The Berwick report describes some of those problems (view report). Among them are a partial loss of focus on quality and safety as primary aims, inadequate openess to the voices of patients and carers, insufficient skills in safety and improvement, staffing which was inadequate for patients’ needs, and very unhelpful complexity and lack of clarity and cooperation among regulatory agencies. He states in his letter to senior NHS management & government officials (view here) that all these problems can be remedied: “In trying to achieve remedy, your most certain and productive pathways will be built on the enormous strengths of the NHS – its people, their commitment, its charter, much of its track record, and the affection and wisdom of patients and carers. I hope that you will invest even more than ever before in learning, growth, development, ambition, and pride. This is the route that can make the NHS a “learning organization” in every sense of the term, and it can unleash momentum for improvement that no simple, top-down, control oriented, requirement-driven culture ever can”.
Berwick concludes his letter with “I urge you to focus on the culture that you want to nurture: buoyant, curious, sharing, open-minded, and ambitious to do even better for patients, carers, communities, and staff pride and joy”.