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CHAPTER 4 EXPECTATIONS OF THE PURPOSE AND INTENDED BENEFICIARIES OF SCRUTINY
Summary
There was strong agreement that scrutiny should not only ensure adherence to minimum standards, but also that it should encourage service improvements. To a lesser extent, it was thought that it should ensure value for money. Although it was acknowledged that, in theory, scrutiny outcomes - such as inspection reports - could play a role in enabling potential service users to choose between different service providers, there was little evidence of this in practice because service users frequently had little choice.
External scrutiny was seen as more effective than internal accountability mechanisms because scrutineers could see things that those working in the service either do not see or take for granted. However, participants thought that there were disadvantages of over-scrutiny.
There was a general consensus that direct and indirect service users are the most important beneficiaries of scrutiny and that scrutiny arrangements should focus on their needs. However, service staff, including frontline staff, service management, and service owners, and, to a lesser extent, the general public, as taxpayers, were also seen to benefit. Participants thought that the general public would not necessarily consider scrutiny of public services important unless they had a personal interest in a particular service.
Purpose of scrutiny
4.1 A number of expectations concerning the purpose of external scrutiny were expressed. There was strong agreement that scrutiny should be designed to ensure adherence to minimum standards, but also an expectation that it should go a step further and encourage service improvements. To a lesser extent, a role was identified for external scrutiny to ensure value for money and accountability. Although much less central to discussions, it was acknowledged that there could be a role for external scrutiny in providing information which would enable service users to choose between providers.
To set minimum standards
4.2 There was widespread support for scrutiny both to set: minimum standards … for a minimum service level so that everybody knows what that is (User of council services) and to ensure that public services meet those minimum or basic standards. Having ensured adherence to statutory requirements and regulations, scrutiny bodies should then be able to reassure service users of the actual quality of experience any service user could expect: but they can look further and see that a reasonable service has been provided within the actual statutory requirements (Relative of care home resident).
4.3 A particular theme to emerge was an anticipation that scrutiny ensures that service standards do not slip - even temporarily - through staff complacency. Participants expressing this view suggested that the threat of scrutiny would encourage providers to maintain basic standards:
… so that staff don't get lazy and always work to a certain standard…. [I] f you know the bosses above you and you are quite pally with them … standards can slip … get lackadaisical. … [B] ut [with] someone from outside coming in and inspecting - you would be more apt to be on your toes. (Recent NHS hospital patient)
4.4 The phrase 'keeping staff on their toes' was used repeatedly in several groups, indicating that the purpose of scrutiny was to ensure that ' you couldn't do a shoddy job' (User of council services).
To make service improvements
4.5 Simply ensuring adherence to minimum standards was not considered to be sufficient. While scrutiny was expected to provide some kind of underlying assurance to current and potential service users that services are 'fit for purpose', it was suggested that, without a focus on improvement, service providers might not aspire to achieve more than the bare minimum essentials required to operate:
If you set a minimum standard then they are never going to rise above it … nothing is ever going to improve. (User of council services)
4.6 Therefore, a further essential element of scrutiny was to encourage best practice ' to make the school better' (6 th year secondary pupil), promoting continual improvement as ' an essential element' of the organisation's culture (Relative of care home resident).
4.7 However, participants did not want to prioritise one function over the other. The consensus was that effective scrutiny involves both functions working together:
… inspection should be to check you're meeting minimum standards but also … encourage[ing] you to keep improving, to reach a higher standard. (Parent of child in a nursery)
To provide impartial views on service quality
4.8 External scrutiny was seen as more effective than internal accountability mechanisms because of its ability to offer new perspectives and allow scrutineers to see things that those working in the service either do not see or take for granted. This was commonly referred to as observing with ' a fresh pair of eyes':
…that phrase, 'you can't see the wood for the trees', when you are in a system and working with it you don't have the same objectivity. (Parent of secondary school pupil)
4.9 External scrutiny was understood to offer both impartiality and objectivity, since it:
… removes that feeling … that… you're best buddies … you are all doing it from the inside, you are all friends with each other, and you all say nice things about each other. [External scrutiny] … takes that away. … [S] omeone else is coming who isn't a buddy and a friend and will be more honest with what they see rather than … colluding with each other. … There is no vested interest. (Parent of secondary school pupil)
4.10 Conversely, in-house assessments were considered more likely to be biased:
Because if you had it within the hospital they would be wanting maybe to give a slightly distorted picture. Maybe it wouldn't be too fair, they would be wanting to get their own standards shown better than they actually are. (Recent NHS hospital patient)
To ensure value for money
4.11 Although discussions about the role of scrutiny focused largely on ensuring satisfactory levels of service quality and encouraging service improvements, it was also expected to ensure value for money and accountability in public spending:
the council [needs] to prove it's giving value for money, because every year your community charge [council tax] goes up (User of council services)
4.12 It should be noted that this is one of the main functions of audit, although participants rarely referred to audit explicitly.
