Ross Millar

Social Return on Investment (SROI) and Performance Measurement

Abstract Social enterprises are being promoted as responsive and innovative way to deliver public services. As part of this promotion, these organizations are being required to demonstrate the social and economic value they generate. Social return on investment (SROI) is a performance measurement tool currently being encouraged to capture this impact. This paper draws on survey and interview data to analyse how SROI is used and understood in health and social care settings. It indicates that despite being accepted as an internationally recognized measurement tool for social enterprise, SROI is underused and undervalued due to practical and ideological barriers.

Jumped or pushed: what motivates NHS staff to set up a social enterprise?

Purpose – The purpose of this paper is to examine the motivations behind public sector spin outs, focusing on the Right to Request policy, which enabled NHS staff to set up their own social enterprises to deliver healthcare services.Design/methodology/approach – The paper draws on empirical data gathered from 16 in‐depth interviews with individuals who had led a Right to Request proposal.Findings – Motivations to spin out of the NHS into a social enterprise were often “empathetic” in nature, built around the good of the service for staff and users. Alongside this, some felt “pushed” out of the NHS as a result of government restructuring policy, with social enterprise offering the only hope to survive as an organisation.Research limitations/implications – The study captures a particular point in time and there may be other perspectives that have not been included.Social implications – The paper is of use to academics, policy makers and practitioners. It provides an important contribution in thinking about ...

Start Up and Sustainability: Marketisation and the Social Enterprise Investment Fund in England

Since the end of the last century governments in many western welfare regimes have been keen to promote the marketisation of public service delivery. This requires changes in the supply of, and demand for, alternative providers in this market, and in particular for many governments this has included third sector providers. This article examines the attempt by the UK Labour government to promote the supply of social enterprises in the market for health and social care services in England, through the Social Enterprise Investment Fund (SEIF), introduced in 2007. The article reports on research evaluating the effectiveness of the SEIF, employing a ‘theories of change’ approach, drawing on a mix of administrative and survey data, qualitative interviews and case studies. The research found that although the SEIF had significant benefits in supporting the start up and growth of organisations, its contribution to their longer-term sustainability was more mixed as most were dependent on grants as a main source of income and were not in a position to compete for public sector contracts. This suggests that there may be limits to the role that public investment can play in such market making

Public, Private or Neither? Analysing the publicness of health care social enterprises

Abstract Social enterprises have been actively encouraged to spin out of the National Health Service (NHS) on the grounds that they can deliver more innovative, cost-efficient and responsive services. This is arguably achieved through a combination of the best of the public, third and private sectors. This article explores this idea by bringing together empirical data from interviews with NHS spin-outs and a framework of ‘publicness’. By focusing on NHS spin-outs, we look at what happens to an organization’s publicness when it leaves the public sector yet continues to deliver publicly funded services.

New development: Spin-outs and social enterprise: the ‘right to request’ programme for health and social care services

The ‘right to request’ policy encouraged and supported National Health Service (NHS) community health staff in England to ‘spin out’ services into independent social enterprises. This article considers the processes and outputs of the initiative and reflects on the likelihood of positive outcomes for patients being achieved. It highlights lessons for future programmes seeking to transfer services out of public ownership.

Hospital board oversight of quality and safety: a stakeholder analysis exploring the role of trust and intelligence

BackgroundHospital boards, those executive members charged with developing appropriate organisational strategies and cultures, have an important role to play in safeguarding the care provided by their organisation. However, recent concerns have been raised over boards’ ability to enact their duty to ensure the quality and safety of care. This paper offers critical reflection on the relationship between hospital board oversight and patient safety. In doing so it highlights new perspectives and suggestions for developing this area of study.MethodsThe article draws on 10 interviews with key informants and policy actors who form part of the ‘issue network’ interested in the promotion of patient safety in the English National Health Service.ResultsThe interviews surfaced a series of narratives regarding hospital board oversight of patient safety. These elaborated on the role of trust and intelligence in highlighting the potential dangers and limitations of approaches to hospital board oversight which have been narrowly focused on a risk-based view of organisational performance. In response, a need to engage with the development of trust based organisational relationships is identified, in which effective board oversight is built on ‘trust’ characterised by styles of leadership and behaviours that are attentive to the needs and concerns of both staff and patients. Effective board oversight also requires the gathering and triangulating of ‘intelligence’ generated from both national and local information sources.ConclusionsWe call for a re-imagination of hospital board oversight in the light of these different perspectives and articulate an emerging research agenda in this area.

