Governing the CommonsGoverning the Commons , The Evolution of Institutions for Collective Action (ISBN9780521405997) by Elinor Ostrom offers a some very useful takes on how humans have previously organised themselves in order to conserve finite resources necessary for their survival. The book was so significant that it won the 2009 Noble Prize for Economics. The Google review of the book is here

A common pool resource is something that can potentially be used by different people, and is not limitless. It could run out, or be made much less easy to access. The same resource can have huge differences in value around the world. E.g water in drought prone areas, wood in villages above the tree line, or fish in open fishing grounds. Once you have used your unit of resource it has gone. Yu cant chop down the same tree twice. The fish you caught over your quota are perceived to be worthless.

This book answers the question , “How have societies evolved ways of managing their Common Pool Resources ?”
In my opinion the most exciting thing about her work is that it offers an insight into how self-sustaining systems have evolved their own rules, often without interference or planning from government or the market economy.

Top down, one size fits all, management of resources is not guaranteed to ensure we still have access to the common pool resources in the future. Diversity of systems is needed so that each system can respond to its own needs, stresses, demands and personalities.

watch this video (8 min) of Elinor giving an entertaining overview

Healthcare systems in 2012 are intensly focused on conserving their resources. The Common Pool Resources ( CPRs ) in healthcare systems are not just the obvious pounds or dollars. Hospital beds, certain medications and even the appointment slots at your doctors surgery are all common pool resources.

In the UK we have been fortunate to have the NHS for the past sixty years. The amount of money flowing into the NHS has been steadily increasing over this time, but those golden days are over. Our political masters no-longer have the means or the will to continue the investment at the same pace. It is time for a rain-check!

The NHS has set up GPs ( General Practitioners or Family Physicians) as the gatekeepers of access to the common pool resources in our healthcare system. Most treatments can only be accessed through the GP. They organise referrals, prescribe medication and monitor response to treatment. GPs in the post- reform NHS are expected to restrict the consumption of the Common pool resources by their patients. They are criticised if their referral rates are substatialy different from similar doctors, and are expected to prescribe within set budget.

Patients essentially have been sold the concept of total choice in healthcare for all. There is an extensive list of medication that patients can request from their doctor without having to pay a fee. Patients can challenge treatment decisions and contest local guidelines regarding specialised treatments which have limited clinical value.

The individual that requests a weight loss medication costing £40 per month is focusing on their own needs and their personal future health. They are not able to take the £40 and spend it on private gym membership because the money is locked in the prescribing budget. They perceive that they may as well take the weight loss drug now because it is available now. It is at no direct cost to them. What have they got to lose ? Who can blame them for taking this option ? Losing weight leads to so may health benefits that this could be cost effective – as long as there has been behaviour change and the weight stays off.

Unfortunately the rules for how the resources are used have either not been put in place, or have not been accepted by the population as a whole. The NHS at 60 years old, is young when you compare it to other systems such as the water rationing systems of the huertas in Alicante that have been managing their system since 1594.

Watch Elinor’s video again. This time think about all the patients inn the UK as harvesting from the common pool resource that is the NHS. What are the regulatory systems that try to limit the money spent on a given health expenditure? Do long waiting lists act as a brake on the systemby discouraging further referrals?

Can you think of any organisms or organisations that could be heading towards extinction? What local rules are needed to ensure that the bigger system stays healthy? How do we ensure the NHS does not go the same way as the Dodo ?

It is possible to draw parallels between ecological systems and healthcare systems. This book suggests 8 principles that seem to underpin the sustainability of these systems. With a bit of imagination it should be possible to blend these rules into the future organisation of the NHS.

Ostrom identifies eight “design principles” of stable local common pool resource management:

Clearly defined boundaries (effective exclusion of external un-entitled parties)

Rules regarding the appropriation and provision of common resources that are adapted to local conditions

Collective-choice arrangements that allow most resource appropriators to participate in the decision-making process

Effective monitoring by monitors who are part of or accountable to the appropriators

A scale of graduated sanctions for resource appropriators who violate community rules

Mechanisms of conflict resolution that are cheap and of easy access

Self-determination of the community recognized by higher-level authorities

In the case of larger common-pool resources,organization in the form of multiple layers of nested enterprises, with small local CPRs at the base level.

These two cartoons explain the concept of the need to look after our common pool resources.

Thanks. Please comment by clicking on the speech bubble.

Stuart Berry
Elinor Ostrom Wikipedia entry

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2 thoughts on ““Governing the Commons” by Elinor Ostrom , and lessons for the NHS

  1. Wonderful video of Olstrom. What an inspiration! But I draw the opposite inference about the NHS. Isn’t the NHS just the sort of top down centralised simple solution that has caused us to waste and misuse healthcare? The sort of thing Olstrom is warning us against.

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