Social Governance – a necessary third pillar for health care governance?
Abstract:
The new white paper on health, Equity and Excellence: Liberating the NHS, identifies three challenges to the delivery of health care. One is explicit in its title, namely to achieve standards of high quality care accessible to all. One is implicit in its title, that is to liberate the NHS from bureaucracy and from the State. One is excluded from the title, namely the need to deal with the national financial debt.
The white paper’s response is to focus on the two existing systems of governance in health care, Financial Governance and Clinical Governance. Unfortunately, as these often pull in different directions, the White Paper’s vision is to introduce more consumer choice and more market-style competition, since through the drive of individual choice, it believes that clinical standards will be forced upwards, whilst through the supposed efficiencies of the market, costs will be forced downwards.
Consumerism and the market however give the wrong messages to health care governance, since consumerism is inevitably self-centred and self-seeking, and for the market, the value that trumps all others is the monetary sign, a sign that has no intrinsic value in itself and which is all too pervasively becoming a tool, no longer for human development, but for exploitation of humans and of our earth. The White Paper understands the moral hazards and perverse incentives of consumerism and the market and addresses these by continuing the growth in systems external regulation despite its claims to the contrary.
If health outcomes are to become a guiding beacon, not only for our health care institutions but also for our society and for our economy, there is a need for new theory of health care governance, a theory that is framed not only by individual choice but also by acknowledgement of our participation in collective humankind; and by values that are not monetary but social, environmental, aesthetic and moral. If our response to the gathering financial storms are not to lead to widening social and economic inequality, then we need a strand in governance that reinforces our responsibility towards each other. Social governance offers such a theory, a theory of a healthy economy, a process of participation, democracy and debate, and an ethic of kinship and community.
Introduction
I wonder if you, like me, are disappointed by the narrow focus of discussions on health issues within health institutions. Do you, like me, find something missing from the way health and health care are defined, constructed, discussed and governed in our times?
The White Paper
In the forward to the new white paper, Equity and Excellence: Liberating the NHS, we learn that “patients will be put at the heart of everything we do”, “that there will be a relentless focus on clinical outcomes” and that “we will empower health professionals, with healthcare run from the bottom up and with ownership in the hands of professionals and patients”. We also learn that, “… our massive deficit and growing debt means that there are some difficult decisions to make [but] only by putting patients first and trusting professionals will we drive up standards, deliver better value for money and create a healthier nation.”
In this summary and aspiration, we see a clear appeal to the two existing systems of health care governance, namely those of Clinical Governance and Financial Governance. There is also something ambiguous and anomalous though. Is health just a clinical outcome? Is money the primary resource needed to bring about a healthy nation? Are professionals, patients and taxpayers the only stakeholders of our health care systems?
Health, its social dimensions and the need for social governance
We know very well that health has social, economic and environmental determinants. Clinical outcomes moreover are influenced by the social and economic circumstances of patients. Quality of care reflects not just technical norms but also the internal values of those delivering the care, which must reflect the external values and mores of the wider society. Perception of the quality of care by users is a judgement that depends upon expectations, expectations that again reflect the values of society. Health, in both its broader definition of well-being, and in its narrower clinical definition therefore has a social dimension that is not addressed in the white paper.
It may be argued that the function of the health service is clinical care and that as a service, or utility, the health service and those who work in it, need to focus on their role to provide clinical services and let the wider society debate and determine the social and economic norms by which we live. Health care however is an important part of the economy. The way, we run, finance and organise our health care, will influence the economy of our country. At present it is economic theories, external to health care, that are influencing its delivery. With health care’s insights into the negative consequences for health of much that passes for economic progress, it behoves that health carers turn more attention to the economic and social parameters of health and to include these parameters not just into debates on how to organise health care but also into those debates on the way that our economy, our society and our politics is run.
Social governance would therefore be a theory, process and ethic that would make explicit the social dimensions of health, both in its social and environmental determinants, determinants such as good sanitation, good food, meaningful employment, environmental harmony and social cohesion. It would emphasise an ethic of kinship, the recognition that as humans we share one humanity and live on one earth. It would be governance that recognises that every decision and action ripples out to affect others. It would be a process that seeks to bring collective and involved responsibility back into health care, responsibility not of professionals alone, but of all, patients, public and staff. Health is both personal and a shared experience. Health emerges not just from clinical practices but also from the ways we live, run our economy and relate to each other.
