Memo to Andrew Lansley - How to save the Health Bill without changing it

The response to mounting opposition to the NHS Bill is not yet meeting the required standard. The concerns are far deeper than either political manoeuvring or self-preservation by empire-builders, although there are obviously elements of both. Before doing anything further if you stop and analyse the resistance you will find a common thread. It is that no-one understands how the reforms will actually get the NHS to a better place, and it is therefore causing fear rather than excitement. In effect it appears to be the fiddling while Rome burns. I have spoken to several GPs involved in new clinical commissioning groups who can see the logic in some of the arrangements but fear the funding will not support the needs of their patients and alongside that existing NHS commissioners are saying that the changes will do nothing to re-position the service to cope in 10 or more years time, that will need hard cash.

The Unofficial Big Society Green Paper (www.bigsocietygreenpaper.org) has a full chapter on the NHS because of it's importance to us and your reforms may well drive efficiency but they have two glaring omissions. Firstly, they do not show how they are compatible with the future financial strains which demographics alone will place on healthcare and the funding of it. This leads GPs especially to be wary of being the gatekeepers of insufficient funding and as a result being the ones to tell patients that they will be left to die. Secondly, the reforms fail to demonstrate how they will protect the NHS against lowest common denominator services which will result from a totally free any willing provider system.

What is needed therefore is a sub-bill which enshrines the role of community-led social enterprise in the NHS and does so within a framework which ensures open competition whilst supporting the funding model through reinvestment of profit. Secondly, you need to address the whole system that funds health, pensions and social care from current day taxation. This system frightens the life out of me and will break at some point, leaving us like Greece. No amount of reform or doing more for less can save a system in which twice as many people need help as those paying for it and that is where we are headed.

The Green Paper talks at length about this issue but in a nutshell you can save the bill by two relatively simple actions, which it will be easy and beneficial for the coalition to support:

1. Commit to a system of competition in which all outputs are measured, not just the financial, and in which the state seeks a return of profit from providers. This will ensure that social enterprise becomes the main delivery vehicle for our healthcare and avoid the danger of back door privatisation.

2. Commit to a new system of funding, on a whole of life basis, which will guarantee that a standard set of treatments and social/pension benefits are available nationally to all those eligible. 

This will not only help financially, it will help voters to believe in your full support for the NHS and also help those inside it to believe that the reforms will not simply be used to squeeze the NHS to save cash. These are not nice to have bolt ons, they will save your Bill. They will underpin the modernisation of the NHS as well as transform the financial position of the country.

Does David Cameron really want a Big Society?

Much has been said lately of co-operatives, mutuals and social enterprises. As long ago as 2004 Rebecca Harding at Delta Research was arguing for a new definition of social enterprise and if anything the waters have become murkier since. If there is a problem in the lack of a definition, and I am in the 'there is a problem' camp, it is that the lack of a definition is holding back the growth of the sector.

That is not the same as saying that we need any new legal forms of enterprise as suggested by Luke Fletcher on the Social Enterprise website (http://www.socialenterpriselive.com/section/features/policy/20120117/social-business-%E2%80%93-the-missing-piece-the-social-economy-puzzle), there are already plenty of ways of creating the right legal forms. It is not types of trading vehicle that are holding back growth but the unidentifiable nature of the underlying enterprise that is the problem.

This manifests itself in two ways. Firstly, it is very difficult to measure the sector, and therefore to judge its overall impact and growth, when its trading vehicles are indistinct from any other. Secondly, it is very difficult for those choosing where to spend their money (state commissioner or individual) to know exactly who they are dealing with. As pure 'show me the money' capitalism finds social enterprise a more serious competitor it can be guaranteed that it will find ways of looking more and more like social enterprise. Whilst I understand all of the arguments about encouraging risk capital by allowing investors to share in the profit of social enterprises, the line needs to be drawn clearly somewhere or it will be possible for anyone to call themselves a social enterprise just because one of their directors bought a Big Issue last week.

This to me is the crux of the problem, and it is especially valid in an age where myriad new social enterprises are being encouraged to bid for state contracts but without any clear structure to support the way that they are to compete. Either the Government has no vision on the subject or its vision is of a huge free for all in which capitalism morphs into whatever it has to look like to retain its share of the business and then runs off with the money as always.

Two things are therefore required, in my opinion. A clear definition of what constitutes a social enterprise and the opportunity (not a requirement) for enterprises which wish to do so, and meet certain criteria, to use a new alternative suffix to Ltd, Plc and LLP. My suggested definition in the Green Paper is "commercial enterprises which trade with defined social goals and which are permanently and beneficially owned by their community" and perhaps they might be designated as SET - social enterprise trust?

On a separate but related subject I am not convinced that mutuals or employee-owned businesses should actually be in this group at all. I struggle to see them a social enterprise, they are just a more homely version of capitalism. Social enterprise should be for the benefit of a wider community and should return a substantial part of its profit to that community in one way or another. I would not rule out employee or investor ownership of a part of such enterprises but it must be controlled and they must be kept away from the main stock exchanges and vulture capitalists by means of their own grouping within the corporate sector. There is a danger that because capitalism has gone to such an extreme we now embrace anything that isn't purely capitalist as a social enterprise. That would be equally wrong and may well let 'free for all' capitalism back in the door to ensure that social enterprise never gets to any useful scale or even dies.

The suggested change would therefore achieve two things: it would provide a stronger platform for investment in the sector, even for partnerships with commercial firms, and it would enable to sector to be measured, rewarded (perhaps through tax or other incentives) and protected. The Unofficial Big Society Green Paper (www.bigsocietygreenpaper.org) goes further and suggests that many of the public sector spin outs should join an entirely new sector which remains in state ownership, but that is too big a diversion for now, we must first clear the fog.

Not long ago we had Lansley and Cameron giving different definitions of what constitutes social enterprise and now we have a push for co-operatives. Although this is welcome I see it as a further blurring of the lines between pure capitalism and social enterprise which can only be to the benefit of the former. Something clearly needs to be done or the cynic in me will have to conclude that Cameron is in fact a double agent - trying to appear #socent friendly whilst playing divide and rule with the sector. In that case the Big Society will have been nothing other than a tool to persuade the poor to help themselves whilst keeping any popular movement toward social enterprise (and its attendant gradual redistribution of wealth) under full central control.