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CHAPTER 5 HOW SHOULD SCRUTINY BE DONE AND WHAT POWERS SHOULD SCRUTINEERS HAVE?
Summary
There was a fair measure of agreement about what should be scrutinised. Participants felt that adherence to regulations, quality of service, value for money, complaints and complaints handling procedures should all be scrutinised. Some quality of service standards were specific to the service in question while others applied to a number of services. Participants distinguished between aspects of service delivery that were relatively straightforward to assess and other more intangible ones, like atmosphere and the goodwill and dedication of staff, that were very hard, perhaps even impossible, to measure. Although some participants thought that scrutineers focused too much on outcomes and ignored processes, most felt that processes as well as outcomes should be scrutinised.
There was less agreement among participants about who the scrutineers should be. In relation to setting standards, participants thought there should be mixed 'teams' of different stakeholders, including independent experts in the relevant field, service users and service staff. Similarly, a range of people were identified as potential scrutineers: independent experts, service users and (to a lesser extent) members of the public. The desirable qualities and qualifications necessary for scrutineers were thought to include first-hand experience and/or expert knowledge of the service being scrutinised, independence from the service, an ability to form objective judgements, and training.
Views about how scrutiny should take place promoted the use of unannounced inspections on the grounds that they provide a more realistic picture of service quality. Participants were suspicious of announced inspections because they allow service providers to prepare and cover up any deficiencies. It was suggested that inspections should be triggered by the outcome of previous inspections or by other 'alarm bells' such as high staff turnover or a large number of complaints.
Participants felt the powers of the scrutineers should relate to the purposes of scrutiny and, therefore, gave little support to the idea of financial penalties on the grounds that service users or taxpayers would end up footing the bill, and/or the service would suffer from a consequent lack of resources. Participants felt that service providers should be given a specified and reasonable amount of time to improve and that they should be given appropriate advice and support. Imposing new management was seen as appropriate in certain circumstances, although it was recognised that it did not fit with the private sector model, and shutting down the service was seen as a last resort. There was also a view that simply 'naming and shaming', e.g. in the press, was an appropriate sanction and an effective way of ensuring improvements. While many participants thought that organisations should be given an opportunity to improve, the group of looked-after young people felt that, where serious problems were identified, there should be no 'second chances' because the potential impact on children was so great. There was widespread agreement that an additional level of scrutiny to scrutinise the scrutineers would be going too far. It was also agreed that the costs of scrutiny should be met from the public purse. This was both because there was no feasible alternative and because it was the only fair way of meeting these costs.
What should be scrutinised?
5.1 In accordance with current practice, participants thought that the following aspects of service delivery should be scrutinised: adherence to regulations, quality of service (both outcomes and processes), value for money, complaints and complaints handling procedures.
5.2 Scrutineers were expected to inspect adherence to specific standards and protocols along with statutory rules and regulations, such as fire safety regulations. However, participants did not expect scrutiny bodies to issue certificates ( e.g. fire safety certificates) but rather to check that service providers possessed them. In effect, therefore, they thought some aspects of service provision should be scrutinised by other bodies ( e.g. the fire service or the environmental health department) rather than by the main scrutiny body for that service ( e.g.HMIE for schools). This appears to suggest a targeted rather than a comprehensive approach to scrutiny.
5.3 Beyond adherence to statutory regulations, participants thought more general standards of service quality should be scrutinised. Some of these standards were specific to the service in question while others applied across a variety of services; for example, the NHS group, parents of school pupils, parents of children attending a nursery, and relatives of care home residents all mentioned cleanliness and nutrition.
5.4 Other issues identified as requiring scrutiny were facilities (mentioned by relatives of care home residents) and activities (mentioned by parents of children in a nursery, relatives of care home residents, and school pupils). Parents of school pupils also suggested that issues such as class sizes, the curriculum, and examination results should be scrutinised.
5.5 Discussions of what should be scrutinised led to debates about how much detail should be inspected; whether scrutiny should concentrate on the ' bigger picture' of overall service delivery or whether it should focus more specifically on particular aspects.
…It's just the main points, is it safe? Is the garden safe? Are the staff doing the right job? (Parent of child in a nursery)
5.6 One argument against in-depth scrutiny was the cost. It was argued, for example, that asking ' highly paid' people to inspect whether staff at a care home had polished a door knob was not necessary. Instead, it was argued ' there should be sensible things so that we've got guidelines' (Relative of care home resident).
