The lost worlds of royal commissions in the NHS: The unaccountable in pursuit of the unanswerable?

Abstract

There have been recent calls for a royal commission (RC) on the British National Health Service (NHS). This article focuses on the impact of RCs and similar advisory bodies, particularly on finance recommendations, of three inquiries with broad remits across the whole of the NHS from very different periods: Guillebaud (1956); Royal Commission on the National Health Service (1979); and House of Lords Select Committee on the Long-term Sustainability of the NHS (2017). These inquiries appear to have had rather limited impacts, especially on NHS funding. First, there appears to be some hesitancy in suggesting precise figures for NHS expenditure. Second, the reports are advisory, and governments can ignore their conclusions. Third, governments have ignored their conclusions. In the 1950s and the 1980s, contrary to the recommendations of the inquiries, NHS expenditure subsequently grew only slowly, and charges were increased. In short, asking an independent RC to provide answers on NHS expenditure is perhaps the unaccountable in pursuit of the unanswerable.

Keywords

Royal commission inquiry National Health Service (NHS)UK

Introduction

There have been recent calls for a royal commission (RC) on the British National Health Service (NHS) (e.g. Saatchi, 2017; Saatchi and Nutt, 2018). Saatchi and Nutt (2018) state that there has been a groundswell of support – including recent editorials in the Telegraph, Sun and Daily Mail – for a RC. Saatchi et al. (2017) state that ‘never has there been a better time or a more compelling reason’ for a RC on the NHS. They claim that the public supports a RC (CPS, 2017), continuing that former health secretaries Norman Fowler (Conservative), Stephen Dorrell (Conservative) and Alan Milburn (Labour) have said that they support this approach, as has the current Liberal Democrat health spokesperson and former Minister of Health, Norman Lamb. The Saatchi paper was cited by Dr Andrew Murrison, who also pushed for a RC in a Prime Minister’s Question (PMQ) on 10 January 2018. An ‘exclusive’ article for the Sun (Hawkes, 2018) stated that as a result of lobbying by ‘dozens’ of Conservative MPs, Health Secretary Jeremy Hunt was ready to trigger a landmark cross-party RC into the future of the NHS.

On the other hand, other commentators agree with the need for cross-party support but argue that other forms of inquiry are preferable to RCs. For example, according to Davies et al. (2018), of the three possible types of inquiry – RC, independent inquiry, parliamentary inquiry – the last would be the most likely to be effective. They argue that the recent record of RCs, such as those on the Reform of the House of Lords and on Long-term Care, is poor. On the other hand, they claim that recent independent inquiries such as Wanless (on NHS funding), Turner (on pensions), Dearing and Browne (on university tuition fees) and Dilnot (on social care) have been influential (but see below). Moreover, RCs are unwieldy and take too long (but see Saatchi and Nutt, 2018). They point out that more than 100 MPs, including 21 select committee chairs, have supported a campaign led by Sarah Wollaston, the Chair of the Health and Social Care, and Liaison Committees, to establish a parliamentary ‘commission’ into health and social care. Similarly, former CEO of the NHS, Nigel Crisp (Saatchi et al., 2017) states that while a RC has some merits in being above politics, authoritative, and open in its deliberations, and would potentially command wide support, it has formal and restrictive processes for taking evidence and consultation, can be very expensive and can be lengthy. However, the biggest argument against a RC is that a more flexible, quicker process that directly involves people from all parts of the health and care system, including patients, families and carers, is a better option.

This article focuses on the impact of RCs and similar advisory bodies, particularly on finance recommendations, of three inquiries with broad remits across the whole of the NHS from very different periods: Guillebaud (1956); Royal Commission on the National Health Service (1979); and House of Lords Select Committee on the Long-term Sustainability of the NHS (2017). There is fairly limited coverage of these in the standard academic texts. While the texts predate the last select committee, Ham (2009) and Klein (2013) cover both Guillebaud and the royal commission in about half a page and a page each respectively. The most coverage is in the magisterial text by the official historian of the NHS. In some 1200 pages and two volumes of text covering the NHS up to 1979, Webster (1988) covers Guillebaud in about eight pages, while Webster (1996) explores the royal commission in about 10 pages.

This article first explores RCs (and similar inquiries) in the NHS, before focusing on the three inquiries listed above in more detail, and then proceeding to a wider discussion and conclusion.

Royal commissions

There has long been an interest in RCs (e.g. Gosnell, 1934; Clokie and Robinson, 1937), with the first commentary in 1849 (see e.g. Lauriat, 2010), and this call is far from new. For example, Gosnell (1934: 93) states that in times of national crisis the perplexed government frequently turns to the device of a RC. However, RCs have fallen out of fashion (e.g. Barlow, 2013; IfG, 2017). According to the Institute for Government (IfG) (2017), while inquiries are now a permanent fixture in public life (with eight public inquiries then under way, and the peak number in late 2010 under the Coalition Government with 15 inquiries running concurrently), the use of other forms of investigation, including RCs, has declined. Rowe and McAllister (2006) state that RCs have declined almost to the point of extinction. Even RCs themselves (Sutherland, 1999) and their supporters (e.g. Saatchi and Nutt, 2018) feel obliged to justify them (see below).

Lauriat (2010) points to the frequent observation in the literature of the difficulty in reaching consensus on either a succinct definition or a thorough description of a RC. Barlow (2013) explains that a RC is an ad hoc advisory committee appointed by the Government for a specific investigatory and/or advisory purpose. RCs have come in and out of fashion over the centuries. For example, they were established at an average of more than five a year between 1830 and 1900, just more than one a year between 1945 and 1975, and at 0.28 per year between 1975 and 2000.

