Introduction

The leadership of health and social care organisations is influenced by factors such as the prominence of health to societal well-being and the partnerships, priorities, politics and governance requirements that enable and constrain the delivery of services. Strong health and social care systems are critical to achieving good health, well-being and a prosperous society. Our world faces many challenges and climate change poses an existential crisis for humanity.  Leading health and social care services through the current and future challenges will be complex and influenced by the responses from governments, corporations and industry.  Priorities, politics, partnerships and governance requirements impact and constrain leaders.  Leaders in the health and social care industry must be adept at working with and recognising the influence of power, politics, priorities and governance.

This text written by health service leaders, managers and academics from Australia provides insights, the latest evidence and key learnings on leadership, people in health and systems and governance. To understand the unique context, the text begins with this chapter, an overview of the priorities, political nuances and governance that health and social care leaders negotiate to deliver services to communities across the world.

The political context of health and social care

Healthcare is inherently political, and often politicised. For example, recent experiences with the management of COVID-19 around the world highlighted stark differences in national government and public health approaches, demonstrating how deeply politics and healthcare are intertwined. Elections around the globe frequently see healthcare, its funding, its people, and its successes and failures co-opted for political ends. Ineffective but politically palatable or ideologically driven health goals are often pursued at the expense of evidence informed best practice.

In 2020-2021, spending on healthcare goods and services in Australia exceeded $220 billion, representing 10.7 % of the GDP (Australian Institute of Health and Welfare, 2023). The USA and UK are currently estimated to spend $4.3 trillion (19% GDP) (World Bank. 2023), and £283 billion (12.4% GDP), respectively (Office for National Statistics, 2022). Globally, over the past 20 years, GDP spending on health has escalated across the world from high to low-income countries, and now sits at around 11% worldwide (World Health Organization, 2023b). Ironically, high GDP spending does not automatically translate into better health outcomes, as demonstrated by the USA, where GDP health spending is almost 19% (World Bank, 2022), but where performance compared to spending is the lowest among high-income countries (Commonwealth Fund, 2021). In Australia, around 15% of our total workforce are employed in health-related jobs (Australian Bureau of Statistics, 2022). Universally, these figures denote a significant investment by governments and the population through taxation and personal spending. They also reflect the high individual and collective value placed on ensuring good health as a foundation for a functional and flourishing society.

An obvious point is that while these social and financial capital amounts are large, healthcare inevitably operates in a resource constrained environment. There is always more money that could be spent, and more interventions that could be funded. Government budgets are finite, and health must (reasonably) compete with other government priorities, such as education, infrastructure, housing, and the environment. Every dollar spent on health is a dollar not spent on another collective priority or communal good, which is the basis of the economic term ‘opportunity cost’. Within the healthcare budget itself, there is always competition for funding for services, which communities receive higher standards of care and access, and which innovation or drug will be subsidised. Compromise, advocacy, and negotiation are therefore an inherent part of leading, managing and funding a sustainable health service.

The inability to translate and implement key research findings into practice is a stubborn feature of healthcare, noting this as a “key failure”, and concluding that “research transfer has become one of the highest priority areas for health services research” (Browman, Snider, and Ellis, 2003, p.10). This persistent failure to translate research into practical change highlights that knowledge alone is often not the key determinant of how practice evolves and improves. Collecting more data and analysing it to make a case for change is not sufficient alone. A political case for change must also be made, and the political will to implement it must be present. As a leader, the ability to identify the interests of all stakeholders, bring the relevant knowledge to the table, and find a mutually valuable path that benefits all stakeholders is a critical skill. Ideas, evidence, and personal or organisational commitment are important, but alone are not sufficient.

As a healthcare leader in this competitive and resource constrained environment, understanding the politics and power dynamics behind how funding allocations, workforce allocations, and service choice decisions are made is critically important. Later in this chapter, you will learn about forming partnerships, engagement with key stakeholders, and developing shared priorities. Recognising and navigating the power and politics, learning how to best use your influence on impact, and how to harness the influence of others will be integral to the impact and success you can collectively achieve.

