We welcome comments on this article which has come out of the Reclaim Social Care Campaign. It is not SHA policy, but it raises important questions relevant to both social care and the NHS.

This is a wide field in which a variety of species flourish, some of which are dangerous invasives. We need to cultivate systematically to ensure that what grows in this field is healthy, productive, and not a threat to other growth. We need to be able to classify, in order to isolate rogues, and then eradicate them. We need to be able clearly to identify some of the more rampant plant life, in order. maybe, to consider techniques of pruning.
I come to this view of the wider challenge from an interest in cultivating a little patch in this field – one area that I think is growing some special and healthy new life. My patch is occupied by a Community Interest Company. This organisation safeguarded one local piece of our National Health Service, by propagating it and preserving it from being hybridised – merged– a with a completely different plant that would have taken us over. We have created an organisation that is of our community, for our community, and owned by our community.
I am a fervent supporter of the NHS, especially having, for 15 years, suffered under the US excuse for a health system. I have been a member of the Labour Party since 1972. The principles of the NHS, as promoted by the Labour Party from 1948, are not negotiable, but there are different ways to organise to support those principles. I believe that there are freedoms in a CIC organisation that make it easier to maintain some aspects of health and social care in conformity with those principles – not everything in the way the NHS organises itself and runs its staff and services is perfect. My purpose in writing this paper is to try to distinguish the different types of possible organisation, to identify the healthy growth points, and also rogue growth.

I start with a straightforward definition:
“A simple definition of “public sector provider” in this context is: one that is constitutionally owned by the community or the State and operates not for profit.”

If one were to operationalise that definition, one would be able to draw a line across one large sector of our field – often called “The Third Sector”. If I understand that term correctly, it contains both charitable bodies and the range of different social enterprises. My simple definition, once operationalised, would separate those two parts of that Third Sector: charitable bodies are accountable through Boards and the Charity Commission – they are not “constitutionally owned by the community or the State”.
The largest part of our health field – diminishing and under threat, but the revered sector whence proliferate (or struggle) the heirloom crops – is defined by the phrase “constitutionally owned by the State”. It should not be hugely difficult to operationalise this definition, in which “State” could be national or local.
That leaves, I think, the cultivators of two sections of field to be pinned down: commercial cultivators and the social enterprises. The word “enterprise” – a word sullied with muck in some horticultural circles – creates a confusion for some, but I think my first definition, with its reference to “constitutionally owned by the community”, serves to draw a line between private enterprise and “mutual enterprise”. I think that an operational definition of private enterprise is achievable.
That leaves the mutuals, or social enterprises. That is a field with subdivisions. Those dividing lines have been traced by Geraint Day and Mo Girach, among others -The semantics of the ‘Big society’: Social enterprises, mutuals and co-operatives, NHS Alliance, August 2010. One subdivision contains CICs, like the one I am associated, whose constitutions place ownership in the hands of not just the workers in the mutual, but the whole community.
There is a programme in this for a whole load of research, I guess:


I would like to ask readers of this paper:

a) If they find the subdivision of the field proposed above useful
b) If they know of any work that pushes forward on defining some of the boundaries in a way that generates precise facts
c) If they know any facts that would give a more accurate version of the numbers guessed in the left-hand part of the diagram above

Once we have divided up the field in a manner that commands some agreement, we can then consider different ways of dealing with different plant species. Even the more aggressive plants might have their uses, if we can refine our horticultural techniques. I believe that there is a lot of mileage in looking at this horticulture from the point of view of risk management. If one can be clear about the risks involved in handling each type of plant, one can be more confident of training each plant to grow to maximise its useful productive capacity. Leaving this (rather seductive) metaphor behind – what one needs to aim at is to understand the types of contract each type of organisation can sustain in a way that optimises their capacity for good, and minimises the risk of bad.
I believe that we can get a long way by distinguishing between contracts in which the best way forward is to share risk between commissioner and provider – those are not safely handled outside public sector partners. But there are also opportunities for what I would call “segregated risk” contracts, where we might watch private enterprise do what it is best at, without massive risk.
But that is another discussion.

And there is a third related discussion we could have: in addition to an operational – i.e. useful – definition of the concepts discussed above, it would be advantageous to come up with legal definitions of some of these concepts. Here are some of the challenges encountered in searching for legal definitions with reference to a CIC:
• The CIC may be “owned” by the citizens of the community/Borough/town, but …
• What are the implications of “ownership”?
• How is the CIC accountable to the owners?
• Our CIC has a Membership Council – community and staff, but …
• Are the members of the Council representatives?
• … of whom?
• What is the “membership”?
We tried launching a membership drive, but foundered on the fact that there was nothing we could offer “members” that we didn’t want to give them simply as one of our population of potential or actual service users. We eschewed the practice of our Acute NHS Foundation (and many other Foundations) – of simply “signing up” everyone who comes through the door, in order to create an artificial “membership” number.

• What if some services are also offered in other communities? What if the organisation is willing to expand into other places it the circumstances are propitious?
• How does one characterise membership in locations where the organisation plays a minor role in the range of care?
• and on and on
The efforts of the CIC to represent the needs of its community may be completely genuine. The CIC may know that the core, at least, of its community is the citizenship of the community/Borough/town that it serves, and that may be enough for pragmatic purposes. It is better to have a practical rationale for pressing forward with doing good, rather than getting too caught up in definitions.
But, if there are readers out there who can help with legal definitions, or examples, or processes for enacting representative monitoring, then please share.

The risk for some social enterprises is that they can be captured by the profit motive or by the private sector. This is a risk that increases as money gets tighter. There are ways to have insurance against that threat, and not necessarily in terms of formal accountability and representativeness. One approach is to mount a diligent programme to embody the principles of organisation in the whole organisation – all members of the staff – and to ensure that principled continuity is not dependent on a small group of founders.
The CIC of which I am a Community Governor has some very creative approaches to ensuring continuity, principle and direction in this way. But that is yet another story.

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