IfG (2017) compares the different types of formal independent investigation of statutory inquiry – non-statutory inquiry, inquest, independent panel, RC – on 13 key characteristics. In particular, contra Saatchi and Nutt (2018), RCs do not generally have powers to compel the attendance of witnesses, to give oaths, or to demand the production of documents (Caird, 2016; Gosnell, 1934; HoL, 2014; IfG, 2017). However, they have stronger powers in countries such as Australia (Lauriat, 2010). According to Rowe and McAllister (2006), there are difficulties in establishing a firm typology of these bodies that have similar key characteristics, which makes rigid categories of such inquiries relatively unhelpful. Lauriat (2010: 29–30) argues that aside from the grandiose title, it is not immediately clear what distinguishes a RC from other governmental committees, and the secondary literature struggles to identify exactly which procedural elements are exclusive to RCs. Moreover, it is difficult to make accurate generalizations (or even identify common themes), due to the wide variation between different RCs.

Klein (1975) states that, like their virtually identical first cousins, committees of inquiry, RCs may be appointed by governments for a variety of reasons and carry out a variety of different functions. A number of commentators have suggested different roles for RCs (e.g. Caird, 2016; Clokie and Robinson, 1937; Klein, 1975; House of Lords Select Committee, 2014; Lauriat, 2010).

According to Lauriat (2010), it is difficult to assess the consequences and judge the ‘success’ of a RC for several reasons: the disagreement over the criteria to be applied; the lack of comparability between different commissions; time lag and attribution. However, one area of evaluation is clearly the discernible impact of the commission. Rowe and McAllister (2006) state that the take-up of recommendations must be one yardstick against which to judge the value of RCs.

If one of the key reasons for an inquiry is to learn lessons and prevent similar events from reoccurring, recommendations must be implementable and implemented (Powell, Forthcoming). The broader literature on inquiries makes some relevant points. According to Williams and Kevern (2016), the ‘instrumental’ model of the inquiry process has a linear progression through three processes: establishing the facts; analysis and reflection; and prescriptions for change. The main input is the historical information from witnesses or written sources and the main output is the recommendation. It follows that, in theory, if recommendations are a correct interpretation of the evidence and are acted upon by politicians, policymakers and executives, change should be assured and inevitable.

Mackie and Way (2015) argue that an inquiry will have failed to achieve one of its core purposes if what it concludes is not implemented. They suggest some ways of improving the effectiveness of and implementation of recommendations. For example, in writing recommendations, thought needs to be given to how to provide practical recommendations which are actually capable of being, or indeed likely to be, performed. If a recommendation is likely to be difficult to achieve or unwanted by the group that is tasked with carrying it out, then steps should be taken to ensure that the recommendation is broken down and is actually a series of practical doable steps. One of their own recommendations involves an ‘implementation action plan’.

IfG (2013) points out that much of the most important work of inquiries is only just beginning when an inquiry report is published and the baton is handed over to the Government. As former inquiry chair Robert Francis puts it: ‘Implementation is – of course – everything.’ However, the National Audit Office (2018) pointed that one of the 33 recommendations of a 2014 House of Lords Select Committee was to ensure that on the conclusion of an inquiry, the secretary delivers a ‘lessons learned’ paper from which best practice can be distilled and continuously updated. However, while eight inquiries have concluded since the Government’s response to the House of Lords report was published, the Cabinet Office was unable to give any examples of lessons learned reports produced as a result of these inquiries.

The lost world of royal commissions

RCs consider intractable policy challenges (IfG, 2017) or are normally used to consider matters of broad policy rather than to investigate a particular event or series of events (Caird, 2016). However, Barlow (2013) argues that RCs have gone out of fashion. There have been just three since Margaret Thatcher became Prime Minister in 1979, compared with 34 over a similar timeframe between 1945 and 1979, with the last one – on the reform of the House of Lords under Lord Wakeham – established in 1999.

As stated above, this article focuses on the ‘discernible impact of the commission’ (Lauriat, 2010). The House of Lords Commission (2014) points out that the terms of reference of inquiries usually conclude with the words: ‘and to make recommendations’. However, the responsibility of an inquiry ends when its report is published; at that stage the responsibility of the Government begins. Similarly, Lauriat (2010) states that after a RC report, any further action must be taken by the Executive or Parliament. RCs have no legislative function and little, if any, control over what is done subsequently with their reports. Mackie and Way (2015) point out that there is no requirement that a body implement any recommendation made by a public inquiry.

The evidence on the impact of RCs is mixed, depending largely on the political climate of the time and the degree of controversy of the proposals. RCs have been less influential in more highly disputed areas of social policy or constitutional reform – one of the main reasons why they have fallen into disuse and prime ministers have preferred other forms of inquiry (Barlow, 2013; Gosnell, 1934; IfG, 2017; Klein, 1975; Rowe and McAllister, 2006).

The IfG report (2017) notes there is little firm procedure for holding government to account for any promises made in the aftermath of inquiries. Of the 68 inquiries that have taken place since 1990, only six have received a full follow-up by a select committee to ensure that government has acted. While IfG (2017) provides examples of some inquiry chairs (such as Francis) maintaining an active interest in their work after the formal conclusion of their inquiries, none of the examples given refers to a RC.