Power and Politics in Healthcare

Later in this book, in the Chapter Ethics in Healthcare Leadership – Knowing, Doing, Being and Becoming the text talks in more detail about understanding power in its multiple forms, used to build or to undermine. As an introductory concept, power can be simply thought of as the ability to cause or prevent change (Collins Online Dictionary, 2023). This chapter also provides more in-depth exploration of the use of power to nurture, compete, manipulate, exploit, and support.

A helpful working definition of politics in our context, is “the ways that power is shared in an organisation”, including how personal relationships are negotiated between people who work together (Bourne and Walker, 2005). Politics, and the gaining, sharing, and use of power determine the types of activities we engage in, and how we engage. Politics shapes the decisions we make, the way that resources are distributed, and how status is built and maintained across our organisations and networks.

At its core, health is a collective endeavour; hence, as a leader, you will need to identify the key stakeholders in any given situation. Bourne and Walker (2005, p.650) described stakeholders those “affected by a project and having moral (and perhaps non-negotiable) right to influence its outcome)”. In health, stakeholders may include funders, politicians, clients, carers, clinicians, organisational leaders, community groups, interest groups, policy makers, educators, researchers, and others. Each of these groups will have varying degrees of interest, influence, and impact. They will also have differing power statuses within the context of the issue. There will also be differences in where the ultimate control or delegation over parts of the decision making, such as approval of funding or access to resources are held among stakeholders. As a leader, your role is to identify the interested parties, clarify their interest, ascertain their expectations, search for values alignment or common goals, identifying where the decision points are, where the authority to make key decisions lies – and ensuring you align these critical considerations. Exploring these basic questions up front will provide a clear platform from which to work, identifying synergies and lowering barriers at the outset.

Partnerships and Priorities in Health and Social Care

Providing effective and efficient health and social care relies on partnerships. These partnerships may be related to care provision, logistics, back-of-house and front-of-house functions, information technology and management, safety and security, planning, funding, and so forth. Thus, partnering in healthcare is essential for providing services to consumers and the health and social care workforce. Partners may be others who work within the health or social care sectors, non-government and government organisations, private sector organisations, or individuals. Effective partnering in health and social care is an important skill, and health leaders understand that many organisations do not have the economies of scale or size to effectively and efficiently deliver all the services required to provide health and social care to consumers. Those who successfully lead in health and social care must have a deep understanding of the importance of partnerships and the priorities of health and social care that change over time, and that these may be related to advances in science and technology, government policies, political pressures, funding and quality and safety pursuits, and safety or quality failures.

The Australian Commission on Safety and Quality in Healthcare (2023 a)  defined person-centred care as a system that “treats each person respectfully as an individual human being, and not just as a condition to be treated. It involves seeking out and understanding what is important to the patient, their families, carers, and support people, fostering trust, and establishing mutual respect. It also means sharing decisions and planning care together”. Much has been written about making equitable, safe, and quality healthcare available through the principles of person-centric care, often referred to as patient-centred care. While healthcare practitioners, healthcare organisations, and those who regulate healthcare systems aspire to implement a person-centred approach, the competing priorities inextricably tied to priorities, partnerships, and power relationships within healthcare can impede the attainment of such a worthy goal.

The evidence is as sound as it is prolific that person-centred care facilitates improvements in safety and quality of care (Rossiter, Levett-Jones, and Pich, 2020). In a systematic literature review, Sobolewska and colleagues (2020) found that person-centred care is well articulated approach in health policies. However, the lack of definitive measures or approaches is a barrier to embedding it into operational services, largely due to the competing priorities of governments and health organisations (Rossiter, Levett-Jones, and Pich., 2020) confounding its implementation (Sobolewska et al., 2020). Consumer and staff satisfaction improvements also attest to the value of person-centred approaches (Huang et al., 2020; Kullberg et al., 2019; Larson et al., 2019; Vassbø et al., 2019a; Vassbø et al., 2019b). Moreover, the complex financial structures and ever present drive towards greater efficiencies and cost-effectiveness measures of health care make implementing patient-centred approaches difficult, other than paying lip service to a worthy concept (Pirhonen et al., 2020).

The systems and processes for the implementation and the sustainability of person-centred care currently in operation in the health and social care structures, coupled with the often competing priorities of governments and the health organisations, mean that healthcare organisations often lose the essence of person-centred care. Sobolewski and colleagues (2020) found three themes that emerged in the publications added to their systematic literature review:

1. the patient versus the government;
2. the health care delivery versus the political agenda; and
3. healthcare organisational processes versus the patient.

