Recent independent inquiries have laid bare the catastrophic impact on innocent lives of major failures by public sector bodies. The Grenfell, infected blood and Post Office inquiries all heard harrowing evidence of human suffering, including the tragic and avoidable loss of life.
Public sector failure also comes with a financial penalty – not just the expense of inquiries to determine why scandals happened, and the cost of government compensation schemes borne by the taxpayer. There’s also the time public sector bodies must spend dealing with the aftermath of failures, inevitably diverting resources from their organisations’ core purposes. And then there is the damage to public trust. Public sector organisations wield huge power over the lives of citizens and are entrusted to act in the public interest. When they let down the public, the consequences are manifold and far-reaching.
Understandably, the public wants to know that those identified as culpable for failure will face consequences. They rightly want those responsible to be “held accountable”. But how much better would it be if public sector bodies could avert the crisis in the first place?
“When leaders are appointed, they must be assessed on how well they address problems, rather than how effective they are at making them go away”
Of course, the old adage that “hindsight is 20/20” holds true. It is far easier to evaluate past decisions from the vantage point of knowing the outcome than it is to foresee problems in advance.
Major failings in public life are invariably due to a combination of factors. The picture is complex – a fact illustrated by public inquiries often spanning several years and producing reports that can run into well over a thousand pages. However, a look at some recent public inquiries – such as the Grenfell, infected blood and Post Office Horizon IT inquiries; independent reviews such as the Windrush review, and reviews of maternity services – reveals recurring themes. These include a failure to listen to and act on concerns raised by employees and / or the public, a failure to learn lessons from past mistakes or similar incidents, and a failure to identify and share emerging themes that might have alerted the organisation to a developing risk. There is often a failure of the board to have effective oversight of issues and concerns. A common characteristic of bodies responsible for a major failure is an overly defensive organisational culture.
Our report, Recognising and Responding to Early Warning Signs, launched on Tuesday, highlights these common themes and sets out to support public sector bodies in getting better at spotting problems at the earliest possible stage, while there is still time to act, and potentially avert a disaster.
To stand a chance of successfully recognising and responding to early warning signs, leaders must do four things. They must realise they have a problem, act to address it, identify the wider lessons to be learned, and be diligent in ensuring that those lessons are embedded fully within the organisation.
"It is often the defensive response of the public sector body and its failure to acknowledge what happened, and offer a meaningful apology, that compounds the pain suffered"
Recognising early warning signs requires organisations to have systems and processes in place to spot problems and a culture where these can be discussed and escalated up through the chain of command. Organisations must bring together high-quality data from across the organisation, allowing the dots to be joined and enhancing an understanding of risk. When something goes wrong, it is often the case that “someone knew”. Building a culture where everyone sees it as their duty to raise concerns and is supported to do so is crucial to the surfacing of problems at the earliest stage.
Acting to address problems requires leaders, at all levels, to have the confidence to take action when issues are raised with them rather than “sweeping things under the carpet”. When leaders are appointed, the expectation must be set that they will be assessed on how well they address problems, rather than on how effective they are at making them go away. The public sector must get better at acknowledging mistakes and apologising for them.
Identifying the lessons to be learned when things go wrong – and when they go well – requires good processes of evaluation and the desire to get better. Public complaints are an example of a seam of data which can be mined to identify themes and prevent problems escalating.
Ensuring that lessons are fully embedded within the organisation requires commitment. If the data suggests a change of approach is required, it is important to ensure that this is followed through, and results in tangible improvements to the way the public accesses public services.
When things go wrong, it is often the defensive response of the public sector body and its failure to acknowledge what happened, and offer a meaningful apology, that compounds the pain suffered. Responding with candour is important following major failures when the public wants to know what has happened. But the responsibility to uphold the principles of honesty and openness goes wider. These principles – like all of the “seven principles of public life” – are an important guide to the behaviour the public expects at all times.
Our report is aimed squarely at those in public life. Rather than making hard recommendations, we offer practical insights and “points for reflection” intended to help leaders think deeply about the processes and culture in their organisation and consider whether improvements can be made. But the questions are not only for leaders; they can help staff at all levels to challenge their leaders to think about these important matters.
No one is perfect. Mistakes will be made because humans are fallible, and the harsh glare of hindsight may show those decisions to have been flawed. But this isn’t a reason not to try to get better at recognising the first signs of things going wrong and to respond appropriately. The cost of failure is too high not to try.
Doug Chalmers is the chair of the Committee on Standards in Public Life