5.7 Participants felt that many important aspects of service delivery were difficult or impossible to quantify, making judgements subjective. For example, a key indicator of quality to participants in the nursery group was ' how happy the children … and the parents are'. In the secondary parents group, ' the leadership of the head teacher', the ' happiness of the teachers' and ' pastoral care' were seen to be important but difficult to quantify:
Schools league tables are basically on exam results so that's a very quantifiable thing. I think something like care isn't so easily quantifiable. (Parent of secondary school pupil)
5.8 In contrast to some aspects of service delivery that are relatively easy to measure, it was suggested that intangibles such as atmosphere and the goodwill and dedication of staff are incapable of being meaningfully assessed. This raised the question of what it is feasible to examine:
When you go to [a particular nursing home] you get a wonderful welcome. But it's basic … lino floors and shared rooms … exceedingly basic: but there's a wonderful caring atmosphere. How do you quantify that? (Relative of care home resident)
5.9 Since some indicators of quality are difficult to quantify, it was suggested that the more readily quantifiable are chosen - but that they may not always be the most important indicators of quality:
The things that are easily measured are the things that are measured. Its easy to measure results, it's easy to measure attendances at school, it's easy to measure truancy rates … they are … easy to capture. (Parent of secondary school pupil)
Whether to scrutinise internal processes as well as outcomes
5.10 There was some debate about whether scrutineers should consider outcomes alone or whether they should also examine internal processes. In general, participants felt that both outcomes and processes should be scrutinised:
… they should be looking at the process as a whole and following it the whole way through - not just looking at the end result. They should be looking at start to finish. (User of council services)
5.11 However, one member of the citizens group considered that service users were only interested in the outcomes of service provision. Another member of the citizens group did not feel that scrutineers were sufficiently knowledgeable to inspect processes:
It has to be outcome because otherwise my fear is that, if it goes deeper than outcome you begin to expect scrutineers to have the same detailed knowledge as the people employed by the organisation … that's not what it's about.
5.12 The opposite view was expressed in the council service users' group, where focusing solely on outcomes was seen as missing the opportunity to identify better methods of service provision. Furthermore, examining decision-making was seen as an effective way of holding public services to account and ensuring value for money.
5.13 Some considered it would be superficial to assess outcomes alone, because consideration of processes would add value to assessments of outcomes. It should, for example, be possible to identify where the glitches in service provision occurred by ' getting into detail of exactly how they are achieving or failing to achieve the particular outcome' (Citizen).
Who should set standards?
5.14 In discussions about who should define standards of service delivery, a number of different stakeholders were identified. Service users, service staff and independent experts were all considered to have an important contribution to make. There was consensus that to cover all the different aspects of service delivery and to ' ensure that the standards drawn up are the right standards', it is necessary to involve ' a cross gathering of all sorts of people'. Members of the general public, as distinct from service users, were not thought to be appropriate because of their lack of knowledge.
Service users
5.15 The involvement of service users (direct and indirect) in setting standards was considered vital. The value of their contribution was a consequence of two factors; their first-hand experience and their personal interest in standards of service delivery:
It's our kids at the end of the day, we want the best for them so I don't think any parent would say, 'Oh I'm not bothered what the standards are'. (Parent of child in a nursery)
5.16 There was a common view that without service user involvement in setting standards, public services may overlook user needs and priorities 8. However, there were some concerns that service users may lack the expert knowledge required to set relevant standards. This was particularly the case in the citizens group where participants identified themselves as potential users of the coastguard service but thought they lacked sufficient expertise to be involved in standard setting.
5.17 More commonly however, lack of relevant knowledge was cited as a reason for involving independent experts alongside service users in setting standards, rather than as a reason for excluding service users from the process altogether.
