June 2009

NHS dental care and the issues of public service ethos, governance, accountability and probity “Every penny of public spending needs watching and safeguarding by independent regulators and through much more transparency otherwise taxpayers and voters will turn away” (Richards, 2009). The current furor over the United Kingdom’s Members of Parliament (MPs) expenses raises a number of issues, not least of which concerns the nature of and arrangements for allocating funds for a public service. The timing of the malfeasance could not be much worse as the reform of public services is high on the Government’s agenda. As with the NHS dental care system, the Cabinet Office (2008) has suggested that the characteristics of a world-class public service involves four elements: excellent outcomes, personalised approaches, being fair and equitable, and; good value for money. While few, if any, would disagree with the goals, the terms themselves lack definition. The publication continues in this vein. It acknowledges that, “all governments have a responsibility to ensure that taxpayers’ spending achieves value for money” and “clear accountabilities are established so that each part of the system knows what is expected of them”. Again all very laudable but, perhaps not surprisingly, there remains a lack of detail in both what the terms actually mean and crucially, how this is to be achieved. A further issue is that there is a tacit assumption about what is meant by a public service; that it is unambiguous and that the boundaries between public and private sectors are clear. necessary reinforcing in these circumstances. The private sector can be a useful servant for public services, if properly supervised; what it can never be is their master.” McRae (2005) argues the public-sector ethos involves people trying to do things well in areas that could not be carried out by the private sector. He went on to add “(the) public sector has aped the private sector without understanding that you have to do this thoughtfully and carefully”. He stated that individuals who work in the public sector, when faced with the danger of being set inappropriate targets and incentives, would become cynical and “will tick the boxes and meet their targets because that is what their political masters require them to do”. This would appear to be an all too common failing within the NHS. The need for governance Irrespective of where the boundaries between public and private lie, a system of governance is required. The Independent Commission on Good Governance in Public Services (2004) defines governance as “the leadership, direction and control of public service organizations to ensure that they achieve their agreed aims and objectives and in doing so serve the public’s best interests”. This requires sound decision-making processes to exist. Morrell (2006) suggests that if clarity in the principles underpinning effective decision-making does not exist, the moral uncertainties and inconsistencies that arise “could be far more damaging to the standing of the NHS as a national institution than inefficiency or mismanagement”. Indeed, for all the rhetoric about devolved decision making in the NHS, while the detailed administration and management of individual units does indeed occur at a local level, the service is held to account through a centralized policy and financial framework. For governance in the public sector, government has relied on the use of targets and performance indicators. The underlying theory is that desired results are specified in advance, and using a monitoring system, some assessment of performance is made against the specification and feedback is given. This sounds all very worthy but as Bevan and Hood (2006) have pointed out two assumptions are made. First, the measurement problems are unimportant, that the part on which performance is measured can adequately represent performance as a whole, and that distribution of performance does not matter. Second, that this method of governance is not vulnerable to manipulation by agents for their own advantages, “gaming”. The authors conclude that the above two assumptions made are not justifiable. Thus, the extent to which the “improvements” reported in the The public ethos Flynn (2007) argues that the “public service” is one in which the finance is derived in the majority from taxation, rather than by direct payment by individual customers. This suggests that it is not the ownership of the service that is important but the way it which it operates. The majority of dental care is provided by individuals who work in privately owned premises but provide care under some form of contractual agreement; the state subsidising the care to varying degrees. A further distinction of a “public service” is this idea of a public good, that the role is not simply based on commercial profit, that there are additional motives behind working for a “public service” instead of opting for the alternative (Bovaird and Löffler, 2003). This is known as the “public ethos”. With the introduction of ‘market-type’ mechanisms in the public sector a conflict arises between commercial profit and the public good to a greater extent than previous arrangements. The Public Administration Select Committee (2002) concluded that “The (Public Service) ethos needs protecting and, where CDH 2545-Editorial-Batchelor.indd 66 10/06/2009 14:41:12