This spring marks two decades since the regime governing public inquiries was last reformed and there’s already a mounting queue of issues for policymakers in parliament, the Cabinet Office and the Ministry of Justice. Unsurprisingly duration and cost of public inquiries, the very issues that mobilised reform back in 2005, are back on the agenda. Yet also on the list is a topic barely mentioned 20 years ago, namely the extent to which inquiry recommendations are carried out and where responsibility lies to get this done. Perceived, real and persistent gaps between the recommendations of public inquiries and their implementation is a mounting source of frustration, particularly amongst families and the public affected by events that justified an inquiry in the first place.
The question of what happens to inquiry recommendations strikes a deep personal chord, since I’ve been up close helping to draft or implement them twice during my civil service career: first, as secretary to the Bristol Inquiry (1998-2001) and later, as lead sponsor within the Department of Health for the project responding to the Mid-Staffs Inquiry (2013). More recently, when I was a panel member for the Renewable Heat Incentive (“cash for ash”) Inquiry in Northern Ireland, we tried an innovative approach to this very issue. For everyone involved, but most especially for the families and members of the public directly affected, a public inquiry is a potentially life changing experience. Yes, people are looking for truth and accountability; but a form of lasting change is equally, if not more, important. This is just as true for a coroner’s inquest and for unexplained deaths in custody and it’s no surprise that the charity INQUEST, which provides expertise on state-related deaths, is now at the forefront in pressing for a national “mechanism” to bring oversight to all inquiry recommendations.
Reflecting on my experience, there is probably no single or easy answer, but a few observations can perhaps aid the debate.
Political will: This is imperative to drive change, and is at its strongest in the first year or two after an inquiry report, yet often fades after that. Ministers move on, priorities change, new topics come to dominate the agenda. The intense effort we led in DH and the NHS to implement (successfully) many of the Mid-Staffs recommendations had, by 2015, been absorbed into business as usual.
Although we published a formal response to the inquiry shortly after its publication, to my knowledge there was no ultimate accounting for what happened to each and every recommendation. With the Bristol Inquiry, while many significant changes were made quite swiftly, it took well over a decade and the unrelenting commitment of a few individuals to bring about the consolidation of children’s heart surgery units – probably one of the most important of our recommendations.
Role of the inquiry chair: Even after their role was complete, some chairs like Robert Francis, Michael Bichard and Brian Langstaff voluntarily stayed engaged in publicly pressing for the changes compelled by their findings. In the case of Bristol, the former chair Ian Kennedy wrote his own report – Bristol, five years on – in the absence of any government-sponsored long-term follow up. Why? Perhaps because each, in his own way, sensed that political will needs bolstering and judged the families are owed nothing less. While wholly admirable, it is surely a sign of weaknesses in the current system that former inquiry chairs have felt compelled to speak out in this way.
Parliament: There is a deep mismatch between the attention of a packed Commons chamber on the day an inquiry report is published and the occasional follow-up with a sparsely attended debate and possibly a select committee hearing. Most inquiry reports never even get that second look: in 2017, the Institute for Government estimated that of 68 inquiries between 1990 and 2017, only six were followed up by a select committee to examine the implementation of recommendations. Parliament has the power to give select committees a more explicit role in tracking and publicly reporting on progress (or lack thereof) with recommendations.
The National Audit Office: In England, this has no role in overseeing inquiry recommendations, but maybe the experience of its sister organisation in Northern Ireland, the NIAO, has a model to offer. In the RHI Inquiry report in 2020, we said the Northern Ireland Audit Office should be responsible for tracking implementation of our recommendations and reporting publicly to the Northern Ireland Assembly. In October, the NIAO published its second look at these recommendations. Auditors used their “rights of entry” to departments to great effect in discerning progress. Reportedly, one of the biggest hurdles was to get beyond departments’ “marking their own homework” and to press for actual evidence that a recommendation had been implemented. The NIAO team’s expertise and doggedness shines through their report.
Ultimately, ministers must be responsible for the commitments they make on inquiry recommendations; yet they and their departments need to be more straightforward about what is feasible and the time needed to deliver change. Parliament can and should play a stronger role; so too can public auditors and regulators in challenging and verifying progress.
We need to remember what’s at stake here, putting right what was nearly always a state or public service failure; we owe it to each other to come up with a better system.
Dame Una O’Brien is a leadership coach with the Praesta partnership and a former perm sec. Read the NIAO’s RHI report