The White Paper and Health Care: the Challenge and the Response
Let me return now to the White Paper. What challenges does the White Paper recognise for the delivery of a universal and quality health care service in England today? It seems to identify three, one explicit, one implicit and one excluded from its title. There is the challenge of quality care for all, the challenge of bureaucracy and the challenge of money, or rather the lack of money.
I will begin with bureaucracy, and this challenge implicit in the title, “Liberating the NHS” and liberating it from what – from bureaucracy, administration and targets, namely from the state. This is a core neo-liberal aspiration. Health care professionals will be freed from central government targets and from central monitoring and administrations costs will be cut by 50% over the next four years.
There are contradictions though since in the White Paper, we learn of the formation of a new NHS Commissioning Board, a widened role for the economic regulator, Monitor, of a strengthened role for the Care Quality Commission, of new local and national Health Watch authorities, of extension of the Commissioning for Quality and Innovation payment framework and that 150 standards of care will be defined over the next 5 years, each with 5-10 measures which will act as markers of high-quality, cost-effective care. The central innovation of the White Paper though is the establishment of GP consortia, given responsibility for budgets and for commissioning of services, a system that must either take doctors away from clinical work or more likely re-employ those administrators previously receiving pay and pensions from the NHS but now paid for by independent GP consortia or the institutions they contract services to.
The second challenge, explicit in the title as “Equity and Excellence”, is the need to maintain and improve standards, a free health service available and equal to all, and a health service more responsive to the individual needs of patients, so that for the patient, “no decision about me, without me” and the government will “replace the relationship between professionals and politicians with relationships between professionals and patients”.
The most pressing challenge to health care, however, not expressed in the title of the White Paper but referred to repeatedly throughout its text is the financial challenge of the government’s budget deficit. So in the first chapter, we are told, “In the Coalition Agreement, the government said that the single greatest priority for the next parliament will be to reduce the deficit. It is now even more pressing that we implement the reforms set out in [in this White Paper] in order to increase productivity and efficiency in the NHS”.
In this way, the new health services are being framed as less bureaucratic, more financially efficient, still of the highest quality through the involvement of patients and through regulation, and still free at the point of service, and governed by systems of Financial and Clinical Governance, both of which will be strengthened by the proposals within the White Paper.
There are however inevitable tensions between clinical and financial governance, tensions that do not need to be spelt out in detail but which can be summarised as the desire of more for less, an impossible and debased principle in many ways, but one which seems to motivate not only many of those in power but many of our country’s citizens. This tension between clinical and financial governance, the desire for excellence yet achieved cheaply, or as the managers and economists would have us believe, achieved efficiently. But human care is only in small part an attribute of the principles applied by Henry Ford, Tesco, Walmart or McDonald’s if any part at all. The dilemma is there, good care requires in a word, care. Care is a virtue and not a system, a human quality, even a human discipline but never simply a technical exercise.
So how to resolve the dilemma of providing better care in a troubled economy. One way, and it seems that this is the way that the White Paper is leading us along is the path of consumer choice and market freedom.
To quote the White Paper, “Patients will have access to the information they want, … [They] will have the choice of any provider, choice of consultant-led team, choice of GP practice and choice of treatment.” “Money will follow the patient.” “There will encouragement of “personal health budgets.”
And again to quote, “The government will devolve power and responsibility for commissioning services to the healthcare professionals closest to patients. GPs and their practice teams will work in consortia”. “[There will be] a more comprehensive, transparent and sustainable structure of payments for performance so that money follows the patient and reflects quality.” “Monitor and the NHS Commissioning Board … will promote competition” [and] “GP consortia may choose to buy in support from external bodies.”
It is easy for critics of the White Paper to view it as arranging the furniture within the home of the NHS so as to make it into a shop front, and with a door open for the privatisation of services. The solution being offered by the government to the tension between Clinical and Financial Governance, seems to be two fold, namely to introduce consumerism and increasingly the market into health care provision.
