— Prof Graeme Currie, CLAHRC WM Co-Director
In the course of a recent NIHR HS&DR funded research programme, which I led, examining the operation of children’s health and social care networks, organisational failure emerged that led to the death of a teenage girl from chronic anorexia. This heightened philosophical concern I have always held in my academic career about the question – ‘Who is responsible for organisational failure, such as high infant mortality rates in paediatric heart surgery at Bristol Royal Infirmary  and the death of ‘Baby P’ in Haringey Borough Council?’ Whilst Sharon Shoesmith, Director of Children’s Services, was held accountable for the organisational failure that led to the death of ‘Baby P’, I argue that this responsibility was misplaced. This may represent a contentious statement for those of you, as frontline professionals, delivering services. But for me, responsibility for organisational failure needs to be located with you. Let me explain further.
The concept of responsibility is complex, as it has an external and internal aspect. The external aspect, also termed ‘accountability’, views ‘being responsible’ to constitute a sense of a political, moral, or legal liability. This entails the potential of being blamed. The internal aspect of responsibility focuses on explaining, not an event caused by action, but the motivation of action. Internal responsibility is something an individual or a group feels toward some role, task or recipient, and a commitment to ongoing responsiveness to changing circumstances. In contrast to external responsibility (or accountability), which can only be established after the event, internal responsibility requires that the most important moment of control comes before potential harm.
Internal responsibility is at the heart of public intuition about professionalism; public trust in the moral basis of professional activity provides the foundation for professional jurisdictions. Hence professionals have a moral imperative to sacrifice self-interest and accept responsibility for the client. In addition, professionals delivering frontline services are much better positioned (than accountable managers) to enact responsibility because they can identify emerging problems as they arise and do something to mediate these.
However, in contemporary organisations, the dynamics of professional and managerial rationalisation of professional practice (professionals socialised towards suppressing emotions), jurisdiction (professionals accountable for only that part of care within their technical jurisdiction), and accountability (standardisation and performance management of care by managers) interact in a recursive manner to narrow internal responsibility and suppress the sentiment assumed to be at the core of any profession. Thus, there exists a misalignment between professional ideals and the way professional practice is shaped by the workplace setting.
Given the above, it may be frontline professionals can justifiably sidestep responsibility through claims they are not jurisdictionally or managerially accountable for failure. Indeed that proved the case following the death of a teenage girl from anorexia highlighted earlier. Each professional was able to claim, ‘I did my bit’ in terms of the care delivered to a vulnerable patient. My prescription is not one of greater managerial ‘control’ over professionals since this was one of the corrupting influences upon responsibility in the first place. Rather than ‘control’ of professionals, I suggest managers need to work ‘with’ rather than ‘over’ professionals to ‘cultivate’ not ‘control’ responsibility on the frontline. Managers need to intervene to activate responsibility for the patient that may otherwise lie latent, so ensuring vulnerable patients do not fall between the cracks of organisation.
First, ‘hybrid’ managers, who span managerial and professional ranks, are well placed to reach into professional organisations to identify individual champions with a disposition for service change. These individuals might be drawn from the ranks of more powerful professional groups. They might be ‘tempered radicals’, who want to ‘rock the boat’ but remain within it (retaining legitimacy with professional peers).
Second, professionals’ sentiment of care needs to be unleashed. In the case of the teenage girl dying from anorexia, the explosion in the number of cases of eating disorders that are characteristic of many health economies and the ‘vulnerability’ of such patient groups might be highlighted. This can take place ‘front stage’ in team meetings or professional development workshops, the aim being to move away from paralysis and absence of service development that commonly accompanies blame, towards emotions of remorse for failure and hope or optimism for change, so translating into a sustained sentiment of care.
Third, the corrupting influences of managerial and professional organisation must be mediated. Frontline professionals, led by professional champions, must be given ‘air cover’ to develop best quality services free from the effect of resource constraints, albeit making a ‘business case’ for the service specified on both a cost and patient outcome basis. Frontline professionals may also need to be buffered from the effect of powerful professionals resisting service change, where service change adversely affects the latter’s interests
Finally, accountability is an antecedent to responsibility. If someone doesn’t feel or even ‘fear’ that they might be held accountable for organisational failure, then they are unlikely to enact responsibility. Hence, as managers develop the capacity and sentiment of frontline professionals to enact responsibility, in particular amongst professional champions, they should allow those professional in whom they desire responsibility to be embodied, to develop processes and structures for service delivery, including the ‘performance’ criteria underpinning what counts as high quality service. In this way, frontline professionals are willingly (given their sentiment of care has been unleashed) co-opted into taking accountability for service delivery, since they have assumed design responsibility for service delivery.
— Prof Graeme Currie, CLAHRC WM Co-Director
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