These themes assist in discussing priorities, partnerships and health and social care politics. However, before discussing priorities, some analysis of what partnering means in health and social care is necessary.

Partnering in Health and Social Care

A partnership is made between two or more people or organisations who agree to administer operations, share profits and liabilities and steward outcomes. These arrangements are usually formal in a business sense. However, informal relationships are also established to support and benefit consumers and providers. Therefore, understanding the meaning and objectives of any partnering arrangements is important. This arrangement is often referred to as partnering. Partnering, in its simplest terms, refers to any agreement to have a relationship between people or organisations and may be entirely a verbal arrangement to work towards a shared goal.

In Australia, a 2019 report of a rapid review with an advisory group of various stakeholders from several state-based jurisdictions by Safer Care Victoria, launched the Partnering in Health Care Framework (Nelson et al. 2019). This framework strengthens approaches to person-centred care to empower healthcare consumers, carers, and family members to participate in healthcare. Nelson and colleagues (2019) led the writing of the rapid review, which is titled Partnering in Strengthening Healthcare: opportunities for patients, carers, and family members to escalate care in Victorian health services  and contains important material relating to the evidence of patient, carer and family member participation in escalating concerns, barriers and enablers for effective escalation processes and evaluation, evidence, and learnings from the process. There are also compelling recommendations on the escalation procedures enabled by the partnering model.  The framework is found here.

A strategic contributor to establishing healthcare partnerships is ensuring that people feel as though they are heard when they raise concerns about the care delivered. It is important to understand the context in which this initiative  was implemented. Implementation was driven by the National Safety and Quality Health Service Standards  (2023 a) and calls for strengthening consumer partnerships with health services, specifically Standard 8 – Recognising and Responding to Acute Deterioration. This Standard is now a requirement for Australian health service accreditation. However, it is important to understand that these partnering arrangements may apply to all standards. In Australia, the Aged Care Quality Standards  (2021) also direct aged care providers toward partnering agreements with consumers in concert with the government’s consumer-directed care policy. Globally, there is a push toward recognising the importance of person-centred care in the provision of care. Partnering is demonstrated to improve quality and practices with health and social care organisations (Clavel, Pomey, and Ghadiri 2019), identify and help solve ethical issues that emerge (Martineau, Minyaoui, and Boivin, 2020), and assist consumers and their families in understanding the elements of partnering and developing strategies and policies (Lasker, Weiss, and Miller, 2001).

Partnering may refer to consumers or their relatives or significant others in their life, or it may refer to arrangements between healthcare providers and other service providers. Partnering arrangements with consumers and their families may be implied or expressly stated in how the health and social care organisations engage with their consumers. Informal partnerships are not meant to infer that there is no legitimate relationship between the consumer and providers of care. The arrangements may well be covered in the scope of practice of the various health professions that provide care. They may be contained in other documents, such as the consent documents used by the healthcare organisation.

Partnering arrangements with other organisations usually require formal documents such as a contract or memorandum of understanding (MOU). Health and social care leaders must understand the differences between a contract and an MOU. A formal document may cover these arrangements, such as a MOU, which is not a written contract but is the expression of a document detailing a ‘handshake agreement’. It documents the agreement in written form, outlining a framework or key terms that may be included in a written contract later. The agreement may be used to guide discussions and actions from two parties who have agreed to work tother and is a useful tool in helping all the parties to the MOU know the purpose of the relationship and generally what will be achieved by the association. In other words, it keeps all parties to the MOU on the same page and is a useful point of reference if any dissent arises.

It should be remembered that the document is generally not legally binding because it is labelled an MOU. However, if its content resembles a contract, it may be legally binding and enforceable. Before any partnering arrangement is implemented, the priorities of what the parties will achieve must be set out. Thus, an MOU is an agreement between the parties. However, it is not a contract, because it does not contain legally enforceable promises. For a contract to be valid, the parties to the contract must voluntarily respond to and accept an offer in a situation where they intend to create a legally binding agreement.

