I’ve been thinking a lot about two words, governance and stewardship, recently. In part this is because, with Josep Figueras, I’ve been working on the text for the Tallinn Ministerial Conference but also because I’ve been teaching about it to our MSc students. I’m grateful to one of my PhD students and to my MSc seminar group for the examples I’m going to use in a minute.
The problem with both of these words is that everyone seems to use them differently. A quick search on Google reveals dozens of definitions of governance; stewardship, a term that came into widespread use following publication of the 2000 World Health Report, has received less attention but it is also clear, listening to it being used, that it can mean all things to all people. As always with health policy, I take comfort from Lewis Carroll’s book, Alice’s Adventures in Wonderland, where Humpty Dumpty says “words mean what I choose them to mean”.
Yet maybe we can turn it round. We may not know what (good) governance and stewardship are but we do know when they are absent. Hence the two examples from my students. One concerns a new EU member state. As with any newly acceding country, its accession was conditional on putting in place an extensive body of modern laws. One of these laws concerned mental health. Yet although the law was passed, no resources or personnel were made available to implement it. No-one was accountable for failing to implement it. Indeed, it was very clear that it was never meant to be implemented. Simply passing it served a purpose and it could now be ignored. This is a failure of governance.
The second example is from the UK. A previous English Secretary of State for Health was confronted with a situation where, having put in place a new system of postgraduate medical training, it was clear that a flood of applicants from outside the UK would leave several thousand British doctors with no job. She issued an instruction that non-EU doctors would be ineligible to apply. The British Association of Physicians of Indian Origin sought judicial review and in a scathing judgement the Law Lords supported them. They noted that the Secretary of State had it within her power to change the rules by bringing a motion before parliament. Clearly wanting to avoid controversy, she failed to do so, instead simply placing a notice on a web site of the NHS Employers organisation. This, Lord Bingham noted “was to suggest a degree of official formality that was notably lacking”, going on to state that “it is for others to judge whether this is a satisfactory way of publishing important government decisions with an impact on people’s lives”. This too is a failure of governance (and as I have argued before, far from exceptional in the UK in recent years).
Of course, these are not unique, and maybe we need to think about assembling a collection of such examples from across Europe. Even if we are unable to define what good governance and stewardship are, we will at least be able to know when they are missing.