news focus: Judith Smith and Kieran Walshe gave evidence to the Bristol inquiry.They believe the government needs to lead by example if it wants to create an open culture in the NHS

The inquiry report makes shocking reading. It describes an inward-looking organisation with flawed managerial structures and systems, and little oversight of clinical practice. A disaster waiting to happen.

Bristol? No, Ely Hospital in 1969.

Ely was the first of several scandals about care in long-stay hospitals that led to the creation of a special authority to monitor quality, the Health Advisory Service.

The parallels with Bristol are striking. But it is worth standing back from the details to consider how the Elys and the Bristols of the future can be prevented.What kind of changes are needed in the NHS, how can they be brought about, and how does the NHS learn from its inquiries?

What changes are needed?

Bristol has already been used to force the pace of change in the NHS. New structures to support clinical governance, the reform of the General Medical Council, national service frameworks and guidance owe much to the Bristol story. But systems and structures alone cannot prevent another Bristol. Organisations can make everything seem fine on paper while in reality there are serious problems.

When the Health Act 1999 made NHS boards, chairs and chief executives formally accountable for the quality of healthcare, it was an important step towards establishing new managerial priorities in which clinical quality issues take centre stage.

But Bristol offers the NHS many lessons beyond the immediate issues of clinical practice and service provision. It was as much a management failure as a clinical one, and it highlights the vital importance of a high-quality, evidence-based health service. There is a need for balance between clinical and managerial leadership, the nurturing of an open culture, and the assurance of adequate checks to dilute the power of individual personalities.

The next step The NHS has a long history of inquiries ignored and good intentions unfulfilled. The reports from Ely, Farleigh, Whittingham, Allitt, and more recently Ledward, Lakeland and now Bristol would fill a bookshelf, and that is all too often where they are to be found, gathering dust. How many inquiries does it take to show the NHS needs robust systems for monitoring clinical and managerial performance, backed up by an appropriately open and supportive management culture?

Perhaps one of the reasons for the NHS's persistent failure to learn from its mistakes is that noone has specific responsibility for following up and implementing the recommendations from inquiries. The Department of Health should be held formally to account and expected to demonstrate that things have changed as a result of the Bristol inquiry report, perhaps by reporting on progress to the Commons health select committee or to the public accounts committee.

Within the NHS, the Commission for Health Improvement is the obvious candidate to take up the many specific recommendations and test whether individual healthcare organisations have responded appropriately. Without both national and local follow-up of this kind, the inquiry report will be filed and forgotten.

Setting the tone The most important lesson from Bristol is that we need a culture in the NHS that enables questioning, fosters learning from mistakes, and empowers clinicians and managers to work together - while still holding individuals and organisations to account for their performance. But the tone is set from the top, and actions speak louder than words.

The current reality is that managers are relentlessly bombarded by edicts and performance targets from the Department of Health, senior executives are summarily sacked on orders from the centre, and failure is clearly not tolerated by our political masters.

Though the Department of Health espouses the importance of an open, learning culture, it is a case of 'do as we say, not as we do'.

If the NHS is to truly learn the lessons of Bristol, we need to see clear evidence of a healthier culture and a more open and questioning style of leadership, not just within health authorities, trusts and primary care trusts, but at the heart of government itself.

What Bristol recommends on leadership and management Healthcare managers should be subject to the same obligations as other healthcare professionals, including being subject to a regulatory body and professional code of practice.

The new Council for the Regulation of Healthcare Professionals recommended by the report should also seek ways to incorporate managers into the systems of continuous professional development, appraisal and revalidation.

The NHS Leadership Centre should, as an early priority, offer guidelines on which leadership styles and practices are acceptable and to be encouraged, and those that are not.