For over a decade, England has used social business models in health and social care as an attractive alternative to either state monopolies or privatisation. This includes the organisational models of social enterprise, co-operatives and micro enterprises, which are seen as having a healthy balance of social and business aims. Similar policies are now being considered in Wales where traditionally there has been a much stronger reliance on the state.
The implementation of the Social Services and Well-being (Wales) Act 2014 is widely seen as having the potential to create a more mixed economy of provision through user led services and greater use of social models. In particular, Article 16 places a duty on local authorities and those commissioning services to promote the use of social enterprises and other delivery mechanisms. As the Welsh Government wish to increase the role of social business models, they are seeking evidence from elsewhere on how best to do this and ensure the sustainability of these models. Subsequently, the Welsh Minister for Health and Social Services and the Public Policy Institute for Wales (PPIW) recently commissioned Ross Millar, Kelly Hall and Robin Miller at the University of Birmingham to explore the existing evidence base and report on the benefits and challenges of using social enterprise, micro enterprise and co-operatives in the health and social care sector.
Evidence from England has pointed to both the strengths and limitations of using these models to deliver health and social care services. Social enterprises have been particularly encouraged in health care as a means to combine the best of the public, private and third sectors leading to positive impacts on staff, patients and communities. Organisational autonomy gives them the ability to reinvest profit into the service or wider community, enabling innovation and change. Staff are empowered to shape decision making leading not only to improved staff engagement and satisfaction, but also more responsive and flexible services. They can also enable those who deliver health and care services to work much more closely with those using services in both their design and delivery. For example, disabled people are often employed within or are on the board of social enterprises.
However there are still relatively few social business models delivering health or social care in England and there are a number of challenges involved in trying to reverse this trend. Whilst English policies including ‘Right to Request’ and ‘Right to Provide’ have actively encouraged health and social care staff to set up social enterprises, such top-down policy mechanisms may not be the best way to ensure staff engagement and motivation. In some cases, staff have felt ‘pushed’ out of the NHS with social enterprise being the only option available to them. Social enterprises also remain dependent on NHS commissioning which can be challenging when some commissioners do not understand or recognise their value. We have therefore seen existing social enterprises struggling with their identity and can encounter what we term ‘sector ambiguity’; they are not clearly part of the public, private or third sectors. Whilst there are opportunities to use this to their advantage in developing partnership and securing funding from different sources, it can also cause confusion for staff and commissioners who may feel that they don’t belong anywhere.
Therefore, as the Welsh government begin the tricky task of transforming their health and social care sector through the use of social business models, they are able to draw on lessons from Italy, Scotland, England and elsewhere. Of particular importance, is the need to work with health and social care staff to develop these new organisational forms. Evidence indicates that the development of social enterprises should be led from the bottom up, by engaging with staff at an early stage. Simply changing organisational structures through top-down policy implementation will not in itself lead to the innovative, responsive and efficient services that are envisaged. Furthermore, even if social enterprises are wholeheartedly embraced by staff, there is still a need to ensure that they have sufficient financial and business support to develop them. Barriers in commissioning and tendering practices for social business models also need to be addressed. Transforming the health and social care landscape in Wales therefore has the potential to empower service users, carers and staff within the sector, but there is also a need to recognise and overcome the challenges that these new organisational forms face.
PPIW Report Publication 'Increasing the Role of Social Business Models in Health and Social Care in Wales'.
Dr Kelly Hall is a Lecturer in Social Policy based in the Department of Social Policy and Social Work. Her main research interests include social enterprise in health and social care.