A number of commentators argue that the influence of RCs cannot be judged in the short term. Clokie and Robinson (1937: 148) point to the belief that commission reports rarely become translated into action until 10 years later. According to Gosnell (1934: 112), some of the recommendations of an important commission may not be acted upon for many years. It was 20 years ‘before important legislative action was taken on the monumental report of the RC on Poor Laws of 1905–1909’. In 1938 Harold Laski determined that ‘on the average, in our system, it [took] nineteen years for the recommendations of a unanimous report of a Royal Commission to assume statutory form; and if the Commission is divided in opinion, it [took]…about thirty years for some of its recommendations to become statutes’ (quoted in Lauriat, 2010). Rowe and McAllister (2006) stress that it is still too early to say what will be the upshot of difficult and, in part, rejected reports, such as the Sutherland (1999) RC (but see below).

There are some resonances of ‘Groundhog Day’, where history repeats itself. Clokie and Robinson (1937: 148) point to the belief that the same subjects of inquiry recur approximately every 20 years. Rowe and McAllister (2006) suggest that those commissions and inquiries that were not accepted in their entirety have returned to the political agenda at subsequent and regular intervals.

The House of Lords Commission (2014) states that all their witnesses who considered the issue of overseeing implementation agreed that a monitoring and reporting of recommendations beyond the inquiry is necessary. The importance of monitoring and reporting on the implementation of recommendations is underlined by examples of inquiries whose recommendations were not acted upon, to negative effect. For instance, Julie Bailey commented: ‘People say that, if the Bristol Royal Infirmary Inquiry (2001) recommendations had been implemented, Mid Staffs would never have happened and our loved ones certainly would not have lost their lives the way they did.’

The lost world of royal commissions in the NHS

There have been a number of RCs on issues related to the NHS. Barlow (2013) lists: Royal Commission on the Law relating to Mental Illness and Mental Deficiency (1957); Royal Commission on the Remuneration of Doctors and Dentists (1960); Royal Commission on Medical Education (1968); Royal Commission on the National Health Service (1979); and Royal Commission on Long-term Care of the Elderly (1999), all of which took about two to three years to report.

Saatchi and Nutt (2018) recognize that a RC may seem an unlikely means of providing this much-needed review of the NHS. They claim that, although once a popular constitutional mechanism to develop public policy outside the partisan gridlock of Westminster, they have fallen out of fashion, with this slide into constitutional obscurity due to two recurring concerns. The first is best captured by Harold Wilson’s claim that they take minutes and waste years. The second is that commissions have tended to lose sight of the political realities, producing lengthy tomes with hundreds of recommendations that are dead on arrival. For example, the RC on Long-term Care (1999) was rejected by the Labour Party for producing unrealistic, cost-blind recommendations. This claim seems to be half-right: its proposals were costed, but was one major reason why two members issued their ‘note of dissent’ or ‘minority report’. As we see below, it was rejected not because it was ‘cost-blind’ but because it was deemed ‘unrealistic’, which has some parallels with our three case study reports. However, Saatchi and Nutt (2018) consider that both of these objections can be answered: ‘given the current political situation, a RC appears the only way of getting any kind of consensus behind significant reform to the NHS’ (p. 3).

Similarly, the chair of the RC on Long-term Care (1999), Sir Stewart Sutherland, felt the need to ask the question ‘Why a Royal Commission?’ He stated that when RCs are created, the cynical view is that either a difficult issue is being kicked into the long grass so that someone other than the Government can take the blame for problems which are impossible to solve or unpalatable in their solution, or that a seemingly independent body will be told by the Government to deliver an unpalatable response for which it does not want to take responsibility itself. In the first case, we can expect a RC to take years to reach its conclusions, and in the second, the government of the day will tell it when to report. Sutherland responded that neither of these views applied in the case of his Royal Commission.

The next section focuses on three RCs and similar advisory bodies, particularly on finance recommendations, of three inquiries with broad remits across the whole of the NHS from very different periods: Guillebaud (1956); Royal Commission on the National Health Service (1979); and House of Lords Select Committee on the Long-term Sustainability of the NHS (2017). These have been selected because they reflect three different types of inquiry from different periods set up by the Government, which focus on broad policy issues covering the whole NHS. Similar candidate inquiries such as Wanless (2004), Barker (2014) and commissions set up for the 70th anniversary of the NHS (e.g. Darzi, 2018; Charlesworth and Johnson, 2018) were excluded.

Wanless (2004) can be seen as a post-hoc rationalization. As Davies et al. (2018) put it, one interpretation of this inquiry was that it was commissioned by the then Chancellor, Gordon Brown, to justify the big increases in NHS expenditure to which the Government was already committed. In other words, it essentially had a preordained outcome. Barker (2014), set up by the King’s Fund, Darzi (2018), set up by the Institute of Public Policy Research, and Charlesworth and Johnson (2018), set up by the Institute for Fiscal Studies and the Health Foundation, are too recent to detect any clear influence on government.

There are different forms of inquiry (IfG, 2017; NAO, 2018; Davies et al., 2018; Powell, Forthcoming). Inquiries such as those related to the Mental Health Act, Serious Case Reviews, and Francis (2013) on Mid Staffordshire are excluded as they focus on scandals rather than broad policy issues (Davies et al., 2018; Powell, Forthcoming).

