Abstract
There have been over 100 public or otherwise independent inquiries in the UK National Health Services, dating back to the Ely Hospital Inquiry of 1969. Inquiries usually address major or serial lapses in duty of care to patients, seeking to set out what happened, explore possible causes and learn lessons for the future.
In this paper, we explore the historical context to public inquiries in health, including their purpose and aim and identify the key themes that have recurred over five decades. These include hearing and heeding the patient voice; enabling staff to raise concerns with confidence; the impact of pressures in the health system; NHS top-down organisation culture; and regulation and inspection as a ‘cure’. This thematic framework is then used to assess the health policy, organisational and service progress that appears to have been made in response to public inquiries, taking the Francis Inquiry into the Mid-Staffordshire NHS Foundation Trust as a case study.
We use the case of the Francis Inquiry to identify and explore the progress (or absence of progress) of the main developments for NHS organisations resulting from the Francis Inquiry including the strengthening of national regulatory bodies for health care quality; having greater transparency of staffing levels and deficits by regular reporting of local workforce data; introducing new ways in which staff can raise concerns or ‘whistle-blow’ where they fear harm is being done to patients; understanding better the potential harms from dysfunctional organisational culture; and how far the ‘duty of candour’ is working in practice.
Drawing on this, we present an analysis of apparently persistent gaps in learning from inquiries in health, this being used to propose a set of potential policy recommendations for health and care in the UK context. These include the need for formal accountability processes to track progress with public inquiry recommendations; exploring how best to manage and support smaller or isolated hospitals; the need for formal accreditation and training standards for all NHS managers; heeding the evidence of the distraction caused by most health service reorganisation; and having a formal and funded long-term workforce plan for health and social care.
The paper concludes by suggesting how this analysis offers insights into how publicly funded and accountable health systems can secure deep and sustained learning and improvement from holding public or other independent inquiries.
In this paper, we explore the historical context to public inquiries in health, including their purpose and aim and identify the key themes that have recurred over five decades. These include hearing and heeding the patient voice; enabling staff to raise concerns with confidence; the impact of pressures in the health system; NHS top-down organisation culture; and regulation and inspection as a ‘cure’. This thematic framework is then used to assess the health policy, organisational and service progress that appears to have been made in response to public inquiries, taking the Francis Inquiry into the Mid-Staffordshire NHS Foundation Trust as a case study.
We use the case of the Francis Inquiry to identify and explore the progress (or absence of progress) of the main developments for NHS organisations resulting from the Francis Inquiry including the strengthening of national regulatory bodies for health care quality; having greater transparency of staffing levels and deficits by regular reporting of local workforce data; introducing new ways in which staff can raise concerns or ‘whistle-blow’ where they fear harm is being done to patients; understanding better the potential harms from dysfunctional organisational culture; and how far the ‘duty of candour’ is working in practice.
Drawing on this, we present an analysis of apparently persistent gaps in learning from inquiries in health, this being used to propose a set of potential policy recommendations for health and care in the UK context. These include the need for formal accountability processes to track progress with public inquiry recommendations; exploring how best to manage and support smaller or isolated hospitals; the need for formal accreditation and training standards for all NHS managers; heeding the evidence of the distraction caused by most health service reorganisation; and having a formal and funded long-term workforce plan for health and social care.
The paper concludes by suggesting how this analysis offers insights into how publicly funded and accountable health systems can secure deep and sustained learning and improvement from holding public or other independent inquiries.
| Original language | English |
|---|---|
| Title of host publication | Policy and organisational responses to public inquiries in health: will we ever learn? |
| Publication status | Published - 22 Apr 2022 |
