In 1965, just 17 years after the NHS was created, a trained psychotherapist called Barbara Robb went to visit a previous client, Amy Gibbs (74), who had been admitted to Friern hospital, Barnet (a London borough). For some reason Amy appeared to have got stuck there. Robb was horrified by the conditions in which the elderly patients (all of them suffering from mental illness or dementia) were kept. She kept a diary of her visits, collected evidence and published a book called Sans Everything. The title alluded to Shakespeare’s line about old age in As You Like It;
Is second childishness and mere oblivion; Sans teeth, sans eyes, sans taste, sans everything.
The News of The World took an interest in Sans Everything, and this publicity encouraged whistleblowers to reveal conditions in other places. TV producers made programmes about the issue (see below). Michael Pantelides, a nursing assistant at Ely hospital in Cardiff, contacted a NOTW journalist to disclose that staff hit patients, stole their food and lied about the cause of their injuries. This resulted in a formal inquiry chaired by Geoffrey Howe QC (who those of a certain age will remember as a prominent politician in Margaret Thatcher’s government). Presenting the report in Parliament in 1969, Richard Crossman, minister of state for Health and Social Security, said,
The Committee finds, first, that most of the specific incidents alleged by the nursing assistant as examples of ill-treatment did occur. Secondly, the Committee finds that many members of staff in the wards made use of food supplied for patients, and that excessive quantities of meat were provided to nursing staff. These aspects of the Report have been referred to the Director of Public Prosecutions. Thirdly, the Committee finds that an atmosphere existed in which well-intentioned members of the nursing staff felt it hazardous to complain; two who did so had to leave the hospital.
In 2019, the 50th anniversary of the Ely Commission was marked by a symposium at the University of Birmingham. Health policy experts came together and reviewed the recurring themes that have arisen from the many inquiries that have come since. It was noted that ‘inquiries often seem to have similar findings, and make the same or similar recommendations over and over again’. This year, the Thirlwell inquiry (which was set up to look at the Lucy Letby murders) published a fascinating timeline of 30 inquiries completed since 1994, together with a systematic analysis of what recommendations had been made and how many had been fulfilled. On the left are the inquiries, on the right are the government responses.
What a litany! Looking at this, it is difficult to avoid the conclusion that the NHS is fundamentally flawed; there must be something wrong, morally, for a single organisation to have thrown up so many problems, so much harm, such injustice. But there is another take on this. Perhaps we should be reassured by its ability to engage in continual self-examination. This ‘glass half full’ view is probably naïve: in many cases, local and national NHS leaders spent a great deal of time and money obfuscating and trying to deny that there were problems, and the inquiries only came about because external groups or individuals persisted. The Francis report into poor care at Mid Staffs is a perfect example. Without Julie Bailey CBE and her group Cure The NHS, we would know nothing about it even today. There are parallels here with the Post Office scandal, which is only visible to us because of Sir Alan Bates and his group.
The worrying point made by the Thirlwell publication is that few of the recommendations appear to have been evidentially implemented. There is a tendency for this country to undertake well designed, thorough, cathartic and visibly just inquiries, for their findings to be accepted at the very highest levels of government, but for history to move on quickly and for the details to be forgotten.
Those of us who work in hospital governance are used to action plans, where the recommendations that we make following investigations into serious incidents are brought back to governance groups until there is evidence that they have been followed through. Sometimes this can take well over a year, but at least they stay on the radar. Most investigators have been burned by their own enthusiasm: any more than three to five recommendations will probably result in failure. The Francis report, with its much wider scope, made 290!
The Institute for Government found that ‘of the 68 inquiries that have taken place since 1990, only six have received a full follow-up by a select committee to ensure that government has acted.’ Dr Phil Hammond, who writes for Private Eye and broke the Bristol Heart Scandal, was asked just recently whether there would be an inquiry into the use of Physician Associates. He wrote a long comment on X, including:
The real tragedy of Bristol is that it made 198 recommendations, many of which have been subsequently repeated in all the other health scandal since, most notably the Mid Staffs inquiry and more recently the infected blood inquiry. The UK is a world leader in public inquiries, and then we ignore the findings so we can have another public inquiry.
Following the Francis report, the safety expert Don Berwick was asked to carry out a general review. He submitted A promise to learn – a commitment to act: improving the safety of patients in England which included many recommendations for ‘fix’ NHS culture. The Duty of Candour came out of this. Later, The Health Foundation published an infographic to summarise how widely they had been adopted. The results were… so-so.
So, if the NHS is not effective in implementing recommendations, are all these inquiries just for show? The accomplished chairs, usually with legal backgrounds, would strenuously deny this. Reading the recent infected blood scandal report chaired by Sir Brian Langstaff, its forensic power, heartfelt disappointment and willingness to examine decisions at all levels cannot be doubted. There was failure everywhere, so much failure in fact that is difficult to know at what point in the long and sorry narrative would replacing failure with success have changed the outcome. There were so many individuals, agencies, interests and complexities.
The point I am arriving at is that inquiries deliver a range of outcomes, not just recommendations. These were delineated by Kieran Walshe:
- Establishing the facts – providing a full and fair account of what happened
- Learning from events – and so helping to prevent their recurrence
- Catharsis or therapeutic exposure – providing an opportunity for reconciliation and resolution
- Reassurance – rebuilding public confidence after a major failure
- Accountability, blame and retribution – holding people and organisations to account
- Political considerations serving a wider political agenda for government
This framework can be applied to previous inquiries, e.g. Mid Staffs.
Lessons learned and the implementation of recommendations are the most fundamental outputs. However, the processes of forensic inquiry, giving those who suffered (or their families) a voice, and allowing society to hear and understand what went on, are more immediate and make a larger impact on society’s perception of the NHS. They ensure that society remains conscious that this enormous organisation of which we all so proud can make terrible mistakes. Those mistakes can be perpetuated over decades, and often require brave and persistent voices to ensure that low standards are not accepted as the norm.
Do other health systems have such troubled histories? If mistakes and injustices are not unique to the NHS but inherent to health systems everywhere (as surely they must – it would make no sense for the UK to be especially cursed) then an absence of inquiries elsewhere suggests that those countries have chosen not to see what that have no wish to address. Perhaps, non-nationalised health systems are so fragmented in terms of governance, it is impossible to sense if things are going wrong, or to create a full picture. This conclusion gives me some optimism about the NHS. Although none of these inquiries came without a struggle, the fact that they took place means that there is a continual process of feedback and improvement. By now, after so many inquiries, surely, we must have one of the safest and morally grounded health services in the world. Many will scoff at that. I hope it is the case.
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