“There’s just no accountability” they cried when I asked why nothing changed. Why are inequalities still worsening? Why are some settings still not safe? Why can’t we make the ‘left shift’? And I knew what they meant – the leaders – but I wondered how this could be when they also complained that too much of their time was spent on governance.

On reflection it seems that the outcomes that matter are rarely within the control of a single person or organisation and therefore outside much governance process. And the big problems we face that are ‘wicked’, shifting, and hard to pin down aren’t served by compliance to standards. Despite this, the default response to crises is usually more rules, more oversight, more structure. So much governance and still no accountability. A feature of the NHS already written about in this same blog earlier this year.

So, what happens if instead of analysing accountability gone wrong we reverse engineer accountability gone right? Have you ever asked yourself “When was there accountability at its best?” I’ve asked exactly that to a growing number of public servants. Here’s what I’ve found so far:

At its best accountability is a relationship, not a task

Accountability is built on trust, shared purpose, and regular communication. It’s actually a feature of an organisation working well and not a task to be given to assigned ‘leaders’.

When we recognise that accountability is not one-way reporting tasks but a feature of relationships, we can map all the relevant relationships. In a single decision, you may be thinking of operational governance and regulatory compliance, but you should also be thinking of colleagues, employees, service users, and family and friends. You may even be thinking about how things would be perceived in the Daily Mail.

What impacts decision-making is how salient to the decision maker these different account holders are — the relationships. The more salient our relationship to our account holders (ideally actual patients rather than online or media outrage) then the better accountability there will be.

At its best accountability is about what matters, not control

I don’t know about you, but all my best experiences of NHS care have been staff breaking rules to do the right thing: extending visitor hours so we got to see a loved one, urgent appointments in the ‘wrong’ clinic, even repeating a blood test until it gave the result that accessed the best treatment.

Accountability at its best is separate from organisational control. Equating accountability with control is an organisational design sleight of hand with sometimes terrible consequences. There are too many examples e.g. Mid-Staffordshire, Morecambe Bay, Winterbourne View, Shrewsbury and Telford.

In caring professions, it matters that we’re doing the right thing, not just doing some things right. If no-one holds me or anyone else to account beyond compliance to organisational process control, then we have a significant crisis of mattering.

At its best, accountability is achieved at people’s discretion, not through a water-tight contract

As well as reporting greater wellbeing at work, those who know that their work matters are also more likely to contribute discretionary effort (see Tomorrow mind by Martin Seligman and Gabriella Kellerman). And examples of accountability at its best are almost always within the context of discretionary effort. Like the volunteer improvement projects initiated by ward staff. Or this GP who stepped into the decision-making gap that opened up between the standardised pathways for this ‘complex’ patient:

“basically he took over a lot of the care in terms of getting me the right combination of drugs. That worked. Now where exactly was accountability for solving my medical problem? I’m not sure, but I think my GP had some of it and he took that accountability and worked with other people to deliver an outcome”

Paradoxically, rigid contracts and bureaucratic policies lead to accountability avoidance. Through obligation, fear or laziness, people do exactly and only what’s in the contract rather than what they know will achieve the best outcome.

At its best, accountability is restorative not punitive

The key question underlying any sense of accountability is ‘why does it matter if we do this? At all? Well? To the best of our ability?’

For example, making a profit matters to a business because if you don’t, you go bust. As disciplinary as you can get. Public services on the other hand need to get better, not go bust. Disciplining a public service by destroying it through financial sanctions does not help anyone in the long run. Punishing scapegoats destroys any motivation among officials to take the kind of risks that improvement or transformation really need. The punitive connotation of simply the word ‘accountability’ in our NHS now creates such strong recoil it is hardly surprising we struggle to demonstrate it in any serious or sustainable way.

Descriptions of best accountability shift the motivation for accountability away from fear of punishment towards the hope for a better, collective future. Rather than avoiding scrutiny, we might choose to embrace it as an essential part of sustaining our essential relationships. A move to Relational Accountability involves openly acknowledging challenges, difficulties and even harms and taking action to make amends. These are essential steps in the restorative practice that reconciles stakeholders and moves us all into the future.

Moving towards best accountability

Control mechanisms and performance reporting will probably always have some role in organisational life and in many instances do good. But they do not create the Relational Accountability that people describe when they talk about accountability at its best. This requires something quite different, and from all of us. So different to our current bureaucracy in fact, that we may conclude that accountability at its best is an unattainable ideal. However, I’d argue that the transformative shifts are actually quite small and subtle. Not hard to do, though perhaps hard to value.

First, each of us must shift our focus to how we make ourselves accountable. Accountability at its best gives us confidence as we go about getting difficult things done. As such, decision makers need to not just welcome but proactively seek out account holders that can most meaningfully judge their actions. As Pendleton and Haslam concluded in their blog:

“Efficiency or productivity improvements are likely to need clear and distinct roles, the ability to make decisions and willingness to be accountable for them.” (emphasis added).

Next, to recognise the whole diverse web of account holders and be motivated by the health of those long-term relationships. The question, especially for complex outcomes, is not ‘who is to blame?’ but ‘how will we live together tomorrow?’ What amends need to be made, not as a performance of action or ‘grip’, but in order to restore trust between stakeholders?

And finally, to amplify the voices and concerns of those that are most relevant to what matters and not to those who can leverage the most control or issue the harshest sanctions. In that diverse web of account holders there are some very loud voices. It is up to decision makers to adjust the volume where necessary to make sure the voices that really matter are audible at the time of decision making, not only in the aftermath of tragedies.

Perhaps if we shape our decision making in this way, things may finally change.

Author

Dr. Amanda Woolley

Amanda is a highly experienced leadership development specialist, facilitator, and executive coach with a proven track record of enabling senior leaders to navigate complexity, set strategic direction, and lead with presence and impact. With experience across academia, the NHS and her own consultancy, Amanda brings a unique blend of academic rigour, practical insight, and relational intelligence to her work.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.