Independent experts
5.18 The perceived value of independent experts was based on four factors; their expert knowledge of the relevant service, their knowledge of best practice, their independence from those responsible for service delivery, and their awareness of statutory requirements:
Professionals are their own best judge. I have a good idea of what make a reasonable teacher and a good teacher and a bad teacher, but it's a layman's assessment. (Parent of secondary school pupil)
What [independent experts] bring is something that is absolutely essential to scrutiny and that's objectivity, because there is always a danger that in-house culture will overlook weaknesses in the organisation and … outside scrutiny brings in an objectivity that sometimes lacks in-house. (Citizen)
5.19 As noted above, there was a widespread view that to set standards, service users require an input from independent experts. The experts would help to compensate for service users' lack of knowledge or expertise and would help guide them. Among the group of secondary parents, there was a suggestion that, although experts could develop guidelines for standards and present them to parents, parents should have an input to that process. A similar view was also expressed by hospital patients, who felt that what was required was:
… a joint effort between the medical profession and the patients. Everybody knows the standard of service that they should be receiving or providing but that's where sometimes it differs, so it should be a joint effort between the lay people who are the patients and the professionals. (Recent NHS hospital patient)
5.20 Although it was suggested that experts (such as retired teachers or social workers) might be out of touch with current standards of service delivery, some participants suggested that this could be overcome by involving service users and current service staff.
Service staff
5.21 There was a view that current service staff should also play a part in setting standards. Like experts, the contribution of staff members was valued because of their experience of service delivery, their understanding of the services, their awareness of the appropriate standards and their implications and consequences.
5.22 A further reason for their involvement was that they were the people who provided the services and had to work towards achieving the standards: it was felt that having an input into the setting of standards would help to ensure their commitment to those standards.
5.23 However, there was an alternative view that staff should not be involved because they would set standards to reflect their own interests, rather than the interests of the service users. For example, one participant said:
I would question whether staff have got the right motivations for choosing standards… I would fear that they are going to look at it from an operational point of view as opposed to a child welfare point of view. (Parent of child in a nursery)
5.24 More commonly, however, participants felt that this issue could be overcome by the involvement of service users and independent experts alongside staff members.
Who should scrutineers be?
5.25 A range of people were identified as potential scrutineers. Those mentioned were, on the whole, those who were identified as standard setters with the key difference being that there was little support for service staff acting as scrutineers and instead these were to be replaced by citizens. Independent experts, service users, and to a lesser extent, trained or knowledgeable members of the public were all thought of as appropriate.
5.26 It is worth noting that in discussions concerning potential scrutineers, the focus tended to be on inspection rather than the other types of scrutiny.
Independent experts
5.27 The reasons for the involvement of independent experts as scrutineers mirror the reasons for them being involved in setting standards: they were seen to provide an independent viewpoint; to have an expert knowledge of the relevant service and to be aware of what to look for; to have an ability to draw valuable comparisons between different service providers and a knowledge of best practice which could be shared; and to be aware of relevant rules and regulations.
5.28 Some types of scrutiny were seen to be the exclusive concern of experts. Regulation and audit (and some aspects of inspection) were identified as areas that require scrutineers to be knowledgeable about current legislation, rules, and regulations and participants were not keen to delegate these functions to non-experts. Thus there was unanimous agreement that certain regulatory issues should be left to the relevant trained professionals. Participants agreed that standards concerning fire regulations should be established and inspected by relevant authorities such as the Fire Brigade, health and safety issues should be decided upon and examined by the Health and Safety Executive, while the setting and enforcing of some standards specific to the service, e.g. concerning exam qualifications or nutrition of care home residents, might require other specifically trained people:
There's no point sending somebody in the Care Commission to inspect the fire regulations, it should be done by the Fire Master and the environmental health should be done by the Environmental Health Department because there are a whole series of people who have expertise in particular aspects. (Relative of care home resident)
5.29 In reality, there is an inspectorate for fire services within the Scottish Executive, although our participants were not aware of its existence. Nevertheless, although participants were not aware of this inspectorate, their comments overall appeared to confirm their support for such a scrutiny arrangement and, in particular, for the involvement of trained professionals in scrutiny.
5.30 It was considered important for experts to act within the sphere of their competence. It was recognised that expertise in one field does not necessarily imply expertise in another:
If you get the right people to inspect the right things, then it's more likely to be effective. (Parent of secondary school pupil)
5.31 However, some did not see experts as necessarily independent of the services, leading to possible collusion between experts and service providers:
… it could be a little case of … if you scratch my back I'll scratch yours. Put your tick in the box and go away and we'll come back next year. (User of council services)
5.32 It was, therefore, seen as vital that experts should be truly independent. In terms of the scrutiny of council services, it was felt that this would require them to be from a different geographical area. It is worth noting that these participants advocated a more stringent test than the 'not employed within the body being scrutinised rule', which is commonly used by current scrutiny mechanisms.
