Social enterprises are increasingly joining forces with other public and private organisations to deliver all types of services to their communities. Sarah Irving talks to Nigel Spencer of N’Gage about the advantages and possible pitfalls of forming partnerships.

The social enterprise sector is full of small organisations performing specialist functions and filling important niches in service provision in sectors ranging from mental health to waste recycling. But with increased government and public interest in social enterprise models, some organisations are being called upon to take on much larger and more challenging projects. According to one expanding enterprise in Manchester, forming partnerships with organisations from the public or private sectors could be the way to meet such challenges.

The Manchester Assertive Outreach programme, which offers support and care to people with mental health needs in Manchester, is one such organisation. It is run by HARP, a pioneering advocacy and support project founded in Hulme in 1989, in conjunction with the NHS’s Manchester Mental Health and Social Care Trust.

According to Nigel Spencer, team manager at the N’Gage Assertive Outreach service, a well-run partnership can offer the best of both worlds. “Different organisations can offer different skills and experiences,” as he describes in relation to his own work. “The voluntary sector is seen by many mental health service users as less threatening and more approachable. The statutory sector – the NHS and social services – can, for them, be associated with getting sectioned and with feelings of fear and mistrust, so it starts off in a position of weakness when talking to hard-to engage, marginalised mental health service users. The voluntary sector is already at one step removed from the ‘official’ psychiatric ‘industry.’ So we can offer skills in social inclusion and engagement, and the NHS can offer clinical expertise, and both can be kept within the same team.”

In response to charges that programmes such as N’Gage represent ‘creeping privatisation’ of the NHS, he emphasises that he sees no natural place for profitmaking companies in community mental health provision, but defends the role of community not-for-profit organisations like HARP, which built up its reputation in mental health care provision over many years.

Spencer admits that some still see the voluntary sector as the NHS’ “poor relation,” and object to non-statutory organisations “muscling in” on NHS responsibilities. But, he points out, “there are some very good voluntary services which have grown up to address gaps in statutory provision. The statutory sector has taken a long time to catch up with voluntary sector in areas such as assertive outreach, which was brought to the UK from the US by voluntary organisations. The voluntary sector has in some ways still got the edge on the statutory sector because collaborative, inclusive ways of working come from them in the first place.”

As well as offering benefits for service users, Spencer also identifies advantages for staff and organisations in developing partnership arrangements. Keeping clinical provision within the Trust means that experienced NHS nurses can remain within the public sector pension scheme and retain other workplace benefits which, he admits, the voluntary and social enterprise sector is unable to offer them. And on an organisation level, he says, “the statutory sector has a stronger record in areas such as governance and risk management.” On the other hand, voluntary sector organisations have something to teach the NHS about staff-management relationships and breaking down rigid hierarchies between managers and frontline workers. The Board which runs N’Gage has been carefully crafted to make sure that staff and those in managerial roles are both represented, and that views from the different levels are fed into decision-making processes. It includes the managers of the three assertive outreach teams, service managers from both the NHS Trust and HARP, representatives of funding organisations and a range of experts in areas such as finance or human resources, co-opted on an ad hoc basis, according to need. Decision-making is by consensus, or if necessary by majority vote, and remains as democratic as possible, and there are also plans to train and support service users to join the Board.

Nigel Spencer emphasises the importance of balance for such a relationship. “The principle of equal partnership is key,” he stresses. “The service is not managed from the head office of one organisation or the other, but from a joint body with staff and managers from both groups. In this kind of relationship there is always the danger of the larger statutory body swallowing up the smaller voluntary sector one, but having a mixed board like this creates some distance, which is really important for maintaining independence.” The partnership model, with its innovative management style, is one which Spencer and his colleagues have developed over their years of delivering services. When the Department of Health decided in 2001 that assertive outreach teams should be a feature of mental health provision throughout the country, HARP was one of a small number of providers already working in the field of mental health provision which took on public contracts. But 6 years’ experience suggested to both HARP and the NHS Trust that some parts of their provision would be improved by bringing in NHS staff and skills to complement those of the voluntary sector, and HARP approached the Trust with the idea of setting up a more formal partnership.

Spencer is cautiously optimistic about the new relationship. Although N’Gage has been offering assertive outreach services in Manchester for 6 years, and successfully bid for an expanded contract in 2006, the partnership approach it is now pioneering is a work in progress. The Trust “appears nervous about aspects of partnership working,” he admits, and stresses the need for “a lot of self-analysis and reflection” by both organisations in coming years. But, he says, the model is “very exciting,” and includes plans to develop an evidence base for the use of such partnerships in delivering mental health services.

