No one watching the heartfelt testimony of witnesses – patients, family members, and carers – at the opening sessions of the infected blood inquiry could fail to be moved. The inquiry will examine how and why thousands of people were given blood infected with hepatitis and HIV in the 1980s, the harm this caused, and how government then dealt with this avoidable tragedy and its consequences.
However, you have to ask: why do we need public inquiries like this one, and what do they achieve? Just as importantly, why do we have so many of them? In healthcare alone, alongside the infected blood scandal, there’s an inquiry into disgraced breast surgeon Ian Paterson; the recent Gosport Memorial Hospital panel report; and a trail of past cases too long to list in full (Bristol, Shipman, Mid-Staffs). The bald truth is that most public inquiries represent a double failure. First, the organisations and systems that should keep people safe and deal immediately and effectively with any problems with the quality of care have failed, often over many years. Second, the authorities that investigate complaints and problems – which in health include the General Medical Council, the Department of Health (DoH) and, in some cases, the police – also failed.
Often, past investigations by these authorities turn out, in retrospect, to be partial and inadequate at best, a whitewash at worst. People campaign long and hard for a public inquiry because they have lost all faith in the ability and willingness of government and its agencies to be honest, open and transparent in finding out what went wrong, holding people and organisations to account, and learning from events.
I’ve attended and advised on public inquiries for years, and although I understand why people want and need them when all else fails, I think we should recognise their flaws and limitations.
First, public inquiries can take a long time both to set up and run, and then to produce their report – many years in some cases. Those delays are pretty awful for all concerned, and mean their eventual findings and recommendations can be out of date before they are published.
Second, inquiries are semi-judicial affairs, with public hearings and cross-examination, just like in a court. They have legal powers to subpoena witnesses and evidence, lots of lawyers representing various parties, and are usually chaired by a judge or QC. I am not convinced that this process designed around establishing guilt or innocence in criminal trials is suitable when it comes to uncovering and understanding complex failures in healthcare organisations, where usually no one person is culpable and where what happened is often open to multiple interpretations and there are competing accounts and perspectives.
Third, inquiries produce reports which vary wildly in content and purpose – for example, the Gosport panel report makes no recommendations at all, but the Mid-Staffordshire inquiry report made 290 recommendations to the DoH. Not all inquiry reports successfully resolve the matters they have studied for so long and so carefully.
Fourth, it is often not clear what happens after an inquiry has reported, or who is responsible for taking action in response to all those recommendations. I have a shelf full of public inquiry reports in healthcare, dating from the 1970s to today, and many of their recommendations sound alarmingly similar – which suggests that not much may have happened as a result of previous inquiries.
Finally, and perhaps most importantly, I am not sure that these inquiries really work for patients and their families. They have often been the most ardent advocates for holding a public inquiry and we can all understand why. But the inquiry process is frankly gruelling and often distressing for those most affected, and involves a kind of protracted reliving of the harm they have suffered.
It is far from clear that these inquiries actually bring catharsis or resolution for those who have suffered considerable harm, and their emotional cost is considerable. So what could we do differently? While the infected blood inquiry is long overdue and absolutely necessary, the problems it is addressing should have been resolved back in the 1980s or early 1990s. We need fewer public inquiries in healthcare and much better ways of investigating and dealing with problems far earlier.
The DoH set up an independent healthcare safety investigation branch in 2017 (modelled on the body which investigates air accidents) and it remains to be seen if this organisation will lead to more timely, rapid and thorough investigations in the NHS.
If we must have public inquiries (and some will always be necessary) a report from the Institute for Government in 2017 made some very sensible suggestions for how they could be improved.
House of Commons select committees should be made formally responsible for following up on inquiry reports and the implementation of their recommendations, so they don’t get left on the shelf. A Cabinet Office unit should be established to provide support and expertise in holding inquiries rather than setting up a new inquiry team for each one. It would produce guidance on how to run inquiries and could also monitor reports and their implementation. And, perhaps most important of all, inquiries should work faster, using investigation techniques drawn from bodies such as the air accident investigation branch. They should also publish interim reports on their findings and recommendations as the inquiry progresses.
The Institute for Government report calculated that government had spent almost £640m on 68 public and other inquiries since 1990, and that is probably an underestimate. There must be a better way to use public resources to achieve the aims of those inquiries, and to meet the needs and expectations of patients, family and the public.
• Kieran Walshe is professor of health policy and management at the University of Manchester
