There is much debate in the UK about proposed changes to the National Health Service (NHS) which will lead to a much stronger market orientation for aspects of the service. Although the changes are ‘proposed’ in the current Government’s Department of Health bill (2011) and previous white paper (Department of Health 2010), various initiatives to develop services into new forms of social enterprise were already being implemented under the previous administration, and allied health professionals (AHPs) were being encouraged to establish themselves in these forms of organization. This discussion paper will explore some of the issues and the background to this development, particularly with regard to the implications for occupational therapy services.
Introduction: market liberalization
Concern about costs in relation to the social and economic issues of healthcare (particularly reduction of funding) is a global phenomenon of neoliberal capitalism (Srivasta & Zhao 2008; Greer 2010; Glasby, Dickinson & Miller, 2011), perhaps even a classical feature of neoliberal government policies. Before coming to power in 2010 the British Conservative Party (2007) claimed that National Health Service reform would strengthen choice and competition, and liberate the health service from government interference, a theme continued in government (Department of Health 2010). Health service users, or consumers would have more power through individualized budgets for those in long term care, and doctors would commission care through service organizations who would be paid by results. Charities and businesses would be encouraged to offer services in a “social market” (Conservatives, 2007: p21). This competitive approach to health policy has descended from the Conservative health reforms of the 1990s. It is not a one party approach, since many (such as Private Financial Initiatives, mechanisms for competitive tenders for building contracts) were continued by subsequent Labour administrations. Present policy has many aspects, such as the formation of new social enterprises to provide local services, which were established by the previous government (Department of Health 2006, 2008; Marks & Hunter, 2007).
The ‘third sector’ of charitable and community groups which were neither public nor private companies had already offering care services in the community alongside some statutory provision and private care firms for several years. It can be claimed that there has been a mixed market in the NHS since it was set up in 1947 because this state provision allowed its clinicians to also practice privately. As discussion of social enterprise solutions in the mixed health economy developed in the middle of the last decade, it was soon evident that new forms of social enterprise were being considered. Confusion soon emerged about their definition (Marks & Hunter, 2007).
Companies “not just for profit”
According to Mswaka (2009: p20) social enterprises range from voluntary groups or “social organizations” to organizations with definite business purposes which have to generate returns for sustainability. Such businesses might be better understood as companies “not just for profit”. The Community Interest Company (CIC) is a new type of company which has been developed in the NHS service environment. A CIC works for the interest of the community rather than profit. It is established through share capital and shareholders just like a conventional limited company, and can either be set up as a limited company or with a limited cash guarantee in the same way as a co-operative.
Some CICs operate on a regional or nation-wide scale and may not be readily understood as social enterprises, unlike local co-operatives or charity organizations. Marks & Hunter (2007) found that the definition is wide enough to include NHS Foundation Trusts. These large social enterprises produce questions of disparity in financial risk. While a NHS Foundation Trust might expect to fall back on the government regulator in event of financial failure, smaller social enterprises may not have this safety net and will have to bear their own risk. Considering the costs of negotiating conditions for the transfer of staff to new employers and balancing their right to retain conditions of service with conditions for new staff; the need to maintain governance and other standards, their financial viability may already be challenged (Department of Health/Social Enterprise Coalition, 2008).
Groups of health workers have been developing primary care social enterprises (Marks & Hunter, 2007), and some occupational therapists have already established CICs (Samuels, 2011). Other forms of social enterprise may deal with more specific needs such as housing or day services for particular client groups. The economic sustainability of these organizations in the face of larger competitors is not well evidenced, as their market base is often concerned with the elements of provision that other businesses may not be interested in servicing. Even the Conservatives acknowledge (2007) there is little evidence that a mixed market economy of locally commissioned social enterprises and businesses work (Marks & Hunter, 2007; The Lancet 2011).
