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
www.elsevier.com/ijns
Available online at www.sciencedirect.com
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.
doi:10.1016/j.ijnurstu.2008.06.001
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.
References
Argyris, C., 1999. On Organizational Learning, Second Edition.
Blackwell Business, Oxford.
Borins, S., 2002. Leadership and innovation in the public sector.
Leadership and Organisation Development Journal 23 (8), 467–
476.
Boyett, I., 1997. The public sector entrepreneur: a definition. Inter-
national Journal of Entrepreneurial Behaviour and Research 3
(2), 77–92.
Burns, J., 2004. Are not for profit hospitals really charitable? Taking
the question to the state and local level. The Journal of
Corporate Law (Spring), 666–682.
The Coalition for Social Enterprise Coalition for Social Enterprise,
2007. Response by the Social Enterprise Coalition to the Depart-
ment of Health’s Commissioning Framework for Health and
Well-being Consultation.
Collinson, J., 2006. Social Enterprise. The Queen’s Nursing Insti-
tute, London.
Crisp, N., 2005. Commissioning a Patient Led NHS. Department of
Health, London.
Guest editorial / International Journal of Nursing Studies 46 (2009) 151–153 153
Department of Health, 2006a. Our Health, Our Care, Our Say: A
New Direction for Community Services. The Stationary Office,
London.
Department of Health, 2006b. No Excuses Embrace Partnerships
Now. Steps Towards Change! Report of the Third Sector Com-
missioning Task Force. Stationary Office, London.
Department of Health, 2007. Commissioning Framework for Health
and Wellbeing. The Stationary Office, London.
Dingwall, R., Strangleman, T., 2007. Organisational cultures in
public services. In: Ferlie, E., Lynn, L.E., Politt, C. (Eds.),
The Oxford Handbook of Public Management. Oxford Uni-
versity Press, Oxford.
Griffiths, P., Jan 2008. Is it worth it? The value of nursing and the
value of educated nurses. International Journal of Nursing
Studies 45 (1), 1–2.
Harris, C., 2007. Social enterprises and the NHS. Community
Practitioner 80 (5), 44–46.
Kirkpatrick, I., Ackroyd, S., Walker, R., 2005. The New Manage-
rialism and Public Service Professions. Palgrave Macmillan,
Basingstoke.
Lewis, R., Hunt, P., Carson, D., 2006. Social Enterprise and Com-
munity Based Care. Kings Fund, London.
Low, C., 2006. A framework for the governance of social
enterprise. International Journal of Social Economics 33
(5–6), 376–385.
Mathiasen, D., 2007. International public management. In: Ferlie,
E., Lynn, L.E., Politt, C. (Eds.), The Oxford Handbook of Public
Management. Oxford University, Oxford.
McCray, J., 2007. Reflective practice for collaborative working. In:
Knott, C., Scragg, T. (Eds.), Reflective Practice in Social Work.
Learning Matters, Exeter.
Meier, J.K., Hill, G.C., 2007. Bureaucracy in the twenty first
century. In: Ferlie, E., Lynn, L.E., Politt, C. (Eds.), The
Oxford Handbook of Public Management. Oxford University
Press, Oxford.
Rainey, H.G., Han Chun, Y., 2007. Public and private management
compared. In: Ferlie, E., Lynn, L.E., Politt, C. (Eds.), The
Oxford Handbook of Public Management. Oxford University
Press, Oxford.
Regine, B., Lewin, R., 2000. Leading at the edge: how leaders
influence complex systems. Emergence 2 (2), 5–23.
Taylor, I., Sharland, E., Sebba, J., Leviche, P., Keep, E., Orr, D.,
2006. The Learning Teaching and Assessment of Partner-
ship Working in Social Work Education. Polity Press, Bristol.
Walsham, W., Dingwall, C., Hempseed, L., 2008. Healthy Business.
A Guide to Social Enterprise in Health and Social Care. Coali-
tion for Social Enterprise and Hempsons Solicitors, United
Kingdom.
Ward, C., 2008. Multi-professional practice with service users. In:
McCray, J. (Ed.), Nursing and Multi-professional Practice..
Sage, London.
Weber, M., 1952. The Routinisation of charisma. In: Merton, R.K.,
Grey, A.P., Hockey, B., Selvin, H.C. (Eds.), Reader in Bureau-
cracy. Free Press, New York, pp. 92–100.
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: [email protected] (J. McCray)
18 June 2008