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SocialEnterprise Newpathwaystohealthandwellbeing2013
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Michael J. Roya,*, Cam Donaldsona, Rachel Bakera, and Alan Kayb
aYunus Centre for Social Business and Health, Glasgow Caledonian University, Buchanan
House, Cowcaddens Road, Glasgow, G4 0BA, Scotland.
Email: Michael.Roy@gcu.ac.uk
bCommunity Business Scotland Network/Scottish Social Enterprise Academy, 5 Rose
Street, Edinburgh, EH2 2PR, Scotland
*Corresponding author
Reference as: Roy, M.J., Donaldson, C., Baker, R and Kay, A. (2013) Social Enterprise:
New Pathways to Health and Well‐being? Journal of Public Health Policy, 34(1), 55–68
Abstract
In this paper we attempt to make sense of recent policy directions and controversies
relating to the ‘social enterprise’ and ‘health’ interface. In doing so, we outline the
unrecognised potential of social enterprise for generating health and well‐being
improvement, and the subsequent challenges for government, the sector itself, and for
the research community. Although we focus primarily upon the UK policy landscape, the
key message – that social enterprise could represent an innovative and sustainable
public health intervention – is a useful contribution to the ongoing international debate
on how best to address the challenge of persistent and widening health inequalities.
Key words: social enterprise, health inequalities, public health, ‘assets‐based’ approach,
salutogenesis
1
Introduction
In recent years, across almost all advanced economies, there has been a remarkable
growth in the ‘third sector’ – the space between private for‐profit enterprise and the
public sector. 1 In the United Kingdom, we have seen significant focus being placed on
the potential of ‘social enterprise’, especially in relation to health, most notably by the
UK Government. However, this has led to controversies: first, about whether such
initiatives in the health sector can even be described as bona fide social enterprises; and,
second, about whether the encouragement of social enterprise initiatives is evidence‐
based and (if so) is being fully exploited in terms of potential for enhancing well‐being.
These issues are related. If encouragement of social enterprise in the health sector
constitutes, at best, mere window dressing and, even worse, an attempt to simply
offload public sector costs, major opportunities for health enhancement and reductions
in health inequalities may be missed.
Defining social enterprise
From being described in the mid‐1990s as a ‘loose and baggy monster’ 2 the third sector
has since, if anything, grown in size, sophistication, and significance. 3 Social enterprises
are key drivers of the ‘social economy’: that part of the third sector engaged in trading
activities. 4 This differs from the work of NGOs, foundations, and the voluntary sector.
Social enterprises do not (normally) rely upon donations or grants to stay in business.
Instead they are generally characterised as businesses (i.e. trading entities) that have as
their primary purpose a social mission. Trading surpluses are principally reinvested in
line with that mission, rather than being driven by maximising profit for distribution to
shareholders and owners. 5
2
The social needs addressed by social enterprises might include provision of health
services directly or health promotion activities, largely amongst more vulnerable
communities. By acting to address a social issue through participation in some broader
trading activity, gains in health and wellbeing may be realised from any social
enterprise, although not necessarily explicitly stated as part of their mission. Some
examples of these, including several that have been successful in significantly scaling up
their activity, are shown at Box 1.
Box 1: Examples of social enterprises ‘enhancing wellbeing through trade’.
The Big Issue (www.bigissue.com) was set up in 1991 by Gordon Riddick and John Bird to offer homeless people the
opportunity to earn a legitimate income and has gone on to become one of the most instantly recognisable brands in
the UK.
Jamie Oliver’s restaurant Fifteen (www.fifteen.net) provides unemployed young people with the skills, confidence and
training to become qualified chefs.
Divine Chocolate (www.divinechocolate.com) was the first ever farmer‐owned fair‐trade chocolate bar, with shares
owned by a co‐operative of cocoa farmers in Ghana.
Aberdeen Foyer (www.aberdeenfoyer.com) works to prevent and alleviate youth homelessness and unemployment in
Aberdeen and Aberdeenshire, Scotland.
Cafédirect (www.cafedirect.com) started with three coffee growing communities – in Peru, Costa Rica and Mexico –
each shipping a single container of coffee, loaned on trust, to the UK. The beans were roasted and sold through church
halls, charity shops and at local events. They are now the UK’s largest fair‐trade hot drinks company.
