At the core of Wilful Blindness is the question as to ‘why are facts ignored?’. The counter is ‘Just Culture’, essential in a challenging and changing environment.
There was something about this particular BBC Radio 4 Analysis podcast on ‘Just Culture’ which rang some bells (link at end of post).
Wilful blindness is a legal term associated most closely with Enron:
“Where there is nowledge that you could have had, and should have had, but chose not to have, you are still responsible”
Essentially, you could have had, and should have had, but somehow managed not to…
The ‘for example’ list is long, and not exhaustive:
- Mid-Staffs patient care
- Child abuse and the Catholic Church
- Rotherham child abuse
- The BBC and Saville et al
- Iraq and Abu Ghraib
- Banks – Libor, FX, and who knows what else
- Safety issues and automotive companies
The Analysis podcast opens with an example from the commercial world, General Motors in the 1990s, when it was clear that commercial profitability depended on cutting costs rather new car sales. In that environment, where the goal was cost-cutting, ignorance is essential to avoid having to deal with the consequences. Costs (corners) were cut. An ignition problem existed for eleven years, resulting in 13 deaths, 54 crashes and at the ‘cost’ of millions of dollars in vehicle recalls.
In the the cost-cutting, deeply competitive, culture that developed within the automotive giant, its steep hierarchy and sheer size (so large and complex where an assessment of consequences is almost impossible) an internal review of problems at corporate giant concluded that although everyone had a responsibility to fix the problem, nobody took responsibility.
At GM a whole language was created so as not to face up to responsibilities or consequences. Employees were told to ‘write smart‘ and not to use ‘judgemental adjectives and speculation‘. In language, don’t say ‘problem‘ talk about ‘the issue‘, don’t say ‘condition‘, say ‘matter‘, and do not say ‘defect‘ but instead ‘does not perform to design‘. Language was used to create plausible deniability.
The podcast highlighted common patterns in such cultures.
Individuals are overstretched, distracted and exhausted. They don’t see because they can’t think. Too many people from same background share same biases, beliefs and blindspots. The organisations within which they work become places where it isn’t felt to be safe to raise concerns, or ask challenging questions. So individuals focus on their tasks:
Obedient, conformist, and unwilling to rock the boat with the knowledge they harbour. And because they know everyone can see problems they imagine someone will do something.
It is a pattern sadly all too recognisable in Rotherham, where there were seventeen reports over sixteen years and so many people involved: parents, teachers, doctors, voluntary organisations, police and Council.
Young people being abused in Rotherham; belonging to everyone, yet belonging to no-one.
A vast array of safe-guarding plans and protocols in Rotherham were never checked as to whether they were being implemented, or were even practically useful. The care of children became ‘process-driven’ with with large numbers of people attending any meeting: if an issue belongs to 35 people in a room, who is actually taking ownership of the issue? The complexity of inter-agency relationships, the exhaustion of competitive social workers, coupled with a climate of fear created a condition where no-one had the clarity, energy or will to speak up.
Many do no speak because they ‘know’ they will be shot down, or ‘imagine’ that they will.
The airline industry is an example where the dominant culture is one where the workforce has become the early warning system of potential disaster, and where everyone feels safe, and is safe, to speak up. It didn’t just happen that way.
After a series of problems in the 1970s the Civil Aviation Authority created a programme that would break through hierarchy and ensure that a concern would reach the person who could make a difference – this includes a third party advice line to offer pathways to raising concerns. The CAA created a ‘Just Culture‘ to assure the industry lived up to the open standards set. In 1980 around 300 reports of concern were fed to the CAA, over thirty years later there are 14,000 in a year. Despite (some would say cut-throat) competitiveness, Just Culture is shared across the entire industry.
Honesty saves lives.
A Just Culture requires systems to be in place that make it easy for people to speak up with their concerns, and where the everyday heroes who have the courage to speak up are praised not punished. People must feel safe, protected and see something done by way of resolution. Courageous leadership prepared to speak early before things go adrift makes organisations better, smarter and more informed. To create that culture takes courage, practice and time.
We need honesty to be equal cross all levels of an organisation, that those everyday heroes remembered and held up as examples.
Heroes such as Helene Donnelly the Mid Staffs nurse: bullied, intimidated, and resigned from the A&E department at Stafford Hospital; a hospital in which patients were failed by a system which ignored the warning signs and put corporate self-interest and cost control ahead of patients and safety. She is now Ambassador for Cultural Change at Staffordshire and Stoke-on-Trent Partnership NHS Trust.
