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How many?
Go on, guess… how many.
How many inquiries have there been into the NHS?
You might as well ask how many raindrops have fallen on Droitwich .
Time after time, something goes badly wrong, a tragedy, a scandal or a systemic failure.
Futures wrecked and a lifetime of angst and pain.
We get the usual solemn faces, followed by the inquiry, the recommendations… and then?
We are treated to yet another Uriah Heep moment in the House of Commons.
In David Copperfield, Dickens describes Heep as wringing his hands in a display of false humility and sycophantic deference.
Dickens uses the gesture as a physical manifestation of Heep’s pretending to be submissive while quietly scheming for power and control…
… or in the case of Parliament, Ministers quietly scheming how they can wriggle out of accountability, shift the blame to their predecessors in government, promising the earth, parking the report on the shelf and nothing really happens.
Dickens at his best. A vivid characterisation of hypocrisy.
Another headline, another missed opportunity… and before you know it, the same thing happens again.
Maternity has made repeated appearances.
Shrewsbury and Telford. East Kent.
Nottingham… and now a national investigation.
Let’s not kid ourselves… this isn’t new. We've been here before;
- Ely Hospital in 1969.
- Beverley Allitt, 1991.
- Shipman.
- Mid Staffs.
- Morecambe Bay.
- Gosport.
- Bristol hearts.
- The infected blood scandal.
All devastating. All investigated. All supposed to be turning points.
The truth? The only turning has been collectively turning our backs on the reports.
Researchers tried to count them… good luck.
There is no single definitive list covering every formal NHS investigation since its founding in 1948. One comprehensive, academic analysis identified 624 references to health-care–related inquiries between 1912 and 2001.
After filtering... yielded 59 serious and relevant NHS inquiries between 1974 and 2002.
Post‑2000 there's been a curious increase. A further five major reports.
By now, we’re probably talking about hundreds of local and national investigations, formal reviews, independent patient safety reports, public inquiries.
You’d need a warehouse to store the paperwork.
The upshot? Over 1,400 recommendations fewer than 1 in 5 acted on. So much for ‘learning lessons.’
The seminal Francis Report, one of the most significant and damning inquiries in the history of the NHS, had 290 recommendations…
... 281 were formally accepted by HMG.
Depending on interpretation, only 50-75, have been partly or wholly implemented;
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Statutory duty of candour… is poorly understood and rarely enforced.
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Revalidation and professional regulation… strengthened but not really led to an improved safety culture.
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Staffing standards… safe staffing guidance from NICE was scrapped in 2015.
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Reshaping CQC inspections... poor evidence of safer healthcare and the organisation plunged into disarray.
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Patient safety structures were created… but obviously the NHS is no safer... now reorganised in the Dash Report... gimmestrength.
The themes never change:
- Poor leadership,
- ignored whistleblowers,
- defensive cultures,
- a fear of speaking up,
- staff bullied into silence,
- workforce shortages,
- patients harmed while the DH fiddled with targets.
You could cut and paste the conclusions from one inquiry into the next and no one would notice.
There is always a huge implementation gap.
Francis himself said;
'... many of the cultural issues that led to Mid Staffs are still there in parts of the NHS. The risk remains.'
The latest in a long sad history is what happened to Yusuf Mahmud Nazir, investigated in the excellent, just published... Carter Report.
One of the most readable I have seen… and I’ve seen a few.
It’s a tragic tale of a young boy, misdiagnosed, misdirected, miscommunicated that ended up in his devastating and unnecessary death.
The report is comprehensive, makes clear recommendations one of which is simply… listen to the parents, they know their child better than any paediatrician.
What will be learned, what will be implemented?
Over a million people a day are looked after by the NHS. Common sense tells us; not everyone will have a satisfactory experience, things will go wrong.
Until we make it OK for people to say… I made a mistake… we will forever be trapped in a Kafka world of inquiries coming to the same conclusions.
In our recent 'In the Loop' podcast Dr Bill Kirkup casts doubts on the usefulness of inquiries… and he is right.
If inquiries worked, we’d have the safest healthcare system in the world.
Instead, we have a system addicted to investigating itself and forgetting the answers.
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