Problems of consumerism and market competition for health care
If consumerism and market competition are being engrained into the provision of health care in England, then it is necessary to offer not just a critique of consumerism and market competition but to offer an alternative theory to resolve the contradictions between financial and clinical governance.
First the critique.
In two profound senses, consumerism and market competition can be considered as detrimental to health.
Health is a term that refers to a wholistic, integrated, responsive, functioning organism, an organism in coherence with itself, with others and with its environment, an organism in creative development and creative response to its circumstances. Consumerism, on the contrary, is a theory that states that human life is fulfilled in individualism, consumption and dissipation.
Market competition extols the virtues of social darwinianism where it is the strong that survive by winning in competition with others. Health care by contrast seeks out the poorer, weaker, sick and injured to bring them back to health and has at its core, values of solidarity, compassion and cooperation.
The problem is even deeper. The competitive market, and the White Paper is clear that commissioning must be competitive, is in a sense an amoral arena which puts profit, personal gain, environmental destruction before health. The consumer market gives the wrong message to both patient and provider. In fact, the market in its present form could be viewed as a health hazard, since the principle of market success is that of financial gain, and there are many ways to make financial gains other than improving services, such as by the externalisation of costs, the exploitation of anxiety, the driving down of wages to the primary producers of goods, and a standardisation of services that does not aspire to the best but to the cheapest or most profitable.
The White Paper understands these problems and a good half of the White Paper refers to regulation, both under the umbrella of Financial and Clinical Governance.
There is an alternative resolution to the tension between Financial and Clinical Governance; an alternative to the self-assertive consumer and the blind-hand (or rather “the dead hand”) of the market. The alternative is to recognise the social implications of our decisions for financial and clinical governance, and to bring clinical and financial governance into a creative dialogue with the communities that health care serves and affects, namely by introducing a third pillar of governance to health care which will be called Social Governance.
Challenges to Health Care – the wider picture
Social governance is necessary because health care faces many more challenges than those offered by the White Paper.
There is clearly the financial challenge. This challenge is however not simply the immediate one of responding to the gathering financial storm and the perceived need to increase financial efficiency. There is also a second, perhaps more profound, challenge. What does the financial value of something actually measure? Is there a need for other parameters of value such as those of health, well-being, social and ecological harmony. Money is a poor measure of any value.
There is the challenge of advancing medical technology which brings with it problems of cost and sustainability. Technological and pharmaceutical innovation in general raises the cost of care and inevitably imposes an increasing strain on resources and for the long term sustainability of services. Advances in technology all too often divert attention away from the social and life-style determinants of health. All too often they are accompanied by increased iatrogenic risk. And in many ways, advancing medical technology can make the aspiration for universal standards of health care provision more difficult to attain, as money and resources are diverted from basic care to the cutting edge of medical science.
There is the challenge of increasing demand for health care. In a world of an advanced, informed, consumerist orientated culture, such as that of the United Kingdom, there is an escalating demand for health care, a demand that is fuelled by an aging population, life-styles that bring with them increased illness, the news-appeal of the many, so-called, medical “break-throughs”, and a philosophy of health that is grounded in biotechnology.
There is finally the challenge of inequity. Repeatedly studies draw attention to the effects for the health of a society in general and for individuals in particular of social, educational, and economic inequality. There is poorer health for all, more social distress, more crime, less trust, more violence. Such studies are unable to make their way into the practice of health care, since the political economic philosophy of today is increasingly and unashamedly individualistic.
The stark omission in health care policy and philosophy in the present White Paper is therefore the absence of a philosophy of health that allows social, broader economic and environmental issues to be part of the framing debates on health. The model for patient and public involvement is that of the consumer. The role of health care institutions is technical, to provide a service. Social governance offers a model that allows the social aspects of health to be part of health care theory and would encourage active, participatory engagement in the pursuit of health at all levels by which we live.
Social governance – what could it mean?
