A significant article appeared in The Irish Times on 23 February 2000, when Padraig Ó Moráin, Social Affairs Correspondent, reported on a paper by Eoin O’Sullivan published in Administration, the journal of the Institute of Public Administration. O’Sullivan co-authored the book Suffer little children which was about abuse in the care system, and his research was important in the RTÉ programme States of fear.
With Dr Joe Robin’s books The lost children and Fools and mad, O’Sullivan’s book forms a trio of essential reading for any manager or frontline care worker in learning disability services. It is vital that we know what can go wrong and how large is the potential for slippage in our ethics and good practice. The terrifying aspect of these three books is that so often we see dreadful practices by concerned people who are not evil, have nothing but good will towards their charges, and are often doing their work at a sacrifice to themselves! We hope that these past times are behind us, but it would be foolish to assume that. Look around you: fascism is alive and well, even after a horrifying world war; anti-Semitism has not gone away either. Abuse, like the mythical Hydra, has many heads!
The serious point that Eoin O’Sullivan raises now, however, concerns the internal ethics and standards of administration in voluntary organisations. He uses the description ‘disorganised, diverse, internally hierarchical, relatively well-funded… [but] unaccountable to a high degree and powerful in their representation’. Do parents or staff recognise any of our voluntaries in these phrases?
Time was, when a small anxious group of parents and their friends–because there was nothing–clubbed together to begin a day service of some kind. Their budget was a few thousand a year, raised by enormous efforts. They pleaded with health boards and government for a few bob to keep going. If they were lucky, they may have attracted some professionals to work free, or part-time for a pittance. In a sense, these were ‘volunteers’, just like the committee of parents and friends. But, thankfully, these voluntary groups lobbied, cajoled, pleaded, and used every avenue open to them to obtain state money over and above their own coffee mornings, street collections, etc. In time, a sea change occurred. To put it another way: the tide came in for the Irish state, and lifted all boats.
Now we have the scenario which Eoin O’Sullivan claims to describe. Whether O’Sullivan is right or wrong, our services have become highly sophisticated and are no longer ‘voluntary’ in any traditional sense. With turnovers of millions, staff numbers of hundreds, all the rigmarole of industrial relations, health-and-safety, company, tax, property, pension law and much else besides–how can we be described as voluntary? Not-for-profit organisations is a better term.
But what may we have lost, and what are the risks that O’Sullivan points to when he describes our favourite Irish voluntaries as ‘unaccountable to a high degree’? Organisations and their managers hate to think that they are unaccountable, but the bigger and more complicated any organisation grows the more elusive the meaning and practice of accountability. The extremes can be seen in the hugely wealthy financial institutions in this state, and even in some individuals.
When our services were small and insignificant, they were accountable because the people they served were well represented and close to the action. Now it is not so and writers like O’Sullivan are drawing attention to this. The state pours millions into our services; we are an important part of the labour market–some organisations are bigger than acute hospitals. Questions are being asked about how efficient we are in the way we use the resources that come largely from the taxpayer.
In the health sector, government policy is increasingly relating budgets to results. A specific statutory framework is currently being created between the health authorities and the voluntary agencies. It is now clearly laid down that in the development of any service, principles of accountability must run. Without doubt, the level of accountability and the way in which this is measured will be a key factor in future dealings between government and services. It is intended that there will be service agreements between the voluntary agencies and the health authorities, which will link health board funding to agreed levels and quality of service provided by the agencies.
Audit programmes to emphasise the accountability of health care professionals are being put in place, but how satisfaction levels of consumers (i.e. people with disabilities and their advocates) will be taken into account is unclear. It is vital that parents ensure that consumer satisfaction measurement is built into any funding agreement where money passes from the taxpayer to the voluntaries.
In the future, government policy will be to regulate the voluntary sector in a way previously unheard of. The Task Force on Voluntary Activity position paper on funding and accountability issues (revised 8 July 1993–Part V Accountability) clearly implied this when it reported:
It seems reasonable that the price to be paid by voluntary organisations for grant aid is accountability both in financial terms and in terms of the quality of service and its responsiveness to the needs, participation and expressed views of the target group.
In the new Irish health systems environment, where there may be competition to obtain government funds and where ‘value-for-money assessments’ will be in place, organisational managers will be forced to develop measures to evaluate efficiency, to maximise the quantity and quality of services. They will face the sometimes unpalatable fact that performance measurement is not neutral but can be used as a weapon with which to exercise control or influence by health board fund managers.
Up to this point, health board and Department of Health fund managers allocating costs to projects for learning disability have avoided evaluating the efficiency of service providers in achieving goals. Fund managers have preferred, instead, to use cost against numbers of places–a simpler measurement than assessing quality. It is precisely here that the largely disenfranchised parent or advocate must be heard, that is, in the measurement of quality and consumer satisfaction.
The old ‘voluntaries’, now better termed ‘not-for-profit’ organisations, are at risk of becoming self-serving and detached from their consumers, perhaps quite unknowingly. The process is almost inevitable as organisations become bigger and more professional, unless consumers insist on being heard on quality issues. Unfortunately, unlike supermarket customers, our parents cannot vote with their feet!
So, what is the message from O’Sullivan’s article? It is this: the so-called voluntary organisations need a different input from their supporters and customers. They need an informed input on quality and service issues, an insistence on structures being in place that can monitor care programmes in a transparent and easily understood way and that can respond to the concerns of the people they serve. That’s what accountability is. Make sure you get it!