Introduction
One of the most notable successes of the UK welfare state since its inception has been the significant increase in average life expectancy and improvement in population health (Shaw et al., Reference Shaw, Dorling, Smith, Marmot and Wilkinson2005). However, these improvements have not been shared equally: accompanying the trend of ever-widening income inequality since the end of the 1970s, health inequalities – preventable and unfair differences in health status between social groups, populations and individuals (Whitehead et al., Reference Whitehead, Dahlgren, Gilson, Evans, Whitehead, Diderichsen, Bhuiya and Wirth2001) – have increased. While mainstream public health initiatives have continued to aim to impact upon individual risk factors, such as smoking, diet, alcohol and exercise, many public health experts would claim that a key requirement in narrowing inequalities would be to act on the material circumstances of the most vulnerable members of society (Marmot, Reference Marmot2010). If low income, social exclusion and hopelessness contribute to poor health, there is an argument for working on the ‘causes of the causes’ of such factors through more holistic, community-based, interventions (Chief Medical Officer for Scotland, 2011; McLean and McNeice, Reference McLean and McNeice2012). There have been a number of moves in recent decades to supplement a public health focus upon individual pathologies and risk factors with greater awareness of the importance of social relationships, purposeful activity, community processes and social contexts in creating health (Bambra et al., Reference Bambra, Gibson, Sowden, Wright, Whitehead and Petticrew2010; Hanlon et al., Reference Hanlon, Carlisle, Hannah, Reilly and Lyon2011) and, even very recently, reducing worklessness has been presented as an important means of addressing the social gradient in health (Bambra, Reference Bambra, Newby and Denison2014).
At the same time, the concept of ‘social innovation’ (SI) has come to the fore. Paradoxically, SI has been presented as both an ‘anchor concept’ for cross-disciplinary research (MacCallum et al., Reference MacCallum, Moulaert, Hillier, Haddock, MacCallum, Moulaert, Hillier and Haddock2009) and as a somewhat amorphous and contested term. SI is described variously as: ‘the generation and implementation of new ideas about how people should organize interpersonal activities, or social interactions, to meet one or more common goals’ (Mumford, Reference Mumford2002: 253) and ‘new ideas that meet unmet needs’ (Mulgan et al., Reference Mulgan, Tucker, Ali and Sanders2007: 5) across different layers of society (Moulaert et al., Reference Moulaert, MacCallum, Mehmood and Hamdouch2013). SI has been particularly championed to combat social exclusion: this is the case at both domestic and EU policy levels, but also further afield, such as in the US, where an Office of Social Innovation and Civic Participation has been created.
Meanwhile, unemployment is currently running at around 7.8 per cent in the UK, equivalent to 2.5 million of the economically active population without a job (Office for National Statistics, 2013). The deleterious impact of worklessness on public health is well documented: employment not only provides income but a sense of control and of purpose, which are important influences on health (Marmot, Reference Marmot, Ferrie, Griffiths, Marmot and Ziglio1999). Being without a job critically undermines the ability of citizens to access money, power and resources; factors identified by the World Health Organisation as among the high level ‘social determinants of health’ (World Health Organisation, 2013).
The question therefore arises: could SI be a means of enhancing individual and community health and well-being by reducing social exclusion? To explore this question we draw upon three examples of social innovations from civil society which work to address unemployment and/or to mitigate its consequences, namely: microcredit for enterprise, Work Integration Social Enterprise (WISE) and self-reliant groups (SRGs). In doing so, we consider whether there is a case for framing such innovations as ‘upstream’ means of tackling the social determinants of health (McKinlay, Reference McKinlay1974).
Microcredit for enterprise
What is microcredit for enterprise?