Social governance is the examination of the wider social, economic and environmental effects of health care activities and the ambition to integrate the health economy into a healthy, functional and responsible economy and community. Its definition includes not only a goal, namely responsible social and economic integration, but also a process, namely participation by those involved in, and affected by health care activities. It is a theory of empowerment of individuals within interdependent communities. It is also a theory of health that recognises that healthy human being has a social dimension which almost all current theories of health fail to adequately recognise. It is the resurrection of those principles of health that understand that health is an impossibility without systems of sanitation, education, healthy food, meaningful work, pleasing environments and shared narratives of life/
Social governance has three aspects. Social governance is a theory of health, a process and an ethic.
The theory of social governance – a healthy economy
Progress in health care began some 300 years ago with the scientific revolution that led to advances in understanding of the anatomy, physiology and pathology of the body and enabled humans to begin to control their physical destiny through pharmaceuticals, surgical techniques and improved diagnostic tools.
Some 30-40 years ago, health carers began to appreciate that health care delivery requires knowledge not just of the body, but also an awareness and respect for the person before them and with it a need to address the psychology, understanding and personal narratives of the patient.
So, at present, in health care we have a philosophy of biology and a philosophy of the person. We now need a philosophy of healthy society. As health carers, we cannot be prescriptive about the form that this might take, but we can offer a critique of the present economic system, a system that makes the accumulation of money its primary goal, not the development of human being. We can also offer our insights into the nature of human well-being and offer suggestions as to what form a healthy society might take. In a profound sense, a healthy society would have to be founded upon a healthy economy, since it is the economy that determines our social relations with each other, helps satisfy our needs and produces the goods we aspire towards.
So what form might a healthy economy take? In essence it would be an economy that had as its primary goal, human development and the recognition that money is simply an intermediary value that too often enslaves rather than liberates. The economy would therefore be geared towards (i) qualitative growth not quantitative growth; (ii) respect for human being and the earth; (iii) an economy in which money serves humanity not humanity serving money.
Today’s parameters of a healthy economy are, nationally, a growing Gross Domestic Product and for the individual, a growing personal income. It is important to recognise that money in itself has no intrinsic value and is but a sign. It is not the “bottom line”. It has at times, and could again become, a symbol allowing fair, mutually advantageous exchange, but sadly in the present economic order, money is transmuting into a symbol for, and increasingly into a fact of, Power. Where once, money was a tool that allowed fair exchange of goods, today it is increasingly a tool for exploitation (of labour, resources and anxiety) through a banking system that works in its own interests through the promotion of debt, debt that leads to debt slavery, to income slavery and to wage slavery.
Part of the role of social governance in health care, and for the wider society is understand those real values that make life worth living. A healthy economy would be orientated towards the promotion of real capital, not financial capital, capital that we would be proud to leave to our children. Real capital would be understand in terms of natural capital (the local and distant resources), physical capital (the aesthetics and quality of the our constructed environment), human capital (the skills, insights and self-esteem of its stakeholders, and most importantly that of human trust) and cultural capital (support given to art, education and healthy recreation). Money becomes a measure of value only when we have forgotten the real values in life.
So what principles might underpin a healthy economy?
A renewed theory of work, since work is clearly important for self-respect and dignity and is necessary as an expression of the innate creativity of humankind.
An economy based upon relationships of care and cooperation not those of profit and exploitation and where the currency we wish to encourage to grow is trust, not the false and illusory goal of an empty, hollow, manipulable sign, the monetary sign.
An understanding that violence is both disease and symptom of disease and that any economy geared to militarism, destruction, weapons or violence is pathogenic and that violence in society is a sign of economiopathology.
An economy that understands the place of beauty as an inspiration for the human soul.
The process of social governance – democracy, participation and debate
The yearning gap in contemporary society is the democratic deficit, with the absence of opportunities for organisational democratic processes, for participation and for debate.
Social governance would therefore be an inclusive, deliberative responsibility.
involving all Stake holders. It complements the vertical structures of surveillance and command that are becoming synonymous with the present practice of financial and clinical governance and does so by experimenting with decision making processes that promotes horizontal relationships of shared responsibility and collective debate.
Drawing on experiments in collective decision making from social enterprises, community groups and shareholder meetings, it is a process of democratic accountability and social integration by which individuals, whether employees, patients or public, can feel that they have an influence and voice as part of a community of care.
