Quality failures in the NHS

doi:10.1136/bmj.39486.406308.80

BMJ 2008;336:340-341 (16 February), doi:10.1136/bmj.39486.406308.80 (published 8 February 2008)

Editorials

Quality failures in the NHS

Changes in leadership and culture are needed to improve learningfrom mistakes

The first 150 words of the full text of this article appear below.

The report of the committee of enquiry into Ely Hospital, Cardiff,in 1969, was the first major inquiry into quality failures inthe National Health Service.¹ Thirty years later the reportof the expert group chaired by the chief medical officer, AnOrganisation with a Memory, emphasised the need for the NHSto learn from its mistakes, and to be more systematic in actingon inquiry reports.² A new analysis by the Healthcare Commissionbuilds on these reports by summarising lessons from 13 majorinvestigations it has undertaken since 2004.³

Readers of the commission’s report can be forgiven ifthey experience a strong sense of déjà vu. Althoughthe investigations it undertook covered a wide range of servicesin different parts of the country, the general themes that emergeare depressingly familiar. The quality failures examined resultedfrom the interplay of several factors, including weak leadership,conflicting targets, inadequate . . . [Full text of this article]

Chris Ham, professor of health policy and management

¹ Policy and Management, Health Services Management Centre, University of Birmingham, Birmingham B15 2RT

c.j.ham@bham.ac.uk

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