5.33 A concern raised about scrutinising teams comprised solely of experts was their perceived inability to appreciate the bigger picture, seeing ' only their subject of expertise and nothing else' or being ' blinkered by what they know'. As one member of the citizens group noted:
Somebody with experience might be saying - well it's always been like this so we'll keep it like this.
5.34 However, both of these concerns were seen to be counterbalanced by involvement of other stakeholders.
5.35 Service users were seen as playing a very important role in scrutiny. In general, members of the public who were not service users, were seen as having some role but less so than service users. Service user and public involvement is discussed fully in Chapter 8.
Qualities of a 'good' scrutineer
5.36 In addition to the status of individuals, the participants went further to identify a variety of desirable qualities and qualifications necessary for effective scrutineers. These included:
- first-hand experience and/or expert knowledge of the service being scrutinised (at least some members of the team must have this)
- independence from the staff, management and ownership of the service being scrutinised
- an ability to form objective judgements
- training in scrutiny methods ( e.g. inspections).
5.37 Training was viewed as essential for scrutineers, be they independent experts, service users or members of the public.
5.38 It was seen as vital that at least some of the scrutineers should have no personal interest in the service that is being assessed since this would make it easier for them to be objective. Objectivity was crucial to perceptions of what constitutes an appropriate scrutineer. Although it was not the majority view, for one participant this effectively ruled out the involvement of service users or their representatives as scrutineers of their own institution:
… any inspector should be totally independent … parents must have a vested interest in the specific school. … I do think … it's wrong that … the people within the school … should be directly involved in the inspection … because they have a vested interest and no matter if they want to be fair, it doesn't strike me as being the right way. (Parent of secondary school pupil)
5.39 However, the general consensus was that this problem could be overcome by involving independent experts alongside service users.
5.40 As noted in Chapter 3 above, participants were much more knowledgeable about inspection and complaints handling than about regulation and audit. As a result, many group discussions focused on these two types of scrutiny. Complaints are dealt with in Chapter 7 and, in the remainder of this chapter, we focus on inspection.
How inspections should be done
5.41 We report on what participants said about who should contribute to inspections, on the pros and cons of announced and unannounced inspections, on the frequency and timing of inspections, and on potential triggers of inspections. Participants identified service users and service staff as particularly valuable sources of evidence for inspectors.
Consultation with service users and service staff
5.42 There was strong support for inspectors to gather evidence in the form of views and opinions from service users. It was also suggested that service users would probably present different perspectives from other groups, such as experts, because they have different needs, expectations, concerns, and priorities about standards of service delivery and may, therefore, identify issues that other consultees would be unlikely to identify. They were also seen to have the detailed knowledge based on experience that inspectors needed to be aware of:
Inspectors should talk to young people who have been fostered because obviously like they know what's happened. Inspectors could just be saying aye it's all right, no problem, it looks fine. (Young person who had been through the care system)
5.43 Many of the looked after young people and the school pupils suggested that all young people using the service should be consulted:
Inspectors should survey all pupils. Every pupil should get the right to say what they think about the school. (6 th year secondary pupil)
Not just a selection of them, they should be speaking to all of them if possible. If not, they should be allowed to write down whatever they want to write down and that should be looked at. (Young person who had been through the care system)
5.44 There was some suggestion in the school group that this would avoid bias from selecting only the ' nicest' or the ' brainiest' pupils:
They never spoke to the ones that have like learning difficulties. They spoke to like the folk that they knew would say nice stuff. (6 th year secondary pupil)
Service staff
5.45 Many participants suggested that service staff should be consulted. One reason was on account of their whistle blowing capacity. As one participant stated:
It would also be quite good if employees at the coal face as it were, had a direct line to the scrutineers. Ultimately, you have got one manager with whom they may disagree or be in conflict. [Listening to what they have to say] is quite a valuable function that any scrutinising body could perform. (Citizen)
5.46 In the nursery group it was suggested that staff might not whistle blow without prompting and, therefore, consultation with them as part of an inspection is imperative:
I don't think a lot of young girls who work in it would ever whistle blow. They probably don't really like the set-up as it is. But it's very hard for an eighteen year old to call in like the Care Commission. They won't do it without another job to go to. So it means that the bad things that are happening in the nurseries are not going to get picked up that easily. (Parent of child in a nursery)
Announced versus unannounced inspections
5.47 There was strong support for the use of unannounced inspections. This was based largely on the element of surprise; unannounced inspections were seen to provide a more realistic picture of service quality than announced inspections. Unannounced inspections were considered more effective than announced inspections because they were seen to make it difficult for service providers to create a false impression of the service.
