The health community remains doubtful of Cameron’s big idea

Health secretary Andrew Lansley has expressed his desire to make the NHS an exemplar in the development of social enterprises, and the British Medical Association has made public involvement a key test of its support for the proposed commissioning reforms. But does this add up to anything more than a motherly serving of reassuring apple pie in unsettling times?

‘Community groups believe “fashionable” diseases such as cancer will hog whatever resources are available’

The big society - or something very like it - is already active in health. This week’s Resource Centre highlights some examples that fit neatly with the prime minister’s idea of enhanced civic responsibility. Research has shown that health is already the busiest sector for social enterprise.

However, the most powerful evidence of the prevalence of community groups in health comes via Patient View’s survey of the sector which is exclusively revealed in HSJ. The survey collected the views of nearly 900 organisations with more than a million members.

This is a significant number - politically, as well as socially - and the government’s desire to appeal to the community minded among the electorate is very understandable in this context.

The context also makes the results of Patient View’s survey doubly worrying for the government. There appears little enthusiasm for the coalition’s NHS plans. At the heart of the concerns lies the belief that, despite government claims to the contrary, frontline NHS services will be cut.

Community groups also believe “fashionable” diseases such as cancer will hog whatever resources are available and that this problem will be accentuated by a weakening of national standards, meaning rarer conditions will slip out of local plans.

At the heart of this schism lies a different view of what community groups should do. For the government, an ideal big society venture is a direct service provider tackling a need that was or would have been previously addressed by a public sector body. Yet that only describes around one quarter of community organisations. The great majority are driven by campaigning activists - set up to disseminate information and to argue for political, financial and organisational change that would benefit those they represent.

The last administration’s unprecedented boost to NHS funding created or re-energised community led projects across the nation. But the way the money flowed to third sector providers also often created a culture of dependency in some direct service providers.

Not only does this mean many community schemes are now facing oblivion as the NHS purse clicks shut, it also tended to stifle the creative thinking and occasional iconoclasm that defines the best schemes. Understandably, if you get the majority of your funding from one source, you tend to bend over backwards to keep that source happy.

In summary, we have a third sector in health with capacity and experience, but often with the wrong mindset to take on the more central and independent role that the government would like to see it adopt.

It is also the case that third sector organisations often find it very difficult to do business with the NHS. In this week’s opinion slot (page 12), Professor Philip Sugarman highlights the continuing complaint that charities are at a competitive disadvantage when trying to unseat existing NHS providers. Smaller organisations also struggle with the bureaucratic burden placed on them by public bodies intent on ensuring good value for public funds and that volunteers have required standards of training or that patient confidentiality is protected.

A true big society revolution could have a significant impact on the future of the NHS - for example, by using third sector expertise in self-management to deliver more effective services for those patients with complex needs.

However, we appear to be a long way from agreeing exactly what that future might look like.