{"id":2683,"date":"2019-07-10T09:50:44","date_gmt":"2019-07-10T09:50:44","guid":{"rendered":"https:\/\/politicalquarterlyblog.preliveweb.site\/?p=2683"},"modified":"2019-07-10T09:52:46","modified_gmt":"2019-07-10T09:52:46","slug":"nhs-public-inquiries-are-like-groundhog-day","status":"publish","type":"post","link":"https:\/\/politicalquarterlyblog.preliveweb.site\/?p=2683","title":{"rendered":"NHS public inquiries are like Groundhog Day"},"content":{"rendered":"\n

Public inquiries sometimes feel\nlike a version of Groundhog Day<\/em> where it is repeatedly stated\nthat \u2018lessons will be learned\u2019. One of the key reasons for an inquiry is to\nprevent similar events from reoccurring, but for that to happen,\nrecommendations must be implementable and implemented. <\/p>\n\n\n\n

Most of the hundred plus NHS\ninquiries that have been held since the Ely inquiry (the first NHS public\ninquiry) have highlighted the same areas for concern: inadequate leadership, system and\nprocess failures, poor communication, disempowerment of staff and patients.<\/a> Either the NHS as an\ninstitution is unable or unwilling to implement the changes embodied in the\nrecommendations; or the recommendations themselves are incapable of being\nimplemented because of the way in which they are produced or expressed.<\/p>\n\n\n\n

There is much evidence to show\nhow other industries, including aviation and oil, have learned from past\nbreaches in safety and adapted their practices successfully. So what prevents\nthe NHS from implementing its own recommendations?<\/p>\n\n\n\n

About the inquiries<\/strong><\/h4>\n\n\n\n

I compare the \u2018implementability\u2019\nof recommendations from the three NHS inquiries of Ely, Bristol and Mid\nStaffordshire. In terms of background, the Ely inquiry was set up in 1967 to\nlook into allegations of various forms of misconduct on the part of members of\nthe staff at the Ely Hospital, a psychiatric hospital in Cardiff [link Hilton].\nIt was chaired by Geoffrey Howe and reported in 1969. <\/p>\n\n\n\n

The Bristol inquiry was set up\nin 1998 to examine the \u2018excess deaths\u2019 in paediatric cardiac surgery at the\nBristol Royal Infirmary between 1984 and 1995, with Professor Sir Ian Kennedy\nas chair. It reported in 2001. <\/p>\n\n\n\n

The (second) Mid Staffordshire\ninquiry was set up in 2010, into the serious failings at the Mid Staffordshire\nNHS Foundation Trust between 2005 and 2008 (see Smith and Chambers, in this issue).\nIt was chaired by Robert Francis, who had chaired the first inquiry that\nreported in 2010. This second report focussed on the wider NHS system,\nreporting in 2013.<\/p>\n\n\n\n

Everybody\u2019s concern, but no one\u2019s responsibility<\/h4>\n\n\n\n

My analysis of Ely,\nBristol and Mid Staffordshire asks: is it clear who the recommendations are\naimed at? And is the problem soluble in the sense of a clearly identified\npolicy tool, or mechanism, or tool to implement, which suggest a clear course\nof action?<\/p>\n\n\n\n

The first issue regards the\nclarity of the recommendations in the sense of: to whom they are aimed and who\nwill take ownership of the problem? This may be seen in a very broad analysis\nof micro (individual patients and clinicians); meso (institution) or macro\n(system) level. <\/p>\n\n\n\n

Some of the inquiries\u2019 recommendations\nwere clearly targeted. The most clear and explicit were those with an active\nvoice: for example \u2018the Care Quality Commission (CQC) should\u2026\u2019 rather than a\npassive voice of \u2018consideration should be given to\u2026\u2019. The vaguest\nrecommendations are seemingly aimed at everyone. For example, Francis\u2019 first\ntwo recommendations that \u2018require every single person serving patients to\ncontribute to a safer, committed and compassionate and caring service\u2019 may be\nseen as \u2018everybody’s concern but no one’s responsibility\u2019.<\/p>\n\n\n\n

A\nrough estimate can be made of active and explicit recommendations, albeit with\na fairly wide margin of error owing to difficulties of interpretation. My\nestimates suggest that just three of Ely’s forty?four recommendations (7 per\ncent) have a clearly identified agent. For Bristol, it is thirty of 198 (15 per\ncent), of which some four are joint. Finally, for Mid Staffordshire, it is 118\nof 290 (41 per cent), of which some twenty?one are joint.<\/p>\n\n\n\n