Among the several functions of welfare, provision in the UK acts as a form of ‘safety net’ during ‘socially critical periods’, such as unemployment, so as to reduce an individual's vulnerability and reliance upon the market (Bartley et al., Reference Bartley, Blane and Montgomery1997). Unemployment can be a turbulent experience for individuals as it is often accompanied by lower income and heightened risk of varying forms of social exclusion. Successive welfare reforms and changes in public perceptions towards claimants have corroded the ability of the UK welfare state to shield individuals from some of the detrimental factors associated with unemployment which can lead to poor health (Baumberg et al., Reference Baumberg, Bell, Gaffney, Deacon, Hood and Sage2012; Corlett, Reference Corlett2012). Leading researchers in public health, including Marmot and Wilkinson (Reference Marmot and Wilkinson2006), argue that rather than just ‘safety nets,’ policy ‘springboards’ are required to offer individuals opportunities to ‘improve their lot’ and re-enter the labour market in an improved position from whence they came. One such ‘springboard’ which has been proposed is microcredit for enterprise.
Microcredit is the issuance of small, collateral-free loans, typically extended to those excluded from mainstream financial institutions for either enterprise or personal purposes, aimed at addressing social, and particularly financial, exclusion. Microfinance Institutions (MFIs) are commonplace in developing countries, where they emerged from the need to combat financial market inefficiencies that tend to discriminate against the poorest members of society. Characterised by innovative lending and operating models, such as group lending, targeting women, progressive lending, relationship banking and flexible, public and regular repayments, it is claimed that MFIs have transformed the ‘unbankable’ into the ‘bankable poor’ (Weber, Reference Weber2004).
Success in reaching those previously excluded has led to the increasing use and adaption of such lending practices by institutions in more advanced economies. In the UK, certain Community Development Finance Institutions (CDFIs) – such as fair finance, and the soon to be launched Grameen UK – offer (or will offer) products resembling microcredit for enterprise. These institutions are conceived as socially oriented, not-for-profit, initiatives that act as a bottom-up tool for community development, with the aim of mitigating financial exclusion and having a positive impact upon the lives of individuals.
The potential for impact
Microcredit for enterprise has the potential to reduce an individual's material constraints, and to possibly improve their psychosocial outlook through their engagement and interaction with the lending institutions themselves and the creation of their own microenterprises. Thus, it has been proposed that microcredit has the potential to address the determinants of health (Mohindra et al., Reference Mohindra, Haddad and Narayana2008; Donaldson et al., Reference Donaldson, Baker, Cheater, Gillespie, McHugh and Sinclair2011). However, there is a substantive gap in knowledge about the mechanisms through which policies and interventions, such as microcredit, that attempt to act ‘upstream’, can impact upon health and well-being.
Hypotheses and research proposals
Academic research on microcredit in developing countries is maturing. This is a consequence of a rise in quality of microcredit evaluations (Duvendack et al., Reference Duvendack, Palmer-Jones, Copestake, Hooper, Loke and Rao2011), general acceptance that microcredit is not a ‘silver bullet’ (Leatherman and Dunford, Reference Leatherman and Dunford2010) and calls for the implementation of more rigorous empirical testing to assess the impact of microcredit (Hulme, Reference Hulme2000).
The search for more robust research designs has led the microcredit sector to look for study designs from other disciplines. In particular, evaluators have looked to the field of medicine, where the randomised controlled trial (RCT) is the recognised ‘gold standard’ for its ability to lead to an understanding of whether a cause–effect relationship exists between a treatment and an outcome (Sibbald and Roland, Reference Sibbald and Roland1998). The importance and difficulty of understanding this causal relationship has been recognised in the microcredit sector (Armendaáriz de Aghion and Morduch, Reference Armendaáriz de Aghion and Morduch2005), and prominent individuals within this sector have embraced this research design (Karlan and Zinman, Reference Karlan and Zinman2010; Duflo et al., Reference Duflo, Banerjee, Glennerster and Kinnan2013). So far, this approach has only been applied to microcredit in developing country settings and there remain firm practical (cost and implementation) and methodological concerns (external validity) associated with this research design (Odell, Reference Odell2010).
