Care scandals and their influence on policy

Policy scandals, in their broader sense, may involve relatively ‘small events’ which nevertheless can have large impacts on policy (Lodge and Hood, Reference Lodge and Hood2002:10), as a result of specific understandings of the events and attributed failings, as framed by various claims-makers, news media and emotions, thus putting pressure on policy-makers to respond amid institutional confines (Butler and Drakeford, Reference Butler and Drakeford2005; Lodge and Hood, Reference Lodge and Hood2002). Care scandals are a particular type of policy scandal, where failings are typically attributed to specific (trusted) (para-)professionals and the policy frameworks in which they work, resulting in the suffering of specific users of welfare state services (see Hutchison, Reference Hutchison2016).

While the impact of earlier health and social care scandals upon policy has been questioned (Butler and Drakeford, Reference Butler and Drakeford2005; Cooter, Reference Cooter1995), more recent scandals within English healthcare contexts have left a more significant mark on prevailing conceptions of ‘problems’ and policy solutions (Warner, Reference Warner2015). For the then editor of the British Medical Journal, the Bristol Royal Infirmary scandal represented a watershed moment where ‘all changed, changed utterly’ (Smith, Reference Smith1998:1917). A new framework of ‘clinical governance’ seemed very much informed by this and other recent dysfunctions, even if the policy was more a coordinating and intensification of pre-existing tendencies. Dixon-Woods and colleagues (Reference Dixon-Woods, Yeung and Bosk2011:1453) argue that it was the peculiar concentration of a number of scandals involving doctors within a short space of time within the late-1990s, as well as the degree of the moral failings and incompetence, that led to such a marked impact on policy and (the demise of self-) regulation.

One of the most influential recent scandals within the English NHS was that concerning hospital care standards within the Mid-Staffordshire NHS Foundation Trust (a local health provider-organisation in central England) (Hutchison, Reference Hutchison2016). Significant levels of preventable mortality and severe neglect (dehydrated and unfed patients; poor pain management), even cruelty, were described across care contexts, particularly those involving older people (Francis, Reference Francis2013a; Hutchison, Reference Hutchison2016). The head of the inquiry into these failings made many recommendations to avoid recurrences of the ‘appalling suffering of many patients’ (Francis, Reference Francis2013a: 3).

The politicisation of the findings and proposals in (prime) ministerial speeches suggested important new policies. The 2014 Care Act ‘delivers key elements of the government’s response to the Francis Inquiry into the awful events at Mid Staffordshire hospital’ (c. 2014:1), while the Secretary of State emphasized ‘the Francis effect’ – with ‘compassionate care starting to replace tick-box targets as the major focus on boards and wards’ (Hunt, Reference Hunt2014:1).

Following the publishing of the Francis report, policy discussions frequently used the term ‘compassion’ both to describe what was missing in these care contexts and to prescribe future remedying plans for NHS policy (Greenhalgh, Reference Greenhalgh2013; Hunt, Reference Hunt2014; Newdick and Danbury, Reference Newdick and Danbury2013). The Inquiry report set the tone for the subsequent orientation towards compassion, advocating the ‘engagement of every single person serving patients in contributing to a safer, committed and compassionate and caring service’ (Francis, Reference Francis2013a:18).

This framing was employed by the Prime Minister (Cameron, in Department of Health, 2013:1) and Minister responsible for health policy, Jeremy Hunt, in several commentaries on NHS failures: ‘People join the NHS because they have innate decency, compassion and caring values that makes them give their life towards helping people get better when they’re at their most vulnerable – but we have a system that all too often crushes that…’ (Hunt, quoted in Winnett and Brogan, Reference Winnett and Brogan2013:1). While some politicians’ uses of the compassion framing tended to locate the cause of care shortcomings in the failures of individual health workers (Hutchison, Reference Hutchison2016; Smajdor, Reference Smajdor2013), structural-governance factors were commonly acknowledged in policy statements.