Guillebaud (1956)

The Guillebaud Committee was set up in 1953 by the Conservative Government after NHS expenditure had far exceeded estimates. Webster (1988: 204) writes that the committee was set up under pressure from the Treasury, but the Ministry of Health considered that an inquiry might reveal the extent of unmet need, believing that the ‘Treasury are here playing with fire and are liable to get badly burned’. The Committee was to be chaired by Cambridge economist Claude Guillebaud, who was accepted for his unexceptionable middle-of-the-road record. The other members were Dr J Cook, FRS (Glasgow chemist); Sir John Maude (Permanent Secretary at the Ministry of Health, 1940–1945), Barbara Goodwin (nominated by the TUC), and Sir Geoffrey Vickers (industrialist, and later author of The Art of Judgement, 1965). With the exception of Maude, the members were inexperienced in health affairs, and Maude admitted that he had lost touch with the health service since his retirement. This meant that the committee was guided by and reflected the views of the Health Departments.

The Minister of Health, Iain Macleod, announced the inquiry on 1 April 1953 (Hansard, House of Commons, 1953), terming it ‘a general inquiry into the function, structure and policy of the service’ (c 1235). He was attacked by Labour MPs Aneurin Bevan and Sidney Silverman. Bevan (c 1230) asked: ‘Is it not an act of the most unprecedented political cowardice to send to a committee a matter which is at the centre of British politics?’ Similarly, Silverman considered that Macleod had subjected a large chunk of public expenditure to ‘an entirely revolutionary and unconstitutional method of dealing with it. If he had made the same proposal with regard to the Defence Services nobody in this House would have had any doubt about its impropriety’ (c 1232).

Although the term ‘cost’ appeared in the title, the committee interpreted its terms of reference fairly widely, as suggested by Macleod. It noted that the current net cost of the NHS as a percentage of GNP fell from 3.51% in 1948–1949 to 3.24% in 1953–1954 (p. 9). Moreover, capital expenditure in 1938–1939 was more than three times as high as it was in 1952–1953 (p. 33). The committee then estimated the future funding of the NHS, concluding that population changes in themselves are not likely to exert a very appreciable effect on the future cost of the NHS (p. 49). It considered the definition of an ‘adequate service’, stating that it is ‘clearly inadequate now in the sense of meeting every demand justifiable on medical grounds’. The advance of medical knowledge and rising public expectations continually placed new demands on the service. ‘We conclude that in the absence of an objective and attainable standard of adequacy the service must… provide the best service possible within the limits of the available resources’ (pp. 49–50).

It then turned to the general structure of the NHS. It was very conscious of the fact that the NHS had only been operating for seven years. Despite certain weaknesses, the service’s record since 1948 had been one of ‘real and constructive achievement’. It considered proposals for reorganization of the 1948 ‘Tri-Partite’ system that essentially was based on the three existing branches of health service administration: one local authority for all branches; hospitals transferred to the local authorities; transferring the work of the Executive Councils to the local authorities or regional hospital boards (RHBs); a central National Board or Corporation. However, ‘we believe that unless an overwhelming case could be made out for any basic reorganization of the Service, it would be in the best interests of the Service to leave the present administrative structure undisturbed’ (p. 53).

The report did not number its ‘Conclusions and Recommendations’, but these can be estimated at about 40 (pp. 240–268). However, most of these seem to be relatively minor in nature, with a large number of endorsements of the status quo: ‘we do not recommend…’. They covered ‘parts’ of: present and prospective cost of the NHS; the general structure of the NHS; the hospital and specialist services (estimated 27); the family practitioner services (estimated 11); the local authority health services (estimated five); Whitley Council machinery (estimated four); and general (one).

The report concluded that no major change was needed in the general administrative structure of the NHS: ‘We have found no opportunity for making recommendations that would either produce new sources of income or reduce in a substantial degree the annual cost of the service. In some instances such as capital expenditure, we have found it necessary to make recommendations which will tend to increase the future cost’ (p. 268). There were two Notes of Reservation. Miss Goodwin considered that teaching hospitals should be integrated into the regional structure (which occurred in the 1974 reorganization) and had stronger views against charges. Sir John Maude saw more weaknesses in the administrative structure and suggested that the service might be transferred to local authorities after an adequate reorganization of local government administration and finance (which essentially was the Ministry of Health view favouring local government before the NHS).

According to Webster (1988: 209), the official press release was headed ‘No fundamental changes recommended. Service needs time to settle down.’ The draft report was announced by the committee’s secretary to his colleagues as a ‘puffball’, while ministers declared that the report ‘says very little’, with Minister of Health Iain Macleod stating that it had ‘very few useful proposals’ (Webster, 1988: 210). Webster continues that ‘the Treasury was infuriated by the perceived waywardness of its brainchild’. It was described as ‘pretty awful’, and ‘highly disappointing and indeed unsatisfactory’. It complained that ‘there was no-one to give evidence…saying that the Service was more than adequate or that more income ought to be collected’ (Cutler, 2000: 231).

The report was announced to the House of Commons on 25 January by new Conservative Minister of Health, Richard Turton, in response to a question from Labour’s Arthur Blenkinsop (Hansard, House of Commons, 1956a). Turton made it clear that ‘in view of the economic situation the Government cannot undertake any additional financial commitments in respect of the Health Services at the present time’ (c 208). The debate on the report was held on 7 May 1956 (Hansard, House of Commons, 1956b). Turton (c 845) moved that ‘this House takes note of the Report of the Committee of Inquiry into the Cost of the National Health Service’ and reported ‘what action I have taken and am taking on the recommendations of the Committee’ (c 846). The Government accepted some recommendations involving fairly minor expenditure. For example, the response to the recommendation to establish a research and statistics department was that ‘I have made a start by appointing a statistician to my Department, together with the necessary supporting staff’ (c 867). Similarly, the Government agreed to a ‘new and special scheme – that for the recruitment on a national basis of a small annual number of younger men and women who may reasonably be expected to be the leading hospital administrators of the future’, with 16 posts offered as a start (c 869). However, in general, Turton repeated his January statement rejecting any additional financial commitments.