Nigel Spencer sees the example of the N’Gage partnership between HARP and the NHS Trust as having useful lessons for other social enterprises in similar circumstances. “The most important thing is that it’s the right organisations working together,” he says. “There is nothing to be gained from putting random organisations together, just because they want to work in the same area. You need to have the right skills, ethos and history.” He cites N’Gage and HARP as a good example of this principle. “HARP has grown, but it has never tried to empirebuild. It’s always stayed within its original remit of working with hard-to-engage people. That’s what it’s good at, whether it’s working with young refugees and asylum seekers with mental health needs, or running a community cafe which benefits both people in the surrounding areas and the mental health service users getting skills and experience by working there. So we have a good reputation and expertise in this area, but we wouldn’t start trying to expand into non-mental health services, just because there was an opportunity to partner up with a statutory body.”

But, he emphasises, working with larger organisations from other sectors could apply to many other social enterprises. This applies particularly to areas such as environmental services or transport where close relationships with local government are common. “Working in partnerships,” he says, “offers small voluntary organisations and social enterprises the opportunity to take on bigger projects than they could do alone, and to introduce new mixes of skills and experiences in to their work. We’ve made it core to our approach, and it could be the way forward for many social enterprises.”

For more comment by Nigel Spencer on opposition to the role of social enterprises in mental health provision, see his comments in relation to article "in sickness and in health"

For more information on N’Gage, contact:

Nigel Spencer, Team Leader, N’Gage Assertive Outreach Team, 136 St Werburghs Rd. Chorlton. Manchester. M21 8UQ. Tel: 0845 0068999

For a range of resources and links on partnership working in social enterprises, see http://www.train2000.org.uk/about/working-in-partnership.html

Useful information on how forming Limited Liability Partnerships can be a useful tool for social enterprises can be found at:

www.opencapital.net/papers/ 2amase%20LLP%20Article%20311006.doc

While ministers are promoting social enterprise as a solution to problems in the NHS, campaigners against health service privatisation are sceptical. Karen Reissman is a leading member of anti-privatisation campaigns in Manchester. Sarah Irving heard her concerns about social enterprises in mental health provision…

Karen Reissman is an experienced community psychiatric nurse working in North Manchester, and although she welcomes some of the changes in the NHS over the last decade, she is deeply unhappy about others. “I’ve had 5 employers in the last 13 years,” she says. “Each time the new headed notepaper and name badges costs thousands. Does it improve anything? No.”

She is concerned about the privatisation of NHS services, including by transfer to the voluntary sector and social enterprise, because of the effects she sees for both staff and patients.

She worries that voluntary sector and social enterprise organisations can win tenders through cutting costs, and this can mean lower standards of care and poorer conditions for workers on the mental health front line:
“One of Manchester’s current assertive outreach teams is voluntary sector. One of the main things this has meant is that experienced NHS staff have been replaced with inexperienced staff,” she explains. “This is partly because the voluntary sector organisation pays less, and because staff moving to it lose their NHS or local authority pensions.

“Experienced staff are likely to be older and therefore more concerned about their pensions, so they are very unlikely to want to move to new social enterprise sector organisations. This means that some of the most severely mentally ill people in the area are being cared for by people who themselves are newly qualified or in some cases trained in-house.”

Another concern is that the transfer of mental health services can also mean a shift in the culture and priorities of organisations. While Karen acknowledges that workers in social enterprise organisations are genuinely committed to their patients’ care, she questions whether the organisations themselves can really meet the demands of the sector:
“One of the other areas being shifted to private sector organisations are community living projects, which run schemes such as arts projects and occupational activities,” she describes. “A lot of these have been or are facing being turned into social enterprise organisations. My concern would be that this changes them from primarily being a treatment and therapy service to an entity which has to break even.

“Staff then spend their time looking for funding and subsidies, or trying to cut costs, rather than delivering the care they want to and which patients need. It downgrades the situation for both staff and patients and moves the organisation from being mainly a service to being a commercial organisation which has to keep its eyes on the bottom line.

“There is one award-winning national project which uses art for people with mental health issues, some of whom have been very damaged by their illness, and helps them express themselves and get some fulfilment from life. Some of the artwork produced might be sold, but that happens in individual cases if it’s appropriate and it helps the patient. It faces becoming a social enterprise, and then selling work or being part of projects that bring in funding will become much more of a motivation.”

