Recent Research Projects

Project: ‘New Connectivities”: Civil Society, the “Third Sector” and Dilemmas for Socially and Economically Sustainable Healthcare Delivery’1 March 2011 -31 October 2011
  •  Funding was provided by the UK Arts and Humanities Research Council (AHRC)
  •  Project participants are Ellen Annandale, Lim Ming (coordinator), Carlo Ruzza

‘New Connectivities’: Civil Society, the ‘Third Sector’ and Dilemmas for Socially and Economically Sustainable Healthcare Delivery

Rationale and context

Since the 1980s, many countries in Europe have been moving to a mixed model of healthcare financing and provision and provider competition (Thomson, Foubister & Mossialos 2009). The so-called third sector is being brought to the heart of the ‘welfare mix’ as an alternative provider in a range of cooperative relations with the state across Europe (Kiviniemi 2008; Saltman et al. 2002). This has far-reaching, but as yet little understood implications for civil society organisations.

Civil society organisations typically are characterised as organic entities which are ‘born within’ civil society. In many countries, such as Britain, Italy and Germany, they are moving from a mediating role (between communities and the state) to a provider role as they are drawn into healthcare markets. This new hybrid role (Kiviniemi 2008) raises significant, and as yet unanswered, questions about the potential loss of traditional forms of connectivity and the formation of new forms of connectivity between health-related civil society organisations, communities and healthcare stakeholders. Currently, there is little understanding of the strategies of civil society organisations for combining different, and often competing, social and political blueprints of their service delivery roles (Kendall 2009): how they ‘select’ sources of financing, their normative criteria for targeting specific populations (which may not fall neatly within a narrowly-defined category of ‘illness’ or ‘disease’) and what input they actually have on policy-shaping and implementation. These are some of the issues that require empirical investigation.

Since the UK has been one of the countries at the forefront of this shift within the European Union, it is a useful point of departure for wider debate. Schemes to bring the third or social enterprise sector into healthcare were begun by the last Labour. Thus, in 2007, the English Department of Health (DoH 2007)[1] set up a Social Enterprise Unit to encourage third sector organisations to compete for contracts from commissioners such as primary care trusts (PCTs[2]).

‘Social enterprises’ are defined as non profit organisations using business solutions to achieve public good. They seek to harness time and energy donated by actors who often are motivated by altruistic principles to the business principles of efficiency and effectiveness. The social enterprise sector has been accorded ‘the potential to spot and move into gaps where services are not being provided’ and deemed able to ‘add value’ by providing services in innovative ways which better reflect the needs of patients and users (DoH 2007). This standpoint is being taken forward by the present Coalition government which envisages the NHS as ‘an integral part of the Big Society’ (DoH 2010:7). Changes for the NHS are intended to ‘create the largest social enterprise sector in the world’ (DoH 2010:5) as power and responsibility is transferred to various civil society organisations such as charities, community groups, and social enterprises (Ashton 2010). The ‘Big Society’, however, cannot function only on volunteerism as traditionally conceived. Effective leadership - the catalyst for competitiveness and for quality of care in the NHS since the late 1990s - is considered essential for the third sector to compete effectively and ethically in the markets they target.

There is some evidence to show that social enterprises enjoy close relationships with socially and economically disadvantaged groups and individuals within their communities; they function with generally positive reputations as either physical places or emotional ‘safe havens’ within the otherwise harsh environments of big cities[3].This suggests that they may enjoy initial goodwill among community groups, but further research is required to investigate the kinds of products and services which these enterprises need to provide in order to be sustainably connected to their communities in coming years (see Hart & Houghton 2007; Peattie & Morley 2008). There is also a need to understand the cognitive and practical disconnections which might exist between social enterprises and the latest management/business theories and practices which can make an important difference to their future role as economic regenerators within, and beyond, their communities (Parkinson & Howorth 2007).

The role and status of civil society groups in this increasingly marketised landscape of healthcare provision becomes, in our view, a matter for urgent and sustained research.

Although third sector organisations are being drawn into the progressive opening up of a competitive healthcare market that has been in train for some time, new paradoxes are emerging: if ‘third sector’ organisations are valued for their potential to reduce costs, they are also assumed to offer superior performance, at least partially because they are not only or not always motivated by profit (Heins et al. 2010). But, in the context of England, superior performance is also linked to their perceived innovative and transformative potential, something which is implicitly contrasted to the megalith of NHS bureaucracy (which is seen as heavily resistant to change). Relatedly, third sector organisations are seen to be driven by a social mission to provide innovative solutions to perceived inadequacies in existing mainstream state provision (e.g. Macmillan nurses, Long-term Conditions Alliance) (New Statesman 2007). 