What Was the Programme Theory of New Labour'S Health System Reforms?

Objectives To examine whether the Health System Reforms delivered the promise of being a coherent and mutually supporting reform programme; to identify the underlying programme theory of the reform programme; to reflect on whether lessons have been learned. Methods Documentary analysis mapping the implicit and explicit programme theories about how the reforms intended to achieve its goals and outcomes. Semi-structured interviews with policy-makers to further understand the programme theory. Results The Health System Reforms assumed a ‘one size fits all’ approach to policy implementation with little recognition that some contexts can be more receptive than others. There was evidence of some policy evolution and rebalancing between the reform streams as policy-makers became aware of some perverse incentives and unforeseen consequences. Later elements aimed to restore balance to the system. Conclusions The Health System Reforms do not appear to comprise a coherent and mutually supportive set of levers and incentives. They appear unbalanced with the centre of gravity favouring suppliers over commissioners. However, recent reform changes have sought to redress this imbalance to some extent, suggesting that lessons have been learned and policies have been adapted over time.

Overseeing oversight: governance of quality and safety by hospital boards in the English NHS

Objectives To contribute towards an understanding of hospital board composition and to explore board oversight of patient safety and health care quality in the English NHS. Methods We reviewed the theory related to hospital board governance and undertook two national surveys about board management in NHS acute and specialist hospital trusts in England. The first survey was issued to 150 trusts in 2011/2012 and was completed online via a dedicated web tool. A total 145 replies were received (97% response rate). The second online survey was undertaken in 2012/2013 and targeted individual board members, using a previously validated standard instrument on board members’ attitudes and competencies (the Board Self-Assessment Questionnaire). A total of 334 responses were received from 165 executive and 169 non-executive board members, providing at least one response from 95 of the 144 NHS trusts then in existence (66% response rate). Results Over 90% of the English NHS trust boards had 10–15 members. We found no significant difference in board size between trusts of different types (e.g. Foundation Trusts versus non-Foundation Trusts and Teaching Hospital Trusts versus non-Teaching Hospital Trusts). Clinical representation on boards was limited: around 62% had three or fewer members with clinical backgrounds. For about two-thirds of the trusts (63%), board members with a clinical background comprised less than 30% of the members. Boards were using a wide range and mix of quantitative performance metrics and soft intelligence (e.g. walk-arounds, patient stories) to monitor their organisations with regard to patient safety. The Board Self-Assessment Questionnaire data showed generally high or very high levels of agreement with desirable statements of practice in each of its six dimensions. Aggregate levels of agreement within each dimension ranged from 73% (for the dimension addressing interpersonal issues) to 85% (on the political). Conclusions English NHS boards largely hold a wide range of attitudes and behaviours that might be expected to benefit patient safety and quality. However, there is significant scope for improvement as regards formal training for board members on quality and safety, routine morbidity reporting at boards and attention to the interpersonal dynamics within boards. Directors with clinical backgrounds remain a minority on most boards despite policies to increase their representation. A better understanding of board composition, actions and attitudes should help refine policy recommendations around boards.

Right to Request social enterprises: a welcome addition to third sector delivery of English healthcare

The NHS in England introduced the Right to Request scheme in 2008, which enabled healthcare staff working in the public sector to carry over community health services into social enterprises. Staff wanting to do this had to apply to primary care trust boards, which were required to consider their requests and, if accepted, to guarantee contracts of between three and five years. This article reviews the Right to Request scheme and provides an overview of the organisations that have been launched to date. It then considers the implications of the scheme in relation to its implied objectives of improving patient care and empowering staff, as well as the impact on the health and social care system and on the third sector more widely

Enacting corporate governance of healthcare safety and quality: a dramaturgy of hospital boards in England

Abstract The governance of patient safety is a challenging concern for all health systems. Yet, while the role of executive boards receives increased scrutiny, the area remains theoretically and methodologically underdeveloped. Specifically, we lack a detailed understanding of the performative aspects at play: what board members say and do to discharge their accountabilities for patient safety. This article draws on qualitative data from overt non‐participant observation of four NHS hospital Foundation Trust boards in England. Applying a dramaturgical framework to explore scripting, setting, staging and performance, we found important differences between case study sites in the performative dimensions of processing and interpretation of infection control data. We detail the practices associated with these differences ‐ the legitimation of current performance, the querying of data classification, and the naming and shaming of executives – to consider their implications.