5.48 There was a widespread view that announced inspections allow services to prepare and cover up any inefficiencies or deficiencies in service quality and 'pull the wool over inspectors' eyes':
If you know they are coming everything is spick and span. Whereas if they walk in [unannounced] they see really how things are running. (Citizen)
Obviously if they know that they're coming they can rearrange things and get things in the order they should be whereas, if it's a spot check, they're getting it at face value. (Young person who had been through the care system)
5.49 As these quotes suggest, announced inspections were commonly viewed with a large degree of suspicion. It was suggested that effectively run service providers should not require advanced knowledge of inspections as they should have nothing to fear:
As a customer, if I was told that the inspector had to give notice I would say to myself, well why is that, what is wrong with the organisation, what do they want to hide? (Citizen)
5.50 To back up their argument against announced inspections, participants often presented examples of preparations being undertaken:
There was one of the firms I was with in the past and the inspection was announced which was approximately ten days before it happened. There was a team of six folk thrown into a place where there was normally only two to make sure everything was perfect for the day of the inspection. To a certain extent, if you announce the inspection that's going to happen - maybe not to that scale. (User of council services)
I have heard one story - wasn't in Scotland, it was Ireland - the teacher instructed their class when she asked a question in the week that the inspectors were there, the kids that knew the answers to the question were to put their right hand up, and the kids that didn't had to put their left hand up, and it presented a picture of a class that was enthusiastic and knowledgeable and of course the teacher was picking the ones that knew the answers. (Parent of secondary school pupil)
We had to write extra essays to put in a folder, which we should have had but we never had it, so we had to do it because they knew they were coming. (6 th year secondary pupil)
5.51 A more unusual view was that announced inspections are fairer because of the preparation time they allow for:
Its only fair to allow people to get all their records together in one place and I think the other organisations involved in inspections, they tell you to have your registers together at such and such a time. (Relative of care home resident)
5.52 It was also suggested that announced inspections might be useful in raising standards (although there was some suggestion this might only be temporary) since they enforce action. For example, it was suggested that knowing there is an inspection looming will result in service providers undertaking things they have intended to do for some time.
5.53 A common view was that a combination of standard announced inspections and unannounced spot checks would provide the most effective inspection arrangements. Unannounced inspections were viewed as an important add-on to announced inspections and were useful for ensuring that recommended improvements had been carried out:
A combination of announced and unannounced visits with at least one of each. Where there are time bound recommendations made in the likes of the report that is followed up by additional visits, to make sure that they have actually been achieved. (Parent of child in a nursery)
5.54 It was suggested that unannounced inspections might be of particular value in following up announced inspections. Unannounced inspections could be determined by need. For example, focusing on outcomes of an announced inspection in which service quality is perceived to have slipped.
5.55 A combination of announced and unannounced inspections was seen to guard against the hostility that unannounced inspections can cause:
[There should be] announced and unannounced inspections. Balanced visits so it's not seen that they are going in heavy handed to the nursery, you know it's not a thing to be afraid of that a nursery should feel they are coming in and highlighting things possibly they do need to improve on or areas maybe they are not aware of. (Parent of child in a nursery)
5.56 While announced inspections might only effect a temporary raising of standards and ensure a defined service quality by a deadline, threats of unannounced inspections were perceived to ensure high standards at all times. Unannounced inspections were seen to achieve high standards by introducing an element of surprise and guarding against complacency since the timing of the next inspection is not known. Although unannounced inspections were perceived to put people under pressure, it was suggested that the threat of unannounced visits ensures service providers are ' on top of their game'.
5.57 However, some participants doubted that spot checks are good for ensuring high service standards was doubtful. Participants who were opposed to the idea of spot check inspections suggested that they did not necessarily result in high standards. For example, in comparing them to roadside checks for vehicles, one participant stated:
You can get pulled off the road at any time by the police to inspect your tyres and exhaust but I don't think that actually makes sure you've done it properly all the time. I'm not sure of the spot inspections. (Parent of secondary school pupil)
Timing
5.58 Participants suggested that the timing of inspections (time of day and time of year) was often too predictable. It was argued that effective inspection necessitates a move away from a fixed timetable of inspections.
