Two years ago, Health Launchpad, based at the Young Foundation, began to develop the concept of the Social Entrepreneur in Residence (SEiR) – a person recruited locally who would scout for potential entrepreneurs and new ideas for services in health and social care. He or she would work to turn those ideas into sustainable ventures, supported by the Health Launchpad team in London, and assist local authorities, Primary Care Trusts (PCTs), charities and organisations with culture change and service design – working at the grassroots to deliver better services for less.
Obviously, David Cameron’s Big Society had yet to be launched while the radical overhaul of the NHS announced in the recent White Paper Equity and Excellence: Liberating the NHS axing PCTs and giving commissioning powers to GPs, was on nobody’s agenda – except perhaps Andrew Lansley, now Secretary of State for Health.
Fortuitously, however, the SEiRs – the first, Eleanor Cappell, established in 2009 in Birmingham and a second, Philip Tulba operating in Kingston since early 2010 – appear in design, delivery and philosophy to be natural citizens of the Coalition’s Big Society. The major influences that have moulded the development of the SEiR are also recurring themes in Cameron’s vision of a Big Society. They include localism, working with not for people and the value of mutuals, co-operatives and social enterprises in the fields of health, social care and regeneration.
What has also come to the fore in the development of the SEiR is the innovatory use of metrics to measure outcomes; the importance of social return on investment and, following in the footsteps of the Marmot Commission, the practical implementation of a wider definition of health. This definition involves addressing the social and environmental determinants of inequalities in health, extending beyond the walls of a GP practice or the A&E ward. It calls for an integrated approach that encompasses vertical community engagement, physical activity, connectedness with others, an incremental approach to managing one’s own long term conditions and the role of high tech interventions such as telecare and the use of web-based support.
The White Paper says that ‘it will be easier for commissioners and providers to adopt partnership arrangements and adapt these to local circumstances.’ In that context, Eleanor Cappell, the SEiR based in NHS Birmingham East and North, has lived and worked in Birmingham for a number of years. Within three months of her appointment, using her contacts and networks within civil society, she had identified 45 ventures with the potential to become commissioned as a mainstream service. The first two of these have now secured commissioned service contracts for 2010 – 11
However, good quality commissioning is itself a challenge. As a result, there is a risk that private sector agencies will quickly fill this space without enabling GPs to develop the right skills and expertise necessary to fulfil the role they have been asked to undertake. In Birmingham and Kingston, SEiRs have demonstrated that their appointment has significantly expanded the ambition and ability of commissioners to create and secure innovative service solutions.
This SEiR expertise is being turned into a training package that could prove invaluable to those entering the field of commissioning as novices. It will allow GPs and Public Health commissioners to enrich their portfolio of skills to the benefit of themselves, their peers and their community. The SEiRs in Kingston and Birmingham both have to negotiate a rigorous set of filters designed by commissioners to ensure quality; value for money and clear outcomes. The SEiR enables the commissioner to have a holistic understanding of needs and gaps in provision and equips them with the tools to make sound investment decisions.
Commissioners will also benefit from the shared learning that a network of SEiRs will bring
The SEiR has also learned how to demonstrate exactly what the White Paper requires basing ‘purchasing decisions on a measurement of the full economic, social and environmental value of services.’ This also includes the acquisition of a set of tools that permits a sound foundation for decommissioning based on evidence based practice and impact assessment.
Andrew Lansley says he has a vision of the NHS as ‘the largest most vibrant social enterprise sector in the world’. Social enterprises require effort, patience, passion, determination and a range of practical skills to ensure that they are sustainable and not dangerously dependent on grants. In Birmingham, two social enterprises, Saheli – working to improve the mental and physical health and qualifications of Asian women and girls and Start Again – helping to improve the mental health of marginalised young people, were given support by the SEiR to develop their core concept more fully, draw up a business plan and long term strategy, cost efficiently and put an accurate price on their offering to the commissioners, using the metrics of social return on investment. Both are now flourishing.