Even if the Scandal was not a ‘watershed’ of the magnitude of some recent scandals accompanied by inquiries, ongoing references to compassionate care across a wide range of health policy documents (e.g. Department of Health, 2016, 2017a) point to an enduring legacy of the main compassion framing of the Scandal. Current policy regarding patient ‘nutrition and hydration’ (Department of Health, 2017b), for example, repeats the strong orientation towards older people and echoes the Francis report’s language in various ways - e.g. through ‘a clear and demonstrable set of values (such as the 6Cs of Compassion in Practice) underpinning a culture of compassionate care and placing the people we care for at the heart of everything, makes a huge difference to patients, carers and to staff’ (2017b:11).

Much more could be said about the problematised concept of compassion, its meaning and its implications for care (see Flores and Brown, Reference Flores and Brown2018; Smajdor, Reference Smajdor2013) but these considerations lie beyond the scope of this article. Compassion is certainly not the only term that might have been used to conceptualise the care failings and appalling suffering that took place, and the framework we develop below is more focused on understandings and politicisations of breakdowns in care. Before attending to this focus, we briefly consider other policy-oriented literature around the Scandal.

Towards an understanding of the Scandal? The predominance of a shorter-term lens

When accounting for care failings within pockets of NHS healthcare practice, many academic analyses echoed the arguments developed in policy-making circles (noted above). In their commentary on the Scandal, Newdick and Danbury (Reference Newdick and Danbury2013) argued that the failure of compassion was the product of an under resourced service committed to reducing costs while struggling to meet central targets. This is a position echoed by others (Dixon-Woods et al., Reference Dixon-Woods, Baker and Charles2013; Pollock and Price, Reference Pollock and Price2013) who follow Francis’s assessment of the financial strain brought about by senior managers at Mid-Staffordshire as they pursued the high status, devolved form of governance of a Foundation Trust: ‘The result was both to deprive the hospital of a proper level of nursing staff and provide a healthier picture of the situation of the financial health of the trust than the reality, healthy finances being material in the achievement of foundation trust status’ (Francis, Reference Francis2013a:45; cited in Pollock and Price, Reference Pollock and Price2013: 2190).

Further commonly considered systemic influences undermining compassionate practice include the distraction of targets and proceduralism, the mixed loyalties of clinician managers, as busy healthcare workers seek to complete their allocated tasks while having to make quick decisions under intense pressure (see especially Francis, Reference Francis2013b; Newdick and Danbury, Reference Newdick and Danbury2013). The combination of these factors, amidst broader contexts of ‘financial austerity, institutional instability and political anxiety’, are cited as facilitating the ongoing ‘institutional disengagement from patients’ which culminated in poor care (Newdick and Danbury, Reference Newdick and Danbury2013:6). Other academic commentators (e.g. Beaussier et al., Reference Beaussier, Demeritt, Griffiths and Rothstein2016) have noted that various agencies tasked with ensuring the quality of NHS care had failed to identify and deal with poor quality services.

Many of these recent approaches reflect recent trends within critical social scientific analyses of healthcare work, policy and organisations. These accounts often highlight the contradictions between orientations towards quality care and patients’ feelings associated with person-centredness, and governance logics towards efficient healthcare based on encoded knowledge. The latter model is task-oriented and requires healthcare workers to make decisions based on national guidelines, as cogs in a healthcare machine rife with alienating incentives and cultures (Flynn, Reference Flynn2002; Bevan and Hood, Reference Bevan and Hood2006). Although such analyses illuminate important major tensions in health policy and the changing nature of healthcare work, they are limited in understanding the Scandal in three related respects. First, in seeking to explain what went wrong, they adopt the common typification of the Scandal and the language of compassion at face value (cf. Smajdor, Reference Smajdor2013). Second, their short-term focus does little to consider what the Scandal has in common with other scandals, and what a more historically oriented analysis can teach us about care failings (see Ferguson, Reference Ferguson2007; Hutchison, Reference Hutchison2016). Third, extant analyses have overlooked the conditions that bring scandals and policy reactions into being, as well as the threats scandals pose to quality decision-making (Lodge and Hood, Reference Lodge and Hood2002; Warner, Reference Warner2015).

