From BMJ-British Medical Journal
Few lessons are learnt from NHS inquiries
The use and impact of inquiries in the NHS BMJ Volume 325, pp 895-900 When things go wrong in the NHS the official reaction is to set up an inquiry. Yet a study in this week's BMJ finds that many inquiry reports highlight similar sorts of failures, suggesting that lessons are not always learnt.
Researchers at the University of Manchester analysed 59 inquiry reports from 1974 to 2002 to explore their use and impact in the NHS.
They found that the number and scope of inquiries is growing and are increasingly concerned with the clinical performance of doctors. Although inquiries have become more open and formalised - often in response to public pressure - there are no rules or guidelines on how to run an inquiry, and few arrangements exist to carry learning about the inquiry process over from one inquiry to another.
Inquiry reports are often long, and many produce similar findings despite addressing failures in the quality of care which on the face of it have little in common, add the authors. Often these failures are organisational and cultural, and the necessary changes are not likely to happen simply because they are prescribed in a report.
The increasing demand for public inquiries in the NHS probably reflects a lack of public confidence in the alternative methods of inquiry and in the quality of care that the NHS provides, write the authors.
They suggest that the credibility and potential biases of inquiry findings should be carefully assessed and that they should be a measure of last resort, used only when other methods of investigation have failed.