some people cynically believe it is all about money, the hunt for cheaper providers less generous on pay and conditions.

A blanket view that the third sector and social enterprise are simply better will not be adequate. Apart from the serious questions about whether it is true, posed recently by the National Consumer Council, it will be challenged by other interests. Once healthcare is opened out to competition, EU rules may apply and favourable treatment for any specific sector needs to be justified.

Passion to improve lives

On the ground, these high level considerations are not the issue. Most social entrepreneurs in health are motivated in the same way as their peers in other sectors – often by personal or community experience that has given them a passion to improve the lives of people living with specific health problems. They may be patients, users, carers, professionals or none of these, but they have seen inadequacies and are driven to end them. They have new ways of working, which they know will help, but they struggle to find a productive way to engage with the NHS commissioning machine.

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Their models do not fit the predetermined lists of primary care trusts or payment by results. Their operations are often small, cash strapped, lacking the financial solvency required to do well in a public tender. They are on the outside track, not part of the NHS club and often unaware of how decisions are really made. Sadly, many of the start-up social entrepreneurs supported by UnLtd simply give up on the NHS and look to other contracts instead.

Even social enterprises offering support services find it difficult. To take one example, Affirmative Business is a catering service in which staff include people with disabilities; it seeks contracts to run cafes in healthcare premises. It has faced bureaucratic and heavy-handed negotiations, public tendering even for tiny contracts, draft agreements that never get signed, or lengthy bespoke contracts that need expensive legal advice. Despite this it has four cafes running successfully. Should it be such a struggle?

It is good that the DoH’s action-plan targets training and awareness for commissioners as a top priority. Larger charities may fare better, having more staff to engage with commissioners and more experience. However, even here, there are serious problems. Commissioners tend only to consider agencies for services they already provide in their area, rather than looking at what they could do. Larger organisations, looking for larger contracts, start to hit some major logistics problems. The NHS pensions scheme is exceptionally generous, heavily subsidised, very expensive to match, and yet matching may be required by TUPE regulations: as a result, third-sector bids look artificially expensive compared to the in-house proposition. In the future, full access to the new NHS IT system for patient records will be essential for clinical services, but is not planned as part of the roll-out. Continuing professional development may be difficult to provide outside the NHS, and qualified staff will regard this as key to career choices.

Developing an organisation to the point where it can cope with these challenges may even be more difficult now than in the past. As Nick Partridge, chief executive of the Terrence Higgins Trust (THT) says, “I doubt THT could develop the way it did between 1983 and 1987 if we were in that position now. It’s also why 23 HIV charities have merged to create the current THT. If we hadn’t pooled our resources, we just wouldn’t be able to bid for new contracts.”

Is it worth the effort?

There are plenty of problems to tackle, so is it worth the effort? A few examples show why it is. The best social enterprises can motivate staff to deliver exceptional service: Sunderland Home Care Associates, one of the 2006 Enterprising Solutions winners, shows how. The best health charities can transform care: Macmillan cancer nurses, carer support in mental health and others too numerous to list. The best patient and user groups can help people to manage their own conditions: the development of self management programmes by the Long-Term Conditions Alliance (LTCA) member charities was groundbreaking.

Patient groups pioneered health information services, writing materials from the perspective of the end user, with agencies like Patient Opinion now taking this into the new arena of web 2.0. The best community health agencies will reach populations missed by mainstream services, ranging from people with complex needs to minority groups, sometimes becoming the gold-star service in their field, as is the Medical Foundation for the Care of Victims of Torture.

All of which brings us back to square one. These are specific solutions designed for specific problems. They are examples of where the NHS could buy in to success that has been created and delivered by charities and social enterprises. Not so much asking the third sector to come in and run failing parts of an existing machine, but recognising new ideas and new value. Not so much “third sector best” but the best of the third sector.

Before we seek the answer, let’s get the question clear. Then let’s go for the best.

Cliff Prior is chief executive of UnLtd, the Foundation for Social Entrepreneurs

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