Insights from existing critical-historical perspectives

In significant contrast to other accounts of the Scandal, Hutchison’s (Reference Hutchison2016) historical comparative analysis locates this case in relation to several earlier scandals in child protection, medicine and social care. This approach echoes Butler and Drakeford (Reference Butler and Drakeford2005) in noting that failures in care, no matter how much suffering is involved, are neither necessary nor sufficient to generate scandals. Instead Hutchison gives an account of the ‘very specific social, cultural and economic circumstances [in which] scandals emerge’ (Hutchison, Reference Hutchison2016:37), highlighting the ‘common phases’ shared by scandals:

While scandals over the years have also been driven by insider care-professionals as whistle-blowers (Dixon-Woods et al., Reference Dixon-Woods, Yeung and Bosk2011), the emphasis here on the relative power of ‘claims-makers’ (e.g. patients, carers, and/or professionals) seeking to bring a problem to wider attention – their access to media and politicians, and the successful way in which they use language to frame the problem in a particular light – follows in a wider constructionist tradition to analyzing social problems based on common features in their emergence (Best, Reference Best1990; Spector and Kitsuse, Reference Spector and Kitsuse1977). These constructionist insights are reflected in important related studies in the history of medicine, whereby scandals are further considered as: facilitating the development of, while resulting from interventions by, claims-maker organisations (see Mold, Reference Mold2015 on patient organisations); involving shifting institutional interests and framings (see Cooter, Reference Cooter1995 on bioethicists); and as successfully highlighting a ‘gap’ between institutional practices and public values, amid wider contexts of shifting hierarchies (Mold, Reference Mold2010, Reference Mold2015).

These historical-constructionist perspectives help us understand why the Scandal emerged and impacted on policy, while the coalition and subsequent Conservative Governments did little in the face of ongoing claims around underfunding of the NHS and its impact on care quality. First, if scandals take place ‘when private acts that disgrace or offend the idealised, dominant morality of a social community are made public and narrativized by the media, producing a range of effects from ideological and cultural retrenchment to disruption and change’ (Lull and Hinerman, Reference Lull and Hinerman1997: 3, cited in Dixon-Woods et al., Reference Dixon-Woods, Yeung and Bosk2011), then it would appear that some care failings are too systemic, while lacking a private dimension and specific carers to blame. A second common theme shared by the Scandal was the portrayal of innocent and vulnerable victims and high levels of harm (Hutchison, Reference Hutchison2016). Third, the Scandal echoes the political conditions of the Ely hospital scandal of the late-1960s and Bristol scandal of the late-1990s in providing a reforming health minister with an opportunity to push his agenda for change (Butler and Drakeford, Reference Butler and Drakeford2005).

Though historical, Hutchison (Reference Hutchison2016) and Butler and Drakeford’s (Reference Butler and Drakeford2005) studies share much in common with synchronic analyses using inter-country comparative designs (e.g. Boin et al., Reference Boin, t’Hart and McConnell2009; Lodge and Hood, Reference Lodge and Hood2002). These cross-case analyses assist in illuminating underlying mechanisms that are common to scandal-driven policy formation, as well as in teasing out aspects of the institutional contexts that shape these. What these studies also share is a rather short-term analytical focus around each case. This is very useful in denoting subtle policy shifts and trajectories, but neglects the many insights afforded by an attentiveness to longer-term socio-historical processes.

We see glimpses of such longer-term analytical orientations in classic constructionist approaches to social problems and policy. Best’s (Reference Best1990) work on scandals and scares around children emphasises the role of successful claims-makers but is also attentive to long-term changes in social conditions, by which developments in obstetric and public health interventions led to falling birth-rates and a related evolution of the role and value of the child within the family (see also Ferguson, Reference Ferguson2007). In the next three sections we develop a longer-term analysis of the social and political factors that shape the changing nature of healthcare scandals.

Changing norms of proximity, care and related tensions: a figurational perspective

In developing our diachronic approach to policy analysis, we draw firstly on figurational researchers (e.g. Elias, Reference Elias2000) whose approach to analysing evolving figurations of interdependent social actors is especially attentive to longer-term historical processes. At the heart of Eliasian analyses of social change is the mutual influence between chains of social relations (sociogenesis) – gradually changing in their relative density, interwovenness and proximity – and shifting emotional propensities (psychogenesis) – for example, towards self-restraint, empathy and identification with others. Elias (Reference Elias2000) describes long-term ‘civilising processes’ taking place in Europe between the middle-ages and the early twentieth century, whereby increasing proximity and interdependencies in social relations gradually shaped, and are shaped by, a changing emotional habitus. This emerging habitus is characterized by a widening of ‘circles of concern’ and empathy for others (de Swaan, Reference de Swaan1995), and a related greater attentiveness to one’s conduct in the presence of others. As the power asymmetries between various groups – employers and employees, parents and children, men and women and, of most interest to us, between healthcare professionals and patients – have gradually receded, so have interaction norms become more informal and negotiated (Wouters, Reference Wouters2007), and so has a habitus of self-awareness regarding emotional restraint and ‘appropriate’ comportment become more ‘second nature’ and essential.

Such changes in norms of interacting and caring are apparent in the work of medical historians. Porter (Reference Porter and Classen2005:381), for example, highlights the contrast between the professional proximity of the early twenty-first century and ‘the routine clinical encounters of the seventeenth or eighteenth century [where] anything more than the most perfunctory and formal physical contact – as, for example, that involved in pulse-taking – was extremely unusual between a doctor and a patient’. Similarly, while current care for older people continues to be marked by ageism (Bowling, Reference Bowling2007), the contrast between current norms and those of the early 1950s, where older patients received little in the way of curative care under geriatricians who rarely visited their long-stay wards (Jefferys, Reference Jefferys, Bornat, Perks, Thompson and Walmsley2000; Raghuram et al., Reference Raghuram, Bornat and Henry2011), is striking. Jolley’s (Reference Jolley2004) study of change in paediatric care (1920–1970) draws on oral historical accounts which ‘show that children did not have access to their parents and that the staff were construed as being nonhuman, largely because of an approach that lacked affection. Nurses did care about the children and about their anxieties and fears but did not show their emotions and hid the affection they had for the children’ (Jolley and Shields, Reference Jolley and Shields2009:165).

Changing forms of, and expressions of emotions within, care have resulted from reducing asymmetries in power between professionals and patients – while also shaping these relations. Hierarchy and deference towards experts has diminished somewhat (Jolley and Shields, Reference Jolley and Shields2009) and, as a result, professional-patient interactions have become more negotiated and the expression and management of emotional labour has arguably become more central to the care relationship – ‘trust has to be won, and the means of doing this is demonstrable warmth and openness’ (Giddens, Reference Giddens1990:121). Studies of interactions involving doctors and nurses from the 1960s and 1970s (Menzies Lyth, Reference Menzies Lyth1960; Stimson and Webb, Reference Stimson and Webb1975) indicate, generally speaking, greater emotional distance and much less negotiation than is seen as the norm in the 2010s.

There is therefore evidence to suggest that norms of care, alongside understandings of what sufficient care for particular groups in society should look like, have changed markedly since the 1950s and even more so since the early nineteenth century. So whereas a short-term lens leads to invocations of narratives regarding worsening manifestations of bureaucracy undermining care (Newdick and Danbury, Reference Newdick and Danbury2013; Smajdor, Reference Smajdor2013) and examples of lamentable managerial and staff conduct (Francis, Reference Francis2013a), a long-term historical perspective reminds us that this is not the first time claims regarding poor care have been heard (Butler and Drakeford, Reference Butler and Drakeford2005; Jones, Reference Jones1993; Martin, Reference Martin and Evans1984).

