Category Archives: decision making

Audit, Inspection and Scrutiny: the three ugly sisters?

This popped into my inbox today:

“The need to drive up the quality of care for patients, whilst delivering efficiency and productivity, is a key principle for the NHS. As pressure on NHS finances continues to build, UKAS accreditation is increasingly being used as an effective way for purchasers and commissioners to demonstrate that they can achieve ‘more for less’.”

I felt a stirring of irritation. This blog is the result……….

I know organisations have to behave commercially and tick boxes in order to thrive. I spend part of my working life encouraging and supporting charities and NFPs to do exactly that, but without losing their heart and soul to it. It is possible. But as an old nurse (registered about a century ago) and vehement supporter of the NHS original principles of free at the point of need and paid for by the entire community I am increasingly dismayed by the passionless, sterile performance of the people tasked with – and paid handsomely for – managing “public” health services. I have seen patients become the enemy, clinical standards side-lined in favour of improvement on the balance sheet, kindness become irrelevant, and buzzwords and trends take the place of clinical and compassionate behaviour. Health and social services are scrutinised, inspected, audited, governed, examined, professionalised more than ever before and we still have Winterbourne, elder abuse, Southern Health (pauses to spit), frequent reports of casual abuse and cruelty (that we know of), and we will all know those “care” homes with a good CQC rating which pong and employ people you would not want to sit next to on the bus. We will all know of supported living services that are little more than one person institutions with little or no meaningful activity and engagement – or to put it another way, that warehouse people in units of one, creating the illusion of choice and a Life but deliver isolation and fear. We have seen Southern Health reduce victims and loving families to statistics and irrelevancies, destroying people in order to prop up a system that sucks and protect the very people who allowed and encouraged the system that killed people and fixed the blame on others, with lies, obfuscation and bluster.

Some inspection agencies, several tiers of consultancy and management and many more are too often yet another layer of “approval” or box ticking to chuck at organisations. Along with services like 111 –  a dangerous irrelevance that often removes much needed funding from frontline services for the return of reduced standards and increased risk –  they also create a cash cow for canny providers without delivering any improvement in clinical outcomes, or supporting real people with the very real challenges of everyday ill health. We seem to simply carry on increasing layers of approval, fresh hoops to leap through (some with fire) rather than examine very basic factors. Often the people creating those hoops are not clinical and have little understanding of how  things actually work in the real world. I keep hearing that we need more funding for this that and the other – I keep seeing a variety of groups being blamed for an ever increasing number of failures and deficits: currently GPs are getting a hammering despite being possibly the last group of professionals who should be blamed and who, along with dedicated skilled nurses have kept things going against the odds. Commissioning services is clunky, inappropriately targeted, poorly contracted and badly managed, which is a criticism of the process –  again often created by people who do not understand the real workings – and not the people who have to work with it. The competition itself reduces the capacity to develop and really grow health and social care support services because contracts are not only badly drawn and managed but are up for renewal so frequently it is impossible to invest in services and also make that holy grail of profit. Profit is not going to be the first thing to go.

I firmly believe in a skilled and educated workforce well managed and led and supported with career choices and pathways. I also firmly believe in holding organisations and individuals to account. I believe those can be delivered without the huge self-propagating self- perpetuating roundabout of new mandatory qualifications and accreditations, incompetent inspections, and without the workshops, consultancies, projects, papers, enquiries, processes, requirements and bottom feeding organisations that have sprung up around services that are actually intended to protect, care for and nurture us.

There comes a time when the volcano erupts, the boil is lanced, the pus drains and healing can take place. We need to recognise that the privatisation experiment which was trumpeted as the way to increase choice and competition which were equally being promoted as in our interests – I am pausing for the laugh here –  is a failure, delivering little more than profits for largely incompetent organisations and draining the body of the NHS of resources and talent. Choice is not what sick people want, overall – they want skilled professional care, close to home, delivered kindly by people they trust and with their involvement in the process. And answers if something goes wrong, with a meaningful apology attached. Dividing professionals and organisations with “competition”, asking for innovation when compassion is good enough, blaming good people for systemic failures and expecting mountains of assessments, graphs, justifications, and hounding good people for honest mistakes does not result in decent health and social support.