Priorities

Greater explanation, discussion, and analyses of the priorities are provided within the relevant chapters of this book. Therefore, they are not explored in any depth here, other than to provide evidence of their importance, and they are listed here as the origins of the priorities.

Priorities are very contextual for all health and social care enterprises; however, in thinking globally about this, when consulting the peer-reviewed and grey literature, four themes emerge for  priority setting for health and social care service provision. There is no intention to suggest that the priorities listed under each theme are exhaustive. They are considered the most significant, have an evidence base, and represent the most challenging problems. It should also be noted that this section focuses on the global priorities and issues that are,  or have emerged. These priorities would be similar for all developed and developing countries.

The definition contained in an article classified as a Clinical Brief by the American Journal of Managed Care Services is a useful definition of value-based partnering (AMGEN, 2018). The publication asserts that “value-based partnering is the term that refers to two or more organisations sharing a mutually beneficial endeavour to deliver the highest value to the health system and society by focusing on improving consumer outcomes in the context of the system and the total cost to society” (AMGEN, 2018).

The four priorities are principally driven by the unrelenting increases in demand for healthcare and social care, as discussed below.

 Priority 1: The health workforce

Workforce challenges in health and social care occur daily in most services, with the need for qualified and experienced clinicians and other highly qualified technical and leadership professionals as a global phenomenon. On their Health Topics/Health Workforce website, the World Health Organization (WHO)  (2023c) describe the impact of the global shortage of healthcare workforce, they estimate a shortage of 10 million health professionals by 2025 and the governments of developed countries are committing significant funding to new horizons in healthcare such as digital transformation in the healthcare sector and this will largely go to salaries and wages. For example, in March 2022 the Federal Government of Australia announced an additional commitment of AUD 537 million over the next four years (Minister for Health and Aged Care 2022). Most clinical settings in health and social care face workforce challenges (Klimek et al., 2020).  See also the part on People in Health and Social Care.

Priority 2: The mismatch between rising demand for health and social care and funding

The population of the world is ageing (Herwartz and Theilen, 2014, Littlejohns et al., 2019, Mitton and Dionne, 2020). This is a direct result of increasing life expectancy and declining fertility rates (Kendig, Lucas, and Anstey , 2013, Stewart Williams et al., 2020). This is particularly evident in developed countries because there is greater access to pharmaceuticals, technology, and clinical expertise. The ageing of the population coupled with an emerging consumerism in health and social care is increasing the demand and the complexity of health and social care which in turn increases the costs of delivery (Fifer, 2019; Fifer, 2020; Williams, 2020a; Williams, 2020b). Most developed countries (perhaps with the exclusion of the United States of America) are striving for equity and equality of health and social care access to improve population health outcomes (Robards et al., 2019).

Priority 3: Safety and quality of care and improving consumer outcomes

Safety and quality initiatives in health and social care reduce adverse outcomes of care, prevent unnecessary hospitalisations, provide for the development of safer health products and technologies, provide financial savings, improve efficiency and effectiveness of care, and improve the quality of life for health and social care consumers. This is discussed in quite some detail in the Safety and Quality chapter of this book.

Measuring the safety of care and addressing the issues that emerge are well established in most developed countries. This includes evidence such as studies with positive outcomes for those with dementia (Grealish et al., 2019; Ho et al., 2021), indigenous consumer access to primary care (Brickley et al., 2023), cerebrovascular accident (Stevens et al., 2022), other chronic diseases that require ongoing management (Sobolewska et al., 2020), and psychoses (Richter et al., 2015). What many of the studies recommend is echoed by having the appropriate organisational culture to effect the necessary changes toward implementing person-centered care (Carlstrom and Ekman, 2012; Sobolewska et al., 2020). Most researchers have concluded that measuring the appropriateness of care and addressing the issues that emerge in a timely and effective way.