The transfer and implementation of this research design to a developed country setting, such as the UK, raises ethical and feasibility considerations. Ethical issues relate to denying potential customers access to credit, so that they might serve as a control group. Additionally, ‘overlending’ to boost borrower numbers could be a concern as the market for microcredit for enterprise in a developed country is relatively smaller than in a country such as India (McHugh et al., forthcoming). Innovative research designs are thus required to evaluate microcredit for enterprise in developed countries.
A financial diaries approach, undertaken in developing countries and now implemented in the USA (Collins et al., Reference Collins, Morduch, Rutherford and Ruthven2009; USFD, 2013), could be adapted to evaluate the impact on social exclusion or health and lay the groundwork for further long-term quantitative evaluations. Longitudinal evaluations could be more successful at capturing impact as the same recipients are followed and monitored continuously over time (Goldstein, Reference Goldstein1968), which is an advantage over the RCT approach.
The complexity of conceptualising microcredit for enterprise as an intervention with a wider social impact necessitates an awareness of learning from evaluations conducted in developing countries. Transferring this knowledge, while continuing to apply and develop innovative research methods, would move this incipient field forward, potentially leading to assessments of whether microcredit could be considered a useful and cost-effective mechanism for addressing certain social determinants of health (Donaldson et al., Reference Donaldson, Baker, Cheater, Gillespie, McHugh and Sinclair2011).
Work Integration Social Enterprises (WISEs)
What are WISEs?
Similarly to the concept of social innovation, the focus upon ‘social enterprise’, and the closely related terms ‘social entrepreneur’ and ‘social entrepreneurship’, has significantly increased in recent years (Defourny, Reference Defourny and Kerlin2009). While recognising that social enterprise is a ‘contested concept whose meaning is politically, culturally, historically and geographically variable’ (Teasdale et al., Reference Teasdale, Lyon and Baldock2013: 1), a social enterprise, as taken here, is a business with social objectives whose surplus revenue is reinvested for these purposes (Dees, Reference Dees1998; Borzaga and Defourny, Reference Borzaga and Defourny2001). Different conceptualisations of social enterprise exist throughout the world (Defourny and Nyssens, Reference Defourny and Nyssens2010; Kerlin, Reference Kerlin2010), but, broadly speaking, social enterprises can be divided into: those driven by an ideological commitment to collectivism and democratic process; and those for whom the primary motivation is meeting social goals, but which adopt a hierarchical and individualistic organisational structure common in the private sector (Teasdale, Reference Teasdale2010). The former, arguably more emancipatory, model is common to most WISEs or ‘social firms’.
WISEs are a specific type of social enterprise with the core purpose of workforce development and/or job creation for disadvantaged populations (Spear and Bidet, Reference Spear and Bidet2005; Vidal, Reference Vidal2005; Warner and Mandiberg, Reference Warner and Mandiberg2006). They may also combine a mission to address social exclusion (Teasdale, Reference Teasdale2010, Reference Teasdale2012) with providing a product or service needed by society (Ferguson, Reference Ferguson2012).
The potential for impact
In contrast to traditional supported employment efforts aimed at disadvantaged individuals, such as people with mental illness, WISEs neither encourage conformity to a particular job description nor setting (Krupa et al., Reference Krupa, Lagarde and Carmichael2003). Rather, WISEs utilise a community economic development approach which, it is claimed, neutralises labour-market conditions of individualism, competition and profit, all of which create a climate of disadvantage (Warner and Mandiberg, Reference Warner and Mandiberg2006). In such a way, WISEs can help to ensure a fairer distribution of, or access to, resources, build social capital, provide an opportunity for disadvantaged and marginalized groups to expand their social networks, facilitate social trust and co-operation and strengthen existing peer support groups (Ferguson, Reference Ferguson2012).