Have a look at this: Laugh and then weep.

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I write therefore I am…….

 

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Decisions Decisions…….

Decision making is a hot topic, in Government, in Business, in our personal relationships. Politicians like to be seen as “decisive”, strong leaders, capable. Their decision making can speak clearly about who they are and who they represent. We make decisions every day from the moment our eyes open, mostly not challenging decisions (which cereal to have…..) but the process will be similar to any decision making: reduce and select the options, weigh them up, obtain corroboration as required, risk assess, choose.  Some decisions then have to be verified – not the cereal decision, but pubic-impact decisions! They have to be demonstrated as good and in the public interest. Doctors, for example, can be held to account in a very public and structured way for their decisions, and quite right too.

In this modern, vibrant savvy age of entrepreneurship, business, public relations and increasingly rapid development of products and policies it has been fascinating to attend local council meetings and watch the archaic and frankly absurd methods used to reach and share decisions. I can recommend it as a means to explore power and how it moves around people and traps them.

Well-intentioned people of all sorts run for government, local and otherwise – and some less well intentioned people too. To be elected all we need is a bit of cash and some voter apathy – produce the right words on the leaflets, smile and kiss babies (or promise toilets in the town centre), get your name known so it is familiar on the ballot sheet and Bob’s your uncle. With voter turn out at its lowest in decades you only need a handful of people to recognise you, a sockful of cash and favours to distribute as required, and not have too much visible mud sticking to you and you can lever your way in. Once in, there are a multitude of ancient processes designed specifically to protect you from scrutiny and consequence. Public council meetings, for example, are run by a Town Clerk who positions him/herself, like the Presidents Bodyguards, ready to take a bullet for the people authorising her/his salary and apparently relevant education, rottweiling away any pertinent and grown up conversation behind the smoke and mirrors of process and protocol. Understatement of the day at my last meeting was “this is not a conversation, not interactive” barked at a member of the public daring to supplement her already submitted, then scrutinised and whitewashed questions with a mild query after the tepid and qualified response from the council.  Not interactive indeed, not there, not anywhere.

One wonderful example of the antithesis of voter engagement was at the last meeting I attended after which a councillor (famous for audibly addressing a colleague with whom she disagreed as a prat, in front of a variety of members of the public including children after the Remembrance Day Ceremony) cantered over to the group  of the public attendees specifically to make a point of her own, and then when someone asked her a question backed off so quickly she almost fell over herself arriving saying “I don’t answer questions”. If not then, when? A gold plated gift wrapped opportunity to engage with voters about a hot local topic. I know – let’s ignore it. Maybe they were all prats? Sadly that is not  an isolated councillor behaving inexplicably but a realtime indicator of some local government attitude.

If I were in that elite group of elected officials who have the privilege to serve their community at the communities expense (and that has Precious Little chance of happening I hardly need to add) I think I might start to question those processes. Yes, they have been there for centuries (as have Scarlet Fever and Plague, both thankfully almost eradicated with universal approval) and yes, they are traditional, but until recently so was sending kids up chimneys and wife-beating. We have civilised ourselves past that. Those protocols, processes, trip-wires, smoke and mirrors, call them what we will, are man-made – like nylon, like poverty – and we can un-make them and create a better, more accountable, more engaged, more people friendly way of making decisions that will, ultimately, impact the entire community. It is probably about time we did so, and in the process expose some of the decisions made on our behalf and their consequences. Good people get elected all the time – as do the less good and the downright dreadful. It is probably time we freed the good ones up to do what they want to do – a bit of good for the community and a bit of proper public engagement. Some of those good ones who sit around, and at the head of, that local council table are becoming stained with their colleagues fallout and grime – how lovely it would be to liberate them.

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