Priority 4: Urgent reforms for health and social care

The following issues are included in this priority:

• Governance of our health and social care systems: Governance is inextricably linked to leadership and is concerned with ensuring that strategic policies exist and are embedded within the system aimed at effective oversight of the systems, coalition or partnership building, regulatory compliance, and attention to system design and accountability (World Health Organization, 2023a). There is a well-recognised need for better systems of governance. This is particularly so in the social care sector, which also requires an emphasis on care governance that looks at social indicators such as social isolation, mood and happiness measures, and those clinical indicators that are care related.
• The inadequacies of health and social care funding: There is also an urgent need to address the inadequacies of health and social care funding systems. This is addressed in some detail in the Governance and financial management in health and social care chapter of this book, and it is explained further there. The purpose of mentioning it in this chapter is to highlight the urgency with which this is needed. A weight of evidence calls for significant and transformative strategies needed in all areas of healthcare, particularly in the areas of aged care, mental health care, palliative care, emergency care, digital healthcare, to name several.
• Funding of clinical and health and social care research: There are two significant areas to cover when discussing research in health and social care; clinical research and health policy and systems research. Both areas require a significant investment of funding to prepare our health and social care systems for the future.
• Clinical and health disciplines research: Clinical research refers to research in which people, or data or tissue samples, are studied to understand health and disease (National Cancer Institute, 2023); thus, helping to find new and better ways to detect, diagnose, treat, and prevent disease.
• Health policy, systems, and services research: This is a neglected area in global health financing and there has been little growth in investment in this type of research for an extended time, with approximately 2% of all global health funding outcomes including an identifiable health policy, systems and services research component globally (Kentikelenis et al., 2023). This type of research has high value to society, providing important information about disease trends, risk factors for ill health and disease, treatment outcomes, patterns of care, outcomes of treatment interventions and, of course, health care costs. Health and social care leaders must firstly recognise the importance of this type of research and allocate secure funding to grow it.

Digital health and the application of artificial intelligence (AI)

Digital health offers significant benefits to health and social care, and it is transformational in the ways that consumers and health and social care professionals interact. These benefits include the obvious ones of health information storage and sharing that information among those who work with consumers and, of course, consumers themselves. Digital technologies are modifying almost every aspect of contemporary life, and health and social care is a significant part of that transformative change, including:

• providing connectivity between health and social care professionals and the consumer;
• versatile working for health and social care professionals;
• the creation of learning opportunities;
• diagnostic tools and decision support;
• workflow automation; and
• information storage.

The barriers to implementation of digital health strategies in health and social care are areas that health and social care leaders must deal with, including:

• Access to technology: While health and social care are undergoing major digital transformations, a major barrier to the uptake of the benefits is consumers’ access to platforms and technologies (Lazarus et al., 2019). Dahlhausen et al. (2022) researched this phenomenon by exploring healthcare stakeholders’ roles and potential to foster consumer access in qualitative research that found, among other things, that healthcare professionals had the greatest potential to promote access and consumer adherence to digital therapeutics and that health insurers, pharmaceutical companies, and consumers need to take action to improve patient access and adherence to digital therapeutics assisted by several macro-level changes to support access, such as including broader information dissemination, improved financial incentives, simplified prescription and activation processes, and a wider adoption of blended care and pay-for-performance payment models.
• Digital literacy of health and social care professionals and consumers: This is one of the most significant barriers to a successful digital transformation and one that was investigated in a Spanish study of 1624 health professionals by Navarro-Martínez, Igual-García, and Traver-Salcedo (2023), who found that while medical practitioners had significantly more training that other health disciplines, there was insufficient training in digital literacy for health professionals and that only 20% of nurses surveyed had received some training from their healthcare employers that related to healthcare technology. Another study Busse and colleagues (2022) examined approaches to improving digital health literacy that support a focus on digital health literacy for all health professionals to improve competency in the digital health space.
• Change management proficiency: For the inevitable systematic changes that must occur in the health and social care workspace, change management proficiency is of vital importance for a successful digital transformation (Scott, Sullivan, and Staib, 2019). The health and social care sectors are undergoing a major transformation toward digital health technologies that assist with easing the challenges for healthcare professionals and provider organisations. Specialist leadership for successful implementation must include change management skills and the ability to navigate an increasingly complex health and social care ecosystem (Nilsen et al., 2019).
• Privacy and information security: The integration of advanced digital health and associated technologies is transformative for the health and social care sectors. There is considerable evidence that these transformative changes have resulted in considerable improvements in the efficiency and effectiveness of healthcare and related services (Eastwood, 2019). However, this integration has fostered the emergence of a new set of challenges for consumers, healthcare professionals and providers, and suppliers of the adopted technologies. This makes for a difficult time for the health and social care sectors, because as we have seen in many data breaches such as the Singapore Health breach, Medibank Private data breach, and most recently, a breach in the implementation of digital systems in the Northern Territory of Australia, health and social care organisations are a significant target for hackers and cybercriminals, potentially compromising private and confidential healthcare data and placing the safety and health of patients at risk.
• The rapid emergence of digital health, including the application of artificial intelligence: Health and social care are experiencing rapid change largely driven by technology, along with the growth in digital health solutions and fast technological solutions that will redefine the nature of work and the nature of research in the field of artificial intelligence. These advances are related to wearables and mobile health that will increasingly be used to collect real time and real-world data for potential use as evidence supporting clinical decisions.

