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“Small is beautiful” goes the old economist’s slogan, and if you’re a gnat on the back of the NHS giant the attractions of the sentiment are obvious. Why not break free of the giant and take off  on your own? Even foundation hospitals could only dream of that, especially after chancellor Gordon Brown had curbed their financial independence, but the Oxfordshire Learning Disability NHS Trust is nothing if not ambitious. It has taken the health and social care white paper at its word and applied to become a social enterprise, a breed of non-profitmaking company for which the government has developed a fondness. This probably wasn’t what the Department of Health had in mind and the trust must have little chance of success, given that the government will risk starting a stampede if the application is successful. Nevertheless, the proposal deserves to be taken seriously.

The trust argues that there is a mismatch between NHS targets and effective learning difficulties services. Certainly, the health service obsession with centrally driven targets, cost-effective  treatment and patient throughput does not lend itself to services where the balance tilts towards long-term health and social care support and, in theory, the promotion of independence. Irrelevant targets are a needless drain on budgets and staff resources that would be better used elsewhere.

Social enterprise status could provide a welcome escape valve for funding pressures, both in Oxfordshire and elsewhere in the country if the idea caught on. Granted the autonomy it seeks,  the trust believes it would be more nimble. That would be in contrast to directors of adult social services if, as has been mooted, the DH were to insist that they took responsibility for all council services for adults. The director’s brief would be a loose, baggy monster, pulling in all directions and impossible to master. Rather like the NHS.


Doubtless the DH thinks a single line of accountability will make it easier to impose central control on adults’ services. But it cannot be in the interests of responsive services and the agile localism that the government has also said it wants. In this sense, at least, Schumacher was right about beauty. 

● See Lukewarm reaction to plan for adult services directors to have wider role and Learning disability trust aims to split from NHS and set up social firm