Since 1980 the Wise Group (www.thewisegroup.co.uk), based in Scotland, has been helping people gain new skills and
get off benefits and into work, reduce reoffending and regenerate communities. In recent years they have diversified
into working to eliminate fuel poverty and create a greener society. The Wise Group is an example of a Work
Integration Social Enterprise, the main objective of which is the professional integration – within the WISE itself or in
mainstream businesses – of people experiencing serious difficulties in the labour market. WISEs are found throughout
the European Union in various forms.
Central Surrey Health (www.centralsurreyhealth.nhs.uk), the first social enterprise to spin out of the NHS in England,
is employee run and owned by their 700 or so nurses and therapists.
3
Policy directions and controversies
The idea of social innovation – new ideas (incorporated into products, services, and
models) that simultaneously meet social needs and create new social relationships or
collaborations – is currently central to European Commission policies on economic
growth and wellbeing 6 , influenced by President Borroso’s vision of ‘Social Europe.’
Under the auspices of a new Social Business Initiative, the Commission has set out a
specific policy aim to ‘contribute to the creation of a favourable environment for the
development of social business in Europe, and of the social economy at large’. 7
Meanwhile, in the UK, the Conservative Party’s Big Society initiative was (at least
initially) intended as an endorsement of positive and proactive roles that voluntary
action and social enterprise could play in promoting improved social inclusion and
‘fixing Britain’s broken society’. 8 Social enterprises play well into such notions, as they
often possess characteristics that governments and corporations seek – credibility,
expertise, and public support. 9
Nevertheless, two controversies have ensued.
• The first relates to the simplistic idea that social enterprises could fill gaps left by
the retreat of the state in elements of welfare provision, rather than act as
partners with the state as potentially more effective and efficient providers of
publicly‐funded services.
• The second surrounds encouragement of social enterprise, that might be seen as
a smokescreen for allowing large private providers into the market to compete
for National Health Service (NHS) funds. In March 2012 the UK’s Guardian
newspaper pointed readers to a ‘Teach Yourself Lansley’ 10 spoof piece that
4
defined Social Enterprise as “(oxymoronic noun) interim nonprofit private
provider paving the way for proper private takeover.”
The NHS: the largest social enterprise sector in the world?
In 2010 UK Secretary of State for Health Andrew Lansley’s first White Paper, Equity and
Excellence: Liberating the NHS, set out the coalition Government’s vision to create the
‘largest social enterprise sector in the world’ in England through “liberating foundation
trusts and handing over services to NHS staff”. 11 Building upon the previous
Government’s interest in employee ownership (or mutualism) as an alternative to
public sector delivery, the Health Department was the first of the UK Government to set
out proposals for how enterprising public sector workers could spin services out of
state hands. This White Paper represented a renewed commitment to explore
alternatives to both state ownership and for‐profit private provision. 12
The ‘Right to Provide’ initiative was announced soon thereafter, offering front‐line
primary care staff in England the opportunity to set up social enterprises to provide a
range of primary and community care services–from General Practitioner and nursing
services, through to sexual health, epilepsy, dermatology, physiotherapy, child health
surveillance, and minor surgery. Right to Provide, unlike ‘Right to Request’ established
under the previous government in 2008 to encourage similar ‘spin‐out’ activity, did not
guarantee staff protected conditions of employment with the organisation they leave
behind.
Under the older program, Right to Request, forty‐five new social enterprises have been
created so far, ranging from small, six‐person businesses to those employing more than
1,000 people with a turnover of £100m or more. Together, some 25,000 staff and
£900m worth of services have been, or are in the process of being, spun out of the NHS
5
to join the 6000 or so estimated to be delivering health and social care in England. 13 One
community interest company (CIC – a type of social enterprise legal structure in the UK)
which was set up by former employees of the NHS to provide essential medical services to
some 30,000 people who live in the Salford area of Greater Manchester. All of the profits on
the services that they provide (free at the point of delivery) under contract to the National
Health Service are reinvested in health and for the benefit of the Salford community. As well
as providing community health services, they have a specific business objective to provide
additional services and opportunities that address the determinants of ill-health for 3,000
people most in need in the following areas: unemployment, fuel poverty, mental health and
social isolation. They also have an active community engagement programme which delivers
projects in local partnerships, and involving service users at all levels in the organisation.