Heroes such as the anonymous Home Office researcher who wrote a report into the sexual exploitation of children in Rotherham; who faced “hostility” from the council from a report which stated agencies working to tackle the abuse showed “alleged indifference towards, and ignorance of, child sexual exploitation on the part of senior managers”, and that “Responsibility was continuously placed on young people’s shoulders rather than with the suspected abusers.” Her report was never published and the council even tried unsuccessfully to get the researcher sacked. Yet her words did not remain silent.
Heroes such as the petitioners against electoral fraud in Tower Hamlets, who faced unprecedented official pressure and efforts to undermine the case.
Mr Erlam spent the last week before the case living away from home to avoid the Met. “To my mind, the clear intention of the police was to discredit me just as the case started,” he said.
Heroes such as the writer of the fifty-three-page report written by Major General Antonio M. Taguba: its conclusions about the institutional failures of the Army prison system at Abu Ghraib were devastating. But the words were out there. That report though was because of Specialist Joseph M. Darby, an M.P. who came across pictures of naked detainees and:
“initially put an anonymous letter under our door, then he later came forward and gave a sworn statement. He felt very bad about it and thought it was very wrong.”
Again the Wilful Blindness of a large organisation under stress and in need of results was clear in courtroom testimony: Specialist Matthew Wisdom, an M.P., told the courtroom testified that he told his superiors what had happened, and assumed that “the issue was taken care of.”
Expecting someone else to take courage and/or responsibility for doing something is hardly absent from matters here in Northern Ireland. From the House of Commons Northern Ireland Affairs Committee Report: “The administrative scheme for “on-the-runs”
104. Only with the benefit of hindsight, can it now be seen that there were several indications that an administrative scheme for OTRs was in operation, including, for example, from Ministers’ responses to Parliamentary Questions; the scheme was therefore an example of something being “hidden in plain sight”.
So many involved, yet the whole scheme required everyone being involved, but no-one being responsible. Mistakes were almost inevitable. Abuse of process ever likely. Everyone can see, but no-one can, is willing to, or is able to bring the facts of the issue to the fore.
The Nolan Show thrives on people exasperated with ‘the system’ who often, in desperation, seek out someone who will listen. Whether or not one appreciates The Nolan Show, its success in in part a product of local public administrations (for there are many) which seem wilfully blind to what is actually happening in their name. Pick from any or all of the stories already outlined above and listen to the echoes on our airwaves, all too regularly. How many people in Northern Ireland could recount an example where they felt frustrated, alienated, and inadequate to stand up and speak on something where they thought someone must surely say something?
In the present febrile atmosphere of the deepening financial pressures on services, due to Stormont’s inability to implement welfare reforms and Sinn Fein’s intransigent ring-fencing of social benefit payments, all the negatives from the above will become even more acute. Even if there is an immediate fix, pressures on departmental finances are unlikely to ease anytime soon.
While political discourse, Unions, senior management, and media focus on ‘cuts’, little if any attention is spent on working out if public money being spent is being spent well, and could be perhaps spent better, more effectively, and more directly to addressing need.
It wouldn’t be speculative to suggest public services in Northern Ireland have frontline staff that are overstretched, distracted and exhausted. We have an engrained public sector culture which has created a management of too many people from the same (public sector) background sharing the same biases, beliefs and blindspots. Have those organisations within which they work become places where it isn’t felt to be safe to raise concerns, or ask challenging questions? Do the frontline staff simply focus on their tasks: obedient, conformist, and unwilling to rock the boat with the knowledge they harbour; believing or perhaps just hoping that because they know everyone can see the problems, they imagine someone will do, must do, something?
Northern Ireland has a bloated public sector. ‘Cuts’ are necessary. ‘Rebalancing the economy’ means less public sector, though that does not necessarily mean reduced or lesser services. Reform is long overdue. However, cuts out of financial necessity are unlikely to produce the change Northern Ireland needs. Yes, it is possible to do better on less, but that is only possible where there is reform emerging from a desire and willingness to have a more honest, open and transparent conversation about what services we need and how best to deliver excellently.
Northern Ireland needs ordinary heroes, and we need to praise them for speaking truth to power.
Margaret Heffenan also talks about the dangers of Wilful Blindness at TED.
And in this presentation she entreats everyone to Dare to Disagree. Many are afraid of conflict in anorganization where they might ‘lose’ one way or another. She encourages people to dare to see – the truth will set you free. Freedoms are only secured by being used.
Finally, she says, in her book: