What have the Big Issue, the Eden Project, celebrity chef Jamie Oliver and NHS occupational health all got in common? The answer is that they all either already are, or are involved in the creation of, social enterprises. In the case of OH, NHS Plus departments in south-west England are currently looking at the feasibility of setting up such a social enterprise model, a model that, if successful, could become a template for other NHS Plus departments.
So, what are social enterprises? Social enterprises, in essence, are an alternative business model promoted by the government as a ‘half-way house’ to straightforward incorporation as a limited company. Social enterprises trade with either a social or environmental purpose. Their remit and business approach is not solely commercial – although they are commercial enterprises – as they have the aim of achieving some form of ‘public benefit’.
There are estimated to be currently more than 55,000 social enterprises in the UK with a combined turnover of more than £27bn, ranging from tourist attractions, restaurants (Oliver’s Fifteen), publishing enterprises, housing associations, co-operatives and even football club supporters’ trusts.
Within the health sector, social enterprises have become an increasingly popular business model. The Department of Health (DoH) even has a unit dedicated to encouraging NHS organisations either to become such enterprises or, at the very least, investigate their feasibility with, what’s more, as of last year, a Social Enterprise Fund to help with set-up costs.
Established NHS social enterprises include Central Surrey Healthcare, one of the pioneers of this form of business model in the health service, which provides community nursing and therapy services to the people of central Surrey and is co-owned and run by the nursing and therapy teams it employs.
Then there is the Expert Patients Programme, a so-called a community-interest company – a specific type of social enterprise – set up by the DoH last year to help primary care trusts (PCTs) commission self-management courses for people with long-term conditions.
Others include the City and Hackney East London Integrated Care Society, which helps to co-ordinate the practice-based commissioning activities of a group of GP practices, and the social care organisation Turning Point which provide services for people affected by drug and alcohol misuse, mental health problems and those with a learning disability, and operates more than 200 contracts with PCTs and local authorities.
And now the social enterprise concept is spreading to NHS occupational health, specifically NHS Plus and, even more specifically, South West Occupational Health Departments (SWOHD) through a project called Peninsula Project Social Enterprise.
The idea, explains Simon Hill, head of special projects and formerly head of staff health and welfare at Plymouth Hospitals NHS Trust, who is leading the project, is simply to establish whether a social enterprise could work as a model for NHS Plus occupational health units in south-west England and, from there, potentially further afield too.
“We have got to where we are by gradually building up a loose network and then a tighter one. We just feel that this could be a good way of looking at whether a social enterprise offers a mechanism for delivering a health and work offering across the region,” he says.
And this could be a particularly auspicious time to be considering such a model, in the wake of the recent review of workplace health published by national director for health and work Dame Carol Black.
“We would like to hitch our wagon to the whole Health, Work and Wellbeing agenda. It is really looking at whether we can offer something that matches the government’s intention of getting people off benefits and back into work,” argues Hill. “Getting down to SMEs with, say, just five people is really difficult.”
The idea has been building up a head of steam since 2003, he explains, though he stresses the project is still some way off from becoming a fully fledged social enterprise, and it may even be decided another route is more appropriate, which is the whole point of the project. There are some 11 NHS Plus OH departments currently in the network, stretching down from Gloucester and Bristol, through Taunton, Bath, Exeter, South and North Devon, Plymouth and Truro. Discussions are also going on with units in Poole, Dorchester and Swindon, he adds.
Co-operation between OH departments is, of course, nothing new. Units have met for many years for educational purposes and combined audits of practice. But, increasingly, there is an emphasis on needing to create more uniformity of practice and standards, and to have more shared processes and procedures, Hill emphasises.
“For example, if the Department of Health issues an edict on serious communicable diseases, at the moment there are 13 or 14 departments in south-west England that are all going to have to produce guidance for their staff, and you can guarantee that they will all be slightly different. If you have 14 different people interpreting it, they will inevitably come up with 14 different solutions or methods of delivery,” he points out.
Room for manoeuvre
One of the big attractions of going down the social enterprise route is that it potentially gives you more room for manoeuvre than being within an NHS-owned unit – more wriggle room, as it were, to set your own direction and priorities and to manage your own affairs, argues Hill. But at the same time it does not mean having to split from the NHS. In fact Hill stresses the intention is still very much to remain part of the NHS family and, critically, to retain the hugely trusted brand of the NHS.
“We would still be under the umbrella of the NHS. We would still be badged as NHS. We would not be looking to be Hill & Harling Incorporated or anything like that,” he says, referring to NHS Plus chief executive Kit Harling.
“But what we do want is to try and find a better structure for delivering OH to the wider community, particularly to SMEs,” he adds.
Being able to offer common, standardised procedures and paperwork rather than, as at the moment, everyone doing their own thing in a sometimes disjointed way, would make NHS Plus a much more viable and attractive option for SMEs, he argues.
Just as importantly, it could mean less disjointed and more effective services being delivered back into the NHS to help tackle the health needs of NHS staff, too.