4.13 Ensuring value for money was regarded as more of an issue in relation to what might be termed 'background services' e.g. the coastguard service and council services such as roads, refuse collection and parks, where everybody is a direct or potential service user, but where the quality of service provision, unless exceptionally poor, tends to carry less salience in daily life. These participants were more likely to consider scrutiny from the taxpayer's viewpoint as they saw scrutiny both as a means of keeping service costs down and of accountability.
4.14 Indeed, a number of service users in the other groups suggested that value for money was the main concern of members of the public. They looked to scrutiny to deliver ' value for money more than anything' (Parent of secondary school pupil).
To facilitate choice of service provider
4.15 In theory, scrutiny outcomes - such as inspection reports - could play a role in enabling potential service users to choose between different service providers 7. However, none of the participants had used scrutiny outcomes in this way, for a number of reasons. One factor was the limited extent to which service users have any real choice, making the use of scrutiny outcomes irrelevant. The choices of relatives of people in care homes, in particular, were often constrained by the limited amount of time they had to choose a home and the lack of places available. The following stories were typical:
The deciding factor for us was the pressure on the hospital and social work and if we didn't choose somewhere pretty quickly they were going to shove her off to [X, 20 miles away] . There was only two vacancies in [Y, where she lived] so I was more or less forced to choose one.
I didn't get a choice as far as my mother was concerned. She had been in hospital for a while. I was told the week before Christmas … that she was being chucked out basically, and I had no choice in the matter. They had picked a home and that was it, and within a week she was out and she was in this home. (Relatives of care home residents)
4.16 Parental choice of nurseries was also constrained by the number of places available.
Basically we had to make a decision and most of them didn't have any places. … [I] t wasn't the place [we wanted]. … I took him out after a month. I just stayed off work because I just didn't feel it was the right decision until I found a better one. (Parent of child in a nursery)
4.17 While members of the above groups at least felt that they were selecting a service provider, even if the choice was very constrained, there was little evidence from other groups that they had any potential to choose a service provider. Clearly, looked after young people are unlikely to be in a position to select a children's home or a foster carer, while, for council service users and those discussing the coastguard service, the issue was irrelevant. However, where choice would have seemed possible e.g. for NHS patients and secondary parents/pupils, there was almost no mention of it.
4.18 All but one of the parents of secondary school pupils indicated that their children progressed naturally to the local school in the catchment area. The one exception was a mother who felt there were problems at one school, and moved her children to another school which she thought had a better reputation, but this was regarded by other parents as exceptional and not the norm. Such lack of perceived choice may have been because the secondary parents and pupils groups were held in relatively rural areas where less choice is available than in urban areas.
4.19 Using scrutiny to inform choices of service provider proved irrelevant and was not identified as a function of scrutiny. While it was accepted, after prompting, that scrutiny could be used in this way, the dominant view remained that people might find inspection reports useful in the absence of other information, rather than as a primary source of information. So, for example, it might be useful for people who were new to an area and could not rely on local knowledge or word-of-mouth. Interestingly, one parent of a child at a nursery saw the potential for scrutiny to share responsibility for a decision: you know that somebody else has looked at it and said it's OK … you can share the blame almost.
Disadvantages of scrutiny
4.20 While there was overwhelming support for external scrutiny to be undertaken, it was suggested that there are some drawbacks, particularly in relation to what was perceived as over-scrutiny. It is important to note that they refer to the consequences of over-scrutiny and are not arguments against scrutiny as such.
