Social enterprise in dermatology
Our social enterprise model in East Cheshire provides a potential solution to escalating NHS costs and the challenges of our ageing population. This week, there was a lot of interest from colleagues around the country in our model. Below is reprinted an article from the British Association of Dermatologists Newsletter I wrote relating to the role of social enterprise in dermatology.
Social enterprise: a future paradigm in dermatology?
What is a social enterprise?
A social enterprise is an organisation that undertakes activities for a societal end, to tackle social problems, improve communities, people’s life chances or the environment. Any profits generated by its activities are reinvested into the organisation itself or used for the benefit of the local community, to maximise the amount of social good achieved. Social enterprises are reported to generate an additional £2.52-£5.67 of superadded social benefit for every £1 invested. A social enterprise is different to an ethical business, which is a business that undertakes commercial activity to generate profit for shareholders, whilst minimising the impact of the business on society or the environment.
Widely recognised social enterprises include The Eden Project in Cornwall, The Big Issue magazine and Divine Chocolate. There are multiple operational and effective social enterprises in the healthcare sector. BAD members may be familiar with the Accelerate CIC (www.acceleratecic.com) in East London providing wound care and lymphoedema services and MedicineAfrica (www.medicineafrica.com), based in the Centre for Global Health, King’s College London, which is an online platform facilitating intercontinental educational and research partnerships.
In 2010, the then coalition government’s stated aim was to develop ‘the largest and most vibrant social enterprise sector in the world’ as part of their reform of the public sector. Coupled with the concept of ‘any qualified provider’ being able to offer healthcare services paved the way for social enterprises providing medical services.
Macclesfield is a rural market town in East Cheshire in the Northwest of England, named in the Domesday Book, once one of the world’s biggest producers of finished silk and the original home of Hovis bread. For decades, dermatology services to the local population of 250,000 were provided in what is now East Cheshire NHS Foundation Trust. The population includes a relatively higher proportion of older patients, outdoor workers and residents enjoying holidays abroad, with a commensurate increase in the
prevalence of skin cancer.
In common with many other dermatology departments in the North West, over the last decade the trust found it increasingly difficult to recruit new consultants and nearby trusts felt unable to manage the service. As such, East Cheshire Foundation Trust divested itself of provision of dermatology services. Other departments in similar predicaments in the region (and in the country at large) have found some of their services put to tender, often to private providers.
Faced with the prospect of the service being put to tender, the lead consultant (TPK) collaborated with Vernova Healthcare Community Interest Company (www.vernovahealthcare.com), an existing, innovative local social enterprise, to propose a means of providing a comprehensive dermatology service, which was subsequently commissioned by East Cheshire CCG.
Vernova Healthcare CIC is a social enterprise under the collective auspices of the 25 local primary care practices. Governance is overseen by a board of directors (all of whom are affiliated with these practices), who ensure that the overarching societal objectives of the organisation are met. Organisational running is managed by the appointed Chief Executive Officer (Justin Johnson), who is supported by a relatively small management team.
Decisions are entirely made in the interests of patients, the local society and environment, are directed by clinicians (as opposed to managers) and once made can be rapidly realised. Any profits made from the dermatology service are reinvested into the service itself (rather than other divisions in the Trust) to provide new dermatology treatments, equipment and models of care. Where there is a want or need by local patients (for example, having the option of regular evening clinics for patients unable to attend during regular working hours), this can be met by the organisation, in keeping with the societal aims of the social enterprise.
NHS employment rights
Provision of the service is supported by the excellent pre-existing team of dermatology specialty doctors, associate specialist, GPSIs, nurses and allied healthcare professionals, who moved en bloc from the employment of East Cheshire NHS Trust to the social enterprise. As a social enterprise and recognised NHS employer, Vernova provides employees with protected NHS pensions and employment rights (in common with NHS Foundation Trusts). These financial equivalents and safeguards (often not available with private providers) provided the mandatory assurance to transferring employees and facilitated the transition.
Recruiting new consultants
We were delighted to welcome three new consultants earlier this year, all of whom are exceptionally well trained and academically highly qualified. Reasons attracting them to work with a social enterprise included the ethical, not-for-profit organisational structure, the added social and environmental impact of their work upon the local community, a greater degree of autonomy, the sense of being valued and appreciated in a clinician-led service, personal experience of the tremendous good that can be achieved in a social enterprise, as well as the excellent team. An additional advantage was the possibility of malleable working patterns (such as longer days and the possibility of working in evening clinics), which gives patients greater choice of appointment times, allows better use of the facilities when they would otherwise be vacant and grants the new consultants a degree of flexibility in fulfilling subspecialty clinical and academic commitments in other centres.
We offer a full range of outpatient dermatological services including general dermatology clinics (which incorporates paediatric and skin cancer referrals), dermatological surgery, phototherapy (UVB and PUVA), patch testing, photodynamic therapy and mole mapping. The arrival of new consultants and specialist nurses has allowed us to develop medical and surgical services and introduce wound care/dressing clinics, such that the vast majority of complex medical cases and surgical procedures can be cared for in house, particularly important for those patients who are unable or reluctant to undertake the 50+ mile round trip to the nearest tertiary centres. We fully appreciate the support of colleagues in Salford Royal NHS Foundation Trust for patients needing tertiary centre expertise and input.
A new model
Advantages of a new modus operandi included the opportunity to move many of the dermatology services into purpose built accommodation, deliberately chosen to be opposite to the local train and bus stations with an attached multi-storey car park (free for patient use), all of which facilitate patient access. Additionally, there are several community clinics offered each week to facilitate access to a geographically dispersed population. To enhance patient care and also help address the environmental impact of our service, the new structure allowed clinicians to move to entirely electronic records where wished, which facilitates instantaneous communication with other team members (avoiding need for copious emails and printed results) and rapid communication with the primary care providers.
Continuation of our local skin cancer MDT was made possible by the support of the MDT coordinator in East Cheshire NHS Trust and our colleague David Mowatt (plastic surgery, Christie Hospital) who provides a bridge with the specialist skin cancer MDT.
A continued hospital presence
Inpatient consultations were not explicitly mandated by the CCG and the Trust did not see the need to employ a permanent dermatologist for this end. However, our moral imperative in keeping with the principles of the social enterprise to best serve the local community, allowed us to come to an arrangement with East Cheshire NHS Trust to receive requests for inpatient review.
From April 2017, we have enjoyed hosting a dermatology registrar from the Northwest Deanery and look forward to start regularly supervising GP specialty trainees. Our unit continues to provide regular educational events for GPs, trainees, foundation doctors and practice nurses, all of which are well-received.
For services facing similar predicaments, we would suggest considering a social enterprise as a means of establishing a new clinician-led service in which staff are content and patients and their local community at large can reap huge social, societal and healthcare-related dividends.