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Our practice is a social enterprise

Like John Lewis Partnership staff, our staff members each own part of the business, explains Dr Mike Attias.

Dr Attias has a stake in a CIC at Arlesey Medical Centre (Photograph: UNP)
Dr Attias has a stake in a CIC at Arlesey Medical Centre (Photograph: UNP)

Back in 2003, and following pressure from local residents, the then PCT decided to make use of the newly conceived PCT medical services (PCTMS) contract to provide a GP service in Arlesey, a small village in rural Bedfordshire.

It recruited a GP from a nearby practice (me) and underwrote new contracts with providers and third parties. The service started from scratch in December 2003.

After a reorganisation of PCTs in Bedfordshire, the PCTMS contract was transferred under TUPE - Transfer of Undertakings (Protection of Employment) regulations - to NHS Bedfordshire, where our contract sat until the divestment of the PCT's provider arm on 1 April 2011.

The options we faced
Our options were to do nothing and be subsumed by an incoming organisation or wait until a tendering process was started by the PCT and bid for the contract. Or put in a 'right to request' under the new social enterprise rules for the NHS.

The last was something we knew very little about but it appealed to us philosophically. The idea of incorporating as a social enterprise, putting the patient at the centre, and wrapping an APMS contract in a framework that lends itself to autonomy, openness and accountability appealed to us all.

This was in 2009. Two years later, after hours of discussion, consultation and exchanges that were not always amicable, but always with a sense of co-operation and 'can do', we now have a small village primary care centre. We also have a viable and sustainable APMS contract that the team owns in a model not too dissimilar to the John Lewis Partnership in which all its staff own a stake.

Social enterprise
Our social enterprise is a community interest company (CIC) limited by shares called Sunnyhill Healthcare. A CIC, we were told, was the best way of maintaining NHS Pension Scheme entitlement and NHS employing authority status.

We formed a company board with executive directors drawn from the staff. Our company articles allow for two patients as non-executive directors drawn from our stakeholder group and elected by the executive directors. All the staff hold a notional share of £1. The company assets are 'locked' in keeping with the requirements of the Community Interest Company Regulator (www.cicregulator.gov.uk).

A social enterprise is a business. However its main aim is not the enrichment of its shareholders but the enrichment of the service it provides. It has to make money to survive and it has to adhere to all rules and regulations in the same way as a GP partnership does.

So what are the risks? We could underperform on our APMS contract and lose it, but we do not think this is a realistic prospect. It might be easier for the PCT (or commissioning body in the new NHS) not to renew the contract or make it difficult for us to meet its requirements - that could be true for other providers too.

WHAT IS A SOCIAL ENTERPRISE?
  • In 2002, the then Department of Trade & Industry defined it as 'a business with primarily social objectives whose surpluses are principally reinvested for that purpose in the business or in the community rather than being driven by the need to maximise profit for shareholders and owners'.
  • Social enterprises can be co-operatives, credit unions, housing associations, community development trusts, and community businesses, companies limited by guarantee or by shares, or industrial or provident societies.
  • A new form, the community interest company (CIC) limited by shares or guarantee, was introduced in 2005. The model was designed for social enterprises and has an 'asset lock' placing tight restrictions on transferring assets out of the business.

Commissioning consortia
Finally, there is the risk that we could be perceived as being 'not-of-the-NHS-family'. This could be a problem if colleagues, especially within commissioning consortia, do not understand what a social enterprise is.

What are the benefits? We have autonomy. The practice answers to the board via its chief executive. There are contractual obligations to the PCT but how we achieve those are entirely up to us as long as we perform in ways that are legal, ethical and conform to good practice as dictated by the profession's regulatory bodies.

We are also more patient-centred: our notion was that if we offer the services that the patients want, we will have a competitive edge.

This is borne out by our growth from a registered list of 2,500 to 2,780 since April 2010. Not all that patients suggest is deliverable, but there are some kernels that enrich our practice of medicine and make our service locally relevant - that definitely gives any business an edge. We are accepted by local colleagues in today's mixed, NHS primary care economy.

I would not advocate a social enterprise model for all primary care set-ups, but it is a way of doing things that could in some instances liberate practices and prompt innovation, participant inclusion and a less paternalistic approach.

My advice to those who may consider the model is to go for a legal form designed for social enterprises, use a reputable legal firm and get advice. Above all, have a shared vision with your staff and patients and negotiate with your commissioners.

WHAT WE LEARNT

1. Take good legal advice.

2. Incorporate with care.

3. Discuss your ideas with staff and patients and with commissioners before you embark on your project.

4. Expect the usual reversals of fortunes.

5. Be tenacious and stick to your idea.

6. Always expect snags to take twice as long to resolve as you think logical.


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