Labour broadly regarded Guillebaud as a vindication of the NHS, and were disappointed that there would be no action to increase expenditure or reduce charges. For example, Dr Shirley Summerskill stated that the Minister ‘has not accepted any of the financial recommendations of that Committee’ (c 869).

Cutler (2000) points out that publication of the report did not lead to a significant reduction in pressure to restrain NHS expenditure, and prescription charges were increased in October 1956. Similarly, although Guillebaud had recommended substantial increases in NHS capital spending, Chancellor of the Exchequer, Lord Thorneycroft was still advocating a substantial reduction in such spending in January 1957.

Report of the Royal Commission on the NHS (1979)

Klein (2013) pointed to ‘the politics of organisational statis’ and sense of crisis that led to the setting up of a RC on the NHS (p. 90; cf. Timmins, 2008). Klein (2013: 96) noted that the report both reflected the growing disillusionment and represented an attempt to maintain the consensus. It reaffirmed the basic philosophy of the NHS, and delivered an overwhelming – though not uncritical – endorsement of the service. In this respect it resembled the Guillebaud Report, but while that virtually silenced political argument about the NHS for 10 years, the RC marked, on the contrary, the beginning of a new debate, with an incoming Conservative Government of 1979.

Webster (1996: 718–719) noted the ‘unusual genesis’ of the RC, owing its origin to a perverse cause – conceived by medical politicians, especially the British Medical Association (BMA), as an apt device to undermine Labour’s policy of phasing out pay beds. When it became clear that the RC would be unable to interfere with the Government’s plans for phasing out pay beds, the BMA largely lost interest in the exercise. The Government was left with the unwanted child. It was shunted onto a branch line, and was rarely mentioned in government circles. The broad remit given to the RC constituted an invitation to diffuse and superficial comment.

The RC was appointed in May 1976 and reported in July 1979. It was chaired by Sir Alec Merrison, the Vice Chancellor of Bristol University, who had recently chaired the committee investigating regulation of the medical profession (Webster, 1996: 618). It contained 15 other members (with two resigning before the final report), reflecting a diversity of interests (Webster, 1996: 619).

It opened by stating that it was appointed at a time when there was widespread concern about the NHS: a reorganization which few had greeted as an unqualified success; industrial disputes; and a chill economic climate (p. 1). It noted that only Guillebaud had considered the NHS as a whole (p. 2). It stated that its evidence contained a complete spectrum of descriptions of the present state of the NHS, ranging from ‘the envy of the world’ to being ‘on the point of collapse’. Its judgement lay between these extremes (p. 13). In terms of international comparisons, it noted that the UK spent less than most over-developed countries, and also performed relatively poorly in terms of indicators of health such as life expectancy, and perinatal and maternal mortality. It concluded: ‘We need not seem ashamed of our health service and there are many aspects of it of which we can be justly proud’ (p. 27). It noted that ‘a common criticism is that the NHS is a sickness service rather than a health service’ (p. 35). It stated that easily the most popular remedy for the failings of the NHS, especially and understandably with those working in it, was that much more money should be made available. Other suggestions included: alternative methods of financing (e.g. charges); the NHS should be taken out of politics; integrating health and personal social services; and further NHS reorganization (pp. 35–36). It stated that there was general agreement in evidence that the structure of the NHS needed slimming (p. 321), and it was considered that there was one management tier too many in most places (p. 325). In contrast to Guillebaud, it suggested that demographic change of the growing number of old people, and particularly those over 75, would be the greatest single influence on the shape of the NHS for the rest of the century (p. 379).

There was no clear recommendation on the level of expenditure. Like the Guillebaud Report, it found no objective or universally acceptable method of establishing what the ‘right’ level of expenditure on the NHS should be. Some of the recommendations would lead to increased expenditure, but others would lead to savings. ‘On balance our recommendations would increase the cost of the NHS…We also considered it right that the nation should spend more on the NHS as it got wealthier’ (p. 376). There seems little doubt that the UK is towards the bottom of the international spending league. However, these arguments do not take us far in establishing what the right level of expenditure on the NHS should be, if indeed there is meaning in the concept of the ‘right level’. International comparisons do not suggest that greater expenditure automatically leads to better health in higher-spending countries. Moreover, it was ‘at least arguable’ that money would be better spent outside the NHS on areas such as housing (p. 334). It continued that spending more on the NHS will not make us proportionately healthier or live proportionately longer. Whatever the expenditure on health care, demand is likely to rise to meet and exceed it. To believe that we can satisfy the demand for health care is illusory (p. 335). It considered methods of financing the NHS such as insurance, supplementary finance, charges and hypothecation. Although the RC tended to favour the existing model of funding, the only clear recommendation was that ‘it is for government to decide how the NHS should be funded, but there is a firm case for the gradual but complete extinction of charges’ (R 112, p. 379).

In total the RC made 117 recommendations. These consisted of: recommendations on services to patients (58); recommendations on the NHS and its workers (29); recommendations on the NHS and other institutions (13); and recommendations on management and finance (17). Some of these were ‘weak’, in the sense that the Government should ‘review’ or ‘consider’, while others appear largely to be fairly obvious, such as ‘proven screening services should be expanded’.

Webster (1996: 725) concludes the RC was a less formidable investigation than suggested by its elevated status, and it turned out to exercise negligible influence and made little permanent impression. The Treasury called it a ‘damp squib’. This was indeed the logical consequence of the circumstances of its genesis.

