Social capital

IIn today's British health service the experiences of patients and the insights of doctors and nurses¹ highlight demoralisation and fragmentation. The solution lies in correcting years of underinvestment, but the nature of that investment must be appropriate: new buildings and staff are not enough.

Public policy experts such as Robert Putnam (who recently ran a seminar at 10 Downing Street²) argue that any complex organisation uses three forms of “capital”—physical, human, and social.^3–5 All three have been run down in the NHS since 1948 and are addressed in the NHS Plan for England.⁶ The planned increase in spending on health and the proposed expansion in staffing, with increased emphasis on good employment practices, may in time address the shortfall in physical and human capital.

However, the greatest loss over the past 50 years may have been in squandered social capital. Social capital consists of those social networks of mutual trust and the associated norms of reciprocity that made the NHS “ours.” The NHS is essentially a national partnership between the citizens and those who work in it. For all partnerships the defining element is mutual trust and generalised reciprocity—the willingness to contribute, confident that at time of need in the future there will be support in return.

The accumulated capital deficit in the health service cannot be addressed in one dimension. Both physical and human capital require social capital to generate changes in process and outcome—and to offer value for money on the investment. Until all three capitals are balanced, the system will not be able to absorb and successfully apply the new investments in the NHS Plan.

So how can politicians, managers, and clinicians generate the social capital needed to sustain the NHS? Firstly, they must understand the nature and importance of social capital that holds organisations together. In the absence of trust and mutual obligation staff become mired in mistrust and self preservation, while the organisation declines. Communities and organisations with high levels of social capital work more productively and cooperatively than those with low levels—and are also healthier.⁷

Secondly, managers need to understand why the NHS's social capital has been eroded. Organisational and management structures grounded in market economics have undermined the community's sense of shared ownership. A hospital centrally positioned 20 miles from the surrounding towns may make exquisite economic sense but ignores the social capital.

The social responsibility of doctors, nurses, and other staff—their professionalism—is devalued by focusing primarily on economic and performance accountability. Though performance management is important, it should be treated as a learning rather than a policing tool. Of course, learning cannot be properly organised when there are chronic staff shortages—low human capital.

Thirdly, politicians and managers must rethink organisational roles, nurturing the principle of subsidiarity.⁸ Decision making should be located as closely as possible to the place where actions are taken. The performance of organisations is most effectively governed when subsidiarity is applied,⁹ and we hope that this will be a key conclusion of the new chief executive's review of the working of the Department of Health.

The three strands of capital—physical, human, and social—must be braided together to make the NHS responsive and sustainable. In particular, all the elements in the NHS that erode the store of social capital must be replaced. Acute and primary care trusts, hospitals, and general practices need to be empowered by the NHS and to engage with and become closer to the communities they serve. If this is achieved the day could return when the NHS is a central but quiet element of our social success.