A statutory public inquiry is not always the most effective vehicle for learning lessons in the NHS

The role and impact of NHS inquiries

Dating back to the first NHS inquiry into failings in care at Ely Hospital in Cardiff in 1969,2 there have been more than 120 inquiries into services and staff in the NHS.3 Public inquiries serve a range of purposes. Most importantly they aim to establish “the facts,” understand why a service failure occurred, and encourage learning from events. But they also aim to promote cathartic change among those involved, provide reassurance to the public, and hold those responsible for wrongdoing or failure to account.4 Governments may use inquiries as a way of exposing the past failings of political opponents or to defer making difficult funding decisions.5

The principal output generated by the Thirlwall inquiry will be its official report containing a set of recommendations detailing key learning points and desired actions for the NHS to implement. The Department of Health in turn will publish an official response after publication of the inquiry report outlining what action it plans to take or has already undertaken. In some cases, inquiry recommendations have been a force for good and have helped to promote specific and long lasting positive change in policy. For example, as a direct result of the Francis report of the Mid Staffordshire NHS Foundation Trust, the then National Institute for Clinical Excellence published the first guidelines on safe nursing staffing levels in acute hospitals. But as a House of Commons expert panel report recently concluded,6 over the past decade many NHS inquiry recommendations pertaining to improving patient safety in the NHS have not been implemented fully and have failed to leverage meaningful change and improvement on the ground. Indeed, the Thirlwall inquiry’s recent review into recommendations from previous healthcare inquiries found that across 30 inquiries in England and Wales, dating back to 1969, just 302 out of more than 1400 key recommendations had been implemented.7 This means that almost 80% of inquiry recommendations have either been rejected, or there is insufficient evidence that they have been implemented or they have not been implemented fully. Recommendations are not, however, binding, and there are currently no accountability mechanisms across government for monitoring whether recommendations have been implemented in full, in part, or not at all, and ensuring that inquiries have an impact.6

Repeated recommendations and reinvention

NHS inquiries repeatedly find the same causes of failings, and these are not changed by repeated recommendations. For example, inquiries often find poor leadership and inadequate governance, dysfunctional organisational cultures, poor communication with patients, an unwillingness to listen to staff, and geographical and/or professional isolation. The situation has been described as “Groundhog Day” as recommendations from previous inquiries are recycled.8 Over time inquiries into failings in the NHS have shifted from a focus on issues to do with the behaviour and performance of individual health professionals (bad apples) to the organisational cultures in which they work (bad barrels), the wider national health policy context (bad cellars), and professional socialisation, education, and training (bad orchards).9 The most consistent remedy drawn out from inquiry recommendations over the past two decades has been cultural reform and renewal. Workplace and organisational culture has been identified as both the culprit and the solution to failings in patient care.10 Since the Kennedy report into failings in paediatric care at Bristol Royal Infirmary, inquiries have consistently argued in favour of “culture change”—but without specifying in sufficient detail how this was to be achieved, with inquiry recommendations being somewhat aspirational and broadbrush.11 Overall, many of the inquiry reports appear to be somewhat optimistic that “things are getting better”: that institutions, policies, and procedures are in place that will not allow earlier problems to reoccur—until the next time it happens again.9

Lessons for the Thirlwall inquiry

If the Thirlwall inquiry is to be the start of meaningful change and reform then it will be important that its recommendations are tightly focused, costed, are implementable, and are clear about who is responsible for each action. The key will be gaining legitimacy for the recommendations among interested parties, including bereaved families, service user groups, and those tasked with interpreting and implementing them. A government select committee should scrutinise the implementation of recommendations by NHS agencies and publish timely progress reports. Otherwise, the lasting impact of the Thirlwall inquiry may be more symbolic than instrumental in that it allows space for public catharsis and healing while leaving untroubled the dysfunctional systems and processes that enabled the tragedy to unfold in the first place.