Social Governance, The Third Pillar of Health Care Governance

The author of this paper would like to invite you for discussion of the paper. Please submit your discussion by leaving a comment on this post.

Chris Bem
Consultant ENT and Neck Surgeon, Bradford Royal Infirmary
chrisbem@btinternet.com
20^th May, 2008

Article for Bulletin of NHS Consultants’ Association

There are at present two pillars of governance in health care delivery today.  These are financial governance and clinical governance.  This article will argue that there is a need for a third pillar of governance within health care, if health care is to play its part in helping not just to repair broken bodies and minds, but to also help humans develop a healthy economy and a healthy society.  This third pillar of governance is social governance.

Social governance is governance that understands that as humans, we are social creatures who live in communities and that these communities extend both in space and in time, geographically across the globe, and historically both backwards to the roots of our cultural traditions and forwards to those who will come after.  The aim of social governance is bring the social dimension of health care into health care delivery.

The two explicit sources of legitimacy within health care delivery today are those of the market and the expert.  One is based on the premise that market freedom improves access to health care by reducing costs through forcing organisational efficiency and outsourcing services to the least costly provider.  The second is premised on a belief that for all problems there is an ideal, technical solution, which can be, and ought to be, systematically imposed throughout health care.  The legitimacy of one rests upon competition, supposedly between equals, that of the other upon a hierarchy of knowledge.

Social governance introduces a third source of legitimacy for health care practice, namely that of kinship, the recognition that as humans we share one humanity and live on one earth. It is the legitimacy of horizontal cooperation for the collective good and of an understanding that the best is usually particular and conditional upon local circumstances.

The challenges to health today and the need for social governance

The first challenge to health care is money.  This problem of money is usually framed in the form of “not enough money”, but this ignores that the monetary sign has no stable or intrinsic value of itself, and is but a tool.

At present, because it is believed that there is not enough money for health care (a ludicrous proposition, similar to the proposition that there is not enough money for agriculture), there are two schools of thought, both monetarist, relating to health care.  One school is to drive down all monetary costs, through efficiencies in packaging and delivery (the Tesco-isation of health care delivery), lowered wages (for some), outsourcing (e.g. radiology reporting, typing), and the externalisation of costs (importing nurses and doctors educated elsewhere, buying surgical instruments made cheaply overseas).  The second school is more radical and seeks salvation to the monetary problem by wanting to divide and parcel up health care so that it can become commodified and thrown out into the market, where it will, by a simple  (but dramatic) change in the relation between carer and cared for, no longer consume money but generate money.  The cared for will receive care because there is financial gain to be made, not because there is natural, human and social, norm to be served.

The first goal of social governance is therefore to develop a real analysis of economic value.  Monetary value does not substitute for economic value.  An economy has value when it contributes to a long-lasting improvement in the material, psychological and social well-being of a population.  Such an economy needs money as a stable medium of exchange.  In the present profit-orientated market, money no longer has stable, universal value but is a manipulable token whereby those who do not work can grow rich through the exploitation of the labour of others, through the exploitation of the natural resources of our earth and through the exploitation of human anxieties induced by our still fragile existence and self-esteem.

Lately, our society has fallen into the trap of thinking that financial (or monetary) growth is equivalent to economic growth.  Financial growth can all too easily result from perverse mechanisms, which destroy the well-being it aspires to.  Therefore whilst the commodification of education, essential services (water, electricity, sewage) and the care of the sick and of the aged all lead to increased financial turn-over, they turn the economy into one of competition and the pursuit of personal advantage (in the form of interest dividends, profit or a bargain).  By contrast, in an economy, guided by the principles of social governance and focused on real economic development, we recognise that economic cooperation for the common good is more important and rewarding than self-seeking competition (whilst not ignoring the benefits for all of healthy, friendly competition).  Through promoting social capital and social cooperation, social governance recognises that we serve best ourselves and those we love, when we serve others well, that we gain more by giving more, that creative labour is more satisfying than passive consumption, and that participation in community, even when problematic, is more stimulating than television video-voyeurism from a safe but impotent distance.

The second challenge to health care is technology.  This may seem a strange analysis, since technology is often considered the solution to so many of the threats to human existence.  Like money, it however is a tool, and cannot be an end in itself.  Like money, it needs to be subjectified into a social as well as a personal vision.  There is the need to acknowledge that my technologically, sophisticated hospital may be diverting resources away from those who already have very little, may be contributing to increasing energy consumption and will no doubt at some point discard into the waste pile its present technological systems to make way for the new.  This is not to adopt a Luddite position with respect to technology but to work for the dissemination and broad spread of technological development, rather than the ambition to always be at its “cutting edge”.   All too often, the technological fix serves also just as a substitute for not addressing the psychosocial problems of our contemporary life.

The third challenge to health care is individualism, or to be more particular the self-seeking, self-referencing egoism of a western consumer for whom all services are there to serve him/her without reference to others, resources or even his/her own health.  Social governance promotes the principle that the good and healthy life is one in which our responsibilities to each other empower us rather than divert us from our true human calling.  Social governance therefore undermines that principle that has guided so much of our economy since first enunciated by Adam Smith in his influential text, “Wealth of Nations” (1776), a principle that stated, “It is not from the benevolence of the butcher, the brewer, or the baker that we expect our dinner, but from their regard to their own interest.”  Social governance opposes, head on, such beliefs that “greed is good” and that “selfish is sensible”.  It recognizes that human consciousness is evolving from consciousness of self to consciousness of others and of our earthly ecology.

