More dialogue, more learning, more action.

To cite: Mountford J, Marshall M. BMJ Qual Saf Published Online First: [please include Day Month Year] doi:10.1136/bmjqs-2013002471 2013 has not been an easy year for England’s National Health Service (NHS). A feeding frenzy led by the popular press exposing deficiencies in care on an almost daily basis, alongside thoughtful challenges from commentators on the 65th birthday (the traditional retirement age in the UK) of what many believe to be ‘a national treasure’ has led to some serious questions about whether the NHS in its current form is sustainable. 2 The question is not new, but the intensity of public interest in the quality and safety of care provided by the NHS is breaking new ground, and happening at a time of rising public expectations and decreasing deference across all walks of life. The publication of a number of seminal reports in 2013 on safety and quality has contributed to this high level of interest. First, in February, a report was published into the tragedy of failings in care at Mid Staffordshire Hospital by Robert Francis, a distinguished barrister. In its many pages were stories of harrowing gaps in care and compassion, and failure at seemingly every level of the system. Crucially, Francis framed Mid Staffordshire as an extreme example of shortcomings encountered in some form throughout the system. His view was that ‘a fundamental culture change is needed’, and he made 290 recommendations for how to bring this about. This was followed in July by the publication of a report by Sir Bruce Keogh, the Medical Director of NHS England, into 14 hospitals with the highest mortality rates. Most recently, August saw the publication of a review into patient safety in the NHS led by Professor Don Berwick, former Centers for Medicare & Medicaid Services (CMS) administrator and founder of the Boston based Institute for Health Care Improvement, initiated at the personal request of the UK prime minister. Into this mix, and making a timely and important addition to the literature, steps a paper from Dixon-Woods and colleagues. The authors report findings from several large studies into quality of care in England’s NHS. The ambition and scope of the work is impressive. This is ‘meta-research’ drawing on multiple different studies, bringing together data from sources as diverse as ethnographic observations and large public health datasets, and using a wide range of social science and other methods to develop new insights into the complex, multifaceted challenge of health system improvement. The approach is ambitious and perhaps, to some methodological purists, contestable. There is a risk that the authors are comparing apples and pears, and such a broad approach may cloud the richness of deeper, more focused analyses. But we think the insights gained by triangulating findings across different studies justifies the authors’ approach, and that the results contribute materially to the growing body of knowledge emerging from the recent national reports. The authors describe how, at a microsystem level, too strong a focus on specific goals and targets can lead to distortion (‘hitting the target but missing the point’), and how an overly managerialist perspective can clash with professional norms. Reflecting on organisational performance, they describe how ‘bright’ and ‘dark’ spots often coexist side by side within the same organisation, thereby challenging policy makers’ propensity to seek single judgments about organisational performance. This chimes with previous findings from USA using quantitative methods comparing mortality rates across hospitals for six common diagnoses which suggested that excellent and poor performance can coexist within one institution, with the department or service being the primary ‘axis’ around which quality is set. Dixon-Woods and colleagues introduce a useful insight into how people use data in different ways—‘problem seeking’ and EDITORIAL