What is the point of Inquiries?

We spend hundreds of millions on Inquiries but largely fail to implement their recommendations. So what's the point? And what could be done?

This piece first appeared in the British Medical Journal on Tuesday 27 August 2024.

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The UK Covid-19 Inquiry has just published its Module 1 report two years after the inquiry began. At least another eight modules are still to be published. The inquiry has cost £94 million so far and is projected to cost over £200 million in total. The first report was forensic, pinpointing major flaws in the UK’s pandemic preparedness and putting forward 10 recommendations. But the recommendations from inquiries are only useful in so far as they are acted on, and mostly they are not.

The Institute for Government examined 68 public inquiries from 1990 to 2017. Together, they cost £639 million and made 2625 recommendations for change. But the institute reported that only six out of the 68 inquiries have received full scrutiny by a parliamentary select committee to hold the government to account for implementing recommendations. Of course, some changes have been made in response to these inquiries, but they are too few and have taken too long. The 2024 Thirlwall Inquiry, investigating the events at the Countess of Chester Hospital following the trial of former neonatal nurse Lucy Letby, started by reviewing 30 healthcare related inquiries over the last 30 years. It found that only a small minority of recommendations had been implemented.

The 2005 Inquiries Act articulates the purpose of inquiries: to investigate events of major public concern and to provide recommendations to prevent them happening again. Public inquiries come with substantial public funding and legal powers, but recommendations are non-binding for governments. Governments are expected to respond to inquiry reports and often face public criticism, but there is no recourse if the government or other bodies fail to implement recommendations. So what is the point of inquiries at all?

There are arguments for not requiring full implementation of all recommendations—for instance, that it removes autonomy from the government to respond to the most pressing current issues. But there can be mechanisms that fall in the middle ground between imposing a legal requirement to implement recommendations and the complete lack of oversight currently in place.

Australia establishes dedicated bodies to monitor the implementation of Royal Commission recommendations, and Judicial Commissions of Inquiry in South Africa are subject to public accountability for implementing recommendations. Both Canada and Ireland require governments to respond fully to inquiry recommendations that are then subject to parliamentary scrutiny, and their implementation is monitored by independent bodies.

Instead, in the UK we seem stuck spending hundreds of millions of pounds and many years of forensic investigation to make recommendations that are rarely implemented. Even worse, we seem to be relearning the same lessons. Many inquiries have highlighted a need for greater regulatory and oversight mechanisms, for greater transparency and better communication between organisations and to the public, for cultural change within organisations (for example, the inquiries into the Post Office; Grenfell Tower; Mid Staffordshire NHS Foundation Trust; and infected blood), and, in particular, tackling the fault of organisations protecting themselves instead of the people who have been wronged.

The bar for a public inquiry is high. Inquiries have examined the most egregious and consequential failures of state, health, business, and public sectors. The UK is failing to meet the second primary purpose of public inquiries: to prevent failures from happening again by learning from the inquiry findings. Recommendations from inquiries, if implemented, provide the pathway from that learning to the subsequent prevention of future disasters.

As called for by Grenfell United, the families of the victims of infected blood, and Covid-19 Bereaved Families for Justice, the UK must have a stronger, more efficient system for ensuring that recommendations from inquiries are implemented. Other countries have mechanisms that can be adapted for the UK context—this is not an impossible task. Doing so is essential to secure justice for the victims of these failures and to ensure that we aren’t simply learning the same lessons over and over again.