Although there is potential for WISEs to impact upon the social determinants of health, it cannot automatically be assumed that this will result in all instances. A range of organisations (including some WISEs) in receipt of UK Government Work Programme contracts have been guilty of ‘cherry picking’, or ‘creaming’, clients (Johnson, Reference Johnson2013). In other words, instead of focusing their attention on those most in need, such as those facing multiple and/or complex disadvantages, they have focused instead on those closest to the labour market in order to achieve outputs dictated by Government-driven Payment by Results (PbR) contracts (Rees et al., Reference Rees, Taylor and Damm2013). The perverse outcome of this is widening disadvantage and increasing costs in the long run. This highlights how funding can dictate how an organisation operates, which could result in ‘mission drift’ and transformation of potential impact (McHugh et al., Reference McHugh, Sinclair, Roy, Huckfield and Donaldson2013).
Hypotheses and research proposals
As with the example of microcredit for enterprise, there is a paucity of evidence around the ability of social enterprises to impact upon the social determinants of health, simply because their potential in this regard has not (or has very rarely) been thought of in such a way before (Roy et al., Reference Roy, Donaldson, Baker and Kay2013). That said, conceptual and theoretical development, informed by a systematic (integrative) review of empirical evidence on the impact of social enterprise-led activity on health and well-being (Roy et al., Reference Roy, Donaldson, Baker and Kerr2012) is well underway. There is some (albeit limited) evidence (see Krupa et al., Reference Krupa, Lagarde and Carmichael2003; Ferguson and Islam, Reference Ferguson and Islam2008; Ho and Chan, Reference Ho and Chan2010; Williams et al., Reference Williams, Fossey and Harvey2010; Ferguson, Reference Ferguson2012) that social enterprise-led activity can impact positively on mental health, self-reliance, self-esteem and health behaviours, and can also build social capital and reduce public stigmatisation by demonstrating that members of marginalized groups can be capable, productive workers and valued members of society. There is also a body of evidence (see, for instance, Lomas, Reference Lomas1998; Kivimäki et al., Reference Kivimäki, Feldt, Vahtera and Nurmi2000) that suggests that such factors influence individual and community health and well-being. There is, however, a clear need for more empirical research to better understand the causal mechanisms at work through social enterprises and other civil society actors upon a range of intermediate and long-term public health outcomes. In recognition of this gap, a five-year programme of research to evidence the impact of ‘social enterprise as a public health intervention’ has been funded jointly by the UK's Medical Research and Economic and Social Research Councils, to commence in January 2014 (Glasgow Caledonian University, 2013).
Self-Reliant Groups (SRGs)
What are SRGs?
SRGs are the result of a Church of Scotland initiated project called ‘Wevolution’ which seeks to offer an alternative model of community development for women in deprived areas of Scotland. Although renamed SRGs in Scotland, the SRG model is influenced by Indian Self Help Groups (SHGs), and retains much of the ethos of the Indian model. Facilitated by Wevolution, women from the same socio-economic backgrounds have organised themselves into groups of five to ten, meeting and saving small amounts of money on a weekly basis. Several groups have started to develop collective microenterprises, the capital for which has come from a combination of group savings and funds administered by local financial intermediaries, with the aim being to create employment opportunities for SRG members, many of whom have been unemployed for several years.
The potential for impact
While it is still too early to determine the impact of SRGs in the UK, some hypotheses can be proposed about their potential based upon the experience of SHGs in India. SHGs have been successful in bringing women together to encourage self-sufficiency and address problems as a community through the utilisation of group lending systems and by linking groups to a bank to access microcredit. This often enables women to start, or scale up, businesses, and the economic power gained from women's increased income has been shown to enhance their ability to address social problems in their communities (Tesoriero, Reference Tesoriero2006), including issues around access to medical care, agricultural management, education and political participation (Mohindra et al., Reference Mohindra, Haddad and Narayana2008; Khatibi and Indira, Reference Khatibi and Indira2011).
We cannot, however, simply assume that similar findings will be seen in the UK context; the welfare state, for instance, provides a level of financial security that people feel they may lose by moving into work, whether self-employment or otherwise. This fear is exacerbated when considering that members of SRGs are often single parents who also have to consider the cost of childcare if they move into work. The worry for many is that employment will not pay more than their benefits, and will not lead to a better standard of living (Ray et al., Reference Ray, Hoggart, Vegeris and Taylor2010). This may limit the impact of SRGs in the UK, just as welfare has, in some ways, limited the impact of microcredit for enterprise in the US (Schreiner and Woller, Reference Schreiner and Woller2003).