We are currently observing new artificial intelligence (AI) and digital health solutions that require sensitive regulation, which is certainly on the horizon in most developed countries (Chen and Decary, 2020). Decision-support systems will be revolutionised to use AI as a solution to support health professionals’ decision-making and robotics will continue to evolve (Amann et al., 2022). Digital diagnostics and digital therapeutic medical devices have also emerged as an exciting opportunity to innovate in the provision of healthcare, but require careful planning related to equity of access, funding, and costs (Grosserueschkamp et al., 2021; Sorace, 2020; Noorbakhsh-Sabet et al., 2019). The enhanced use of AI raises new questions about tort liability and risk mitigation (Chamberlain, 2022).  See Innovation and performance in health and social care organisations and Leading innovation in healthcare through digital health technologies chapters.

Governance

Health funding is a valuable and often scarce resource and strong stewardship and governance implicit to maximising benefits from health spend and investment. Governance and governance frameworks provide the systems, policies, and procedures by which an organisation is controlled and operates, and the mechanisms for holding the organisation and its people to account (Governance Institute of Australia, 2023). Governance is identified as an area of reform for the health and social care systems nationally and internationally. Governance systems, provide the frameworks describing who has the authority to act on the behalf of the organisation, and to identify who can make decisions and who is accountable for organisational performance and the delivery of services (Chartered Governance Institute).   Governance frameworks enable leaders and managers to run the organisation and meet the needs of the broader community and stakeholders (Chartered Governance Institute).

In health and social care, a strong governance framework should cover finance, human resources, information technology, and management and clinical operations. Governance has four key components, as explained in the table below.

Table 1: Created with reference to the key components of governance (Governance Institute of Australia, 2023)

Governance structures and systems

Most health and social care organisations take a structured approach to governance, with the Board or senior leaders responsible and accountable for governance. Governance structures include regular meetings with agendas, minutes, and reporting to discuss compliance, finance, risk, opportunities, accountability, and emerging issues. Governance structures, for example, Boards, should ensure diverse representation and involvement of individuals with the right skills and knowledge. Importantly, to be effective, structures and systems should be responsive to emerging needs.

Governance frameworks and systems will be unique to each organisation and are informed by legislative, credentialling, service agreements, and other needs and constraints. These frameworks guide organisations to do the right things and take responsibility for the decisions and actions taken. Governance frameworks assist organisations to comply with financial reporting and other requirements – see Governance and financial management in health and social care chapter. Ethical approaches are an integral component of governance and are addressed more fully in the Ethics in Healthcare Leadership – Knowing, Doing, Being and Becoming chapter.

Risk management is an important element of governance systems. It involves a proactive and ongoing approach to the identification, remediation, and minimisation of risks to all aspects of a health and social care organisation. All individuals and organisations confront risks and their impacts. Risk awareness involves recognising the potential for incidents, hazards, and damages that occur within the health and social care environment that can result in harm to the workforce, the public, visitors, patients, and health and social care consumers. Risk awareness and management apply to financial management, decision making, and information assets (Woodward, 2010).   Understanding risks and being aware of their impacts can assist individuals and organisations to prevent errors, reduce waste, and avoid harm to the workforce, patients, and all who interact with health and social care organisations (Woodward, 2010).

What does a governance structure look like?

Governance frameworks and systems will be unique to each organisation and informed by legislative, credentialling, service agreements, and other constraints. In health and social care, a wide range of services (clinical and non-clinical) are provided. A robust governance structure will include the elements of corporate, environmental, social, and clinical governance.