The current climate, according to a King’s Fund report on Right to Request, is less
conducive to the establishment of sustainable social enterprises in the health sector
than under the previous government 14 partly due to the withdrawal of guaranteed
employment conditions. A number of social enterprises have also lost out to the private
commissioning apparatus of the public sector generally (neither confined to health, nor
to central government) seems to work in favour of private sector providers – those able
to compete on price alone. This result does not take sufficient account of the wider
social returns and ‘blended value’ 17 (economic returns with social and environmental
impact) that social enterprises offer. Further, the lack of a legal definition of a social
enterprise has led to cynicism of a different kind: has the term been co‐opted by others?
Those that consider that the only answer can be state provision are just as guilty as
private sector opportunists in ‘masquerading’ as social entrepreneurs, 18 as we have
6
arguably seen with the case of Circle Health, the “social enterprise” that has recently
taken over the running of Hinchingbrooke Hospital in Cambridgeshire, England. 19,20
Despite such controversies, it is difficult to find fault with the idea that there has to be a
role for the third sector in delivery of health care. But, an unqualified case for the role of
social enterprise cannot be made at this point. The sector, too, has to become more
proactive in defining itself, articulating value, and establishing research alliances to
generate its evidence base. There is no absence of (particularly online) debate on such
issues, as Box 2 illustrates.
Box 2: Ceri Jones, Social Enterprise UK on why ‘social enterprises should not be regarded
suspiciously in healthcare’(February 2012)
“Social enterprise has become part of the government's public service agenda, which means that it's also become
entwined in the wider discussion surrounding the future of the NHS, somewhat unhelpfully [...] While our politicians
may be saying it's the next best thing since sliced bread (and we would agree), many ordinary people are suspicious
of social enterprise because they haven't seen one at work in their community before. People need to see it to believe
it. In the interim, Government needs to explain to the general public the different options on the table when it comes
to their services.”
If policy is to encourage genuine social enterprise to flourish as an alternative provider
of public services, an evaluation culture needs to be embedded to take account of
whether social enterprises do deliver better outcomes and better value (over and above
simplistic and narrow notions of price) than more standard public and private
provision.
Social enterprise and determinants of health
Focusing as they do on alternative forms of health care provision, the above debates
should not detract from the potentially much bigger issue of thinking about ‘social
enterprise as public health intervention’ and evaluating it as such.
7
Interventions that work to address the social determinants of health – the conditions in
which people are born, grown, live, work, and age – are an area of global interest. No
matter how good the local healthcare system, access to that system, and the lifestyles of
individuals, are dependent to a very large extent upon factors in the social environment.
The social determinants of health are mostly responsible for health inequalities ‐ the
unfair and avoidable differences in health status seen within and between countries. 21
Even as recently as 2010, we have seen that these inequalities are widening and
deepening. 22 Our own city of Glasgow in Scotland serves as useful illustration, with one
quarter of its citizens defined as ‘deprived’; and life expectancy gaps of up to 28 years
between the richest and poorest. Additionally we have seen higher levels of poor health
experienced over and above than that explained ‘simply’ by socio‐economic
we do not know what works best to address the underlying causes, which are likely
comprised of a complex array of factors acting in concert. The ‘new pathways’ we are
thinking about are those that, rather than acting on individual risk factors such as
smoking, alcohol, diet, and exercise, address inequities more broadly by acting on the
social, economic, and environmental circumstances of the most vulnerable members of
society.
The final report of the WHO’s Commission on Social Determinants of Health published
in 2008 offered three high level recommendations for reducing persisting and widening
inequities: improve daily living conditions; tackle the inequitable distribution of power,
money and resources; and measure and understand the problem and assess the impact
of action. 25 Taking each of these in turn offers a useful framework upon which to build
an argument for social enterprise as public health intervention.
8
Improving daily living conditions
The social mission lies at the heart of every social enterprise: their raison d’être is to
improve the lives of individuals and communities. They achieve the means to do so
through economic activity in the market. The difference they make could therefore be
framed in terms of the ‘assets’ they look to create, enhance, and improve – both within
individuals and the communities in which they live. Such an ‘assets‐based’ approach to
public health has been actively promoted by such senior figures as the Scottish
Government’s Chief Medical Officer, who has been calling for interventions to promote
well‐being in the context of building upon the potential strengths of individuals and
communities (rather than focusing on deficiencies), with communities and outside
conditions through social enterprise involves creating, enhancing, and improving
physical, mental, and social well‐being, focusing particularly on measures to enhance
what Antonovsky 28 termed ‘sense of coherence’ – the skills and confidence to manage
the demands of life, to respond to an environment that is both comprehensible and
manageable.
