Social Enterprises and the NHS - Unison

that enjoyed within the NHS. There was more scope to
meet the needs of local people. A number of
interviewees were keen to have control of their budget
and were critical of the fact that if organisations
performed well financially, the money could be diverted
elsewhere.
To my mind, coming from a commercial background, it
makes the whole thing unmanageable, it destroys the
morale of staff, because why should they worry about
trying to break even? (Chair).
6.4 Obstacles
The major stumbling block in setting up social
enterprises from within primary care, namely terms and
conditions of staff, is discussed separately (see subsection
6.8). There were also other obstacles, which
arose out of the model or approach adopted, from local
circumstances or from generic difficulties in setting up
new businesses. Where there was a lack of integration,
then excluded groups could fear a decline in influence.
From a commissioning perspective, PCTs could be
concerned about appearing to favour some clusters of
commissioners over others. PCTs often failed to
appreciate difficulties facing small organisations. For
example, short-term contracts were not practical for
new organisations as many of the start-up costs took
place in the first year. One interviewee described the
difficulties of the lack of start-up funds.
When you’re starting off, you didn’t have any time to
have staff in place, train them, get ready to prepare for
people using the building, we had to literally open the
door on day one and take risks, and quickly develop a
project. And especially for the health and fitness facility,
we had to just open the door and get it used and get
busy, generate some income, you know, without too
much thinking about it (General Manager).
Many PCTs were concerned about the risks of
contracting with new organisations or of ‘letting go’.
And what we have to do is convince the PCT that they
should let us run this, and not them run this. We have to
convince the PCT that the people that they second to
us are our staff, whoever pays them… they’re our staff,
and they will do what we want. Because if they don’t do
that, then it won’t work (GP and Director).
Some interviewees described the hesitation of
community-based staff when faced with uncertainties
about their future employers. Other staff were described
as not understanding the potential benefits of the model
or its relevance to their current situation. Some GPs
were slow to change.
I think a lot of people didn’t understand what a social
enterprise meant, what it was they were trying to
achieve (Practice manager).
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There were difficulties in dealing with the new larger
PCTs which had other priorities particularly as PCT
reconfiguration, in October 2006, overlapped with efforts
to develop social enterprises in three of the initiatives.
Delays could then sap enthusiasm and momentum and
one of the social enterprises was described by an
interviewee as ‘almost like a ship that’s been built and is
stuck on the slipway’ (Lay member of Board).
Other obstacles derived from a fear of creating large
impersonal organisations which would make it difficult to
‘sustain the local flavours of health provision’.
6.5 Social enterprise models: advantages and
disadvantages
There were different dimensions to the choice of model.
First was the business model adopted; second was the
organisational model and, related to this, the degree of
integration across different professions. The business
model was separate from the organisational form and
from the contractual arrangements with the PCT (for
example, through APMS or SPMS).
There was a range of business models in the case
studies. A sine qua non, given the nature of these
organisations was the fact that they were not concerned
with making profits for shareholders. This had important
implications for decision-making and the ethos of the
company.
When we sit around the board table and make decisions
about how we’re doing business, we are not constantly
thinking about ‘we have to make the bottom line pay
off’, we are constantly thinking about ‘how do we do
this better for the patient’, and that makes a very big
difference to how we go about doing business, and I
think that is a result of being a social enterprise (Clinical
Director).
One of the case studies was a not-for-profit company,
limited by guarantee, and with a three year APMS
contract to provide practice-based commissioning.
This was considered preferable to a company limited by
shares, partly because of issues connected with staff
supply agreements with the PCT.
Two of the case studies were community benefit
societies and one of these had explicitly rejected a
company limited by guarantee because of the problems
of raising capital. One of these was a mutual model and
owned by the community. A further example was a
company limited by shares, where all employees were
co-owners. The healthy living centre was both a
registered charity and company limited by guarantee,
and run as a social enterprise. In this example, new
initiatives could be seen as divisions of the company.