On 18 July 1979, Conservative Secretary of State for Social Services, Patrick Jenkin made a statement on the RC (Hansard, House of Commons, 1979). He stated that the RC recommends that the administration of the Health Service should be simplified by eliminating, in most cases, one tier of management, and it recognizes that management decisions should be taken at the lowest effective level. He continued that a number of the commission’s recommendations would be costly, as the commission itself recognizes. But the commission states: ‘It would be unrealistic to suppose that the fortunes of the NHS can be insulated from those of the nation.’ On the question of private practice, the commission sees no objection to a significant expansion of the private sector, provided that the interests of the NHS are adequately safeguarded. Nor does it consider the presence or absence of pay beds in NHS hospitals to be significant at present, from the point of view of the efficient functioning of the Health Service. It is, of course, the Government’s policy to welcome the contribution that independent medicine can make to the health care of the nation, and the proposals had been published in a consultative letter the previous month. However, he stressed that ‘this report has been made to the Government, and it is now up to the Government to respond with our own proposals’ (c 1791).

For Labour, Stan Orme welcomed the report, which ‘reaffirms the basic principles that underpinned the establishment of the Health Service over 30 years ago’. However, he was ‘dismayed’ that the Government had not accepted the RC’s recommendation that there should be no change in the financing of the NHS, which is based on taxation of the whole community, and was considering other forms of financing such as insurance that were rejected by the RC (c 1791). He also argued that the Government had rejected the RC’s views on phasing out pay beds and reducing charges (c 1792). Jenkin responded that ‘the Government do not necessarily share the view of the Royal Commission that a service financed almost 100 per cent out of taxation is the right answer’ (c 1792). For the Liberals, Alan Beith asked: ‘Why did not the Secretary of State wait to read the critical report of the Royal Commission on prescription charges before putting them up?’ (c 1796).

On 23 January 1980, Jenkin moved that ‘this House takes note of the Report of the Royal Commission on the National Health Service’ (Hansard, House of Commons, 1980). He stated that the Government would match Labour’s commitment of 0.5% growth in resources each year, but that removing charges would not be possible (c 459–460). He stressed that ‘the commission, as an advisory body, was not faced with the practical consequences of abandoning charges’, but noted that Labour invariably demand the abolition of charges in opposition but invariably put them up in government (c 460). Despite the clear conclusion of the RC, he made no apology for setting up an investigation into the possibilities of increasing the insurance element as a means of financing the NHS (c 462–463).

Jenkin argued that the RC’s view of taking decisions at the lowest effective point illuminates the proposal in the consultative document ‘Patients First’ (c 463). However, the Government rejected the RC’s proposals to abolish Family Practitioner Councils (FPCs) and to make Regional Health Authorities (RHAs) directly accountable to Parliament (c 464). He stressed that ‘In round figures, it is estimated that the cost of the Royal Commission’s recommendations could be another £2 billion a year. Obviously, that amount of money does not begin to be available under present circumstances’ (c 467). Mrs Sheila Faith (c 514) considered that, by recommending the abolition of all NHS charges and that all finance should come from taxation, ‘the commissioners live in a dream world with regard to economics’ (even though one of the original members of the commission, Prof Alan Williams, was a professor of health economics!).

Labour criticized increased charges. For example, Laurie Pavitt (c 527) considered that the ‘greatest sin of the Secretary of State and this Government was their Scrooge act of last July’ in increasing the ‘season ticket’ price for prescriptions for particular groups. Similarly, Roland Moyle (c 563–564) pointed out that all opposition members who took part in the debate referred to the problem of charges, and that the RC and the Government ‘part company’ on charges, with prescription charges going up by about 300 per cent.

The one significant change that may be attributed to the RC is the ‘shedding of tiers’. The 1982 NHS reorganization saw the Area Health Authorities, created only in 1974, abolished, with the single tier below regional level being the District Health Authority (e.g. Timmins, 2017: 383–384).

House of Lords Select Committee (2017)

A House of Lords Select Committee to consider the long-term sustainability of the NHS was appointed on 25 May 2016 and ordered to report by 31 March 2017. It stated that the NHS was in crisis and the adult social care system was on the brink of collapse. ‘Our conclusion could not be clearer. Is the NHS and adult social care system sustainable? Yes, it is. Is it sustainable as it is today? No, it is not. Things need to change.’

It argued that while the NHS had evolved considerably since 1948, the drivers of change – from demographic factors and changing disease patterns, to technological and medical advances, income effects and increasing relative health care costs – were intensifying at a relentless pace and fuelling rising public expectations. The system, which was originally designed to treat short-term episodes of ill health, was now caring for a patient population with more long-term conditions, more co-morbidities and increasingly complex needs. It noted that in comparative terms, the UK had historically spent less on health when compared with other nations, has fewer hospital beds, fewer doctors and fewer nurses per head, and often worse outcomes for survival from stroke, heart attacks and many cancers. Other problems included a culture of short-termism; low productivity; wide variations in provider performance; slow adoption of new technologies; lack of integration between health and social care; and a lack of focus on prevention. It contained chapters on service transformation; workforce; funding the NHS and adult social care; innovation, technology and productivity; public health, prevention and patient responsibility; and towards a lasting political consensus. It noted that in order to achieve long-term sustainability of the NHS, ‘radical service transformation’ was needed. There was widespread agreement on the vision – integrated health and care services delivering more care in primary and community settings – but service fragmentation and volatile funding allocations are making the necessary service transformation difficult.

