A 'SIB effect' in measuring, understanding and governing social value? A comparative analysis of two social prescribing services in the English NHS

Social prescribing is an innovation in health services which enables professionals to refer patients with complex health conditions to sources of social support provided by local third sector organisations (South et al, 2008).... [ view full abstract ]

Social prescribing is an innovation in health services which enables professionals to refer patients with complex health conditions to sources of social support provided by local third sector organisations (South et al, 2008). The period since 2012 has seen the emergence of social prescribing as a key  component of NHS sustainability and transformation policy and whilst most services have been commissioned in the 'traditional' way there is increasing interest in financing social prescribing through social impact bonds (SIBs).

Commissioners are attracted to social prescribing because of its purported ability to create social value (Dayson, 2017) but how social value is measured and understood, and how this is affected by, mediated through and accounted for as a result of different approaches to commissioning and financing public services is under-researched.

This paper will present a comparative analysis of two social prescribing services in the English NHS, one financed through a 'traditional' commissioning model, and the other through a SIB. Our comparison draws on in-depth qualitative research in both areas to address the following research question:

To what extent is there a 'SIB effect' in the measurement and understanding of social value?

In addressing this question we frame social value and SIBs in the context of two competing paradigms of public management: New Public Management (NPM) and New Public Governance (NPG).

Our findings suggest some similarities between the two cases: (a) a strong neo-corporatist approach (i.e. NPG) to the development of the service and;  (b) a common approach to measuring social value.  However, they also suggest some differences that can be attributed the different models. In particular, in the SIB model we find that (a) more resources are spent trying to create and utilise rigorous measures of social value; (b) the more ‘rigorous’ measurement methods raise significant practical and conceptual problems and concerns; (c) social value evidence is used in a more overtly performative way, and we see evidence of ‘gaming’; and (d) attempts are made to shift the challenges of demonstrating value to those lower in the implementation hierarchy.

In conclusion we argue that the financing mechanism for a public service can have a direct effect on the way in which social value, and the service more generally, is governed. This includes formal governance mechanisms, such as performance and payment indicators and the ways in which they are applied; and informal governance mechanisms, including the ways in which commissioners, accountable bodies and delivery partners discuss and interpret social value evidence. Whilst both services embodied neo-corporatism and the broader principles of NPG during the development process, during implementation it was quite different: in the SIB case many of the traits of NPM took hold; and whilst we also found some evidence of NPM 'creep' in the non-SIB case it was far less evident and the service has remained truer to its neo-corporate origins. This potential ‘SIB effect’ is important and may well affect the decision to implement a SIB in the first place if it was more widely understood.