The SEiR works with people with ideas – whom often at the initial stage may not see themselves as entrepreneurs – to offer practical and coaching support to create a commissionable package that brings co-production and co-design to life. He or she then helps to broker a deal with those who hold the public purse and, supported by the HL team, seeks additional funding if required. The SEiR also then ensures that the venture or service delivers sustainably for at least a period of three years. The creation of a social enterprise or co-operative in conjunction with the NHS or charity or local authority is an often a tricky course to navigate successfully. The evolution of the SEiR means that the Young Foundation’s Health Launchpad now has a body of knowledge, learning from failures and success, and working in both the clinical and community sphere, that will have value to others who are now expected to travel through what might be unknown territory.
In Kingston, for instance, the report, YouCanKingston, written as a result of a comprehensive mapping and co-production exercise with local people on the Cambridge Road Estate, produced a number of proposals for new services. The methodology “blended design thinking” – a new term coined by The Young Foundation – is itself innovative, addressing the gaps in service design. It will be refined further with subsequent SEiRs and disseminated widely. In Birmingham, a member of the Health Launchpad team is working with the commissioner’s staff to help design a new dementia service.
Service design will become even more important as the new Public Health Service and GPs consortia are pressed to commission interventions that work upstream and which address health inequalities. One of the key challenges commissioners face, for instance, is managing the knowledge gained from predictive risk modelling. Data can be pooled and analysed to identify older people whom over the ensuing twelve months will make unplanned admissions to hospital. The Young Foundation is looking to test this new tool through SEiR led ventures , many of which will focus on reducing emergency hospital admission rates and institute a new range of services to help older people to live well in the community.
Health Launchpad is so far in discussion with GP consortia in four London boroughs. We are also in talks with the public health sector in Kingston and planning to engage others, for instance, in Bedfordshire and Norfolk. We aim to publish a report on the creation and development of the SEiR and the lessons learned so far.
Over the past two years, the team developing the SEiR have been refining the methods, screening processes and customising support systems. In doing so, it has learned the value of one of the foundation stones of the Big Society – improving the quality of life for all requires that we forge new partnerships, welcome innovation and regard communities as the source of some of the most viable ideas and strongest often untapped assets
Appendix
The White Paper’s central themes that impact on the development of the SEiR are:
- Patients are to have greater choice and control, they will participate in an information revolution and they will become shared decision makers, ‘no decision about me, without me’.
- 500-600 GPs consortia, each with a budget of around £100m will act as commissioners who base purchasing decisions on a measurement of the full economic, social and environmental value of services. Commissioners should also involve charities, social enterprises and co-operatives (‘civil society organisations’) in commissioning and delivery to facilitate a shift in accountability from top down targets to ground up social action and responsibility. The White Paper says, ‘Government will make it easier for professionals to do the right thing for and with patients to innovate and improve outcomes’.
- Payments will reflect outcomes not just activity.
- The Government expects ‘more joined up working between health and social care services following discharge [from hospital]’.
- A new Public Health Service will be created that is run by local authorities, each with a budget of around £20m. As part of this reorganisation, Health and Wellbeing Boards will have a role in public health commissioning, promoting ‘integration and co-ordination in health, social care and children’s services’.
- A white paper on Public Health will be published – probably in December – that will give more detail on how funds will be targeted at the areas with the poorest health and how Government expects local authorities to shape behaviour and influence choice. ‘A new health premium to promote action to reduce health inequalities’ is promised.
- The NHS is expected to release up to £20 billion in efficiency savings by 2014 so intelligent commissioning and decommissioning, a field of growing expertise for the SEiR, will obviously be vital.
- Andrew Lansley, the health secretary, has said that in the NHS he wants to create, ‘the largest and most vibrant social enterprise sector in the world.’
- QIPP – Quality Innovation Productivity and Prevention will continue to be woven into the NHS’s DNA
Written by Yvonne Roberts
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