The committee made 34 recommendations. These included the establishment of an Office for Health and Care Sustainability, which should look 15–20 years ahead and report to Parliament; the transfer of budgetary responsibility for adult social care at a national level to a new Department of Health and Care; broadly implementing the Dilnot Commission (2011) system of capped expenditure on funding social acre (see below); the Government should, in the development of its forthcoming green paper on the future of social care, give serious consideration to the introduction of an insurance-based scheme which would start in middle age to cover care costs. It stated: ‘We are of the clear view that a political consensus on the future of the NHS and social care is not only desirable, it is achievable.’

It may be too early to detect how the committee’s recommendations will be implemented by government, but the early signs are not promising. The response document (Secretary of State for Health and Social Care, 2018) was fairly limited in stating that the Government was either already carrying out the recommendations, or appearing to sidestep them. For example, for R17 – ‘We recommend health spending beyond 2020 should increase at least in line with the growth of GDP and do so in a predictable way in that decade’, the response was that it was difficult to commit a future government, but ‘The Government is committed to protecting the NHS budget and devoting a significant share of national resources to the NHS’. Similarly, the response to R18 – ‘Beyond 2020 a key principle of the long-term settlement for social care should be that funding increases reflect changing need and are, as a minimum, aligned with the rate of increase for NHS funding’ was that ‘We regularly update our understanding of future needs for social care, working closely with leading academics. This will feed into decisions about funding for social care beyond 2020 including the Green Paper on social care reform.’

Discussion

There does not seem to be much questioning of the legitimacy of inquiries since the vehement attacks on the setting up of Guillebaud in 1953 by Bevan and Silverman (see above). However, there appears to be rather limited impact, especially on funding, of the three documents discussed above.

First, there appears to be some hesitancy in suggesting precise figures for NHS expenditure. Guillebaud (1956: 49–50) concluded that ‘in the absence of an objective and attainable standard of adequacy the service must…provide the best service possible within the limits of the available resources’. However, it suggested that NHS expenditure was probably too low, particularly on capital expenditure, and was generally against NHS charges. Like Guillebaud, the RC on the NHS (1979) found no objective or universally acceptable method of establishing what the ‘right’ level of expenditure on the NHS should be, but noted that ‘On balance our recommendations would increase the cost of the NHS…We also considered it right that the nation should spend more on the NHS as it got wealthier’ (p. 376). The House of Lords Select Committee (2017) recommended that health spending beyond 2020 should increase at least in line with the growth of GDP and do so in a predictable way in that decade. However, this would not amount to much additional funding with the slow growth in the economy. For example, in the 2018 Spring Statement, Chancellor Philip Hammond stated that the economy grew by 1.7% in 2017, with OBR forecasts of 1.5% for 2018, 1.3% for 2019 and 2020, 1.4% in 2021 and 1.5% in 2022 (Hammond, 2018).

Second, the reports are advisory, and governments can – and do – ignore their conclusions. In terms of the reception, Parliament in both 1956 and 1979/1980 was asked to ‘take note’ of the reports. In 1979 Jenkin stressed that ‘this report has been made to the Government, and it is now up to the Government to respond with our own proposals’. In 1956 Turton made it clear that ‘in view of the economic situation the Government cannot undertake any additional financial commitments in respect of the Health Services at the present time’. Similarly, in 1979 Jenkin quoted the RC that it ‘would be unrealistic to suppose that the fortunes of the NHS can be insulated from those of the nation’. He stated that ‘the Government do not necessarily share the view of the Royal Commission that a service financed almost 100 per cent out of taxation is the right answer’. In 1980 he stressed that removing charges would not be possible: ‘The commission, as an advisory body, was not faced with the practical consequences of abandoning charges.’ He stressed that the estimated cost of the RC’s recommendations could be another £2 billion a year: ‘Obviously, that amount of money does not begin to be available under present circumstances.’

Third, and related, governments have ignored their conclusions. In terms of policy impact, in the 1950s the Treasury effectively trumped Guillebaud and the Ministry of Health, with little reduction in pressure to restrain NHS expenditure, and NHS charges increased some nine months after Guillebaud. Similarly, Jenkin raised prescription charges in 1979 without waiting for the RC, and NHS expenditure subsequently grew only slowly.

Returning to the literature on broader inquiries, almost 20 years ago the Chief Medical Officer (2000) highlighted the importance of learning. However, he stated that there has been little formal evaluation of NHS processes of inquiry to see what impact they have, but anecdotally, there was an impression of variable focus, different levels of rigour, differences in methodology and in the way that recommendations are framed and adopted. He concluded that inquiries – and in particular, external inquiries – are not always effective learning tools for the NHS. In particular, formal external inquiries may be less effective than internal service reviews or audits in ensuring that active learning takes place within organizations.

Stark (2018) rejects the ‘conventional wisdom’ to argue that inquiries are effective policy learners. He produces a ‘policy learning typology’ containing the following learning types: individual; organizational; single loop; double loop; instrumental; social and political (pp. 26–27). On the basis of an international comparison of post-crisis learning to natural disasters of four cases in Australia, Canada, New Zealand and the UK (including two RCs), he claims that inquiries are most effective at producing ‘instrumental learning’ (developing better policy tools) and ‘cognitive organizational learning’ (enhancing coordination and interconnectedness). However, he admits that because his inquiries investigated a ‘natural’ disaster, this may have meant that the lesson-learning process was less political, and the need for reform more widely accepted, than in other policy areas (p. 5).

