Perhaps the most important contribution of the next stage review was to put quality and safety back firmly among the NHS's priorities.

This seems counter-intuitive: surely in such a highly professionalised service, where the product may be literally life or death, quality will always have been the key driver.

Unfortunately the quality movement has to date not been embedded in NHS practice, unlike the airline industry, where persuading people to fly at all has been closely associated with demonstrating safety, or the car industry, which bought into quality as a survival measure.

Perhaps the historical dominance of the medical profession has played a part in ours and our patients' faith in the safety of practice. People seem less convinced by a working assumption that quality is a major driver of policy and investment.

In developing the strategy Investing for Health, NHS West Midlands did identify quality and safety as a core theme and locally we have a dedicated programme to support improvement. However, we have been struck by the scale of the task. Our collective comfort zone is a left brain rational approach which focuses on evidence and measurement and it rapidly became obvious why safety has so far failed to take off in the broader service. It can be pretty boring.

While much of management and medical training has acculturated us to the rational, it is not the reason most of us came to work in the NHS. If we really want to make a difference to quality, we also have to engage right brain thinking: creativity, imagination, empathy. It is not sufficient to know why we ought to do something, we need to want to do something different to make us and the people we work with feel better.

This polarity of the rational and creative does not imply one approach should triumph over the other. The reality is that we need to both maximise our technical knowledge and pay attention to core process while tapping into the experience of patients and thinking of new approaches. Neither technical competence nor warm regard alone will be sufficient to build a service which feels both safe and responsive to our public.

System-level focus

Three themes have emerged as a focus for further work if we are to achieve our regional aspiration to host the safest, highest quality of services: encouraging people to take personal and professional responsibility for the quality and safety of their own practice, developing a partnership with patients and public and shifting the system to make it easy for each of us to do the right thing.

The work of the US based Institute for Health Improvement and our own NHS Institute for Innovation and Improvement has demonstrated the huge impact we can make if we invest in system level activities to support increased safety. Structurally, the Department of Health has invested in the NHS Institute for development, the National Patient Safety Agency to highlight trends and opportunities for intervention and the Healthcare Commission/Care Quality Commission to benchmark and investigate.

All these institutions, however, depend for impact on effective and consistent local processes, many of which require more effort from staff on the ground and therefore lack resilience.

Culturally, we continue to resist systematisation at a local level. We acknowledge the existence of variation, whether in incident definition and reporting, investigations, prescribing or performance management, but remain reluctant to acknowledge the link between differential approaches and variable outcomes for patients.

The uncomfortable reality is that much improvement activity is about getting the basics right, investing in core processes which deliver consistency, ensuring effective communications and handovers and measuring impact.

Some of our reluctance perhaps stems from a sense that this implies a rather cold and impersonal service. While we systematise the processes, we must simultaneously personalise the experience. At a system level this should ensure good access to information about local service availability and performance and more open discussion of the trade-off between locality and safety, particularly for core services such as emergency care and maternity.

Changing attitude and service

At an individual level, we need to promote "realistic hope" in our clinical conversations and be prepared to acknowledge the limitations of therapeutic interventions, to focus on care and support.

The constitution may have an unfortunate emphasis on rights in the absence of responsibilities, but the Wanless report on NHS finance was clear that the service is unsustainable without a shift to real engagement of patients and public in looking after our own health. This requires system level investment in marketing skills and capacity and individual interactions which promote our own understanding of our health status, how to improve it and how best to look after ourselves when we do develop the inevitable three or more long term conditions.

Personal interaction is most difficult to manage for. As managers we can invest in system level infrastructure to support communications, processes to identify and log and investigate operational failure and training for core competence; and we should model the behaviour we wish to see.

Ultimately, however, it will be the attitude and skill of the practitioner which will define the patient experience. We need to investigate and promote good practice as actively as we respond to failure.

Our training brings left brain strengths in science, evidence and measurement and our vocation is grounded in right brain competencies of empathy, conversation and imagination. Increasingly, we shall need to call on both if our public are to experience our services as world class, or even as acceptable