Long before recent new public management tendencies in healthcare governance, campaigns against poor care for, and ongoing abuse of, older people in long-term care hospitals in the late-1960s (e.g. Robb, Reference Robb1967) had significant effects on NHS policy, leading to the institution of a watchdog (Hospital Advisory Service) and a health ombudsman (Martin, Reference Martin and Evans1984). First-hand accounts of doctors working in geriatric care in the NHS suggest that what would be considered as highly deficient neglect in the 2010s was standard practice in the 1950s (see Jefferys, Reference Jefferys, Bornat, Perks, Thompson and Walmsley2000). This shift indicates rather different norms of care that are remarkable in 2018 in the extent to which they were accepted by so many, with the exception of various foreign-trained doctors and emerging geriatrician-specialists who questioned them (Raghuram et al., Reference Raghuram, Bornat and Henry2011: 328-331). Common lived experiences of housing and hygiene have also changed dramatically, rendering very different basic standards and expectations of hygiene and cleanliness care in NHS hospitals.

These changes in socio-interactional and material care norms have important implications for understandings, expectations and practices of care – a relational ‘process’ aimed at ‘meeting socially recognised needs’ (Thelen, Reference Thelen2014: 41; our translation). Below we describe three specific mechanisms that heighten the propensity of care to breakdown in ways which arouse strong emotions: institutional lags; more informal care being less stable; and tensions in the recognition of needs shaped by organisational and social changes.

Heightened organisational sensitivities to dysfunction: an increasing responsiveness to scandals

Not only have long-term shifts in social structures and emotional habitus made practices and perceptions of inappropriate care more likely, but overarching institutional governance has also become more attuned to recognizing failings (Power, Reference Power2004; Rothstein, Reference Rothstein2006). Historical accounts of the early NHS denote a rather different way in which concerns of poor care were handled (Martin, Reference Martin and Evans1984). Complaints raised by Robb (Reference Robb1967) and others about long-term care for older people were first contested, then dismissed by investigating committees. It was not until a further newspaper report of abuse occurring at Ely hospital, Cardiff – providing long-term care to adults with various levels of learning difficulties and psycho-geriatric patients (Howe, Reference Howe1969) – that more serious changes were instituted (Martin, Reference Martin and Evans1984).

Less asymmetric healthcare hierarchies, as sketched in the sections above, render care professionals and welfare state organisations more accountable and, in many cases, more responsive to patients and the public than was the case in the 1960s. The NHS and the professionals who staffed it were in various senses still venerated and deferred to in the 1950s and 1960s (Stimson and Webb, Reference Stimson and Webb1975), especially senior professionals (Jolley and Shields, Reference Jolley and Shields2009). A greater skepticism towards professionals and expert systems amongst more recent generations (Giddens, Reference Giddens1991) renders concerns of wrong-doing or failures more likely to be uttered. Patients’, relatives’ and front-line professionals’ concerns or complaints are also more likely to be heard, partly assisted by the reporting and complaints (including whistle-blowing) systems which have gradually emerged since the early 1970s (Mold, Reference Mold2010), but also as a result of more general changes in the accountability structures which exist within late-modern public institutions. A language and organisational apparatus focused on ethics and quality improvement also makes professionals’ questioning of existing practice more possible (Cooter, Reference Cooter1995:268; cf. Jolley, Reference Jolley2004).

