Trust Well Earned: a New Approach to Accountability for Better Healthcare

At the moment, accountability does not make enough of a contribution to better healthcare and social care. Patients and clients find that they do not always get the help they need as a result of requirements regarding accountability. Moreover, healthcare professionals have less time and attention to devote to them, and they regularly have to fill out questionnaires without knowing what the whole point of doing that is. Healthcare professionals are not always able to provide the healthcare and social care they believe is necessary, because doing so would not fit the narrow framework within which they must be accountable. Distrust is growing: professionals are protecting themselves, and learning is being made more difficult. The administrative burden for professionals, which they feel does not serve any good purpose, leads to lower job satisfaction and ultimately means that fewer people want to work in the healthcare sector.

According to the Council for Health and Society, the cause of this growing unease lies primarily in how the practice of accountability is now set up. At the moment, this is imposed 'from the outside in' by outside accountability forums such as regulators and payers, but also by professional and umbrella organisations, which also see to it that arrangements are handled uniformly across the board. Healthcare providers have become suppliers of information on accountability to external parties. Healthcare professionals themselves do not always see the use of this information. Accountability now focuses on the pursuit of only a limited number of values, such as legitimacy or safety, and these values are then also specifically fleshed out, for example by asking whether the paperwork involved is in order, and whether healthcare has been provided in accordance with protocol. The value of accountability for patients, clients and healthcare professionals is much less evident. There is also little scope to learn from it and make improvements.

Healthcare and social care are increasingly characterised by complexity. Patients and clients often have multiple requests for care at the same time. These requests depend to a considerable degree on an individual’s personal situation, and they can also change over time. But the organisation of care is also complex: healthcare providers are working together more and more in circuits and networks across different disciplines, organisations and systems. The way in which accountability is now structured does not fit in with this complex practice: it is still assumed that what good healthcare is, can be measured objectively and easily, and that this can also be established outside the practice of healthcare itself.

In the Council's view, the fact that accountability is insisted on even where it does not contribute to good healthcare has to do with a number of underlying causes: the constant search for certainty and the desire to minimise risks; the discrepancies between policy and practice; vested interests; and the fact that there is no downside for whoever is demanding accountability. Current policy aims to have fewer rules and better indicators, and tries to make it easier to provide information. These are good initiatives that can reduce administrative burdens in the short term, but that do not adequately address these underlying causal mechanisms. As a result, the level of unease about the current way of being accountable will not decrease. In addition, the complexities of healthcare cannot, by definition, be captured in indicators. Indicators are at best just that: indications to look further, to investigate what the story is behind the figures and percentages. And that does not happen often enough.

According to the Council for Health and Society, accountability should come about in a completely different way. The starting point should not be the one demanding accountability, but the one demonstrating it. Accountability must be at the core of acting professionally, and must be all about improving healthcare and social care. In a relational sense, this also requires a different interaction between the healthcare provider on the one hand and the regulator, the purchaser, and the government on the other hand. Reciprocity is central to this relationship: it involves being in dialogue with each other, exploring differences in interpretation together, and clarifying data. In the Council's view, five basic principles are important to the establishment of this improved accountability practice:

a. Who? The primary initiative is for healthcare providers to take. They take responsibility by using different methodologies such as team reflections, reviews, and narratives, and they work on the experiences and feedback of patients, clients, caregivers, employees and other stakeholders. In principle, regulators, healthcare buyers and patient organisations build on the way in which healthcare providers themselves take responsibility. In order to test whether this also contributes to good healthcare, regulators will occasionally take an organisation’s pulse. This provides an opportunity for caregivers to show that they have arranged things well, and provides starting points for joint learning and improvement. However, if a healthcare provider does not take full responsibility, regulators may ask additional questions and intervene if necessary.

b. About what? Shared, open principles and a responsible attitude. Accountability is about explaining the tough decisions that healthcare providers make in specific situations instead of complying with generally applicable standards. In this context, trade-offs between quality, affordability, accessibility and pluralism, as well as having the scope for reflection and learning, are important.

c. Where? Embedded in practice at various levels. Accountability must be much more fully embedded in practice. This can happen when healthcare providers invite others to give feedback and think along with them.

d. When? Part of a learning process, looking ahead. The focus should be more on the future and how things can be done better, rather than on the past and who is to blame. Complexity also requires a more natural embedding of accountability in an iterative learning process: acting together, engaging in reflection, and adjusting plans. The outcome of this learning process is unpredictable, and is partly determined by the interactions among those involved.

e. How? Conversation based on various sources of information. Accountability is based on several sources of information and on input from several actors: healthcare providers themselves, but also patients, clients and other involved parties, as well as on input from parties such as the Healthcare and Youth Inspectorate, but also insurers and partner institutions. It is more effective to start a conversation on the basis of incomplete information than to keep searching for the ideal dataset. It is also important that there be an open discussion. These days the prevailing idea that transparency is synonymous with full disclosure often just gets in the way.

Accountability based on these principles will contribute, in the Council’s view, to good healthcare and to a practice of continual learning and improvement, and that in turn will increase the level of trust among the parties involved. It will enable healthcare providers, on the basis of the feedback they get, to adapt their own working methods or to show others how things can also be done; it will contribute to joint decision-making by the patient or client and the healthcare provider; it will ensure that healthcare professionals can respond to the specific context around the demand for care; it will help make things meaningful for professionals, patients and clients; it will increase the level of job satisfaction; and finally, it will oblige healthcare providers to make the arguments for the choices they make explicit.

Approaching accountability differently, with the aim of providing good healthcare and social care, requires changes in both words and deeds. In order to help those involved to bring this change about, the Council has recommendations to make in four areas of change.

  1. In the first, the initiative is for healthcare providers to take. The Council recommends that healthcare providers take the initiative when it comes to other forms of accountability. They can do this by using different methodologies and by organising themselves into learning networks. This also means a different interpretation of the work of internal supervisors; they must question management board members more actively about their own accountability structure and, in doing so, they must also look, to the extent possible, for practical solutions within their own roles.
  2. In the second area, the initiative is for external regulators and healthcare buyers to take. They, too, should look more closely at day-to-day practice and be aware of the importance of the context involved. Regulators are advised to carry out more thematically focused oversight and to work with professional teams. Healthcare buyers will conclude multi-year agreements with healthcare providers. This will leave room for multiple interpretations of what constitutes good healthcare, facilitate learning and improvement, and entail dialogue.
  3. In the third, the initiative should be taken jointly by healthcare providers, healthcare buyers and patient organisations. The Council recommends that these parties continue to develop quality frameworks based on shared principles and a responsible attitude. The Board also recommends that healthcare providers and buyers redefine the concept of legitimacy and that they be accountable for quality and efficiency, rather than for whether the paperwork is in order.
  4. In the fourth area of change, it is a matter of a different attitude on the part of those involved: it should be verifiable, modest and proportional. It is important that those involved test whether accountability does in fact contribute to good healthcare and social care; that they be modest about the extent to which good care can be encouraged, and risks reduced, outside the field; and that they keep a sense of proportion by taking account of the negative effects of requirements regarding accountability. 

The need for change is considerable: after all, patients, clients and healthcare professionals are the ones who lose out with the current approach to accountability. What we need is accountability that contributes to good healthcare and support, and that enhances trust. It is to this that the Council wishes to contribute with this advisory report.