Guest editorial

Social enterprise—A new challenge for nursing practice

and collaborative partnerships

Keywords: Collaboration; Nurses’ employment; Nursing skills; Organisational culture; Service user response; Social enterprise

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International Journal of Nursing Studies 46 (2009) 151–153

Re-engineered service delivery models are emerging in

the United Kingdom (UK) National Health Service (NHS)

and the wider health and social care context. Reflecting a

global interest in social responsibility and collective

responses to social issues, social enterprise models of health

care are viewed as a solution in the move to individualised

care for service users and carers (Ward, 2008). In the UK the

possibility of new forms of services in primary and com-

munity care (Crisp, 2005) are becoming a reality, as the

policy intentions of Our Health, Our Care, Our Say (DOH,

2006a) and the market in personalised health and social care

increases. Funding incentives exist for local authorities to

opt for individualised budgets for social care in England,

together with the potential for Primary Care Trusts to operate

different commissioning strategies for its constituents.

The social enterprise model as a vehicle for the delivery

of personalised care, is one feature of the modernised NHS

and it sounds very attractive. ‘‘Social Enterprises are busi-

nesses that deliver goods and services but in pursuit of

primarily social objectives (Lewis et al., 2006). The UK

government supports more involvement of the third sector in

service delivery (DOH, 2006b) and encourages social entre-

preneurship in the provision of health and social care in its

new commissioning framework for health and well being

(DOH, 2007).

We might ask ourselves the question where do nurses

stand in relation to social enterprise? As Griffiths (2008)

writes in a previous editorial, nurses do matter to society and

to individuals in society, and therefore how they are

employed and enabled to practise is a significant issue.

For many nurses and midwives at the service delivery

end, the option of providing collaborative care for people

in active partnerships, would be a strong driver for realloca-

tion to a social enterprise.

Nevertheless new demands would need to be faced.

Unlike other countries such as the US and Canada, Japan

0020-7489/$ – see front matter # 2008 Published by Elsevier Ltd.

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and in Europe where social enterprises are a major provider

of care services, in the UK service delivery and professional

practice largely takes place in the government funded NHS.

The need for a change of organisational culture and struc-

tures (Rainey and Han Chun, 2007), the adaptation of

collaborative skills and knowledge (McCray, 2007) and a

re-examination of public sector values (Kirkpatrick et al.,

2005) are challenges faced by many professionals who

collaborate.

For many UK nurses, the shift in organisational culture

and any perceived dismantling of familiar NHS structures

may prove problematic to a professional group embedded

strongly in a public sector ethos.

Walsham et al. (2008) describing the development of new

health care social enterprises in England, refer to the risk

taking involved in the setting up of such models. They note

the need for a major process of culture change for employees

required to instill a commercial focus across such organisa-

tions (Walsham et al., 2008, p. 11). One UK business model

offering previously NHS provided services, now operates

with clinicians as co-owners, many of whom are nurses. A

key challenge identified for their future is that of engaging

staff and creating a more business like approach to costs and

intervention decisions, moving away from the NHS status

quo (Walsham et al., 2008, p. 31). Further, social enterprises,

leaders and managers are required to demonstrate innovative

behaviours (Borins, 2002) with attention being paid to the

external environment and the needs of stakeholders (Boyett,

1997). These are vital strategies, in order to meet the

challenges faced by all social enterprises in relation to

governance (Low, 2006), representation and regulation (Col-

linson, 2006).

For those nurses prepared to respond to the social enter-

prise agenda a new portfolio of skills will be required

including financial accounting and business planning and

advanced networking skills for leaders (Regine and Lewin,

Guest editorial / International Journal of Nursing Studies 46 (2009) 151–153152

2000). Just as essential will be enhanced collaborative skills

as part of multi-professional leadership and practice (Taylor

et al., 2006) to build new partnerships with service users and

carers and other professionals. For many nurses this oppor-

tunity to offer high quality service provision or additional

health related support that may not always be available in the

NHS may be the key motivating factor for employment in a

social enterprise.

However, for service users economies of scale required

to make services viable and valuable to commissioners as

NHS funding decreases, may mean that the very personal

and specialist service they wish to receive remains elusive

for the majority, creating a new set of complex bureaucratic

relationships (Meier and Hill, 2007). Burns (2004) writing

on the US tax laws in relation to the 3 model hospital system

(private, public and not for profit) notes that as costs rise, not

for profit hospitals offer increasingly less charitable ser-

vices to patients. In the UK inevitably, the market is also

likely to determine what is feasible from a cost perspective.

Building good relationships and accessing marginal groups

in society takes time and skill, and the risks involved in

losing funding may mean that some models of social

enterprise are unable to collaborate as effectively as they

would like with service users. The Coalition for Social

Enterprise (2007) writes of the dangers of short term

commissioning to enterprises for people with long term

mental health needs. Providers may change leading to

positive relationships being severed. This may inhibit rather

than empower those mode 2 professionals (Argyris, 1999),

which would include nurses, who have been developing

user centred practice.

Conversely social enterprises viewed as offering a

refreshing and alternative service to the Weberian (1952)

bureaucratic vision of public sector services, may have other

subsequent negative factors for the community. In order to

grow and maximise their business, social enterprises must

achieve buy in and support from service user stakeholders in

communities, and short term individual wants may overtake

broader and long term community needs. Dingwall and

Strangleman (2007) suggest that a user driven model of

health care in the UK would risk massive over consumption

of antibiotics for minor illnesses, increasing the likelihood of

emergent resistant bacteria and its likely impact on a wider

community. They argue that denial of some services may be

for the good of broader society. In this scenario perceived

need for cultural change in the context of public sector roles,

actions and values and its impact on nursing practice may be

viewed with a less rose tinted shimmer.

We can see that a number of tensions exist for public

sector professionals who seek to pursue a role in social

enterprise in health care in the UK. Other countries such as

the US have had contracting out and different models of

commissioning and delivering services for decades. The

Nordic countries have had alternative models of state sup-

port since the nineteenth century (Mathiasen, 2007). In the

UK these models have largely been small scale in the

healthcare sector. Consequently it is easy to see why some

nurses may feel reticent about leading or working for social

enterprises. From an employment perspective, pensions and

employment rights will be a critical issue (Harris, 2007) for

those who are currently qualified and employed in the NHS.

For some nurses a secondment model or loan model may

operate, ensuring TUPE (Transfer of Undertakings Protec-

tion of Employment) applies. For others The Social Enter-

prise Coalition (2007) suggests that other work benefits may

tip the balance in favour of the social enterprise. Newly

qualified nurses already facing a different future in terms of

job prospects and pension rights may be the ones best placed

to rise to the opportunities and challenges that social enter-

prises represent. And whilst currently it is not yet common-

place for nurses to work for a healthcare social enterprise, we

suggest it may not be the right employment setting for some.

Nevertheless as health services reconfigure, the need for

increased business skills along with sophisticated collabora-

tive practice will become essential for all UK nurses rather

than as presently the domain of a few.

Funding

None declared.

Ethical approval

None declared.

Conflict of interest

None declared.

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Janet McCray*

Health and Social Care Leadership at the

University of Chichester, United Kingdom

Cally Ward

Department Of Health, Valuing People Support

Team/Care Services Improvement Partnership

CSIP as the National Lead for Family Carers,

United Kingdom

*Corresponding author

E-mail address: J.McCray@chi.ac.uk (J. McCray)

18 June 2008