Dentistry has been particularly hard hit during the COVID-19 pandemic. The impact on patients, dental businesses and the dental workforce has been a matter of great concern and sombre discussion across the dental community. Although the full extent of the COVID-19 impact on oral health will not be known for some time (maybe years), it is not difficult to envisage the pronounced impact it will bring upon those who are most vulnerable and there is a serious risk of widening oral health inequalities. The pandemic has caused many of us in the dental profession to reflect on our aspirations, employment, and what role each of us plays in our communities and society overall.

All parts of the dental community have signalled a desire to build back better, stronger and more resilient than before, taking into account lessons learnt.1 However, this begs the question: what is better and how do we know it is better? There is general agreement and consensus as to what this will look like clinically,2 but there is much less attention on what the most effective healthcare models to deliver this are, and specifically what principles and values will underpin delivery of dental care. In particular, how will these models address persistently poor oral health in groups experiencing social exclusion? There is a need to consider this alongside clinical strategy, as evidence indicates that progress on addressing oral health inequalities is stalling,3 with those most in need being least likely to benefit.

The National Health Service (NHS) Long Term Plan highlights the important role of social enterprises in developing innovative models of care for people at risk and with complex needs.4 So, what is social enterprise? Social enterprise is all about combining business with social justice, and using business and enterprise as a force for good and a way of bringing about positive social change.5 Social enterprises can take many forms, ranging from large multinational companies to small local start-ups. They are a significant part of the UK economy, representing nearly half a million businesses and employing approximately1.44 million people.6 Social enterprises in the UK pay more tax than Amazon, Facebook, Apple, eBay and Starbucks combined.7 While there are many different legal forms, one thing that unites social enterprises and distinguishes them from mainstream business is the need for societal benefit as a key driver of success. One of the more common models of social enterprise is that of a community interest company (CIC). CICs are limited companies with special additional features, created to conduct business, or other activity, for community benefit and not purely for private advantage. This is achieved by a 'community interest test' and an 'asset lock', which ensure that a CIC is established for community purposes to which the assets and profits are dedicated. Registration of a CIC has to be approved by the regulator, who also has a continuing monitoring and enforcement role.8

Social enterprise has a significant role in the NHS where services are delivered via a mixture of state-run and independent health providers. The concept of social enterprise in health policy has been promoted by the Department of Health and Social Care (DHSC), and today, around a third of all community health services are delivered by social enterprises.9 In 2006, a social enterprise unit was established at the DHSC, and the 'right to request' and 'right to provide' provided a pathway to increase social enterprise delivery in the NHS marketplace. Despite social enterprise being commonplace in the health and social care system, there is still a lack of understanding about the benefits that a social enterprise can bring to the healthcare system and, most importantly, to patients. Due to the lack of recognition, social enterprise providers sometimes struggle to access NHS capital and other benefits provided through state management. Ensuring a level playing field is crucial to enable social enterprise to flourish and support the NHS.

Social enterprise in dentistry is much less common than in the wider health and social care system. The Public Services (Social Value) Act 2012 requires NHS commissioners to consider how an area's social, economic and environmental wellbeing can be improved through the procurement process.10 It is unclear, however, how the added value of social enterprise is viewed as part of the procurement process, if at all, and what metrics are considered important in its weighting and assessment. What is clear is that businesses that strive for social value are an important part of the healthcare market and can bring benefits to local communities through extended reach and engagement. This is highly appealing to addressing oral health inequalities as services can be designed around the patient or local community and not based on a one-size-fits-all commissioning philosophy.

Most examples of social enterprises in dentistry relate to former community dental services that transferred into social enterprise as a part of a larger community health provider. Despite the smaller numbers, there are examples of successful and innovative providers across the country. Some examples include the Community Dental Services CIC in the East of England and East Midlands, Smile Together CIC in Cornwall and Peninsula Dental Social Enterprise (PDSE) CIC in Devon. The latter is the clinical service provider for the Peninsula Dental School at the University of Plymouth. PDSE is the only model of its type supporting a university dental school in the UK. What is different about these providers is the more locally accountable approach to running services rather than reliance on decision-making as part of a larger NHS body. This offers flexibility and agility, and allows them to generate solutions to problems through re-investment of surpluses for community benefit in a way that is faster and more responsive to community needs. A good example is services developed de novo at PDSE to address unmet oral healthcare needs in local people experiencing homelessness and other vulnerable groups.11 These initiatives are transformative for patients, and deliver social impact and longer-term benefits to the health system.

While there are many successful business models for dentistry, and social enterprise is just one of them, the perils of profit-first models have been highlighted recently with potentially serious risks to patients.12 Social enterprise is not the only answer and will not be the only answer for dentistry. However, where there is a need to focus on wider outcomes such as social, economic and environmental outcomes (the so-called 'triple bottom line'), social enterprise offers an alternative approach, particularly for services that routinely work with vulnerable patients. As we consider how we build back better, a focus on the triple bottom line is a good place to start. The question was 'is social enterprise good for dentistry?' The answer is yes, because what is good for patients must be good for dentistry.