Social enterprises can thus be thought of not only in the context of delivery of health
services or even necessarily in promoting the benefits of healthy living, but as well‐
placed to provide an alternative mechanism to tackle such factors as ‘capabilities’ 29,30 or
‘social connectedness’ – what Putnam (and others) would describe as social capital: “the
norms and networks of civil society that lubricate cooperative action among both
mental functioning, health and well‐being. Glasgow Centre for Population Health
(GCPH) recently profiled the work of nineteen projects illustrating how asset based
9
approaches are currently being applied in Scotland. 33 However one more example of a
social enterprise using just such an approach in their daily practices is Unity Enterprise
wide range of customers, from the general public to housing associations to local government,
including maintenance and housing support services, community care, education, training,
business partnerships, and cafes. They even operate a travel agency. Through these services
they provide training, work experience, guidance and support, personal development,
education and social activities for young people and adults experiencing disabilities and/or
social disadvantages. In 2010 they were awarded a contract to provide the onsite catering for
those working on several construction sites of the Commonwealth Games in Glasgow, due to
be held in the city in 2014, providing a number of people, including those with mental health
Tackling the inequitable distribution of power, money, and resources
It is, however, vital to retain a critical perspective on the developing work on ‘assets’
simply because the evidence base remains very poor. Equally, it is perhaps too easy to
abstract psycho‐social factors (e.g. sense of coherence or hope for the future) from the
material realities of people’s lives as if they are unrelated to social and economic
advantage. 35 The work of Marmot and Wilkinson over the last 30 years in the field of
health inequities reminds us that the widening gap may be better explained by the
deficit in income inequality, i.e. structural inequities, rather than by the deficit approach
of public health, which may in turn explain both the intractable nature of health
inequities and why strategies to date have not had the desired effects.
With that sobering thought in mind, the high degree of autonomy, decision making not
based on capital ownership, and the participatory nature of social enterprises, which
10
can often involve the various parties affected by their activity, 36 injects a degree of
participatory governance in social enterprises that can be significantly empowering. For
example, Theatre Nemo (http://www.theatrenemo.org/) is a social enterprise based in
Glasgow which aims to improve, through the creative arts, the lives of people who have
experienced mental ill health. Their governance structures involve people who have not
just suffered mental health issues themselves, but also have specific experiences of
returning to active community life after a period of imprisonment. In many cases, social
enterprises aim to further democracy at a local level through economic activity. There is
good evidence that improved empowerment increases both health and well‐being
factors–self‐efficacy, confidence, and self‐esteem. 37
Measuring and understanding the problem and assessing the impact of action
The role of the Third Sector in delivering health care and addressing social determinants
of health, particularly in developing countries, is not, of course, a completely
unexamined area. Considerable relevant experience and knowledge is embedded within
the international development literature, just one example among many where the so‐
called developed world might have much to learn from developing countries. 38
Similarly, attempting to understand and measure the economic, environmental and
social impacts of social enterprise and wider Third Sector activity is not entirely new:
the use of tools and techniques such as Social Accounting and Audit (SAA) and Social
Return on Investment (SROI) has been gaining traction over the last decade or so and
this area continues to develop. If, however, scarce resources are to be directed towards
social enterprise‐led activity rather than alternative public health projects, strategic
evaluation of their impact is fundamentally important: like many other supposed
panaceas, a robust evidence base to support (or indeed refute) their case for adoption is
11
required. If we fail to develop an evidence base for social enterprise that encompasses
impacts on sense of coherence, social connectedness, wellbeing and income, a major
opportunity will be missed because so little is known globally about the longer‐term
impacts of social enterprise activity on health and well‐being. 39
Beyond case studies, we know little about links between actions to strengthen
individual and community assets with improvements in health and well‐being. 40
Additionally, there is a need to develop further the ways in which social enterprises can
explain more fully and accurately the value they create, and how they can evidence this
in ways that are (or will become, in time) acceptable to a wide range of stakeholders and
potential funders alike. In one sense, our arguments point to the need for large
collaborative programmes of research, addressing issues of the effectiveness and cost of
social enterprise versus more‐traditional forms of service provision. Furthermore, social
enterprises need support to articulate their wider benefits more effectively and
evidence these appropriately. More nuanced questions, likely requiring more qualitative
as well as quantitative approaches might address how social impacts are best achieved.