There are, however, some facets of SRGs which, based upon research in the UK, we can tentatively suggest may well lead to improvements in health and well-being. SRGs operate an internal lending system using group savings, providing additional loan capacity which can act as a ‘safety net’ from which members can borrow for consumption purposes, rather than having to resort to credit from expensive money lenders. Access to affordable finance can reduce stress and worry and improve psychological well-being and physical health (Dobbie and Gillespie, Reference Dobbie and Gillespie2010) and there is evidence that a reduction in financial related stress leads to more rational decisions regarding finances which, in turn, lead to an improved ability to manage money (Lenton and Mosley, Reference Lenton and Mosley2012).
Research around the impacts of social capital also points to some potential impacts of SRGs. SRGs have the potential to enable members to form relationships within and between other SRGs, and with outside support agencies, thus expanding social networks. Support can be both emotional and practical, with a common aim to overcome or work across societal power gradients, which, it has been argued, is an important factor in health promotion (Szreter and Woolcock, Reference Szreter and Woolcock2004). Such bridging relationships across societal power gradients are recognised as being the hardest to gain, but will ultimately reap the greatest rewards over time (Hawkins and Maurer, Reference Hawkins and Maurer2010).
Hypotheses and research proposals
Work is under way to establish an empirical evidence base for the impact that SRGs could have on addressing issues related to social exclusion, and thus health and well-being. A longitudinal ethnographic study is under way which will provide insight into the impacts of SRGs as directly experienced by those involved (Hill O'Connor, Reference Hill O'Connor2013). Although some progress has already been documented in relation to women's involvement in the groups, it is hoped that this study will soon yield testable hypotheses for further research, and shed light on the mechanisms and pathways by which such involvement might lead to enhancements in health and well-being.
Conclusion
The retreat of direct state provision in many areas of UK social policy in the cause of austerity (Sinfield, Reference Sinfield, Farnsworth and Irving2011) has led to an increased demand for civil society actors to provide support and attempt to fill the gaps, while simultaneously reducing the resources available to enable them to do so. This is likely to lead to considerable human, social and economic costs in the future (New Economics Foundation, 2012), particularly in places where the worst of the impact has fallen upon the most vulnerable, excluded and marginalised in society. A diverse body of evidence suggests that a dynamic and engaged civil society can enhance the relevance and acceptability of actions addressing the social determinants of health (Blas et al., Reference Blas, Gilson, Kelly, Labonté, Lapitan, Muntaner, Östlin, Popay, Sadana and Sen2008). However, if social innovation is ultimately to fulfil its true potential as an ‘anchor concept for research in creative arts, human organisation, economic diversity, neighbourhood regeneration, regional renaissance, governance and other areas’ (MacCallum et al., Reference MacCallum, Moulaert, Hillier, Haddock, MacCallum, Moulaert, Hillier and Haddock2009: 2), then we agree with Grimm et al. (Reference Grimm, Fox, Baines and Albertson2013) that much more theoretical and conceptual development is required, particularly to apply it coherently to new disciplinary areas, such as in public health.
Furthermore, when focusing on specific SIs there is a need to apply a critical lens to assess the potential and realised impacts of the innovation (McHugh et al., Reference McHugh, Sinclair, Roy, Huckfield and Donaldson2013) and recognise that SI is not, in and of itself, necessarily socially positive (Nicholls and Murdock, Reference Nicholls, Murdock, Nicholls and Murdock2012). Irrespective of the potential for SI and the attention it is currently receiving, particularly at a European policy level, the large-scale research programmes that will provide the necessary quality and range of empirical evidence to demonstrate impact upon health and well-being, and an understanding of the causal pathways and mechanisms of action, simply do not yet exist.