The growing voice and power of patients – emerging out of reducing power asymmetries and legitimated and facilitated by policy (e.g. Department of Health, 1991; see Mold, Reference Mold2010) – alongside the enhanced resources and authority of inquiries (Butler and Drakeford, Reference Butler and Drakeford2005), has created a very different context in which complaints are considered. Whereas the answerable government minister suggested Robb’s (Reference Robb1967) complaints constituted an abuse of free speech (Martin, Reference Martin and Evans1984: 5), such a response would be less thinkable in the 2010s. To the contrary, a normalisation of inquiries has played an important role in amplifying and refashioning care scandals, rather than disputing them.

An ‘inquiry culture’ can be understood within wider developments in modern societies, such as increasingly refined understandings of the causality of many phenomena, which have been linked to a shrinking tolerance for unexplained events (Turner and Pidgeon, Reference Turner and Pidgeon1997; Wilkinson, Reference Wilkinson2010). Organisations, not least within the modern, bureaucratised and highly scrutinised welfare states, are compelled to find reasons for dysfunction; and, in various ways, this need to explain and to blame is bound up with organisational practices towards risk management (Power, Reference Power2004; Rothstein, Reference Rothstein2006). Risks differ from dangers in that ‘they are seen as the consequences of decisions’ (Luhmann, Reference Luhmann1993:101), with the ubiquity of risk management driven by the pressure to maintain ‘myths of control and manageabilty’ (Power, Reference Power2004:10), despite the limits of planning amidst pervasive uncertainty.

Warner (Reference Warner2006:223) analyses the growing trend of instituting inquiries into scandals within such a risk management framework. In her account, ideals of organisational learning and potential for future prevention serve rational-forensic functions, in attempting to comprehend what could be (and should have been) done differently, alongside a cathartic function including the apportioning of blame (see also Wilkinson, Reference Wilkinson2010:33). The social value of the inquiry response to scandal can therefore be seen ‘as a reaction to the cultural experience of anxiety, in particular anxiety relating to rapid social change’, despite various arguments questioning their effectiveness in learning and prevention (Warner, Reference Warner2006:223).

Rothstein (Reference Rothstein2006) argues similarly that, over time, the priorities of such organisational attempts at learning become less oriented to the effective reduction of risks for clients or patients and instead the ‘reputational risk’ of the organisation becomes the key concern (see also Habermas, Reference Habermas1976). This warping of policy priorities may therefore explain both a growing sensitivity towards failure over time and the proliferation of dysfunctional policy-making, as lessons are learned and priorities are selected in a far from systematic way (Habermas, Reference Habermas1976; Lodge and Hood, Reference Lodge and Hood2002). At the national level, ministers and other policy-makers are required to show a zero-tolerance for care failings, as was visible in political reaction to the Scandal. At local level however, concerns with other forms of failings (such as financial or productivity) may distract from failings involving sub-standard care.

These organisational processes which warp institutional logics around risk and accountability must also be understood as influenced by the media (Rothstein, Reference Rothstein2006). The ambivalence of media coverage of poor quality care – prolonged indifference accompanied by occasional moral outrage (Butler and Drakeford, Reference Butler and Drakeford2005) – helps fuel the dysfunctional reorientation of organisations away from patient vulnerability towards reputational risk. Longer-term changes in news media reporting, and its relationship to policy-making, is one further important feature of a historically sensitive account of the Scandal and its policy impact, to which we now turn.

Pressures on governance: the changing role of media in generating scandals

Habermas’s (Reference Habermas1989) description of the role of news media in facilitating rational discussion within the small public sphere of various eighteenth century polities has been critiqued as overly romanticized, but this account nevertheless serves to emphasize the longer-term effects of media commercialisation and corresponding instrumentalisation, especially in the later twentieth century: ‘This expanded public sphere, however, lost its political character to the extent that the means of “psychological facilitation” could become an end in itself for a commercially fostered consumer attitude’ (Habermas, Reference Habermas1989:169). Habermas charts this shift in terms of the oligopolistic development of the newspaper printing industry, the technological and capital requirements of more recent electronic media, and the corresponding instrumentalisation of newspaper editorship.