Research along all of these lines would overcome some of the above controversies, as
many of the debates are currently taking place in evidence‐free zones. Perhaps rather
predictably, from our example earlier, the National Audit Office (NAO) found that there
were no set measurable objectives specifically for the Right to Request Programme
against which to evaluate its success. 41 (In the same report the NAO were critical of the
Department of Health for not setting out objectives or ‘contracting for additional
benefits’, the result of which, they argue, is that this will reduce the likelihood that such
benefits will be delivered.)
12
Conclusions
All of the above arguments raise challenges for government, researchers, and the social
enterprise sector. A society cannot claim to be 'big' unless it is inclusive of its most
deprived members. Put simply, deprivation, in a health context, means people dying
sooner and living less healthy lives. Whilst it is important to think of problems in terms
of their scale, a ‘one size fits all’ solution is unlikely to be found any time soon. Instead
the solutions are likely to be found at the micro rather than the macro level and rather
than immediately leaping to scaling up activities, it might be more useful to think about
the conditions in which small scale social enterprises can thrive and proliferate,
capitalising upon the personal relationships that are so vital to healthy communities.
Working (and thinking) locally will likely be an ever more important facet, as we have
already seen in the integration of health and social care, where it is suggested that the
gains of taking a ‘personalised’ approach to services are not only realised at the
individual level, but support individuals to form groups and draw on community
contributions. 42 From their position within the third sector, social enterprises can work
at the interface between communities and the state as ‘specialist providers, innovators
and monitors’ of the sort Beveridge 43 envisaged, providing a pluralist perspective and
moderating the centralist and bureaucratic tendencies of statist social democracy. 44
They can also work as key agents in the development and maintenance of community
assets and in the encouragement of self‐help in ways that provide promise for further
enhancing well‐being.
From a research perspective, important scientific challenges remain to be overcome:
trying to measure things that are important but difficult to quantify; and applying and
sustaining longitudinal, mixed‐method studies that embody robust comparators. If
13
judged impractical due to the resource intensity and thus prohibitive expense involved,
an alternative might be to involve a series of pilot programmes in an exploration of
assessing and measuring personal and community well‐being and the links to social
enterprise activity. Whatever approach is adopted will require a grand collaboration
between the social enterprise sector and academia of a sort that does not yet exist.
Clinical/university research partnerships embarking on large, independently–funded
studies aimed at measuring outcomes of health interventions have demonstrated that
such ambitious collaborations are feasible and generate important evidence for policy
making (despite the fact that even the medical profession does not routinely collect data
on health outcomes in patient records).
Our experience of the types of partnerships that are required to investigate the full
potential of social enterprise as a pathway to enhanced health and well‐being is that
they only work effectively if: a) entities are under threat; and/or, b) entities share
common values. Identifying whether Government, health services, and the social
enterprise movement share common values may well be a useful starting point. Such
values might include a shared commitment to local decision making, involving those
affected by such decisions, and respecting the autonomy of local initiatives, including
social enterprises, that are created by a group of people on the basis of an autonomous
project and governed by these people. While such initiatives may depend – to a large
extent – on public subsidies, they should not be managed, directly or indirectly, by
public authorities or other organisations. Contracts need to be specified in a way that
relates to communities, in a way that recognises the inherent best value in local people
doing local work, and in local knowledge. It may therefore mean having to become more
relaxed about a potentially uneven patchwork of services.4 It will almost certainly
14
involve developing a shared (broad) definition of health, which takes account of such
concepts as sense of coherence, social capital and capabilities.
About the authors:
Michael Roy MSc is a PhD Student at Glasgow Caledonian University’s Yunus Centre for
Social Business and Health who worked as a freelance researcher and as a policymaker
within central government in Scotland. He also set up and ran his own social enterprise.
Cam Donaldson PhD is a health economist and holder of the Yunus Chair in Social
Business and Health at Glasgow Caledonian University and National Institute for Health
Senior Investigator.
Rachel Baker PhD is a Reader in Health Economics at the Yunus Centre for Social
Business and Health at Glasgow Caledonian University and President of the
International Society for the Scientific Study of Subjectivity.
Alan Kay MA, is an Associate Tutor with the Scottish Social Enterprise Academy,
Director of the CBS (Community Business Scotland) Network and helped to found the
Social Audit Network.
15
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