5.59 As opposed to routine inspections, strong arguments were made for inspections to be conducted flexibly, on a random basis, and, where service provision was 24 hour, it was agreed that inspections should take place throughout the 24 hours. For example, relatives of care home residents were concerned that inspections take place between the hours of 9am and 5pm, taking no consideration of perhaps more vulnerable or problematic off-peak times of day such as ' in the middle of the night', or ' at 6am'.
5.60 It was perceived to be the case that even when inspections are unannounced, they are relatively predictable. For example, where service providers are aware that they will be inspected within a six monthly period, it will often be apparent when the inspection is due:
But perhaps the unannounced one shouldn't be at a six monthly interlude so that people know its coming. (Relative of care home resident)
I think they should vary it because there's no point in going in unannounced if you do it the first week in February every year. (Recent NHS hospital patient)
Frequency
5.61 Views on the ideal frequency of inspections were dependent on a number of factors. These included type of inspection (a full 'top to toe' inspection or a spot check of selected issues) and the need for one (for example, because problems were identified in a previous inspection).
5.62 Participants suggested the frequency of inspections could be determined according to need. The frequency of subsequent inspections would therefore depend on how service providers had been rated in a previous inspection. If bad practice were revealed in an inspection, for example, a follow-up inspection (either announced or unannounced) was seen to be necessary:
One every year, the official one and then possibly, I think, in the case of a good home where there's very little to complain about, there may be a year goes past and it doesn't need an unannounced one. If there are problems to be resolved maybe an unannounced one within three months or whatever, but not a predetermined time. I think the unannounced one should be done according to the need and prioritising the work in homes with a little bit more support and encouragement. (Relative of care home resident)
5.63 Frequency of inspections was also seen to be dependent on the level of inspection. Participants suggested that small inspections or 'mystery shopper' style assessments for example could occur fairly regularly while full inspections examining service providers 'from top to toe' would be required less frequently.
What should trigger inspections?
5.64 Participants cited a number of factors which they believed should initiate inspections. These included previous record, a change in the provider's circumstances (such as change in management) and 'alarm bells' such as the number of complaints received about a service provider.
5.65 It was suggested that the focus of scrutiny procedures should be on poorer performing service providers: checking that issues the service providers claimed were 'in hand' had really been followed through, and on ensuring that requirements or recommendations made at the previous inspection had been implemented:
[reading from an example report] It seems to be that everything on this, you know, 'washing machine broke down, new one has been ordered', 'a shortage of paper towels and liquid soap, supplies are due to come in later that day', it's all something that's going to happen in the future, but did they go in the next day and check that the supplies had arrived and did they find out that the washing machine was going to arrive and that it had been ordered? That's where an unannounced check would be good. (Relative of care home resident)
5.66 Similarly, it was proposed that concerns raised by 'mystery shopper' exercises (the group of recent NHS hospital patients suggested a 'mystery patient') could trigger a full inspection.
5.67 It was suggested that the quality of service delivery may be at risk in services where circumstances alter. It was therefore proposed that new management could trigger inspections:
Or there has been a change of management or something, that could be negative or positive, who knows, but I think you are absolutely right and trained inspectors will know 'this is one we need to keep an eye on' and do spot checks. (Relative of care home resident)
There was a large volume of teachers left our secondary school and that should be a trigger: why are they leaving? (Parent of secondary school pupil)
Obviously like a problem like [named school] went through an awful time of it with bullying and there was a problem they removed the Head Teacher and they had to put in another Head Teacher. Surely there should be worries or concerns for parents who have got children at that school as well. (Parent of secondary school pupil)
5.68 Essentially such approaches, in which better/lower risk services are inspected less frequently, would result in a focus on poorer performing/high risk services as one way of helping ensure service quality. One view was that this was the most cost effective approach to inspection:
Focusing on where anything had slipped rather than on strengths, that's a waste of money. (Relative of care home resident)
5.69 The number of complaints or concerns was identified as a factor which could influence the frequency of inspections. Similarly, it was suggested that other 'alarm bells', such as high staff turnover or service staff reporting incidences of non-compliance or bad practice, should enable inspection agencies to inspect a service provider:
When the school receives a lot of complaints an extra inspection should be undertaken, that's just commonsense so that they know what's going wrong, really. (6 th year secondary pupil)
Follow up actions and powers of scrutineers
5.70 Where scrutineers identified problems in service provision, a number of potential 'next steps' were discussed by participants. Depending on the seriousness of the problem, these ranged from being given time to improve, the imposition of new management to closure of the service provider (all of which are currently exercised by scrutiny bodies or the Scottish Executive). Less typically, there was also a view that simply 'naming and shaming' the service provider would be an effective way to ensure improvement. Each of these views is discussed below.