In its overarching goal of building large and stable numbers of viewers or circulation, the mass media correspondingly has become a vehicle of publicity (Habermas, Reference Habermas1989), used by a range of state and private interests. Such instrumentalisation of editorial decisions results in the salience of various reliable rules and norms regarding the characteristic components of ‘good’ (sellable) stories – with these rules coming to dominate editorial judgements (Negrine, Reference Negrine1994). Hughes and colleagues (Reference Hughes, Kitzinger, Murdock, Taylor-Gooby and Zinn2006:256-8) identify various features of ‘newsworthiness’: high levels of harm where those affected can be linked to the audience; potential moral dimensions in terms of blame; as well as the nature of the people involved – for example innocent victims. It is in light of these rules that the ‘marketability’ of some lapses in healthcare (e.g. the neglect of frail older people exposed by the Scandal) but not others (more systematic underfunding) becomes further comprehensible. Imperatives to cover such stories place the NHS and other welfare institutions (such as child protection services) under an especially sensitive media gaze (Warner, Reference Warner2006). Such coverage is rooted in, while also gradually shifting, lifeworlds of understandings, norms and values around particular vulnerable groups and their needs.

One further marketable characteristic of a story relates to the potential for it to be framed in terms of a familiar narrative, albeit with a novel quality or twist (Alaszewski and Brown, Reference Alaszewski and Brown2012; Negrine, Reference Negrine1994). The prior existence of memorable, iconic events or scandals (Butler and Drakeford, Reference Butler and Drakeford2005) would therefore seem to heighten the likelihood that later occurrences, ostensibly similar in nature, will attract media attention (Warner, Reference Warner2006) – due to the ‘meaningful’ resonance of these events as ‘interpretable within the cultural framework of the listener or reader’ (Galtung and Ruge, Reference Galtung and Ruge1965: 66–7). Past scandals involving healthcare dysfunctions and lapses in dignified care, alongside a general attentiveness to NHS failings, can thus be seen as making it more likely that the problems within Mid-Staffordshire received significant amounts of media coverage, helping ‘transform’ suffering into a scandal (Butler and Drakeford, Reference Butler and Drakeford2005) in a rather different manner than would have been likely a half century earlier.

These heightened accountability pressures facing welfare state organisations have rendered governments and policy-makers increasingly sensitive to media reporting and the related reputational risk (Rothstein, Reference Rothstein2006). In turn, governments have become increasingly skilled and organized in managing and deflecting media criticism: for example, in working with cases of failure to politicize concerns and mobilize support for certain forms of change (Boin et al., Reference Boin, t’Hart and McConnell2009).

In reacting to media coverage, governmental actors are thus also able to shape media interest, either through distracting from and ignoring potential scandals, or by fueling and legitimising concerns in attempting to ensure a certain account of a scandal – such as an apparent breakdown in professionals’ compassion – becomes defining (Butler and Drakeford, Reference Butler and Drakeford2005; Warner, Reference Warner2015). Inquiries have become a fundamental tool for governmental action within these contexts, as a means of showing action and taking problems seriously, offering short-term catharsis (Dixon-Woods et al., Reference Dixon-Woods, Yeung and Bosk2011) while deferring longer-term solutions, as well as assisting in the framing of new policy. But far from a linear process – whereby incident leads to scandal leads to inquiry, followed by policy – Butler and Drakeford (Reference Butler and Drakeford2005:5) describe a more ‘complex, reciprocal relationship’: for example, whereby existing political tensions make scandals within certain policy domains more likely.

In contrast then to the 1960s when healthcare professions were more able, and ministers apparently more willing, to contest public concerns about care standards, a growing relative authority of lay concerns, alongside an increased political awareness and readiness amongst ministers to manipulate scandals for their own ends, represent a fundamental historical shift in political conditions. These conditions are salient in analyzing the emergence and influence of the Scandal in the years running up to 2013 and since.