Free market economics and disparities
UK health professionals are worried that a market economy for health is going to generate instability and differences in provision, providers will go bust and others might be bought out by bigger and better financed operators; even while the health reforms were being negotiated in government, Southern Cross, a provider of 31,000 care home places was in financial difficulty, shedding jobs and concerning clients and their families about their security (Samuels 2011; Marks & Hunter 2007). Free market economic approaches increase disparities in wealth and therefore in health. The experience of relative poverty and lack of access to amenities and opportunities within a society which contributes to poor health (Phillips, 2006). Consequently it is significant that a 2009 House of Commons report into health inequalities noted that while health in the UK was improving generally there was evidence of an increasing disparity (House of Commons 2009). Thomas, Dorling and Davey Smith (2010) found that despite the UK’s recognition for strategies to reduce differences (Pickett & Dorling, 2010), the level of disparity expressed in life expectancy equaled that of the 1930s. Pickett & Dorling (2010) find little difference in health strategies over the last 30 years. The key issue in the inequity is that while life expectancy overall has increased, it has increased much more for the wealthy. Their conclusion is that some people may be reluctant to relinquish their access to good services to enable the amelioration of health for all, that the threat to society may not come from the anti-social behavior targeted in Government rhetoric, but from the extremities of privilege.
Social enterprises and some of the underpinning economic and social theory that supports them have long been a factor in the questioning of the free market imperative (for example, Illich, 1975) through their orientation to human needs and the art of living well (Cruz, Stahel, & Max-Neef, 2009). Ridley-Duff and Bull (2011) argue that there is a new economic phase developing in capitalism during which social enterprise models may become prominent due to the problems experienced across the business sector in recent years.
However, many social enterprises, like other small businesses and charity sector enterprises, encounter difficulties (Ridley-Duff & Bull, 2011) with insufficient set up capital, internal problems and disagreements from poor planning and inability to anticipate challenges, and having to compete with bigger market players. Social enterprise based provision centered on small numbers of clients are usually uneconomic. Specialist services may be more feasible in a larger city of, say, 500,000 inhabitants because of the prevalence of conditions (such as early onset dementia) in a population of this size. This becomes more difficult in rural areas where populations are more dispersed, or as is common in the UK, rural and urban areas are mixed. Other environmental factors such as the availability of transport, the ability to share administration with other similar enterprises, having and maintaining an interface between different and changing parts of newly established services may create strains on a new business.
Occupational therapy as a social enterprise
As occupational therapists become involved in social enterprise responses to care needs, with the responsibilities of demonstrating their social value and meeting outcomes, it is quite possible that pressures will develop. Many social enterprises are quite small organizations and will be operating in the uncertain markets of the new NHS framework (Marks & Hunter, 2007).
In the UK and Europe therapists have often been integrated into state health care systems or private enterprise delivery of health and have not had community development roles. Occupational therapists have been engaged in ‘work integration social enterprises’, for example Italy’s social farms or Sweden’s co-operatives concerned with the preparation of people with psychiatric conditions for work (Fazzi, 2010; Gahnström-Strandqvist, Liukko & Tham, 2003) or Spanish occupational centres which provide work activities for people with disabilities (Vidal Martinez & Valls Jubany, 2003). In traditional occupational therapy a concern with the performance of occupational elements detracts from the usefulness and appropriateness of the interventions: clients were often humiliated by therapeutic activities they found pointless. The profession has at times lost a sense of the value of doing because occupation was separated from its social function to become what Molineux termed “a labour in vain” (2004:1).
Recently there has been an increasing political emphasis on developing community associations and organizations to address both social and health issues and this has been a source of the emergent roles agenda for occupational therapists. The tendency towards occupational interventions around lifestyle issues, independent living and preventative health on the one hand and towards co-operative and charity run housing projects for certain groups of people with disabilities on the other appear to be areas where emergent initiatives have been focused. Occupational therapists have worked in local projects alongside other community members to develop facilities whereby social networking can be facilitated and people with disabilities can be a visible, active and productive force in community life, for example in horticulture (Sempik, Aldridge & Becker, 2005).
