Understanding the persistence of value problems in third sector delivery of health services: evidence from the implementation of ‘Green Social Prescribing’ in the English NHS

• In Event: Third sector and health

Abstract

This paper seeks to understand the challenges experienced by third sector organisations providing health related public services. Even though numerous policy reforms since the 1990s have sought to increase third sector involvement in the provision of health services (Wistow et al, 1994; Osborne, 1997 and 1998) many third sector organisations still struggle to access funding to support their work and experience persistent challenges with the sustainability of their provision (Dayson et al, 2023; Milbourne and Cushman, 2015). Drawing on qualitative date (n=137 interviews) from a large national study of efforts to embed green social prescribing (GSP) in the English NHS, we argue that uncertainty about funding for the third sector is the primary factor holding back its growth and development. To explain this apparently intractable challenge, we identify three types of co-ordination problem linked to the ontology and epistemology of value (Beckert, 2009) as major barriers that key stakeholders struggle to overcome.

We characterise problem one as value of what? It is an ontological problem relating to the phenomenon that different stakeholders need to understand the value of. The second problem we characterise as value to whom? It is a further ontological problem relating who different stakeholders believe the benefits of GSP ought to be accrued by or for. We characterise the final problem as how do we know and agree that value has been created? It is an epistemological problem relating to what data, measures and types of evidence are meaningful for different stakeholders. We explore each of these value problems through an institutional lens (Thornton et al, 2012) that reflects the different scale and perspectives associated with GSP as complex multi-scalar phenomenon operating across multiple layers of governance and implementation. The micro scale reflects perspectives of third sector organisations delivering nature-based activities who received referrals through a GSP pathway. The meso scale reflects the perspectives of regional NHS-led integrated health and care systems who commission and implement GSP services. The macro scale reflects the perspectives of central Government departments and agencies – health, environment, physical activity etc – who sought to create the policy conditions to develop and implement GSP at scale.

Although focussed on GSP and the English NHS, our findings ought to resonate in other policy fields and jurisdictions. Increased involvement of the third sector organisations in public service delivery and mutli-scalar partnerships with state are long-term trends in many social and liberal democracies (Salamon, 1987; Young, 2000). This paper provides some pointers as to types of systemic and epistemic changes that may be necessary to put state-third sector relationships on a more sustainable and equitable footing. Given the embeddedness of markets in social relationships and processes (Beckert, 2009), we suggest that a deliberative approach to building consensus about the ontology and epistemology of value – drawing on the three value questions posed in our paper - could be an important and necessary step in this process.

References

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Authors

• Christopher Dayson, Sheffield Hallam University

• Catherine Harris, Sheffield Hallam University