4.21 A range of potential problems was acknowledged, most notably the use of staff time, the increase in bureaucracy, undermining trust in professionals, the costs, and private sector providers opting out of provision.
Staff time
4.22 Unnecessary costs to service users and taxpayers due to the amount of staff time diverted away from service provision - both before and during an inspection - was identified as a potential disadvantage of scrutiny. As one participant noted:
Look at the National Health, they demotivated so many nurses, they are having to fill out so many forms and take them away from their real job. (Recent NHS hospital patient)
4.23 It was suggested that there sometimes appears to be constant disruption from relentless scrutiny (in the broadest sense) with service staff spending time on ' tick box' paperwork instead of concentrating on service provision.
4.24 One view was that time and money are wasted on reassuring service users and the general public about the quality of services, with participants suggesting that some of the scrutiny might be unnecessary because public sector staff are generally committed to good service provision.
Bureaucracy
4.25 When discussing expectations of the purpose and nature of scrutiny, there was a view that it was overly bureaucratic:
There are far too many tiers of inspectorates, audits, or whatever, that's what's costing this country. (Citizen)
4.26 It was suggested that too many rules and too much bureaucracy can be detrimental to service providers and users. In addition, scrutiny was felt to have an excessive focus on health and safety:
I will give an example, recently it has gone over the score, I think with health and safety… our local school, there was a healthy and safety report through the HMIE report, and all the coat pegs in the school have been removed. They have been there for twenty, thirty years but suddenly they are removed. Nobody has ever killed themselves on a coat peg. Now the children have to carry their jackets round with them all day round school, come rain, hail, or shine. I just think it's ridiculous, there's nothing been put in its place. It's gone too far. (Parent of secondary school pupil)
4.27 The above case of the school was seen to be manifested elsewhere:
I think that's right, its not just school it applies to other things, hotels and hospitals. We are breeding a nation now of scrutineers and an extra layer of management and control and its becoming heavy upstairs we should be downstairs stoking the boilers. (Parent of secondary school pupil)
Undermining trust in professionals
4.28 Scrutiny activity was viewed as having the potential to undermine trust in professionals. It was suggested that scrutiny regimes serve to question the commitment of staff and their ability to provide services. Scrutiny is seen to make them 'jump through hoops' to prove they can provide the service effectively:
The thing you mustn't ever overlook, the average person employed in any organisation is pretty committed to achieving effective performance. You mustn't ever make the assumption that everybody is trying to dodge.
Especially in public services because a lot of the jobs they do are very, very difficult and dangerous, and they wouldn't be in that if they weren't committed to doing their best in the situations they find themselves in. It's not a job you go into just to pass the time or get a big pay packet. (Citizens)
4.29 Scrutiny was also sometimes linked with what was seen as a negative 'blame culture':
Most doctors are terrified of being sued and other industries like the airlines they don't have a blame culture, they want to know what happened so they can put it right next time. There was a case of a transatlantic flight where the pilot and the co-pilot both fell asleep because it's a very boring job doing that. It's all on autopilot you don't do anything. There was an incident, nobody's life was lost or anything, but they both admitted that they fell asleep. Whereas if they had a different culture like they have in the NHS they would probably be sacked for falling asleep. Because they both felt they had admitted it, now they have something like an alarm clock that goes off every fifteen minutes. So you need that kind of culture where the hospital people are prepared to say, oh I made a mistake, then you can put it right. (Recent NHS hospital patient)
Closure of privately run services
4.30 It was suggested that the negative aspects of scrutiny outlined above could lead to private sector providers, who were perceived to have a choice of whether or not to provide a service, opting out of service provision in that field if it became too difficult or burdensome.
I think we're in grave danger as you pointed out of losing trust in the professionalism of the people who run the individual homes and if we over regulate them they are just going to lose interest. (Relative of care home resident)
Cost
4.31 During the discussions, concerns were raised about the cost of scrutiny. The following quote sums up the dilemma very nicely; that while identified as necessary, scrutiny is also seen to be a costly activity:
The thing that worries me is that I see that all these things are a massive bureaucracy that is costing a lot of money. I mean somebody has to make the regulations, and somebody has to make sure they have been enforced, and somebody has to inspect the inspectors, and somebody has to make sure we get value for money for that, but that auditors for that must cost a fortune. (User of council services)
Who should benefit from external scrutiny?