The capacity and resources of civil society groups to provide informational resources in this new landscape should also be further examined as the pressures on them to interface with specific, and diverse, communities grows. How will they meet the needs of socially and economically vulnerable groups as connectivities between state healthcare providers and commercially-driven stakeholders change? Indeed, the whole focus on patient choice and autonomy so heavily emphasised in health policy must come under renewed scrutiny if these connectivities loosen. The issue goes beyond the mantra of Liberating the NHS (DoH 2010):‘no decision about me without me’. Third sector organisations are assumed to be better at providing patient choice because they are deemed ‘closer to users’ and thus better enabled to build trust, give voice to communities that are hard-to-reach by statutory services, and so on. International comparisons can be highly productive since social entrepreneurship models in intercultural contexts have built their success upon forging new ties with the public and commercial as well as community sectors to exploit untapped markets in hard-to-reach areas and communities (Borzaga & Defourny 2001).  In Europe, the U.S. and Africa, social enterprises have been able to combine commercial instincts and practices with their social mission in ways which promote economic inclusion among societal groups. In the wider context of global health initiatives and health governance the claim is often made that NGOs can be responsive to global health deficits and thus provide democratic public spaces for citizens to articulate their needs in potentially antagonistic or violent contexts (Doyle & Patel 2008; Maupin 2009).

However questions still need to be raised as to whether innovation, transformative potential, closeness to the client and so on are sustainable in the increasingly marketised and contractualized service environment of the NHS. As Doyle and Patel relate, ‘market mechanisms such as competitive tendering, sort-term renewable contracts and performance measurement, has led to a preoccupation with organisational survival and a willingness to deliver programmes regardless of their utility’ e.g a push to short-term, unsustainable interventions for service organisations (2008:1934). Civil society organisations are also heavily dependent on volunteers and their donation of time and energy. Their extremely close connections to under-resourced communities as well as to many third sector organisations are dependent on the efficient and timely acquisition and dissemination of information to e.g ethnic constituencies and local community self-help groups because such ‘social’ information changes frequently and often is completely absent in policy-making circles. We currently know neither when, and how, such ‘informational connectivity’ takes place nor know selective biases enter into these interactions. Even less is known about how newer and emerging technologies may play an empowering role in interactions between civil society organisations, volunteers and the community groups and end-users they serve. Understanding these issues would lead to better informed, more nuanced and effective policies to compensate for any shortfall in civil society volunteerism.


Aims and objectives

Based on the issues raised above, this scoping review aims:

§  To analyse the implications of the potential loss of traditional forms of connectivity between civil society organisations, communities and various healthcare stakeholders.

§  To identify and trace the formation of new forms of connectivity between civil society organisations, communities and various healthcare stakeholders.

§  To synthesise international, cross-cultural research on the combinatorial possibilities of business-led practice and social passion which social enterprises in the U.K. can exploit to forge new community programmes based on economic prosperity and social inclusion.

§  To uncover and evaluate evidence that forms of connectivity driven by social passion and benevolence can be economically and socially innovative and transformational for ‘health communities’ and end-user groups.

§  To discover how volunteers within the third sector mobilise forms of ‘informational connectivity’ and what the current fissures are in these efforts – technological, social and political – in order to propose evidence-based policy solutions.

Emerging areas of research innovation, potential lacunae in research and recommendations on potential future directions and priorities

The aims and objectives will enable us to propose an innovative future research agenda related to:

§  Whether existing forms of connectivity between civil society organisations and communities are likely to be lost and, if so, how they might be regained and/or new forms of connectivity fostered.

§  Whether civil society organisations are likely to change the ways that they interface with patient/clients e.g will personalised care be jeopardised or enhanced and under what conditions?

§  Responses of patients/clients to change (an under-researched issue) and their levels of awareness of change in the organisations they use. Some might embrace and value the emerging ‘social enterprise’ model and others not. Is there potential of conflict amongst community clients? How far will responses vary by e.g. health conditions, kind of service; geographical location; type of community, family, and individual social characteristics.

Contributions to the ‘Connected Communities’ Programme

Our scoping review and activities will open up new areas of inquiry into the “changing nature of ‘connectivity’ within and between communities”. To understand the impacts of changing connectivities upon service delivery under fast-changing institutional conditions of marketisation, we will contribute a rigorous analysis of how the various linkages between the third sector, the communities they traditionally serve and the state may gradually erode and/or strengthen over time. Our feedback-gathering activities and dialogues with other experts in related, cross-disciplinary fields of social health and innovation will add a new dimension to this broad objective. We will also add depth to the Programme’s focus on communities as complex cultural, social and economic systems by asking what strategies of connectivity civil society organisations use and why. How do they make ethical choices about financing support, targeting selected populations, communications, and so on? Crucial here will be the ways in which what we call ‘informational connectivity’ will change with the communications technologies that social enterprises will want to utilise to maximise their reach to new markets and the consequences this will have for client connections.

Furthermore, the dimension of ‘health leadership’ will enable us to uncover changing norms of practice in this area as care workers and volunteers seek to redefine their role in the ‘Big Society’. How will social enterprises provide transformational leadership to their volunteers so that the latter continue to connect with individuals and groups with social passion? The bonds between volunteers and organisational leaders in the changing field of social enterprise will shape the efficacy of the third sector’s engagement with communities for the foreseeable future. Finally, our activities bring a critical, international perspective to bear the question of how health providers can combine existing connections with their communities with new forms of engagement to businesses, management theory and practice. Our research and activities will bring a pragmatic dimension to these questions by proposing theories about the appropriate and sustainable sacrifices social enterprises and other civil society organisations may have to make in order to serve their communities well in fast-changing economic and political conditions. While the question of community enterprise is very far from being a zero-sum game, much research will be needed to facilitate actions which lead to a ‘win-win’ scenario for the diverse communities and end-users which rely on civil society organisations to maintain quality of life.   

