Social Enterprises and the NHS - Unison

8 Conclusion
The history of social enterprises is linked to that of the
social economy, defined by Amin, Cameron and Hudson
(2002) as:
non-profit activities designed to combat social exclusion
through socially useful goods sold in the market and
which are not provided for by the state or the private
sector. The social economy generates jobs and
entrepreneurship by meeting social needs and very
often by deploying the socially excluded.
The contemporary use of the term ‘social enterprise’,
especially in respect of developments in public service
reform under New Labour, is becoming disconnected
from its roots in the cooperative movement, communityfocused
businesses and local regeneration activities. It
has expanded to cover a wide variety of third sector
businesses to the extent that, depending on definition, it
can encompass organisations as diverse as BUPA (a
provident association), and small community-owned
development trusts. Should, therefore, any non-profitmaking
organisation which reinvests surpluses into
health-related services be described as a social
enterprise? At the same time, the discourse has
broadened from an original emphasis on social
regeneration and sustainability to entrepreneurship,
leadership, and applying business approaches to
socially useful endeavour, broadly defined (see for
example, Shaw, Shaw and Wilson (undated)); from
providing care in disadvantaged neighbourhoods to
providing choice through diversity; and from community
empowerment to a spectrum of involvement, including
that of professional groups.
Concurrently, a range of health policies, often developed
for different purposes, have promoted the involvement
of social enterprises in providing mainstream services.
Increased interest in this area is partly fuelled by policy
ambiguities over how health care services will be
commissioned, whether PCTs will continue to
commission and provide services and the role of the
commercial sector in providing health care over the
longer term. As there is a widespread assumption that
NHS provider organisations will change their shape by
2008, many are considering which legal forms and
organisational models best suit their aims, despite the
fact that key issues of risk, pensions and terms and
conditions of employment remain unresolved. Providers
are urgently seeking to position themselves at an
advantage in what many see as an increasingly
competitive market in primary care services.
Much is expected of social enterprises as a solution for
many of the perceived ills of public services including
the NHS. Innovation, nimbleness of response, services
more attuned to what people want, and flexibility all
figure prominently. However, a number of contradictions
emerge. Some of our interviewees emphasised that not
enough had been done to promote in the NHS the
50
qualities associated with social enterprise, and that
flexibilities already existed to be able to achieve this. It
was also claimed that the dominance of contractual
relationships could work against innovation and service
development, the very point often of establishing social
enterprises in the first place.
Moreover, collaboration and sharing of good practice
could prove difficult in an increasingly commercial and
contractual environment; decision-making could be
slowed down by the introduction of rigorous
arrangements for accountability; and a responsiveness
to the local community could be lost in the search for
viability in a competitive market or through services
being provided by multi-nationals without a local
presence. Why, it is argued, should companies with, for
example, headquarters elsewhere in Europe, the US or
Australia worry about the state of public services,
regeneration or probity?
The incursion of social enterprise into mainstream public
services has aroused hostility from those who do not
agree with wholesale changes in the ownership and
provision of public services, who consider that social
enterprise may in fact smooth the path for greater
involvement of the private sector in providing these
services, and who point to long-term consequences of
greater involvement of commercial companies leading to
a potential fragmentation of care and a greater
emphasis on contractual accountability as opposed to
local involvement.
At the same time, it cannot be denied that local
interviewees were enthusiastic about the potential of
social enterprise. For some, its creation is all about
strengthening a social ethos and a public service
orientation amounting to a robust defence against the
very incursion of the private sector into NHS services
and locally-based general practice which many fear. For
others, it provides a route for better involvement of staff
and patients and the opportunity for greater local
accountability. And for some large third sector
organisations social enterprise represents a major
opportunity to expand into providing mainstream
services, especially in relation to services which span
different organisations.
Looking outside the UK, Borzaga and Defourny (2001)
in their study of social enterprises across Europe point
to a number of potential weaknesses. One is the
tendency for social enterprises to evolve into new
organisational forms which serve to limit the original
innovative characteristics which constitute their appeal.
Another is the high governance costs which derive from
their character as ‘organisations without well defined
owners’ and their limited size, given links with local
communities, (although this may be less of an issue
where social enterprises are well developed and where
they can group together). They also point to a number