4.32 A number of beneficiaries of scrutiny were identified, including, most importantly, service users, service staff, and, to a lesser extent, the general public (mainly as taxpayers). In some cases, participants suggested all these people should benefit from scrutiny:
…Everyone, if they get the service right and the value right, and the cost right, it includes everybody. I think that's what it should be about, it shouldn't be about punishing people but it should be about making sure that everybody benefits from improved services and the best value, that kind of thing. (User of council services)
Service users
4.33 There was a general consensus that direct and indirect service users are the most important beneficiaries. Since they are directly affected by services, it was argued that scrutiny should be geared towards their benefit.
4.34 Service users were seen to benefit from scrutiny in a range of ways; ensuring and providing reassurance that services are delivered to adequate standards, providing protection, helping inform judgements of service quality, and, to a lesser extent, enabling them to be informed in their choice of service providers.
4.35 One benefit for service users was simply the reassurance that they are given some form of protection from service failings or inadequate practice:
If you don't have relatives then it's maybe very important that they have somebody protecting them. (Relative of care home resident)
4.36 On occasions, it was suggested that it might be indirect service users who required the reassurance about protection of users, such as 'g iving parents the peace of mind' that the nursery met the standards. A parent of a secondary pupil echoed this feeling:
I'm not sure the pupils themselves would always know what was … coming out of an inspection, certainly parents would. … [Parents need to know] that the best possible education is being given to their children … and that children going to that school are confident that somebody has come and said 'yes, the school is doing what it's meant to do'. (Parent of secondary school pupil)
Service staff
4.37 Various levels of service staff were viewed as being beneficiaries of scrutiny, including frontline staff, service management, and service owners, and it was felt they would benefit in a number of ways.
4.38 Frontline staff were identified as beneficiaries of scrutiny procedures that offered them protection by telling them ' what they are doing is the right way to do it' (Parent of child in a nursery).
4.39 Further benefits to staff included maintaining morale: ' it's good for the staff to know that the patients trust them and if they're getting this kind of scrutiny they will be trusted (recent NHS hospital patient); and providing motivation and encouraging stability: ' if you have a good set up they will stay for longer rather than having turnover of staff' (Parent of child in a nursery). Benefits such as these were frequently seen to have knock-on benefits for users since satisfied staff tend to provide better services for users. However, there was a recognition that feedback could sometimes be excessive:
Obviously there is going to be some things that a foster carer does that doesn't merit them actually being told you can't foster any more. Like small things that really aren't detrimental to the person's care and that they can improve on. (Young person who had been through the care system)
4.40 At a senior level, service managers were considered to be potential beneficiaries of scrutiny:
… if I was on a senior management team, then I would be treating it as a very useful tool to use, to work with. (Parent of secondary school pupil)
4.41 As well as benefits for frontline staff and management, benefits for service owners were identified:
The owners of the business are going to benefit just because everybody else is benefiting. The kids aren't going to be changing every few weeks and the parents aren't going to be complaining. (Parent of child in a nursery)
4.42 Ultimately, both the Scottish Executive and councils were identified as beneficiaries of scrutiny; the former through ' good press' (Parent of secondary school pupil), and the latter as suggested by this parent of a secondary school pupil:
… councils may benefit … because it may give them either the authority to carry on doing what they are doing and saying you are doing a good job, or to say this isn't working we … [need] to do something about it.
The public
4.43 Finally, the general public, as taxpayers rather than service users, were identified as beneficiaries as the procedures were seen to ensure that services represent value for money for the taxpayer:
… after all we are the ones that pick up the tab aren't we? (User of council services)
4.44 However, there was a view among the parents of children using a nursery that, other than value for money, the general public would not necessarily consider scrutiny important because they have no personal interest in the service.
Especially if you ask maybe old people, they wouldn't really as you said, they wouldn't particularly have an interest in that, they would rather have a library next door than a nursery. (Parent of child in a nursery)
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