According to Karen, privatisation of the NHS in Manchester is proceeding quickly, fragmenting teams and cutting resources, including reducing the number of mental health beds in the region and making it harder for community nurses like her to spend adequate time with their patients.
“There are several bits of privatisation going on in the Manchester area at the moment,” she says. “Four of the Community Mental Health Teams are up for private tender at the moment, and it is likely that some of these will go to joint NHS/voluntary sector projects.”

Mental health workers in Manchester are currently balloting for strike action against privatisation and cuts in community mental health teams. “The chaos is frustrating, but it also motivates people to do something if we can get them organised,” argues Karen. “As bad as it is, it would have been worse if we hadn’t acted.

“Thatcher tried to tell people that private was good, public bad. She convinced some, but when they saw the privatised rail services they came to their senses.”

For more information on NHS Campaigns in Manchester see www.stopthecuts.nr

With funding, staffing and morale in the NHS regularly in the headlines, the government is promoting social enterprise as one answer to current challenges.

In this special feature, Enterprising looks at the situation for social enterprises, hears from enthusiastic new organisations providing health and social care services in Greater Manchester, and talks to a sceptic who sees social enterprises as bringing ‘soft privatisation’ of the NHS.

During 2006 the Department of Health announced the establishment of its Social Enterprise Unit to, according to health minister Patricia Hewitt, “act as a catalyst for change, providing a ‘hub’ of ideas, energy and support for existing and emerging social enterprises.”

The Unit is part of a wider strategy by the government to encourage development of social enterprises providing health and social care services. Hewitt stated in spring 2006 that: “There is no doubt at all that the potential of co-operatives and social enterprise is very firmly on the Prime Minister’s radar screen. And the potential, in particular, of social enterprise to contribute both to our public service reform agenda and to neighbourhood renewal and regeneration is very well understood at the top of Government.”
She went on to claim that: “even though social enterprises might not be organised as worker or customer controlled businesses, social enterprises are close to those they serve, and respect those with whom they work. And in many cases, those whom they serve are also those whom they employ. In spirit, they are close to the principle of democratic member control.”

For some, such as the social enterprises who describe their new roles on the next page, this is good news. Support for social enterprises – from business advice to a new credibility in NHS commissioning – has inspired the foundation of new social enterprise organisations, and increasing numbers of practitioners, from frontline dentists and nurses to support roles such as patient opinion researchers, are exploring models such as co-operative working and Community Interest Companies.

Despite political enthusiasm, there has also been scepticism from some quarters. NHS campaigner and psychiatric nurse Karen Reissman explains overleaf why she sees social enterprises as just another part of covert government attempts to privatise the health service.

An experienced worker, who did not want to be named, also expressed reservations. “My experiences and ongoing battles at various North-West social enterprises to get our work funded make me very sceptical about even the possibility of social enterprise. I am just not sure it can be done. Mostly social enterprises are forced to think big because they are still living in the mainstream capitalist arena.”
Organisations representing healthcare workers have given varying reactions. The UNISON union, one of the country’s largest, which represents large numbers of health workers and auxiliary staff, is running a major national campaign against any move of NHS services to the private sector.

The Royal College of Nurses, meanwhile, has given a more nuanced approach, welcoming some opportunities for flexibility and autonomy for health professionals, but questioning the Department of Health’s more gung-ho assertions:
“Whilst the government appear to consider community interest companies as a convenient, sustainable and alternative means to provide public services and overcome deficits, there is no evidence to suggest that CICs in themselves can achieve that outcome,” commented a RCN document, going on to say more broadly of social enterprises that: “no evaluation has been undertaken to substantiate the Department of Health’s view, neither has an analysis been undertaken regarding how best to use the new employment and service options recently created in the NHS and Local Authorities. Nonetheless, the White Paper recommends utilising partnership arrangements and contractual flexibilities already available as a means of establishing new “community care” integrated services.”

Priority, the RCN argues, has to be given to continued development and maintenance of employment standards for nurses and other health professionals, and it questions whether social enterprises can always be depended on to guarantee that staff are well-trained and in stable employment. Karen Reissman argues that they can’t, while supporters of the developments feel that employee ownership or membership offers new opportunities for both staff and patients. If current trends continue, many more social enterprises in the North-West will be joining CHAP, the Big Life Company and BlueSci in finding out.