A very warm welcome to the launch of our report ‘Recognising and Responding to Early Warning Signs’, which we are publishing in the 30th anniversary year of the Principles of Public Life. It is wonderful to see so many of you here today.

I am Doug Chalmers, Chair of the Committee on Standards in Public Life. And I am delighted to welcome a panel with very rich and varied experience of the public sector. I am joined by one of my colleagues on the Committee, Professor Gillian Peele – an academic – who co-led this review with me, Dame Clare Moriarty and Dr Bill Kirkup. Clare is CEO of Citizens Advice, and had a previous distinguished career in the Civil Service where she served as Permanent Secretary of two government departments. And Dr Bill Kirkup, whose background is in healthcare and who has led investigations into failures of maternity services and served as a member of the Hillsborough Independent Panel. 

In terms of format, I will introduce the report and then invite some reflections from our panellists. Before we open up into a broader Q&A session. 

Many of you will be aware of the Committee and our work, so I won’t delay us with a lengthy history. The top line is: the Committee is a majority independent body, with cross-party representation. We advise the Prime Minister on ethical standards across public life by conducting reviews into institutions, policies and practices. And we also promote the Principles of Public Life, first set out by the first Chair of the Committee, Lord Nolan, back in 1995. 

And now to our report. So, what do we mean by ‘early warning signs’? And why do we think organisations in the public sector need to get better at spotting them?

Early warning signs are any indicators that things might be starting to go wrong. They are hard data, such as customer complaints. And soft data, such as the insights gleaned by a manager ‘walking the floor’ and having informal conversations with staff. These signs can tell us that something is not as it should be – whether that is a policy creating unintended consequences or a project that is not quite going to plan or data analysis revealing an unexpected drop in performance.

Recent independent inquiries are sadly extreme examples of what can happen when problems escalate to the point where there is a major failure. Grenfell, Infected Blood, Post Office, Windrush, failures in maternity services. First and foremost, there is the human impact – immense suffering, including the tragic and avoidable loss of life in the most serious cases. Secondly the tax-payer bears the cost of expensive inquiries to determine why scandals happened and government compensation schemes then follow. But failures are also bad for the organisations at the centre as they must spend time dealing with the aftermath, inevitably diverting resources from their organisations’ core purposes. And then there is the damage done to the public trust in those bodies, in those institutions.

Major failings in public life are invariably due to a complex combination of factors. As a Committee we were struck by how often the same themes come up: 

• a failure to listen to and act on concerns raised by employees and/or the public, 
• a failure to learn lessons from past mistakes or similar incidents,
• a failure to identify and share emerging themes that might have alerted the organisation to a developing risk,
• a failure of the board to have effective oversight of problems. 

We wanted to draw these themes to the attention of public sector bodies to help them get better at spotting problems at the earliest possible stage – while there is still time to act. To do this, we spoke to people from a range of organisations in the public sector to ask them about their experiences and insights. We spoke to Chief Constables, senior leaders in the NHS, Permanent Secretaries, Chief Executives and Chairs of Public Bodies, departmental sponsorship officials and people such as the Cross Government Complaints Forum and others – and I am delighted to see some of you here today. We also held an open consultation and were grateful for the illuminating responses that we received through that stream.

The outcome of our review is the report you see before you. It is designed to be a useful resource. As well as sharing insights from the leaders and practitioners we spoke to, we have included ‘20 points for reflection’ to help leaders think deeply about the processes and culture in their organisation and consider whether improvements can be made. But the questions are not only for leaders; they can also help staff at all levels to request that their organisations pay attention to these important matters. 

Public life is more complex today than ever, with a multitude of public bodies involved in the delivery of public services, as well as contracted private providers. We are not saying that it is easy to spot problems starting to emerge within and between organisations in the same delivery chain – just the sheer volume of correspondence means that is not easy, but that is not a reason not to try. In fact, it’s a reason to try harder!

To stand a chance of successfully recognising and responding to early warning signs we have found that leaders must do four things. They must realise they have a problem, they must act to address it, they must identify the wider lessons to be learned and they must be diligent in ensuring that those lessons are embedded fully within the organisation. Our report shows that this depends on getting the processes right and in building the right culture.  The two being very firmly interlinked.

