The NHS Confederation reports that social enterprises deliver a third of all community health services. Evidence tells us they have high levels of staff satisfaction and retention, are often innovative and reinvest their profits into services rather than divert them to shareholders. How are social enterprises able to offer such a distinctive, albeit so frequently underappreciated contribution to the NHS and social care?
Adam Lent, Senior Consultant in the Leadership and Organisational Development team at The King’s Fund, has recently been showcasing some pioneering examples of social enterprises delivering inspiring and innovative models of care. These case studies show how social enterprises are helping to reduce strain on the NHS and create replicable models for both health and social care, delivering the shifts Government has pledged to deliver – from sickness to prevention and from hospital to community.
Out of hospital
Spectrum Community Health CIC’s Butterfly Project works with a very marginalised and ignored group – female prisoners – many of whom come from poor and excluded communities. Over half have experienced domestic violence, sexual violence and abuse as a child.
Adam describes how the Butterfly Project set itself a simple but challenging goal – to increase the cervical screening rate to 90% for the 500 prisoners held at HMP Styal in Cheshire. This was ambitious – the screening rate at the prison was only 64% when the initiative began in 2020, and the rate for the English population is not much higher at 69%. Yet the Butterfly Project secured its goal. 92% of women at HMP Styal underwent cervical screening between 2020 and 2022. This is an achievement that has proved sustainable with a 91% rate by 2024.
So, how did the Butterfly Project achieve such great results? By doing something different. Most medical procedures occur outside the prison walls, requiring prisoners to be escorted, often in handcuffs and prison vehicles, to a hospital or clinic accompanied by a prison officer. This is a process that reinforces stigma and inevitably adds considerably to the anxiety of any medical procedure. Adam describes how, instead, Spectrum went to where the people are, conducting cervical screenings at the prison itself.
Peer mentors were also part of the model. These are prisoners who play a vital role not just in spreading the message about cervical health but also talking directly with those who may be anxious or doubtful about undergoing screening. The Butterfly Project’s staff placed a premium on friendliness and providing care in a welcoming environment. Adam concludes that the Butterfly Project teaches us that, with the right practices, enough time and a considerable dose of humility, it is possible to transform engagement with even the most excluded people and communities.
How to save £6bn
Another inspiring example can be found at the Jean Bishop Centre in Hull. We know that frailty increases an individual’s likelihood of attending a GP surgery by over 50%, undergoing emergency care by 216% and adds almost £6bn to the NHS bill each year. Yet the centre has managed to cut emergency admissions for the most severely frail people by 50%.
Adam highlights how the key to success has been flipping the usual model of care on its head so it is the individual who shapes the support they receive rather than the public sector. As such, assessment of a person’s needs begins with a very detailed conversation about their experiences, their hopes and their needs.
Armed with that understanding, clinicians and others working at the centre can work out exactly what is needed to maintain the health and wellbeing of someone with frailty. This regularly involves bringing in wider community and voluntary sector support, often located in the centre themselves, enabling immediate connection to the people looking for help.
This approach has had an impact across the whole of Hull. When it first opened, the centre set itself the goal of reaching as many of the 3,000 people with severe frailty in Hull as it could. Within two years, it had worked with 90% of that population. That led not only to the 50% reduction in emergency admissions for the most severely frail in that group but also a 10-25% reduction in GP visits for the rest of the group. Work with a wider cohort with less severe frailty has led to an overall reduction in A&E admissions for people over 80 by 13.6%, for residents in care homes by 18%, and reduction in medicine costs of £100 per person per year.
The social enterprise model
The Jean Bishop Centre is run by City Health Care Partnership (CHCP), which span out of the public sector in 2010. It boasts high levels of satisfaction from both service users and staff; 96% of people that use their services say they are satisfied and 97% are happy with the standard of care and support given.
CHCP is a social enterprise, which means that its profits are reinvested into services, colleagues and the community. Staff surveys show that 92% feel their role makes a difference to patients and 90% would recommend CHCP to friends and family for care. Perhaps this helps explain why retention of staff is high amongst social enterprises. Spectrum is also an employee-owned social enterprise.
While underappreciated, these are not new models in our health and care system. The NHS itself was built upon a co-operative tradition, taking inspiration from the Tredegar Medical Aid Society in South Wales, a local, mutual, grassroots, democratic healthcare model. Today, out-of-hours social enterprises provide urgent and integrated care covering two-thirds of the UK population. Local Healthwatch organisations are set up as social enterprises. In 2009, Andy Burnham began a decade-long experiment with social enterprise known as the ‘Right to Request’, building on the pioneering work of Central Surrey Health.
Now, the NHS Confederation reports that around a third of all community health services are delivered by social enterprises. Around 60 of the largest social enterprises deliver services valued at approximately £2.4bn every year. These are all independent organisations, with missions to serve the community, and reinvesting profits, while delivering services under contract. As with CHCP, many also have a high degree of staff ownership and participation.
There is now a good body of evidence that tells us that social enterprises have high employee engagement, are increasing productivity faster than public services more widely, are developing new services, innovating faster than others and have a lower average staff sickness absence. Research suggests that they also perform marginally better in CQC ratings.
When will Government see the opportunity?
You might expect SEUK to champion the social enterprise model. SEUK is a membership organisation raising awareness and making the case for social enterprise, building markets and influencing Government policy. Equally, if the UK’s national trade body for badgers published a report on how badgers can help deliver Labour’s five missions, you might just raise a sceptical eyebrow. But perhaps less so when the King’s Fund is highlighting social enterprise pioneers.
Sometimes we struggle to get our message across to Government because of this ‘they would say that, wouldn’t they?’ problem. Of course, Government is right to be wary of any special interest group lobbying for its members. But perhaps the merits of the social enterprise model are too often ignored due to more systemic challenges.
We have a dysfunctional NHS England and a social care sector with huge pressures and staffing challenges. There is high staff turnover among policymakers, some of whom just do not get social enterprise or even suspicious of it, wedded to more well understood public sector models. Social enterprise is not in the job description of anyone in DHSC. But perhaps most significantly, social enterprise often brings good news, while ministers are understandably distracted by bad news and short-term crises.
This can be frustrating for us and our members. But most of all it is tragic for everyone else. This is because the evidence tells us that the experience of social enterprise could significantly improve the health and care system more widely. At a very basic level, these independent businesses must be financially responsible and break even, unlike some NHS providers. Yet their profits are reinvested in communities rather than being paid out to shareholders. This model in itself should be enough to interest ministers, policymakers and system leaders.
As Government draws up its 10-year plan for the NHS, this is the time to look up from the fire fighting and identify the pioneering models that can show us the way to a better NHS and social care system for the long-term. If the plan is to shift to prevention and shift to community, there is no better place to start.
Does your care organisation have any experience of working with a social enterprise? Leave a comment on this feature or join the conversation to share your thoughts.
Dan Gregory is Associate Director at Social Enterprise UK (SEUK). Email: [email protected] X: @SocialEnt_UK