Principles of Social Governance

Three guiding principles of social governance are proposed.

1. The encouragement of social values – values such as fairness, cooperation, service and responsibility, values that help us to become more human by living in humanity with each other.
2. The promotion of a healthy economy – namely an economy that is life-enhancing and sustainable, whose primary goal is human development and not the increased circulation of money by whatever means, good or foul.  A healthy economy is one in which money is the servant not the master.
3. The development of democratic responsibility –  which of necessity must begin with increasing participation by communities in the decisions taken, supposedly on their behalf, by the myriad bureaucracies increasingly controlling our  life (of which there are few less ambitious than in health care), and by corporations supposedly ever more sensitive to our needs (and increasingly taken as the model for optimising health care delivery).

Themes for Social Governance

There are numerous pressing issues for social governance, many already on the agenda, issues such as the carbon footprint of health care, the need for ethical procurement of health care consumables, the empowerment of patients and stakeholders within health care delivery.   Social governance provides a unifying theory for these issues, and helps show that health care can be  (should be) an important economic activity in its own right that encourages us to acknowledge our need to care for each other’s biological well-being and to respect each other’s human dignity.  It addresses the hazards to physical and communal health that markets pose when unfettered by regulation, social purpose or moral insight.  It aspires to the formation of living, active communities which help give purpose and meaning to life.  It seeks to ameliorate the threats to the environment that our economic activities pose.  Social governance would also look to involve the health economy in activities that promote peace, social enterprise, culture and well-being.

Process of Social Governance

The processes of social governance are important.  Most importantly, social governance must be distinguished from Corporate Social Responsibility.  Corporate Social Responsibility is hierarchical, a response to externally driven norms, often formal and legal and employs existing power structures within organisations.  Social governance, by contrast promotes horizontal relationships of mutuality and interdependence, feeds on the innate, inner sense of kinship that many humans feel for each other, and actively experiments with new tools for decision making and participation.  Social governance promotes the values and processes that will provide governance over Corporate Social Responsibility.

Social governance is therefore a process of democratic accountability and social networking by which individuals, whether employees, patients or citizens, can feel they have an influence and a voice through being part of a community that allows and encourages discussion of the goals and functioning of the organisation and of the wider society.  It is a process of empowerment of individuals within communities.

Social governance also builds on the idea that economic capital refers not only to financial capital but also to natural capital (the local and distant environment), physical capital (the aesthetics and quality of the organisation’s buildings), human capital (the skills, insights and self-esteem of its stakeholders), social capital (the willingness to take the views and needs of others into consideration) and cultural capital (support given to art, education and healthy recreation).  These aspects of social governance allow a trail of social audit to be developed.

Benefits of Social Governance

Numerous studies show that health is, at least in part, socially determined.  If social governance can to any degree improve the social functioning of society, it will have consequences not just for social equity but also inevitably for individual health and well-being.  Therefore social governance is not only a response to the need for social responsibility on the part of citizens, but also an organisational and institutional response to the call to reduce the economic and social inequalities between and within societies, as called for in the recent WHO report on social determinants of health.  It helps direct a nation’s economy to well-being and health, helps substantiate the need for health care services to extend without discrimination to all sections of society and points out that life and health develop not from a competition for survival but from mutual collaboration.

Social governance promotes collective responsibility for the organisation in which we work and for the society in which we live.  It helps the move from consumerism to creative labour, from social alienation to active participation. It recognises the important resource that humans are, and that work, when done in pursuit of the right goals is part of a healthy, meaningful life.

The importance of empowerment for personal well-being and a sense of ownership for the functionality of an organisation is well-recognised.  Social governance provides a means for empowerment of individuals within responsible communities.  It is both a shield and protection against rough times ahead (an insurance better than any privately financed scheme) and a training ground for meeting the challenges of the future as a single humanity.

Conclusion

There is a need within health care for a third pillar of governance to complement those existing pillars of financial and clinical governance.  This third pillar is social governance.  Such a system of governance will help health care delivery to remain equitable and open to all, despite the worsening storms brought about by the falling global economy.  Social governance could also give to the health economy an important pioneering role in showing a way out of the present financial storm and help in the development of a stable, sustainable economy.

Some references and reading material

“Social Audit Toolkit”, Freer Spreckley, Local Livelihoods, 4^th edition, 2008 (www.locallivelihoods.com)

Bhutta MF: Fair and ethical trade in health procurement

Lancet 2008;372:1935-7

Closing the gap in a generation: health equity through action on the social determinants of health, World Health Organisation, 2008

Vladimir Benacek: Three Dimensions of Modern Social Governance: Markets, Hierarchies and Kinships (http://unpan1.un.org/intradoc/groups/public/documents/nispacee/unpan021401.pdf)

“The Great Transformation: the political and economic origins of our time”, Karl Polanyi, Beacon Press, Boston, 2001 (original edition, 1944)

“The Philosophy of Money”, George Simmel, Routledge 2008 (original edition, 1978)

“The Reinvention of Work: a new vision of livelihood in our time”, Matthew Fox, Harper, San Francisco, 1994

“The Gift”, Lewis Hyde, Vintage Books, 1979