5.71 The researchers also raised the possibility of financial penalties as an outcome, but there was widespread rejection of this on the basis that service users or taxpayers would end up footing the bill, and/or that service delivery would suffer from the lack of resources.
Time to improve
5.72 As a first stage, particularly with relatively 'small' problems, there was widespread agreement that service providers should be given a specified, and reasonable, amount of time to improve (very much in accord with current practice). As the quotes below illustrate, this was often expressed in preference to an alternative option of shutting down the service provider.
I think it should be worked to try to improve it. If it's little things that they are not doing, I think it should always be improved rather than shutting it down. (Parent of child in a nursery)
…obviously there are 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)
5.73 There was considerable support for the view that service providers should not just be given time but should be given appropriate advice and support to improve. This was where the sharing of best practice between service providers and the 'independent expert' scrutineers' would be particularly valuable.
It's quite a good idea I mean, if you've got a unit that is working really, really well and one that's working really, really badly, the staff [in the first unit] can say we do it this way and that way and [the staff in the second unit] can benefit from this. (Young person who had been through the care system)
They can't just tell them what the bad things are and leave them to change them on their own. (6 th year secondary pupil)
Imposing new management
5.74 Imposing new management was seen as one option which might be appropriate in certain circumstances e.g. where there were big problems or where a service provider had failed to improve after a certain length of time.
If the school fails an inspection then the Head Teacher and senior member of staff should be replaced because it's their fault. (6 th year secondary pupil)
5.75 However, difficulties with this approach were also identified. In relation to privately owned care homes and nurseries, it was felt that imposing new management would not fit with the private sector model.
5.76 A participant in the NHS patients group also questioned whether there were enough experienced managers available.
Closing down service providers
5.77 It was acknowledged that the ultimate step may have to be the closure of a service provider. However, this was very much seen as a last resort and that an effective system of scrutiny should ensure that it happened very rarely. The following quote was typical:
…if they have regular inspections then it should never have got to the point where standards aren't being met because they should have been given a warning on one inspection saying, you need to achieve these blaa, blaa, blaa, by a certain date and if they haven't then, OK they could shut it down but it shouldn't come as a surprise. (Parent of child in a nursery)
5.78 The impact of closure on service users was also recognised - particularly in relation to vulnerable groups such as care home residents, who might be deeply distressed by having to move.
…my Dad would just be devastated if that [closure] happened. (Relative of care home resident)
5.79 Similarly, the practicalities of having to find alternative provision, e.g. for school pupils or NHS patients, reinforced the view that closure must be a last resort. Moreover, it was felt that closure was simply not an option for services such as the coastguard service, because it would leave a gap in provision.
5.80 However, there was a somewhat different perspective from the group of looked after young people. While they were willing to allow foster carers time for improvement on relatively small issues, they felt that there should be no 'second chances' where serious problems were identified, because the potential impact on children was so great. It is worth reproducing in full the discussion on this point.
There should be no chance for them to start up and then pass [a follow up inspection] and then be crap anyway. They are meant to be on the ball all the time.
Basically they should pass it first time.
They are substitute parents really if you think about it. People go in for like respite and that, why should one foster carer get to mess up?
Give one person a bad experience and keep on fostering for years and years and years until something else happened and then that's them saying all these years we've been putting so many young people with that person.
There was a thing in the news a couple of weeks ago, a foster carer had been fostering for twenty years. Her neighbour had been complaining about the way the kids had been getting dressed and coming out with bruises and all sorts she'd been smacking them with frying pans and stuff.
I saw that.
Fourteen years this women had been fostering but because it cost too much to check her up she got away with it.
