Opinion, Berkeley Blogs

Unaccountability is bad for public health and democracy

By Bruce Newsome

The British Parliament’s Public Administration Select Committee (PASC) has reported that the authorities for investigating healthcare failures in Britain are too numerous and unaccountable.

I am pleased that at least one committee has criticized the structure of British healthcare, but the PASC airily follows all previous inquiries by recommending a lot of cultural change, and a little structural change, outside of the Department of Health itself. Thus, probably nothing will improve before yet more scandals, more investigations, more findings of the obvious, more recommendations for change – perhaps for another decade, like the decade that has passed since around 1,200 avoidable deaths at Mid-Staffordshire Hospital.

The British political elite’s refusal to improve the government’s own accountability defies the most basic solution to human-sourced risks (people must be accountable for the risks for which they are responsible) and undermines the most basic principle of democracy (government should be accountable to the electorate).

Why a new report?

The good news is that the PASC has focused on the ultimate authority for complaints against healthcare – the misleadingly titled Parliamentary & Health Service Ombudsman (PHSO), which is neither accountable to Parliament or government, nor responsible for any of the health services – not even the National Health Service (NHS) in its most general sense.

I commend the PASC because, by comparison with the Health Select Committee, the PASC suddenly looks engaged. The Health Select Committee failed to investigate the PHSO. It does not audit any organization to a set routine; its most recent “accountability hearing” was of the Health & Care Professions Council in early 2014. This was overdue, since the HCPC absorbed responsibilities for social workers from the General Social Care Council, which was abolished in 2012 without any accountability for years of incestuous self-regulation of the most scandal-ridden profession in Britain. The Health Committee accepted the HCPC’s largely self-serving and evidence-free testimony without effective challenge, while ignoring critical testimony, before concluding that perhaps social work could be better regulated, without any recommendation as to how.

I commend the PASC with reservations about its belated and incomplete engagement: the PASC’s report is not the product of proactive or routine regulation. On page 5, it admits several unrelated inquiries into avoidable deaths dating back to 2005, of which none prompted its own inquiry. Instead, it was prompted by a single academic article published in 2014. Why this article in particular, rather than the numerous earlier informed comments on these issues? The PASC does not explain.

Similarly, the PASC does not mention years of independent private complaints about the PHSO. For instance, in November 2014, the charitable Patients Association declared that the  PHSO “is unaccountable and wholly ineffective”; correspondents had reported that the “PHSO is failing families, leaving them distressed and totally worn down”; the Patients Association called on the PASC “to address the failings” of the PHSO “and establish a truly independent, transparent and people’s Ombudsman.” One month later, the PASC announced its investigation into the complaints system.

The myth of cultural change

The PASC unambitiously and unscientifically follows all previous inquiries in calling for a change of “culture.”

In February 2013, Robert Francis QC completed a public inquiry into the scandal at Mid-Staffs. He made 290 recommendations, the most profound of which was a legal duty of care, which surprised ordinary people who naturally had assumed that “carers” already had a legal duty of care.

In August 2013, a clinical professor completed an inquiry into safety within the wider NHS, which recommended a legal duty for all healthcare workers to admit their mistakes, a “zero harm” culture, and “minimum staffing levels.”

In January 2014, the Secretary of State for Health (Jeremy Hunt) promised an “open culture that learns from errors and corrects them”, following the example of the airline industry. (That promise, by the way, came in a response to Francis’ report of one year earlier, which itself took three years to produce, nine years after the first of the deaths at Mid-Staffs.)

So we come to March 2015, when the PASC “commend[s] the Secretary of State for Health’s determination to tackle the culture of blame and defensiveness”.

This wisdom after the fact is years overdue and yet still not profound. Politicians are unwilling to investigate a structure for which they are ultimately responsible; they appoint vested lawyers and healthcare insiders, who incestuously consult each other and conveniently blame “culture,” which - as an attribute of a collective - is nobody’s responsibility. Nobody consulted a scientifically-minded organizational designer or risk manager.

The need for structural change

Cultural change is useless without structural change. As taught at the most introductory level of risk management, culture is just one of the three main dimensions of any collective. To change culture, one would need to change structure and process too, otherwise the dimensions would be incongruent. The culture needs to support the structure and processes of risk management, and vice versa. For instance, if members normatively think of the processes of risk management as too burdensome (a cultural problem), they are less likely to follow the processes (a procedural problem). To reiterate the process would be useless – the practitioners already know the process, they just don’t culturally value it.

A change of culture starts with structural change. Structure refers mainly to patterns of responsibilities and authorities. The authorities are those persons or organizations assigned to determine how risk should be managed. The responsible parties are supposed to manage risk as determined by the authorities.

Tangible structural recommendations would include stronger leadership of compliance, more frequent and deeper investigation of non-compliance, more rewards for compliance, more punishment for non-compliance, and more frequent reviews and audits.