The Chief Medical Officer (CMO) (2000) considered that inquiry recommendations are not always sufficiently helpful or focused. Similarly, Black and Mays (2013) stated that recommendations should be few in number, focusing on priorities, rather than trying to be comprehensive, and should be implementable at a reasonable cost. Williams and Kevern (2016) suggest that one response would be to accept that recommendations are incomplete instruments of change, and pay more attention to the process of implementation. Put another way, it can be suggested that recommendations should be ‘active’ with a clearly identified agent (e.g. the CQC should…), and should be as SMART (specific, measurable, attributable, relevant, and timed) as possible. Stark (2018) argues that attention needs to be paid to all five stages of the inquiry process: information acquisition; knowledge production; knowledge transfer; knowledge institutionalization; and knowledge recall. He uses these stages to make a number of prescriptions to improve policy learning, such as inquiries should recommend the means of oversight through which the implementation of their reforms can be audited across the long term (p. 179). Lauder (2013: 180–183) suggests a number of features that may help to communicate lessons: an executive summary; a clear purpose; thinking behind the recommendations; placing of recommendations; differentiating recommendations; numbering of recommendations; link to explanation; story structure; document presentation; indexing; accessibility; responsibility; timescale; and peer review. Although it is not the responsibility of inquiries to cost recommendations, some thought should ideally be given to cost, or at least feasibility of implementation. The Academy of Medical Royal Colleges and Faculties in Scotland (2015) looked into the lessons to be learnt from the recent reports on the quality of hospital care. It found a number of common ‘key issues’ such as ‘Poor leadership from senior medical staff often resulting in a defective culture’. Responses from professional organizations seemed to be variable, and in some cases produced further recommendations rather than focusing on implementing the existing ones. It pointed to a variety of ‘visions’, ‘action plans’, ‘Expert Governance and Improvement Support teams’ and ‘Workforce Vision Implementation Plans’. However, these seemed to produce further words rather than action, with little sign of ‘SMART’ objectives.

Conclusions

Saatchi and Nutt (2018) point out that there is wide cross-party support for establishing a RC to consider and secure the long-term future of the NHS. They claim that it would be an opportunity to find common ground on some of the major challenges facing the NHS. A RC, which would be not just cross-party but above party, should exploit its ability to secure the bipartisan support needed to embed lasting changes.

One of few voices against setting up a RC is Vize (2018), who argues that ‘virtually everything about a commission would harm the NHS’. He stresses problems such as delay and freezing action (cf. Webster, 1988). However, the material presented here suggests a further reason that, while past performance may offer little guide to the future, the historical track record of inquiries is not good. It has been suggested that inquiries rarely offer firm conclusions on expenditure levels. Even then, governments, particularly in times of austerity, tend to reject their conclusions. Put another way, one strength of a RC – its independence – is also its weakness in terms of implementation. Vize (2018) concludes that whatever else the NHS lacks, it is not insight, evidence and analysis, with advice from many think tanks, Parliamentary Select Committees and agencies such as the National Audit Office: ‘We don’t need a royal commission. The truth is already out there. We need a government with the courage to face up to tough choices and make some decisions – now, not in six years.’

In the past, perhaps, RCs were a powerful instrument of social reform (e.g. Clokie and Robinson, 1937; Klein, 1975). However, Lauriat (2010) argues that it is no coincidence that the zenith of the British RC corresponded with a period when utilitarian, rationalistic ideals of law reform prevailed. Perhaps another reason is that in the Victorian era, inquiries were one of the few means of discovering information. However, in recent years the problem is almost that there is too much rather than too little information. It is difficult to see what a RC on the NHS could add to the vast research output on the NHS, as well as independent reports on health and social care. For example, recent years have seen reports such as Barker (2014), Warner and O’Sullivan (2014), Charlesworth and Johnson (2018) and Darzi (2018). Similarly, in social care, Davies et al. (2018) point out that since 1997 there have been: four white papers; two formal green papers plus ‘a statement’ that was halfway between a green paper and a white one; one ‘policy paper’; five public consultations; two commissions, one of them a RC; and assorted attempts by think tanks to resolve the issue, including substantive pieces of work such as a King’s Fund study of 2006, a Joseph Rowntree Foundation study in the same year, and the Barker Commission of 2014.

Rudolf Klein (personal communication) suggests another suitable period of Butskellism¹. While finding a consensus may once have been possible, it is more difficult to artificially create one. Asking a RC to find the magic bullet of NHS expenditure might be ‘déjà vu all over again’. Even in the period of Butskellism, the ‘Oliver Twist’ solution of asking for more did not result in a feast of expenditure. As the official historian of the NHS puts it, despite formidable backing from major independent inquiries such as the Guillebaud Committee, the Phillips Committee on the elderly, the Piercy Committee on the disabled, and the RC on Mental Illness, as well as mounting public indignation over the plight of the elderly, the disabled, the mentally ill and the mentally handicapped, it proved impossible to achieve a real increase in capital outlay on facilities for these groups, even in the latter part of the decade (the 1950s) (Webster, 1988: 222). More broadly, we might coin ‘Gosnell’s iron law’: ‘when a commission’s recommendations involve a considerable financial outlay, their adoption is likely to be retarded or indefinitely postponed’ (1934: 113). Davies et al. (2018) consider that inquiries, whether government-sponsored or not, do not necessarily lead to solutions (but see Stark, 2018). The historical evidence seems to confirm Einstein’s observation that doing the same thing again and expecting different results is madness. Asking an inquiry, including a RC, to provide answers on NHS expenditure is perhaps the unaccountable in pursuit of the unanswerable.

Footnotes

Declaration of conflicting interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Martin Powell

Note

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