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Expertise and patient-centredness: the keys to success for social enterprises in the health-sector

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Central government is promoting social enterprise as the solution to many problems in statutory-sector delivery, as part of a larger move towards localism and distributed responsibility. The intention seems to be that social enterprise will enable a discretion to innovate, while reducing the stagnation in the statutory-sector that’s arisen in a centralised bureaucracy with a culture of conservatism averse to innovation and responsiveness. Social enterprise and localism, it is proposed, will deliver statutory services that are up-to-date and responsive to the public’s needs.

Social enterprise may or may not be a good medium, but what is a ‘good health-service’, according to whom, why, and how is it best delivered? Unfortunately, answering these questions are also being devolved, despite the immensely greater resources of a civil service to answer them. This may be due to the belief that market-competition can provide answers to anything, even if those answers have nothing to do with competition and everything to do with science. But such a lack of expert guidance from the Dept Health in translating health-science to real life is not new.

I believe that the main reason for devolving the responsibility to answer these questions is that the Dept Health itself has never had great expertise in health-science; it seems to consist largely of managers with a small number of clinicians, particularly physicians, as advisors, rather than clinician-scientists. Imagine if the Ministry of Justice had mostly managers and a smattering of policemen rather than lawyers, or the Dept of Education had only managers and a smattering of sports-teachers. Oh dear, perhaps they do. But why this is so in the Dept Health is historical and it can be linked directly to the culture of the NHS, why it has failed to come up to date in health-service delivery, and how few health-service managers have any critical education in health-science themselves.

One shouldn’t need to state that managers are not scientists any more than a builder is an architect and a mechanic is not an engineer. But one does need to state that physicians, as clinicians, are not health-scientists. As with mechanics and engineers, physicians can understand the same basic literature as scientists and they often build their careers as researcher-technicians, churning out one drug-study after another, typically without critical insight into the study’s design and its limitations. While such a researcher-technician knows ‘how’ to do the task once the ‘what’ has been specified, he or she is different from a scientist who knows ‘what’ should be done, ‘how’ (from a broad range of methods), ‘why’, and — most importantly — ‘what’ should not be done and ‘why not’. Everyone has their opinion but, in health-services, it matters how broadly and deeply informed it is, above all to the patients. Standards matter, and if you don’t keep them, you get poor outcomes.

Part of the problem lies in the fact that those clinicians who are also scientists (i.e., who have earned a PhD on top of their clinical qualifications) and who are qualified to be the architects and engineers of health-services are not routinely used as a resource. This is part of the same problem of the NHS being built around managers and physicians, rather than patients, and is the same problem that successive governments are trying to solve, currently through the initiative around social enterprise.

I doubt that social enterprise is a solution to much other than civil-service stagnation, but social enterprise is here and acute strategists must adapt to this new medium to deliver both health-outcomes and financial outcomes. As centralised government failed to deliver either, it is now devolving the responsibility to social enterprise. This leaves social enterprises in the health-sector with a problem as the recent draft of the NHS Mandate focused on two particular ideas — health-outcomes and patient-centredness — which service-delivery organisations will be required to make real. Although it was evident that even the Mandate-draft’s writers understood neither concept particularly well — especially in terms of how you operationalise and therefore measure these concepts — devolving the responsibility makes the need for expertise in health-science even more evident, and only those social enterprises that know how to deliver these will survive and grow.

As with the Dept Health and the NHS themselves, with their physician-centred model of services, this is not something that most health-services know how to do. One example is a north London haemophilia-service that tried to demonstrate patient-centredness by providing summer picnics; nice as that is, cucumber sandwiches don’t help a person with haemophilia to get on with a healthy life while maintaining the blood’s level of clotting-factor. Equally, just providing the right pills for the disease is also not enough and it is why the NHS, with its physician-centred services, is costing so much and failing so badly. Providing a ‘good patient-experience’ on top of a physician-centred disease-service is no more effective than either alone.

In contrast, services that are actually patient-centred help a person with an illness get on with a healthy life, by addressing all the physical, mental, behavioural, and social aspects of a person’s illness, and helping the patient become autonomous and skilled in getting well and staying well. A solid finding in the scientific literature is that integrating services for the behavioural, mental, and social aspects of illness is the most effective — and cheapest — way of helping patients to resume as healthy a life as possible — and thereby use services less. Obviously, this reduces financial costs, especially in the most expensive services, which are for the chronic conditions. Only those health-services that realise that patient-centredness is not just about ‘muffins and massage’ and can design and deliver effective, patient-centred health-services can succeed in achieving the outcomes of good health, reduced costs, and public goodwill. I doubt many services have the expertise in health-science to succeed. 

Dr Rupert Whitaker, Chairman of the Tuke Institute

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