Description of Activities

We will conduct seminars and interactive lectures by visiting experts from within, and outside, the U.K. as well as a coordinated series of workshops, focus groups and feedback sessions with selected audiences such as local authorities, charities, Leicester City Council and social entrepreneurs who engage with all these constituents. We have also planned actual as well as virtual dialogues with colleagues in the field of global health (e.g. Professor Catherine Panter-Brick of Yale University.

Management and coordination

Scoping studies ‘aim to map rapidly the key concepts underpinning a research area and the main sources and types of evidence available’ (Mays et al. 2001:194). Since they are typically concerned with novel or ‘breaking’ areas of research, data-gathering is wide ranging.  A document management system will be set up to collate, query and maintain records of:

§  Monthly summaries of activities and records of interviews with stakeholders (in person, via Skype, video conferencing), expert debates and workshops hosted at Leicester University.

§  Detailed records will be kept of each scoping activity, including minutes of meetings and an audit trail will be maintained by support staff.

Outcomes (in addition to the online publication and report to AHRC)

1. Publications: at least two journal articles in two of the following journals: Journal of Civil Society, Voluntas, Journal of Health Services Research and Policy, Sociology.

2. Presentations at conferences and to policy audience. In England: e.g. the Social Enterprise Annual Conference; King’s Fund ‘Big Society’ events; in Europe: the European Sociological Association Conference (Prof. Carlo Ruzza coordinates the Political Sociology section); in the U.S.: the Annual ‘Global Health Innovation’ conference (Spring 2011 at Yale University).

3. Features and op-eds in national and local newsletters, including Radio Leicester, Leicester Speaks.


Ashton, B. (2010) Big Society. Political Philosophy and Implications for Health Policy. London: King’s Fund.

Borzaga, C. and Defourny, J. (2001) Social enterprises in Europe: a diversity of initiatives and prospects, in C. Borzaga & J. Defourny (eds) The Emergence of Social Enterprise. Routledge: London.

DoH (2007) Welcoming Social Enterprise into Health and Social Care. London: HMSO.

DoH (2010) Liberating the NHS (the Lansley Report). Cmd 7881. London: HMSO.

Doyle, C. and Patel, P. (2008) ‘Civil society organisation and global health initiatives: problems of legitimacy’, Social Science & Medicine, 66: 1928-1938.

Hart, T. and Houghton, G. (2007) Assessing the economic and social impact of social

enterprise: feasibility report, Centre for City and Regional Studies: University of Hull.

Heins, E. et al. (2010) ‘A review of the evidence of third sector performance and its relevance for a universal comprehensive health system’, Social Policy and Society, 9 (4): 515-526.

Kendall, J. (2009)  Handbook on Third Sector Policy in Europe: multilevel processes and organized civil society. Cheltenham, Edward Elgar.

Kiviniemi, M. (2008) ‘The state of our knowledge and future challenges’, in S. Osborne (ed.) The Third Sector in Europe. London: Routledge, pp. 357-370.

Maupin, J. (2009) ‘Fruit of the accords’: Healthcare reform and civil participation in Highland Guatemala, Social Science & Medicine, 68 (8): 1456-1463.

Mays, N., Roberts, E. and Popay, J. (2001) ‘Synthesising research evidence’. In N. Fulop et al. (eds) Studying the Organisation and Delivery of Health Services: Research Methods. London: Routledge.

New Statesman (2007) Getting new Ideas and New Value from Social Enterprise. 16th July.

Parkinson, C. and Howorth, C. (2007) ‘The language of social entrepreneurs’, Lancaster University Management School Working Paper .

Peattie, K. and Morley, A. (2008) ‘Social enterprises: diversity and dynamics, contexts and contributions’, Research Monograph, ESRC/Social Enterprise Coalition: Cardiff.

Saltman, R., Busse, R. and Mossialos, E. (eds) (2002) Regulating Entrepreneurial Behaviour in European Health Care Systems. Buckingham: Open University Press.

Thomson, S., Foubister, T. and Mossialos, E. (2009) Financing Health Care in the European Union. Copenhagen:WHO.

[1] Different NHS funding arrangements pertain to England, Wales, Scotland and N. Ireland. Therefore hereafter we refer only to England.

[2] PCTs will be replaced by GP Commissioning Consortia and their local health improvement role will move to Local Authorities (DoH 2010).

[3] One of the investigators of this bid, for instance, has worked with an AIDS support charity and a mental health advocacy organization in Leicestershire since August 2010. Interviews with service-users and other support networks show the depth of community involvement of these civil society organisations with stakeholders.