By Neil Small, Emeritus Professor of Health Research, Faculty of Health Studies, University of Bradford, UK. (Contact details below)
A challenge to public trust.
The interaction between health and care providers and the people who access their services forms the warp and weft of public trust in these organisations. It’s different with private sector companies, we know they are motivated by profit and we interact with them accordingly. We also know that some of them see their long-term commercial interest as being best served by ensuring a good quality service for customers. To achieve this sort of service they need staff who invest in providing it, and this sort of staff has to be looked after. Other private companies are interested in a quick pursuit of profit, they are likely to see staff and customers as solely instrumental in achieving this, and as being expendable if they don’t. We, as consumers, hope we can spot which of these types of company we are doing business with and make our choices accordingly. We do need to be careful – the second sort of company may try very hard to appear to be the first kind.
Public institutions are changing, a wide range of services are being privatised or commercialised. What sort of institutions are they becoming and how will they decide between competing priorities? In the past we might have assumed that a children’s home or hospital had an ethos, a distinguishing character guiding its actions, that was the same as the ethical principles that underpin the service it offers, that ethos and ethic were the same. But a privatised children’s home or a commercialised hospital trust might have an ethos which prioritises financial goals over an ethic of meeting the care needs of clients or patients. In 2022 the biggest private providers of children’s homes in England made profits of more than £300 million. Many had failings in the care they provided, for example Your Chapter Holdings was criticised by Ofsted who reported that in one of their homes, “children and young people are not protected or their welfare is not promoted or safeguarded”. Your Chapter Holdings showed profits rising from £1.7 million to £2.2 Million (The Observer 29/10/23: p 15). The Public Inquiry into the Mid Staffordshire NHS Foundation Trust describes an institution that prioritised meeting financial targets over providing adequate staffing levels on their wards. The Inquiry then catalogues the harm this did.1 These are just two of many examples of care failures across the NHS and care sector.2 But some of these failing institutions did more, they ignored, undermined, bullied or dismissed members of their staff who complained about shortcomings in care. It is this attitude to staff that is central to the Post Office/ Horizon scandal. Much of the attention given to this after the broadcast of ITV’s Mr Bates v’s the Post Office has drawn parallels with other failures of recent years. It’s a convincing parallel to draw.
The Post Office and its postmasters (sic).
There was a change in the corporate structure and business imperatives of the Post Office when it split off from Royal Mail in 2012. Now a private limited company whose sole owner is the UK Government, it has become almost entirely a franchised enterprise made up of independent business owners, “Postmasters” and other retail partners (WH Smiths for example – the Communications Workers Union called this sort of deal “blatant back-door privatisation”). On its corporate website the Post Office identifies itself as a commercial business driven by a strong social purpose corporate.postoffice.co.uk (accessed 11 Jan 2024). (The Post Office’s Latin motto translates (roughly) as “service, sincerity and diligence”). That social purpose includes serving “those people who rely on us” something actualised by the Postmasters “whose actions are a positive impact on their communities, providing a community hub”. “Not all value can be counted in economic terms” the website says. But the Post Office has also been prioritising a shift from being (in economic terms) loss making, as it was in 2012, to profit making.
The Horizon scandal has illuminated how the Post Office manifested a suspicion of its franchise holders by elevating a faith in its technology (the Horizon system) rather than having a default assumption that staff were acting properly. As well as this disdain for staff it is the split between the corporate ethos and the espoused ethic of the company that puts the Horizon scandal alongside the many other examples of institutions where one narrow financial goal displaces a wider function when that function cannot be captured in pounds and pence on a balance sheet.
It is a mistake to see each scandal that crosses our path as an isolated event, especially when we can see how many characteristics they share. Not making connections weakens our understanding not just of why this scandal occurred but why we have so many scandals.
What’s new?
It’s always been the case that there have been care failures, it’s always been the case that public organisations and private businesses are motivated to protect their own positions by prioritising organisation needs over service needs and it’s always been the case that it’s difficult to right wrongs and to get change from below, including change sought by dissatisfied staff. What’s different now is that the fabric of the society in which these events play out feels thinner. It’s been stretched by a concerted attack on the value of the collective, of solidarity and loyalty. These ideas are not compatible with the elevation of the individual, the valorisation of the successful and the assumption that value is a market commodity3.
In 1936 Walter Benjamin 4 wrote about how superstructures change more slowly than the substructure. This substructure has been changing since the ascendancy of neoliberalism in the 1980’s via the impact of its twin agendas of privatisation to favour the market economy and austerity to reduce the size and ideological salience of the public sector. It’s not been a smooth ascendancy but this forty year arc of history has inclined to the markets needs. The superstructure has been less an arc and more a roller coaster, a place of gains and losses and of greater polarisation. But the numerous and widely spread scandals evident this century do suggest that people, as well as institutions, are changing and that change is towards the substructure’s individualism and its dismissal of the idea of justifiable need as a defining feature of our social contract. In a paragraph that risks metaphor overload I return now to the idea of the interaction between the institution and the individual forming the warp and weft of public trust. The social fabric is looking threadbare. We can expect to see more holes appearing and more people falling through them, more failures not less.
- Sir Robert Francis. (Chair) 2013. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London, The Stationary Office. HC 898-111.
- Neil Small 2023. Failures in Health and Social Care, routledge.com/9781032365176
- Neil Small 2023. Health and Care in Neoliberal Times routledge.com/9781032365145
- Walter Benjamin. 2008. The Work of Art in the Age of Mechanical Reproduction. London, Penguin. (1st published 1936). P2
Keywords: Post Office/Horizon: care failures: children’s homes: Mid-Staffordshire NHS Trust: social contract.
Neil Small. Emeritus Professor of Health Research, Faculty of Health Studies, University of Bradford, UK.
Website https://www.bradford.ac.uk/staff/nasmall
X @NeilSmallUK