Social governance needs to be distinguished from corporate social responsibility. Corporate social responsibility requires that corporations, as institutions abide by laws, respond to social and ecological issues and do not infringe human rights. One of the roles of social governance is to inform and exercise governance over corporate social responsibility. Social governance would provide the theories and inspirations that support the development of responsible, democratic systems to monitor the social, health and environmental consequences of an organisation’s activities, corporate or otherwise.
The ethic of social governance – an ethic of kinship
The defining principle of medical ethics today is that of autonomy. Autonomy is defined as respect for the individual and whilst it is important that respect for the autonomy of patients and individuals is exhibited in all interpersonal relationships, autonomy cannot be the guiding principle of any organisation, since in a sense autonomy, “auto-nomos” is self-rule and the polar opposite of ethics which examines and understands the effects of actions on others.
An ethic of respect for personal autonomy requires a balancing ethic of kinship, an ethic that recognises that as humans we share one humanity and live on one earth and that our values, our decisions and our choices affect others, not only those near to us, but also in our world of globalised trade, those who are far away and often unprotected by the laws and regulations of our own land. An ethic of kinship therefore expresses itself through
1. solidarity and community: As we face the storms to come of climate change and financial crisis, it is likely that we will be better served by the promotion of feelings of solidarity and mutual community rather than the pursuit of insurance schemes or accumulation of money in the bank.
2. fairness and justice: There is a need to aspire not just to high standards but also to universal standards, that patients and public themselves would be involved in defining and achieving, standards that would become the norm for all, wherever they might live and by so doing advance the cause of a global medical ethic.
3. responsibility: Through accountability, we address our responsibility to others. It is also important for us to express responsibility to Self, in other words to Truth and one of the greatest threats today to psychic health is duplicity and misrepresentation that lead to a creeping and spreading cynicism. There is also responsibility to our environment, which is our physical home. At times, we are also called to be responsibility for others, since one day we may well hope and wish for others to show a similar responsibility for us if we lie dying or injured.
The White Paper and references to social governance
There are references in the White Paper that can be considered to be progenitors for Social Governance. The forward to the white paper talks of ownership being placed in the hands of professionals and patients and early in the document, there is a section under the title of Putting Patients and Public First with the strengthening of the collective voice of patients and public through arrangements led by local authorities and Health Watch England, located within the Care Quality Commission. There is also background talk of a “Big Society”. In one section, the paper expresses the desire for GP consortia to become a powerful network of social enterprises (though in the following paragraph happily contradicts this by indicating that they must compete with each other).
The benefits of a theory, practice and ethic of social government
- recognition of our responsibilities to each other
- recognition that health is a collective endeavour
- empowerment of health organisations to influence the debates on our economy and society
- the development of a science of health that includes the social in its paradigm.
Social governance therefore provides another dynamic to health care governance. It cannot hope to resolve the tensions between clinical and financial governance but will try to promote constructive dialogue between these existing systems of governance, help us move beyond egoistic demands to collective responsibility and replace competition by cooperation.
It is possible to see the present White Paper as a reaction to the Power of the State, an attempt to diminish the bureaucratising power of government to rule and control our lives. It is likely however that in the place of State Power, the reforms of the White Paper will move power away from government to those of Corporations. Social governance offers an opportunity to empower the third source of power in the modern world, namely that of Civil Society. It could help align health care not with the power of corporations but with the power of civil society and through experiments with democratic participation and debate, begin to transform the State from a threat to an umbrella of support.
Conclusion
I have offered a third model of governance for health care. This is social governance. which has three dimension, a theory of health, a process of organisation and an ethic. I believe it offers a platform by which to oppose, where necessary, and influence constructively, where appropriate, the recent White Paper. It also offers a stream of thought that allows those conceptual seeds in the White Paper that mention public involvement, and social enterprise to be watered and encouraged to root and develop shoots that will give health not just to health service organisation but also to the diverse industries, institutions and organisations that relate economically and socially with health care providers.
Author:
Chris Bem Bradford Teaching Hospitals Foundation NHS Trust
chris.bem@bradfordhospitals.nhs.uk
chrisbem@btinternet.com