I want to touch briefly on three themes of our report today.

The first is leadership and culture. The second is information and scrutiny. The third is the public.

We say in our report that leadership is the most important factor in an organisation that identifies and addresses emerging issues promptly and is willing to learn from mistakes. 

When you look at scandals in public life, it is often the case that ‘someone knew’. It is the job of leaders to build a culture where everyone has a voice and feels safe to speak up if they spot an early warning sign that something is wrong.

Leadership matters at all levels – it is the head of the organisation, of course – but it is also really important to recognise that daily interactions with middle managers or with direct reports can have a powerful impact on the culture that develops within the organisation and the expected standards of behaviour.

It is not enough for leaders to say that they welcome potential problems being brought to their attention early. Good leaders genuinely believe in the benefits of staff raising issues that can help them to fix problems before they escalate. And they demonstrate this through their actions. One of our contributors put this really well – she said, “If you do not take action, people will not come forward. If people do not come forward, you will not be able to take action!”  That interaction throughout all the leadership that affects the culture in public life.

If leadership really is this important, how can public sector organisations ensure they have leaders with the motivation, character and skills necessary to build open cultures where problems are raised and dealt with? Well, I think they need support and clarity about what is expected of them.

Leadership training that gives leaders the confidence to deal with problems in the right way might help leaders to feel better prepared when things go wrong and less inclined to ‘sweep things under the carpet’. This should include how to handle a crisis appropriately and how to get comfortable delivering bad news to their own leaders and ministers – and doing it early. Because bad news does not get better with time. Line managers at all levels need training and support so that they are able to create the right atmosphere for their staff to feel safe saying they have made a mistake, or that they feel a project may not be going to plan, and line managers need to know how to handle such challenging conversations.

When leaders are appointed, the expectation must be set that they will be assessed on how well they address problems and learn from them, rather than on how effective they are at making them go away. 

And it is important to try to avoid penalising leaders for raising issues. For example, our report talks about how organisations in the public sector are often linked in delivery chains and the importance of information flows and effective relationships in managing these flows up and down the chain. It is important to find ways to support the leadership of organisations that raise issues up and down the chain so that they are not disincentivised from being frank about the problems they are facing in time and money. 

The second theme is information and scrutiny. 

Bringing together high-quality data from across an organisation and interpreting it intelligently allows leaders to connect the dots and understand the bigger picture. To do this, organisations need analysts who can triangulate data and spot trends, but they also need their leaders to want to understand what the data is saying about their organisation. Hard data can be a prompt for a leader to ask probing questions and, as one of our contributors put it, “poke in the dusty corners.”  Another contributor told us how she was constantly looking for corroborating evidence or dissonance with the formal paperwork that passed through her desk on a daily basis and where she found dissonance, she would start pulling at the thread to get to the root.

We have seen some recent high-profile examples of boards that have failed to grasp the significance of red flags and act before it was too late.

There is no doubt that the quality and timeliness of the information to which a board has access is critical to the exercise of the board’s scrutiny function. But of equal importance is the ability and willingness of the non-executive directors to ask the difficult questions and look beneath the surface. Ensuring a Board has the right balance of skills, backgrounds, experiences and independence of judgment is critical to it providing an effective challenge to the organisation.

Finally, the third theme I want to touch on today is the public.

Public sector leaders have a responsibility to lead organisations that put the public first, and this means recognising mistakes, taking swift action to put things right, and when appropriate that means timely and meaningful apologies, learning the lessons and embedding them in the organisation so that the same mistakes do not happen again. 

Public sector bodies need to be mindful of the power imbalance that exists between them and the users of their services. But public bodies should not only be approachable and responsive when people have cause to complain. They must also be proactive in reaching out to ensure they are hearing about how the public is experiencing their services and open to suggestions to how improvements can be made.

I hope that opening pitch has given you a feel for the report and whetted a few appetites as people pick up the book in front of them.  We want the report to prompt discussion in organisations, and we look forward to hearing your views today.