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This is not a blog which expresses instant opinions on current events. It rather uses incidents, books (old and new), links and papers as jumping-off points for some reflections about our social endeavours.
So old posts are as good as new! And lots of useful links!

Friday, February 8, 2013

Quis Custodiet Custodes? Transparency, trust and accountability

Last April, I wrote about the accountability of public bodies on my blog -
"Some 15 years or so ago, transparency and accountabilitybecame a big issue  in my professional field (of governance). I have only recently begun to question the motives which have been at work. Reassuring at one level in the story it told of how various public organisations were held to account by citizens, it demonstrated one of many apparently superior elements of the capitalist model of governance over the communist one which had been the default system of the countries in which many of us were working post 1989. For example, in 2001 I myself wrote this briefing note on the issue for my beneficiaries in the Presidential Office of a Central Asian State.
But, at another level, the emphasis (in the UK at any rate) on the need for more and m"ore scrutiny of government business has perhaps had a hidden agenda – part of the wider agenda there has been for several decades to convince people that government activities were inherently inefficient and malevolent – and that the private sector would do it much better. But, while we were devoting more and more energy to scrutiny, for example, of local government activities, regulations and controls were being lifted from banks and financial agencies".
 This week a shocking report was issued on the apparent failure of a panoply of control and accountability bodies in the British health system. An article written the day before the report was published summarised the issues very well.
An estimated 400-1,200 patients died as a result of poor care over the 50 months between January 2005 and March 2009 at Stafford hospital, a small district general hospital in Staffordshire. The report published on 6 February 2013 of the public inquiry chaired by Robert Francis QC is the fifth official report into the scandal since 2009, and Francis's second into the hospital's failings.
His first report, published in February 2010, was an independent report under the NHS Act rather than a full-blown public inquiry. It examined the quality of care at Stafford hospital in 2005-09 and the many reasons why it was so bad, such as inadequate staffing, and produced devastating conclusions.
The new public inquiry began in July 2010. Its remit was "to investigate why and how a wide range of commissioning, supervisory and regulatory bodies and systems in the NHS failed to detect poor care at Stafford and to intervene". As such it probed the role of the bodies and individuals all the way from the hospital itself – including the trust's board and its patient liaison group – up to the most senior figures at the Department of Health in Whitehall, including ministers, senior civil servants and key figures in the NHS.
Its brief included its duty "to examine why problems at the trust were not identified sooner; and appropriate action taken. This includes, but is not limited to, examining the actions of the Department of Health, the local Strategic Health Authority, the local primary care trust(s), the Independent Regulator of NHS Foundation trusts (Monitor), the Care Quality Commission, the Health and Safety Executive, local scrutiny and public engagement bodies and the local coroner."
None of the links in what should have been the NHS's chain of monitoring and scrutinising hospital care, and intervening if necessary, did its job properly.
 Andrew Lansley, the then health secretary, commissioned the full public inquiry in June 2010, soon after the coalition took power. It was held under the Public Inquiries Act 2005. Labour in 2009 and 2010 had refused to accede to persistent requests from relatives of victims of the Mid Staffs scandal to hold such an inquiry. Instead ministers commissioned the first Francis report as well as two other, separate inquiries into specific aspects of how the hospital and local healthcare system operated. They were led by Professor George Alberti, the DH's national clinical director for emergency care, and Dr David Colin-Thome, his counterpart at the DH for primary care. They reported in April 2009.
Francis's report into care at Stafford hospital in February 2010, based on evidence from over 900 patients and families, was scathing. "I heard so many stories of shocking care," he said. "They were people who entered Stafford hospital and rightly expected to be well cared for and treated. Instead, many suffered horrific experiences that will haunt them and their loved ones for the rest of their lives."
Francis cited a litany of failings in the care of patients. "For many patients the most basic elements of care were neglected," he said. Some patients needing pain relief either got it late or not at all. Others were left unwashed for up to a month. "Food and drinks were left out of the reach of patients and many were forced to rely on family members for help with feeding." Too many patients were sent home before they were ready to go, and ended up back in hospital soon afterwards. "The standards of hygiene were at times awful, with families forced to remove used bandages and dressings from public areas and clean toilets themselves for fear of catching infections." Patients' calls for help to use the toilet were ignored, with the result that they were left in soiled sheeting or sitting on commodes for hours "often feeling ashamed and afraid". Misdiagnosis was common.
"A chronic shortage of staff, particularly nursing staff, was largely responsible for the substandard care," Francis found in his first report.
In addition, morale was low and "while many staff did their best in difficult circumstances, others showed a disturbing lack of compassion towards their patients", he added. "Staff who spoke out felt ignored and there is strong evidence that many were deterred from doing so through fear and bullying."
He laid much of the blame on the trust's ruling board. The action they took to investigate and resolve concerns "was inadequate and lacked an appropriate sense of urgency". Its members also "chose to rely on apparently favourable performance reports by outside bodies, such as the Healthcare Commission, rather than effective internal assessment and feedback from staff and patients". He was particularly critical of the trust's failure to take patients' complaints seriously enough.
Crucially, Francis also highlighted the key impact of the trust board's decision to try to save £10m in 2006-07, as part of its desire to gain foundation trust status. "The board decided this saving could only be achieved through cutting staffing levels, which were already insufficient." It also ignored staff's concerns, he added.
Needless to say, the scandal is being used by both left and right in their battle for votes. The disaster occurred on the New Labour “watch” and arguably was linked to the major structural changes the Labour Government had been pushing for 10 years to give both market mechanisms and private companies a stronger role in England’s (Scotland has not bought this “commodification” model) National Health Service. The Coalition Government in power since 2010 has gratefully built on that principle and is using the scandal of care in that hospital to bolster its argument for the need for the dramatic increase in marketization they have introduced in recent months.

Until this latest report, however, no one was really looking at the effectiveness of the control bodies. The incredible growth of regulatory and auditing bodies in Britain in the last 25 years was the subject more than a decade ago of a considerable literature. And English municipalities were required in 2000 to set up “Scrutiny” committees. This 2010 House of Commons research report gives a brief overview; and a blogpost of  mine in that same year gave a wider perspective.

But perhaps it is time we looked at the counter-productive aspects of all this – in the spirit of Ivan Krastev’s new book entitled In Mistrust We Trust: Can Democracy Survive When We Don't Trust Our Leaders? 

The print at the start of the blog illustrates the famous Panoptican of control dreamed up by the English philosopher, Jeremy Bentham 

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