The Grenfell Tower Inquiry, Infected Blood Inquiry, and Thirlwall Inquiry have each produced extensive recommendations aimed at driving reform and restoring public confidence. The attention generated by their findings has been substantial. Less attention has been paid to a more difficult question: who is responsible for ensuring that those recommendations are actually delivered? That question goes to the heart of a growing challenge within the public inquiry system. Whilst inquiries are highly effective at allocating responsibility for historic failings, they often have a far more limited role in creating accountability for future implementation.
The distinction between findings and recommendations is an important one. An inquiry can identify what went wrong, explain why it happened and propose measures designed to reduce the risk of recurrence. What it cannot do is compel implementation. Responsibility for acting upon recommendations rests with governments, regulators, public bodies and private organisations. That is constitutionally appropriate. Public inquiries are not legislatures and inquiry chairs are not policymakers. However, the consequence is that the success of an inquiry ultimately depends on organisations that were never responsible for producing the report in the first place.
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The legal authority of an inquiry often ends at precisely the point where the practical challenge begins. This can create an uncomfortable paradox. An inquiry’s findings may be subject to years of forensic examination, whilst the implementation of its recommendations receives comparatively little scrutiny once public attention shifts elsewhere. One of the more striking aspects of the Thirlwall Inquiry has been its examination of recommendations arising from previous NHS inquiries.
In reviewing inquiries conducted over the past three decades, the Inquiry found repeated examples of recommendations that had not been fully implemented, had been implemented only in part or had become difficult to track over time. That finding should give pause far beyond the healthcare sector. Most major organisations are not short of recommendations. Public bodies, local authorities, healthcare providers and corporations are regularly subject to recommendations arising from inquiries, regulators, inspectors, auditors, coroners and internal investigations. The challenge is rarely identifying areas for improvement. The challenge is prioritising, implementing and evidencing change amidst competing operational and regulatory demands.