Under-reporting of risk

Compare the prescription above with current cultural impunity and structural unaccountability. In a rare editorial, followed by an interview, the Health Ombudsman (Julie Mellor) criticized the NHS’ “toxic cocktail” of a “culture of defensiveness” and “a failure to listen to feedback.” Her most tangible recommendations were for 24-hour telephone lines and staff responsible for answering complaints. She did not suggest that the subjects of complaints should be more accountable. The PHSO refuses to investigate persons — only the organizations that have failed to satisfy complainants locally. In fact, the subjects of complaints are often anonymized in reports. Consequently, the worst that an organization can expect is a ruling that “mistakes were made,” for which it should apologize and perhaps compensate (to the inconsequential tune of a few thousand pounds), but no particular person is ever named as responsible.

Unaccountable systems are riskier systems. Unaccountable practitioners are not incentivized to control risks beyond the demands of their personal ethics, which can be over-ridden by natural, everyday contradictions as simple as laziness and distraction. When practitioners are not held to account, they develop cultures of impunity and are not forced to learn from mistakes.

In November 2013, the HCPC admitted finding that 20% of British adults had encountered behavior from a health or care professional that cast doubt on his or her fitness to practice, yet only 6% of British adults actually complained. In 2014, the HCPC’s testimony to the Health Select Committee claimed an “easier route” for complainants (page 21), but I could not work out what this supposedly “easier route” is.

If the complainant were dissatisfied with the HCPC’s handling of a complaint, his or her only recourse would be the PHSO. The PHSO traditionally has investigated only 1% of complaints, as if 99% of complainants had the time and motivation to complain unnecessarily. In January 2015 the Health Select Committee reported (page 3) that “most” complainants (i.e., more than 50%) are motivated to protect others from failings, not for personal gain.

In July 2013, Mellor – after more than 18 months as Ombudsman – suddenly promised a ten-fold rise in the number of PHSO investigations, but the PHSO actually investigated only six times as many in fiscal year 2013-2014 as in the previous year – or less than 8% of complaints received by the PHSO. The PHSO receives a tiny fraction of all the complaints handled by the 70-odd actors in the complaints system. The PHSO investigated merely 2,199 complaints in 2013-2014; the NHS alone received 175,000 complaints that year.

Mellor hypocritically testified to the PASC that “local” authorities were to blame for “under-reporting of incidents and therefore an under-investigating of incidents, and therefore continuing risk to patient safety” (page 7). However, most of the written evidence that the PASC received about the PHSO was critical.

This is most obvious in the PHSO’s investigation into the avoidable death of a three-year-old child (Sam Morrish) from sepsis. In July 2014, the PHSO reported with self-satisfaction that it had found malpractice at local providers, without admitting that it had frustrated the child’s parents with inexplicable delays (lasting more than two years) and factual errors in earlier drafts. The PHSO’s own errors only came to light because the parents (Susannah and Scott Morrish) spoke to the news media (there being no authority to which they could complain about the PHSO). The Secretary of State (Jeremy Hunt) wrote to Mellor criticizing her failures personally, but she has not had the decency to resign or reform, although she has promised “streamlining” – amongst other platitudes.

If dissatisfied with the PHSO, the complainant has no official recourse than civil action, which is practically and financially infeasible, except perhaps for those in the metaphorical wealthiest 1%. The complainant has no right of appeal against the PHSO. No parliamentary committee or politician can overrule it. The PASC can only examine its reports.

The need for structural change

For a decade now, British inquiries and politicians have fallen over each other in their eagerness to call for cultural change, without recommending the structural changes that would drive cultural change. They are self-serving – they do not want to be responsible for negative events, so they pass the buck to a bewildering array of quasi-non-governmental organizations (QUANGOs), which pass the buck between each other, to avoid the responsibilities of oversight and investigation, lest they come to share the blame with the subjects of complaint.

The PASC’s most useful contribution is to draw attention to more than 70 organizations involved in health complaints or investigations, of which “[n]o single person or organization is responsible and accountable for the quality of clinical investigations or for ensuring that lessons learned drive improvement in safety across the NHS.”

None is subject to the Department of Health, which happily informs hundreds of complainants per month that it has no role in complaints. In reply to the PASC, the current Secretary of State explicitly ruled out a complaints department (on logistical grounds).

The PASC, in consultation with the Secretary of State, recommends “a national independent patient safety investigation body.”

I agree with the recommendation for an investigative authority that is singular, national, and independent of the providers and deliverers, but it should not be independent of the Department of Health – it should be the Department of Health itself. The Department of Health is the ultimate provider of public health; it is accountable to the political administration and thence the electorate; it must admit its own responsibility for everything that happens in British healthcare, rather than to refer complainants to some successor to the PHSO. The Department of Health will need to start by reviewing tens of thousands of complaints that the PHSO arbitrarily refused to investigate.