What? Or, the problem with\nsermons<\/strong><\/h4>\n\n\n\n

The\nsecond issue\nconcerns policy instruments or tools. Marie-Louise Bemelmans?Videc<\/a><\/p>\n\n\n\n

 et al outline three broad types of policy\ninstruments, which have been termed incentives, authority and persuasion but\nare usually called \u2018carrots, sticks and sermons\u2019.<\/p>\n\n\n\n

The first type\nconsists of incentive\ntools such as the conditional transfer of funds or charges and fines. The\nsecond type used coercion as their principal resource. Governments employed\nthem through their hierarchical system, and their most common typologies\ninclude permissions, guidance, and compulsory actions. The third type of\npersuasion referred to a series of discursive strategies aiming to change\nbehaviour through providing information or using moral?based arguments, or\nsermons. <\/p>\n\n\n\n

An example of a sermon\nis \u201cThe\neducation and training of all healthcare professionals should be imbued with\nthe idea of partnership between the healthcare professional and the patient\n(Bristol, para. 2).\u201d Often, such sermons are not enforced by incentives or sanctions.\n<\/p>\n\n\n\n

As is show on table 2 in the longer version<\/a> of this article, sermons are the main policy tool accounting for some 89 per cent of Ely recommendations, compared to 66 per cent at Bristol and 63 per cent at Mid Staffordshire. Although Ely was a very different type of hospital in a different era, it seems that the Bristol sermons did not prevent the failings at Mid Staffordshire. This suggests either that sermons in general do not work, or that these sermons did not work, as they were either not implementable or implemented.<\/p>\n\n\n\n

Conclusions<\/strong><\/h4>\n\n\n\n

The data suggests that more could be done to arrive at practical recommendations of a series of practical doable steps that are clearly \u2018owned\u2019 by an identifiable agent. Pulling these issues together, given the large number of potentially responsible agencies, it is suggested that recommendations should be \u2018active\u2019 with a clearly identified agent and that a clear policy tool or mechanism should be identified rather than rely on a vague tendency to sermonise.<\/p>\n\n\n\n

A longer version<\/a> of this article originally appeared in the <\/em>Political Quarterly journal.<\/em><\/p>\n<\/span>","protected":false},"excerpt":{"rendered":"

Public inquiries sometimes feel like a version of Groundhog Day where it is repeatedly stated that \u2018lessons will be learned\u2019. One of the key reasons for an inquiry is to prevent similar events from reoccurring, but for that to happen, recommendations must be implementable and implemented. Most of the hundred plus NHS inquiries that have been held […]<\/p>\n","protected":false},"author":148,"featured_media":2685,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"categories":[1395,1476,1396],"tags":[],"coauthors":[1624],"class_list":["post-2683","post","type-post","status-publish","format-standard","has-post-thumbnail","category-comment","category-health","category-uk"],"amp_enabled":true,"jetpack_featured_media_url":"https:\/\/politicalquarterlyblog.preliveweb.site\/wp-content\/uploads\/2019\/07\/cropped-natanael-melchor-43LwvC-eQPM-unsplash.jpg","_links":{"self":[{"href":"https:\/\/politicalquarterlyblog.preliveweb.site\/index.php?rest_route=\/wp\/v2\/posts\/2683","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/politicalquarterlyblog.preliveweb.site\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/politicalquarterlyblog.preliveweb.site\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/politicalquarterlyblog.preliveweb.site\/index.php?rest_route=\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/politicalquarterlyblog.preliveweb.site\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2683"}],"version-history":[{"count":0,"href":"https:\/\/politicalquarterlyblog.preliveweb.site\/index.php?rest_route=\/wp\/v2\/posts\/2683\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/politicalquarterlyblog.preliveweb.site\/index.php?rest_route=\/wp\/v2\/media\/2685"}],"wp:attachment":[{"href":"https:\/\/politicalquarterlyblog.preliveweb.site\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2683"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/politicalquarterlyblog.preliveweb.site\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=2683"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/politicalquarterlyblog.preliveweb.site\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=2683"},{"taxonomy":"author","embeddable":true,"href":"https:\/\/politicalquarterlyblog.preliveweb.site\/index.php?rest_route=%2Fwp%2Fv2%2Fcoauthors&post=2683"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}