One of the many frustrating consequences of reading the deliberations of the Covid-19 public inquiry is the realisation that, at best, we won’t have the report until 2026. Should we be reconciled to the process taking such a long time and costing so much money (potentially up to £200 million)?

Inquiries, like health care failures, seem to be coming thick and fast in recent years. But this has not always been so. For a while (around the turn of the century) there was what turned out to be a hubristic assumption that augmenting governance would obviate the need for external scrutiny. We were not far into the new century when it became apparent that self-policing was missing many of our most egregious failures. As to the length and expense of inquiries (and with apologies to Jane Austen), it is a truth universally acknowledged that a complex inquiry that draws on the expertise of lawyers must be in want of a big budget.

Public Inquiries examine events to reduce the chances of failures in the future. They can also identify where, when and by whom key mistakes were made. Many inquiries produce impressive reports but there is not a clear route from report to implementation. This is, in part, an artifact of the complexity and duration of inquiries compounded by the length of time taken to set them up.

The Infected Blood Inquiry offers an illustration. The deaths, pain and loss the inquiry sought to get to grips with were linked with prescribing practices in the 1970’s which accelerated in the 1980’s. The inquiry started in 2018, its report is expected in 2024. It has pursued a range of avenues of interest, pharma, doctors, politicians. But many patients given contaminated blood and their families and friends who experienced the catastrophes that followed are not here to directly input into the Inquiry or to see a reckoning with those who recklessly pursued a hazardous practice.¹ Executives from drug companies, doctors who continued to prescribe contaminated blood or politicians who did not act on the many warnings that had been given are unlikely to still be on the scene. Nor is there a clear route from Inquiry findings to ensure changes in practice in private sector drug companies, in a health sector where short term-expediency and strains of curtailed budgets are still setting up the failures of the future or where short termism and the default of avoiding difficult decisions still characterises our politicians.

Even when Inquiries have what is ostensibly a narrow remit, a single hospital trust for example, the inquiry team look at context. But this is a circumscribed context. It will include governance structures external to a single hospital but inquiries are neither instructed or equipped to critique the decisions and social circumstances that give deep background to the events under scrutiny. Hospital failures are incubated by the accumulating impact of austerity and the erosion of a social contract by a long-term promotion of markets.²

When we don’t get to grips with how to translate inquiry findings to changes and we operate with a circumscribed appreciation of context it is no surprise that we see a succession of similar care failures, in care of older people, in learning disability services, in mental health, in maternity services. Stafford, Morecambe, Shrewsbury, Nottingham, Liverpool and many others present a picture of serial failures in care occurring, despite the insights of inquiry report writers.³

But there is another way of looking at inquiries. Are they about process or outcome? You may think “outcome” is obvious but the harm done to individuals and to the polity, of voices being unheard and decisions being hidden, may be of similar significance.

Care failures result in inquiries because of the bravery and tenacity of those people who push to get the story into the public domain, often these are patients or the friends and relatives of patients who have been most impacted, often they are staff whistleblowers who risk their careers. The struggle to bring to light issues of concern is characteristically accompanied by unbearable pressure on people with little experience of seeking change. It occurs in the context of the pain of their own loss.

Inquiries can bring things into the light that have been hidden or denied, sometimes for many years, and they can give a voice to the people who were most impacted by failures. It is difficult for those who are accustomed to have access to the machinery of power, economic or political, to appreciate the sense of desperation felt by those whose experience is of not having a voice when they find themselves impacted viscerally by neglect or cruelty, or when someone close to them dies in circumstances they believe are avoidable.

Returning to the Covid-19 inquiry, its wide remit includes prior readiness and investigation of aspects of the response from a wide range of institutions and individuals. It includes a considerable commitment to listen to the voices of all (adults) who consider themselves impacted and who wish to contribute. This “process” aspect of the inquiry seems well-served, although it will be a challenge to integrate patient and public voices with the contrasting discourses of science, public administration and politics. As to the “outcome” aspects, we have already seen revelations about decision making in government that is likely to undermine public confidence not just in politicians but in politics. We can try and stay hopeful that we get a report that answers the questions we have, that offers a reckoning and a route to change. But I suspect many of us feel pessimism of the intellect and an, at best, (very) fragile optimism of the will.

References

1. Wheeler, C,2023. Death in the Blood: The Inside Story of the NHS Infected Blood Scandal. Headline Books, Terra Alta WV.

2. Small, N. 2023, Health and Care in Neoliberal Times. Routledge, London.

3. Small, N, 2023. Failures in Health and Social Care. Routledge, London.