Latin America is witness to considerable and destructive degrees of inequality. Some communities have much less access to services (for example to psychiatry in Chile) than others in the same country (Vicente et al, 2005), or even within the same city administration (Galheigo, 2005; Barros et al, 2010). The various limitations experienced by people with disabilities have to be understood as arising from multiple factors, not simply determined by functional, economic or cultural dimensions (Garcia Ruiz, Santacruz Gonzalez, Carillo Raujo & Cobos Baquero, 2008). Since the 1970s some Latin American occupational therapists have been working with a more critical perspective which is framed in social and political concepts, and engaging in community based interventions which address poverty through strengthening social networks, development work which includes families and people with disabilities in decision making and cultural representations (Galheigo, 2005; Garcia Ruiz, Santacruz Gonzalez, Carillo Raujo & Cobos Baquero, 2008; Barros et al, 2010; Paganizzi & Mengelberg, 2010). Given the scale of inequality and the considerable lack of advantage to people living in the Sao Paolo’s favelas or Argentine asylums, for example, the benefits of these actions can only be realized with groups slowly and at local level (Paganizzi & Mengelberg, 2010). Latin American occupational therapists have worked with a range of local actors, disabled people’s organizations, families and other professional groups to establish co-operatives, cultural activities and community projects (Garcia Ruiz, Santacruz Gonzalez, Carillo Raujo & Cobos Baquero, 2008; Alburquerque et al, 2010; Barros et al 2010; Paganizzi & Mengelberg, 2010; Galheigo, 2011). These activities extend into protest and demonstrations (Alburquerque et al, 2010.) Demonstrations and protest need not simply be standing around or marching with placards, and organizations such as Colectivo Habilitar use these opportunities to improvise street theatre, so protest takes the form of a performance event.
This kind of thinking may be challenging to occupational therapists in the UK, requiring them to develop collaborations with circus arts or other kinds of theatre groups, for example, if they are to develop similar initiatives, but some of the directions for UK reform have actually come from Latin America (Meads, Griffiths, Goode & Iwami, 2007). The Marmot review (Marmot et al. 2010), was prefaced by a misquote of Chile’s radical poet, Pablo Neruda’s call to “rise up with me against the organization of misery”. It set out a range of strategies in which local community members can be engaged in tackling the health effects of low income through debt advice, generating work opportunities and small enterprises in the local economy and community development approaches. Some of the examples, such as fire safety campaigns by fire services, do not directly involve health practitioners.
The reprise of market forces and neoliberal economics is also a Latin American theme of old, and is a direct descendent of the Chicago Boys economics of Pinochet and Thatcher (Moreno, 2008), and the debt current policy owes to earlier market reforms is acknowledged (Conservatives, 2007). The idea of market choice which predominate in current health policy (Department of Health 2010, 2011) supposes that every person must solve their own problems through the services these actors provide. If this principle is followed through then life itself – the process of doing being, becoming and belonging which relates to survival and maintenance (Wilcock, 2006) – becomes a privatized commodity enacted through individual choices (Illich 1975, Max-Neef, 2010). Through its individualistic methodology and models occupational therapy has contributed to this subjective construction. It has developed an extremely liberal concept of the individual as an occupational being, where each person constructs himself as best he can – for example through such concepts as resilience and empowerment. Dickie, Cutchin and Humphry (2006) argue that this perspective is far from holistic, and is derived from the limitations of the profession’s clinical environment.
Conclusion: This could be the right time
This clinical environment is threatened now, and the profession will have to develop many new strategies to work with clients, carers, and commissioners, through the turbulence of establishing new economic bases for care services. There has an increasing tendency amongst occupational therapists and scientists to try and orient the claims of the profession and its underpinning knowledge base to address the breadth of human potential, diversity and complexity (Kinebanian & Stomph, 2009). At the same time as this paradigm shift has been claimed for the profession (Pollard, Sakellariou & Kronenberg, 2008) it can only really be said to be partially realised. Calls can be made for practitioners in wealthy countries to learn from their southern counterparts, occupational therapists can determine new and newly borrowed practices, develop theories and produce research to evidence them, but they have not been able to drive a political agenda for radical change on behalf of the profession, and many of them may not feel that this uncertain time is right for that kind of approach. Perhaps Ridley-Duff and Bull (2011) are right and the time has come for social enterprise as one of the ways in which new services can be negotiated. The development of social partnerships around these different forms of working have led to some exciting and innovative practices in Latin America, born out of necessity in meeting both historical issues, but also the more recent dominance of market forces in determining social and health strategies.
Acknowledgements: Thanks are due to Jennifer Creek and Alejandro Guajardo who offered critical comments on early versions of this paper.
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