Social governance: a necessary third pillar of healthcare governance

There are at present two pillars of governance in healthcare delivery today. These are financial governance and clinical governance. Health, however, has social, cultural, economic and environmental parameters,^1,2 which at present play little substantive part in the theory and governance of healthcare delivery. Health services are also an important part of the economy. The economy gives structure to society, and so healthcare organization has an important influence on the values, relationships, security and aspirations of a society. I, therefore, propose that a third system of governance is introduced into healthcare, namely that of social governance.

Social governance would be a theory, process and ethic that made explicit the social dimensions of health, emphasized an ethic of community, and developed processes of collective responsibility for healthcare provision. It would give to healthcare a role not only to repair broken bodies and minds, but to help develop a healthy economy, healthy environment and healthy society. Such governance is particularly important in the face of the government white paper on health,³ which many see as having the potential to erode the values and principles of the National Health Service, and opening healthcare to market inequities, profit-seeking healthcare providers and self-seeking consumerism.

Social governance is governance that gives healthcare a role and responsibility in promoting a democratic, fair, healthy and sustainable economy and society. It begins with processes within healthcare institutions that encourage organizational functionality, cohesion and responsibility through involvement of staff, patients and the public, and extends out to form links with those, often on other continents, whose labour and resources help us in our pursuit of health. It is governance that brings theories of the social and environmental determinants of health into the functioning and goals of healthcare institutions.

In healthcare today, we have a philosophy of biology founded upon the continuing advance of biological sciences. We also have a philosophy of the person resting upon respect for the individuality and autonomy of each patient. When we turn to society, however, especially when we look globally, we see increasing social inequity with widespread poverty, malnutrition, violence, destruction of human habitat and degradation of the human condition, despite our growing physical wealth and knowledge. Perhaps these are symptoms and signs of a disordered, pathogenic economic system, which it is our vocation, as healers, to understand and offer remedies for.

In its most simple sense, a healthy economy cannot only be equated to a quantitative growth in money, whether as gross domestic product or personal income, since in itself money is a sign with no intrinsic value, a value only when all other values have become forgotten, and a tool more often for exploitation and harm than for development and benefit.^4–6 A healthy economy would be directed towards the qualitative improvement of the human condition and not the exploitation of labour, anxiety, resources and privileged knowledge for personal gain.⁷

The processes of social governance are difficult to define and illustrate since today, we have become accustomed to governance that depends upon hierarchical and bureaucratic control with only a nod to democratic involvement. Social governance by contrast would be a process of horizontal, democratic participation, ownership and belonging.⁸ It would actively promote debate since, in debate, we learn to articulate our opinions and so empower ourselves, learn the skills of communication and arts of negotiation and help to form collective narratives of life and meaning that help promote social cohesion.

Processes of social audit would monitor the ways our behaviours and economic practices affect others and how they contribute to the development of social capital – human capital (health, skills, knowledge, self-esteem, social trust), natural capital (water, food, energy), physical capital (quality, aesthetics and sustainability of the constructed environment) and cultural capital (education, art and recreation).⁹

Social governance needs to be distinguished from Corporate Social Responsibility. Corporate social responsibility is hierarchical, a response to externally driven norms, often formal and legal. Social governance would promote the values and processes that will provide governance over Corporate Social Responsibility.

The guiding ethic of social governance is human kinship¹⁰ by which we understand 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 globalized trade, those who are far away and often unprotected by the laws and regulations of our own land.

The guiding principles of an ethic of kinship would be those of solidarity, fairness and responsibility. In solidarity, health institutions would recognize a need to respond to humanitarian crises across the globe, participate in global health initiatives and support cross-border institutional linkages. Through a feeling for justice, we would support a campaign for Fair Health, recognizing that there is a need to aspire not just to high standards of healthcare, but also to universal standards.¹¹ Health institutions would also commit to policies of Fair Trade so that those who produce the goods that contribute to our health, can make progress in their own aspirations for health and development.¹² Through accountability and audit, we address our responsibility to others and the environment. Through responsibility, we give meaning to human life.

Numerous studies show that health is, at least in part, socially determined. Social governance enables these social theories of health to be included in the framing debates on healthcare delivery and involve all health carers in the promotion of an equitable, responsible, cohesive society.

The importance of empowerment for personal wellbeing and a sense of ownership for the functionality of an organization is well-recognized. Social governance provides a means for empowerment of individuals within responsible and caring communities.

Social governance can help reverse the growing democratic deficit, a serious threat to healthy societies since such a deficit leads to political apathy, private cynicism, acquiescence to policies of doubtful public worth and eventual existential escape through the pursuit of money to find personal freedom from ‘the system’.

Finally, social governance would offer a way of resolving the inevitable tensions between financial and clinical governance, tensions that will grow if the economy stumbles further and which the government white paper seeks to resolve through increased consumer choice and increased market freedom. Social governance would address the social implications of financial and clinical decisions and help bring clinical and financial governance into creative dialogue with the communities that healthcare serves and affects.

A third model of governance for healthcare has been offered. This is social governance. It provides a way to bring social theories on health within the orbit of healthcare policy at all levels. It offers a stabilizing third paradigm or pillar for governance where financial and clinical governance come into conflict and helps to ensure that high quality healthcare in England remains a universal right and public service. For those critics of the white paper, Equity and Excellence: Liberating the NHS, where necessary, it offers a platform for opposition, and, where appropriate, it offers a perspective for constructive influence.

Footnotes

DECLARATIONS —

Competing interests None declared

Funding None

Ethical approval Not applicable

Guarantor CB

Contributorship CB is the sole contributor