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Good inquiries should be short and sharp

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One of the great ironies of the Francis review process is that it was the resulting analysis of the 14 trusts with poor mortality figures that delivered the greatest value.

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The irony emerges from the fact the analysis, led by NHS England medical director Sir Bruce Keogh, was a spur of the moment decision. It was made when it became clear that, despite a three year gestation, the worthy but verbose Francis report offered nothing on which the government could take instant action – and therefore counter the inevitable “something must be done” headlines.

Back in February, the greatest hope was pinned, first on the Francis report’s recommendations and then, as they were digested, the “zero harm” review being prepared by Don Berwick. However, the publication of the Berwick report has produced another sense of anticlimax.

This reaction was largely unfair. The Berwick review team deliberately placed the emphasis on culture change as the only way to deliver sustainable quality improvement. They rightly pointed out the demands for new rules and regulations indicate a service still too often waiting with Pavlovian eagerness for the next set of central “guidance”.

However, the report took an age to effectively restate the importance of issues Professor Berwick has long championed. Had it been produced in, say, April as part of the work guiding the Keogh review, it would have felt more relevant to the specific challenges facing the service.

Hope and concern

The Keogh review recovered from unpromising beginnings because its leader took advantage of the timing and the nature of the work. With just five months to carry out investigations into 14 organisations and draw out conclusions for the system, Sir Bruce had to be very clear about what he was trying to achieve and how he would do it. 

He also understood the review could provide a useful testing ground for the investigations that would be undertaken by the new chief inspector of hospitals. 

‘The most obvious concern is that, despite being announced in February, the inquiry will not start not produce its final report until “sometime next year”’

His main report was a triumph of conciseness – with a limited number of specific recommendations. The analysis of individual trusts gave those organisations a real sense of where and how they could improve; lessons that will have been learned by others in similar positions. 

So, what hope should we attach to the inquiry into care failings at Morecambe Bay? The first interview with its chair, Dr Bill Kirkup, gives cause for hope and concern.

Lessons for the service

The most obvious concern is that, despite being announced in February, it will not start to take evidence until September and will not produce its final report until “sometime next year”. That timescale is likely to come under further pressure if Dr Kirkup is successful in extending his terms of reference to cover a nine year period and to resist any “ringfence around what we could look at”.

‘A lengthy, sprawling inquiry can sap the lifeblood from an organisation more effectively than any other method’

Dr Kirkup says he has no intention of duplicating the Francis report’s work by delivering a “root and branch review of how the regulation works”. But he also wants to take the opportunity to learn wider lessons for the service. 

The Morecambe Bay inquiry has two constituencies to serve: the families affected by the poor care at the trust and NHS organisations who want to avoid causing the same harm. There will be an understandable desire on the part of the former to learn everything that contributed to that poor care – and no doubt for blame to be attributed where appropriate.

Dr Kirkup will need to balance those wishes with the pressing desire for the service to understand the key lessons of what went wrong at Morecambe Bay. He may also want to consider that a lengthy, sprawling inquiry can sap the lifeblood from an organisation more effectively than any other method: just look at Mid Staffs.

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