Stewardship of the common good

Don Berwick has been in the UK recently, challenging and supporting the NHS to continue in its quest to become more of a learning organisation: being open to change, engaging in authentic dialogue and building systems that overtly celebrate and sustain cooperation. One of his engagements was with the Q community, which is striving to do just this.

Q is a growing community of 447 people from across the UK, led by the Health Foundation and supported and co-funded by NHS Improvement. Its long-term aim is to create, at national scale, capacities for improvement to increase the dosage and use of improvement expertise in the sector, and foster a learning environment to improve health and care. Q is about resources, activities and a fledgling infrastructure – connecting, supporting, mobilising and developing people and improvement projects.

One of the many evolving projects within Q is defining how it will work as a community – how it will make decisions, share good practice and resources, and be accountable.

The model we are piloting is based on the work of Elinor Ostrom, another visionary thinker, who used the age-old language of ‘stewardship’ of common resources. In Governing the Commons; the evolution of institutions for collective action, she described a way of working that was not based on hierarchy or self-interest but on energising people to work together, across boundaries and disciplines and with shared goals. Q is embracing this aspiration and exploring how to embed it in Q’s ways of working.

There are already many thousands of activities seeking to make health and care better throughout the UK. The key challenge going forward is to engender the values of cooperation, sharing and stewardship in order to gain the maximum benefit for patients, service users and their families. The resources we each bring to improvement efforts – time, energy ideas and investment – have greater value if we are better able to pool what we each have and what we know for deeper and wider impact.  

While the original commons literature was informed by the idea of common land available for grazing, one Q member has suggested a more relevant analogy for Q is of a modern-day ‘common’ or park – such as we see in cities, towns and villages – where there are multiple users. Some people take responsibility for managing and improving the space and agreeing and ensuring the rules of the common are met (such as not cutting down trees or digging up the grass). The vibrancy of the space depends on everyone bringing something different to the protected space – their picnics, kites or more organised ball games or activities and occasional fairs – and sharing the use of the commons. This is depicted in the picture below.

A community-based approach, as Mary Dixon Woods described it at a Q event in 2015, has huge potential. By using the language and spirit of ‘the commons,’ Q is communicating a clear message about the non-hierarchical, diverse nature of the community, embedding the values of co-production, shared decision-making and stewardship within its national and local structures. This draws on the strengths of a distributed governance model, in which members’ input into decision-making operates on multiple levels, and connections and interactions between each other across different parts of the UK converge to contribute to the common good.

In 1968, the biologist Garrett Hardin wrote a paper using the grazing commons as a metaphor for the problem of over-population. He argued that many of the world’s resources – food, water, energy – were being squandered because human beings were unable to self-organise in the interests of the collective good. He called this ‘the Tragedy of the Commons’.

Ostrom and Berwick, and more recently Ham and Alderwick, envision a different future, one in which people from different disciplines and diverse backgrounds in health and care choose to converge around a shared goal, and commit to cooperation in the interests of all. The growing talent of people that is now the Q community is doing the same. In a world increasingly divided and divisive, this is a welcome development.

Anna van der Gaag (@AnnavdG) is a founding member of Q and is Visiting Professor at the University of Surrey