Published: 12/08/2004, Volume II4, No. 5918 Page 19

A new wave of not-for-profit NHS organisations with the public interest at heart could help breathe life into communities, says Dr Richard Lewis

Both Labour and Conservative parties appear to be united by a belief in unrestricted patient choice. Arguably, it works well with planned care - patient satisfaction in choice pilots has so far been high. However, consumer models of empowerment may not apply nearly as effectively elsewhere in the NHS.

As well as choice, patients also need 'voice'. Voice is an ongoing form of engagement allowing a wide range of interests to influence the wider planning and delivery of care - not just through a crude selection of provider when care is accessed.

The government has sought to revitalise community engagement in the NHS though oversight and scrutiny committees and patient forums and, particularly, through membership of foundation trusts. However, providing 'voice' through foundation hospitals runs a number of risks. Most obviously, that with added 'people power' the power balance between provider and commissioner may increase the already pervasive sense of 'provider capture'.

But the movement towards foundation governance of hospitals sits uneasily with the shift towards provider plurality. If stakeholder engagement is important, the introduction of the private sector offers no such democratic underpinning. Where NHS provision by private providers remains a minority interest, the primacy of shareholder interests over those of stakeholders may not matter much.

However, the use of private providers may quickly be more extensive - in particular, in primary care and chronic-disease management. Already, a pharmaceutical company is piloting chronic-disease management in a primary care trust in London, and private providers of general practice are beginning to emerge. Opportunities for non-NHS providers are set to expand as PCTs concentrate more on commissioning.

But the assumption that provider plurality must involve forprofit companies should be challenged. Instead, the NHS could encourage the development of a new cadre of not-for-profit organisations, with the public interest at heart.

Social enterprise could be encouraged, with local people involved as members and directors, linked to true community partnership boards. Experience in the US suggests there are big profits to be made in chronic-disease management. These could be reinvested in local health services, not siphoned off to shareholders.

The development of public benefit organisations is part of the wider agenda to revitalise communities and be supported by the government. As PCTs test the market for new services, support needs to be available to encourage NHS staff and local people to form new types of organisation. These could be 'community foundation trusts'. However, new legal forms may also be needed. Here the government is introducing the community interest company, a new type of not-for-profit organisation dedicated to the public benefit and with greater freedom for social entrepreneurship.

While these are not intended for NHS hospitals, there is no reason they could not be used for many smaller organisations.

Plurality could offer the dynamic service transformation that the government so urgently demands - and without losing the ideals of public service that have bound the NHS together for so long.

Dr Richard Lewis is a visiting fellow at the King's Fund.