Environmental, corporate and social governance

Corporate governance defines the processes through which a company or health and social care organisation sets goals and objectives and pursues these within the regulatory and funding constraints to achieve agreed organisational goals and objectives. While the focus between profit driven companies and not-for-profit and government run organisations might differ, the central tenants of accountability, transparency and responsibility remain the same.  Corporate governance provides stewardship, transparency and accountability over people, finances, physical and information assets. Environmental and social governance refers to how health and social care organisations operate with respect to the planet and its people. In countries, such as Australia, the United Kingdom, Europe, and the United States this broader perspective of governance is included in governance frameworks. It would be remiss to speak about governance and the optimisation of health system performance without reference to the Quadruple Aims  of enhancing patient experience, improving population health, reducing costs, and improving the work life of those who deliver care (Arnetz et al., 2020; Bodenheimer and Sinsky, 2014; Sikka, Morath, and Leape, 2015).  Similarly, the Sustainable Development Goals 2023 Report (United Nations, 2023, p. 38) describes a need for “increased finance, political commitment, coordinated policies, international cooperation, ecosystem stewardship and inclusive governance are all urgently needed for effective and equitable climate action”. Climate change, equality issues, discrimination, and other major social and environmental concerns are major challenges for the world. There is now growing recognition that these challenges are the responsibility of companies and governments. Sustainable practices, waste reduction, human rights, the environment, and climate change should be included as part of governance and the responsibility of leaders and Boards of Directors.

Clinical governance

Clinical governance is an area of interest to all health and social care organisations. Clinical governance has a long history, with Scully and Donaldson (1998 p. 1) noting that “clinical governance is a system through which National Health Service (NHS) organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish”. In Australia, clinical governance is defined as the set of relationships and responsibilities established by a health service organisation between its state or territory department of health, governing body, executive, workforce, patients, consumers, and other stakeholders to ensure good clinical outcomes (Australian Commission on Safety and Quality in Healthcare, 2023a).

Many developed countries globally have similar publications to Australia, which has a National Clinical Governance Framework that is underpinned by the National Safety and Quality Health Service (NSQHS) Standards (NSQHS, 2023), in particular the clinical governance standard. The National Australian Clinical Governance   Framework includes the following components:

1. governance, leadership, and culture;
2. patient safety and quality improvement systems;
3. clinical performance and effectiveness;
4. safe environment for the delivery of care; and
5. partnering with consumers (Australian Commission on Safety and Quality, 2023b).

These components recognise that governance requires leadership and a ‘no blame’ culture, where mistakes can be openly discussed, and harm minimised. Clinical governance involves safety and quality improvement systems that proactively manage risks and identify opportunities for enhancement on a continuous basis (Scully and Donaldson, 1998). Effective clinical and other practices based on evidence, resources to deliver care (people, finances, and physical buildings) are the foundations of a well performing health and social care system – see the part of the Text on People and chapter on Governance and financial management. Safe environments protect consumers and the workforce from injury and recognise that a range of approaches are required to prevent exposure to harmful chemicals, pathogens, abuse, or other physical risks.

First Nations people suffer disadvantage and delays to care due to unconscious bias, intergenerational trauma, colonisation and cultural differences – see the Cultural Safety and Awareness Frameworks in Health and Social Care: Whose Cultural Safety?. Leaders play a role in creating safe environments for First Nations people through adopting cultural safety considerations and working with First Nations community leaders and communities to deliver culturally appropriate care and the Cultural Safety and Awareness Frameworks in Health and Social Care: Whose Cultural Safety? chapter describes this in depth. Finally, working with the consumers of health and social care services and identifying how to deliver care that is safe, appropriate, effective, and sustainable is key to clinical governance. See Safety and Quality in Healthcare, Cultural Safety and Awareness Frameworks in Health and Social Care: Whose Cultural Safety? and Leading a Healthy Workforce chapters.

Research governance

This refers to the processes used by health and social care organisations to conduct research according to ethical principles. Research governance processes include approval for research, and ensuring that any research conducted complies with regulations, legislation, and codes of practice, establishes intellectual property ownership, risk and financial management and reporting requirements (National Health and Medical Research Council, 2011)

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