They do checks and if they had to fail even once then they are struck off and can't ever take it up again.
(Young people who have been through the care system)
'Naming and shaming'
5.81 Being given time to improve, the imposition of new management and closing down service providers were seen as the main powers that scrutineers should have. However, as the following quotes illustrate, there was also a view that simply publicising negative scrutiny findings ( e.g. in the press) would be an effective way of ensuring improvements - either because the service provider would be shamed into taking action or the general public would force them to take action.
If they are going to make public in the local [newspaper] …how many complaints they have had, etc. it's a fairly powerful beast. (Relative of care home resident)
I think the best power that they could have is the power to go public to the public, to say this is what's happening in the real world. This is why your services aren't working, a name and shame thing, this is underperforming, that guy's not doing his job. It will never happen but that would be nice. (User of council services)
5.82 The opposing view was that such 'naming and shaming' would have negative consequences - it would demotivate staff and, in the case of private sector providers, may lead to them simply closing down their business.
Scrutinising the scrutineers
5.83 There was widespread agreement that an additional level of scrutiny, to scrutinise the scrutineers, was going too far. Participants recognised that there was a potentially infinite number of scrutiny levels. 'Where do you draw the line?', 'how far do you go?' and 'bureaucracy gone mad' were typical comments.
5.84 It was felt that scrutineers should be accountable but that the features already identified as important for effective scrutiny - training, independence, objectivity, consistency, transparency - would be sufficient.
5.85 One suggestion was that a service provider should have the opportunity to offer feedback on the experience of the inspection itself and on the inspector's report. Where inspectors were consistently getting negative feedback or having reports disputed, action could then be taken.
5.86 However, participants did not have a clear idea about who would be taking this action. In general, it was felt that the relevant division of the Scottish Executive e.g. 'whoever is in charge of delivering education to Scotland', should be responsible for the scrutiny of that area. Beyond that, participants tended to be vague about who exactly the scrutineers would be accountable to, and who would be checking for consistency or following up the problems identified from service feedback.
Who should pay for scrutiny?
5.87 The dominant view was that the costs of external scrutiny should be met from the public purse - variously described as 'the government', 'taxpayers' or 'all of us'. There were two main reasons for this. The first was that it was the only feasible option. The following comments were typical:
There isn't anybody else who could fund it. (Recent NHS hospital patient)
[In answer to the suggestion that the tax payer should pay the cost of external scrutiny]: Yes. Who else? It seems an unnecessary question to ask. (Citizen)
5.88 The second, equally important, reason was that it was the only fair way because everyone benefits from the service and from the results of scrutiny.
…education actually affects all of us in society and although we, as parents, benefit by having children's education paid for by the State, ultimately the State benefits by having well educated children who come out and then fulfil the requirements of the economy, so I think it should be all tax payers (Parent of secondary school pupil)
…you can't ask particular sections of the community to pay for a service that benefits the population as a whole. (Citizen)
5.89 Even if service providers were charged for their own scrutiny, it was felt that the costs would ultimately come from the public purse, because most services were paid for by the public purse. Any fees that the service provider was required to pay would either reduce the resources spent on the service itself or increase the cost of provision. In relation to privately run care homes and nurseries, it was thought that any scrutiny fees would either reduce resources spent on the service or be passed on to the paying customer.
5.90 There was a more exceptional view that scrutiny should be paid for by service users because they are the people who benefit. Significantly, this view was only expressed in relation to the scrutiny of services people did not use, not by service users themselves. For example, a participant in the Citizens' group suggested that people who go yachting could be required to pay for insurance, which would contribute to the cost of the coastguard service (and the scrutiny of it) in the event of needing to be rescued. Similarly, another participant was unhappy about paying for a service she did not feel she used:
Researcher: …who do you think should pay for the scrutiny of nurseries?
Participant: … The people that use them. I don't have any children, I don't use an education service, I don't use nurseries and I would really object to being asked to pay for it. I do object to being asked to pay for a service I have never used and will never use. (User of council services)
5.91 Regardless of the ultimate source of funding for external scrutiny, one participant made the point that independence could be compromised if service providers paid scrutineers directly:
I think that has to come from outside otherwise it starts to contaminate the whole process I think. Although what I will say is make every council contribute to it. (Parent of secondary school pupil)
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