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iners or funders. This has become the standard practice of an audit
society .18
This view of changing systems of accountability is accurate
enough, but may provide less to celebrate than its advocates claim.
The forms of managerial accountability that have been widely
introduced also have unwelcome effects. The portmanteau term
managerial accountability encapsulates the difficulty: management
and accountability are quite different matters, and their combination
is problematic. In general, management is downwards and prospective,
17
For evidence see Michael Moran, The British Regulatory State.
18
Michael Power, The Audit Explosion (London: Demos, 1994), and The Audit
Society: Rituals of Verification (Oxford: Oxford University Press, 1997).
Trust, accountability and transparency 173
but accountability is upwards and retrospective. In business, managers
manage the workforce and the work prospectively, but are retro-
spectively accountable to a board and to shareholders, whom they do
not manage. In universities, heads of department manage a range of
academic activities within the units they head, but are retrospectively
accountable to a university council and to funding bodies, whom
they do not manage. In schools, head teachers manage the staff and
work of a school, but are retrospectively accountable to governors
and education authorities, whom they do not manage. In the UK,
NHS hospital trusts those who manage the delivery of clinical
services are retrospectively accountable to the trust board and
through it to a range of external bodies, whom they do not manage.
However, the currently fashionable managerial systems of
accountability conflate management and accountability. They use
the methods of management to discharge the task of holding to
account. The very means that are used prospectively to secure
performance of tasks are re-used retrospectively to hold to account
those who carried or failed to carry out those tasks. For example,
professionals and institutions may be managed by setting them
objectives and targets, and then held to account by judging perform-
ance against these targets, rewarding good performance and sanc-
tioning poor performance. A managerial approach to accountability
makes good sense where those who manage others (prospectively)
later hold them to account (retrospectively), using the same meas-
ures of performance for both tasks. It makes much less sense if those
who hold to account but do not manage try to set detailed managerial
targets in order to provide themselves with convenient and uniform
measures by which to hold others to account. Yet this bizarre form of
managerial accountability at a distance is now quite common.
Managerial approaches to accountability are now used far beyond
the confines of a given professional setting or institution and its
management. The reasons given for doing so are simple. Managerial
approaches to accountability are thought to prevent insiders from
judging their colleagues performance in undemanding ways. It
confronts problems of professional cosiness and capture head on, by
ensuring that professional work is not merely accountable to, but in
174 Rethinking Informed Consent in Bioethics
many respects managed or controlled by, external bodies who may be
at considerable distance from the work. This form of management-
at-a-distance secures independent judgement of performance of pri-
mary obligations, but at high cost. For it undermines or perhaps
overrides the managerial responsibility of those who actually are
supposed to manage, and may end up holding them to account for
succeeding in meeting standards set without adequate attention to
professionally informed judgement of quality of performance. This
conflation of management with accountability can create requirements
to perform to standards that are counterproductive and which under-
mine high-quality professional work.
Managerial forms of accountability might nevertheless work for
complex professional tasks if it were possible to agree on salient
measures of adequate performance that could provide a basis both
for managing and for holding to account. However, professional
tasks do not always have a well-defined set of simple and easily
measurable outcomes that provide a basis both for managing and for
holding to account. That is why it was traditionally assumed that
informed (expert, professional) judgement was essential for holding
those with complex primary obligations to account. Yet once man-
agement and accountability are merged, targets will often be sim-
plified so that they can be used to control professional action and to
reduce the influence of professional judgement. For example,
because managerial approaches to accountability aim to marginalise
professional judgement, they typically focus on relatively simple
surrogate indicators of performance, which can be easily defined
and measured, rather than on informed, professional evaluation of
the performance of primary obligations. Surgeons may be judged by
success rates (regardless of patient mix); hospitals by waiting times
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