“Clearly we still have a prime responsibility to deliver occupational health to the NHS. But it is about improving the quality and consistency of local delivery. There have already been cases of NHS bodies willing to look elsewhere, or even actually going elsewhere, for their OH services,” he emphasises.
So far activities within the network have included successful combined bids for the provision of OH services to support small and medium sized enterprises in the public, not-for-profit and commercial sectors, Hill points out. Similarly, individual departments have had success in winning large contracts in the wider public and commercial sectors.
There has been interest from the manufacturers’ organisation EEF in the region about developing a partnership relationship. There has also been interest in the idea from Plymouth and Torbay County Council, Plymouth University and College and other local employers.
At a practical level during the past 12 months, a core data set has been established for occupational health reports to managers on staff referred for opinions in relation to their work and wellbeing. This, stresses Hill, is to ensure there is consistency in the advice for NHS staff wherever they work in the South West.
A common health declaration and screening procedure has been drawn up for staff rotating between south-west England NHS trusts, including clinicians having duties in multiple trusts.
The network has put out much more consistent information for staff required to undergo or being offered HIV testing under Department of Health guidance. This has taken the form of a region-wide Frequently Asked Questions leaflet. Similarly, generic health and wellbeing guidance has been published in a common leaflet to ensure the same key messages are presented to NHS staff by all OH practitioners with SWOHD.
Looking forward, explains Hill, some departments are already collaborating over bids to the NHS Plus capital scheme and supporting each other with temporary staff transfers at times of difficulty. A new SWOHD-backed OH nursing degree and competency courses has also been established in partnership with Plymouth University.
The next step from here could be either a community-interest or social enterprise company, Hill explains. “Under such a concept, trusts would become commissioners of the services they required, but no longer have to carry the administrative burdens of being in-house providers. The company so created ought to be more agile and resilient in providing an attractive healthy working offering to the wider public and private sectors within the region.
“There is now a sense among SWOHD that we have debated the issue long enough and we need to create a model whereby the advantages and disadvantages of the concept can be clearly exposed and a rational business judgement taken,” he adds.
But anyone thinking of going down this route also has to recognise it is not a soft option – as a social enterprise you still have to file accounts to Companies House, submit articles of memoranda and so on.
Re-investment of profits
“You are, in almost all respects, a commercial entity. But one of the biggest differences is that you have an asset lock,” Hill adds.
This is a key part of the community-interest company social enterprise model, and means that any surplus has to be reinvested back into the enterprise rather than lost to the greater NHS pot, one of the most common grumbles among NHS Plus OH practitioners.
“Everyone is really keen to see what it might look like. I suspect we could draw up a model in perhaps two to three months. But I think we would have to look very hard at the governance issues. For instance, what role would the Strategic Health Authority have or even the Department of Health?” explains Hill.
Hill gave a talk on the project’s progress so far to NHS Plus practitioners at the organisation’s inaugural Health at Work in the NHS conference at the University of Warwick in January.
“The response from the conference was really quite positive. Two-thirds of departments around the country are looking at what we are doing and whether it might have a broader application,” he enthuses.
If successful, the social enterprise model could work in other parts of the country, agrees NHS Plus project manager Keith Johnston.
“What we are doing at the moment is simply looking at the viability of the model and identifying what are its strengths and weaknesses. I think a lot of OH departments are going to be following its progress quite closely,” he says.
From the SME perspective, the main attraction is getting a service that is less mired in bureaucracy, less part of a lumbering whole and so potentially more capable of responding to individual needs and requirements, Johnston says.
But there are also potential barriers to be considered, with perhaps the biggest one being the issue of what happens to your employees’ pensions. The NHS pension is one of the most generous in the public sector and not a benefit to be given up lightly.
But, clearly, if you are employed by a social enterprise, then you are not employed by the NHS and so would not be able to remain part of the NHS Pension Scheme.
Johnston suggests a half-way house such as that enjoyed by GPs, who are nominally self-employed but work under contract for the NHS and therefore retain membership of the NHS Pension Scheme, could be one way around the issue. This is something that has worked for existing social enterprises, such as Central Surrey Health, for instance.
“But the difference for OH is that they would not be providing healthcare under the GP contract,” he points out.
“It is a real issue for existing NHS staff. It may be that in the early life of the social enterprise staff may still be employed by the NHS and simply seconded from it,” Johnston muses.
Whatever the final outcome, what is clear is that OH as a social enterprise is uncharted, albeit exciting, waters for a profession potentially on the cusp of great change. “Building a social enterprise could be freeing and empowering,” says Hill, before adding candidly: “But it is quite scary. Only the good will survive.”
• The Department of Health’s Social Enterprise Unit includes information on setting up a social enterprise, funding and funding sources, pathfinders and case studies: http://www.dh.gov.uk/en/Managingyourorganisation/Commissioning/Socialenterprise/index.htm
• The Social Enterprise Network is the only national network for those with an interest in social enterprise and social entrepreneurship in health and care, with advice, resources and discussion forums. http://www.networks.nhs.uk/networks/page/155
• The Social Enterprise Coalition provides a national platform for showcasing the benefits of social enterprise, sharing best practice and influencing policy.