'Never mind the patient, tick the box'
Regulation and inspection are often increased after a crisis
Scandals lead to inquiries and to recommendations - leading to a focus on filling in forms and ticking the right boxes.
But in this week's Scrubbing Up Sue Bailey, president of the Royal College of Psychiatrists, says it's time to listen to those receiving the care.
Why do care standards break down? We've all read heartbreaking stories of elderly people with dementia or patients with learning difficulties being neglected, mistreated and abused.
When things go wrong, inquiries are set up, reports are published and lessons learnt.
Think Winterbourne View; Mid-Staffordshire; childcare in Rochdale, or the Carlisle Report.
At heart, the recommendations boil down to improving communication, listening, learning and acting. It means taking notice of what patients and service users have to say.
Blame culture
But when trying to deliver the right kind of care, the health service often addresses regulation, standard setting, inspection and monitoring.
This approach aims to improve scrutiny and accountability, which most people would agree is a "good thing".
But there is a risk that a constant focus on targets, procedures and performance can lead to a tick box approach to healthcare.
This usually ends up placing more controls on healthcare workers, greater monitoring and prescriptive procedures.
Unfortunately, this is often at the expense of professional judgement, leading to dissatisfied and demoralised staff - with the all important relationship between the patient and healthcare worker forgotten.
I'm not saying that people shouldn't be held to account for their actions, but the present blame culture doesn't help anyone.
Healthcare is, or should be, a moral as well as a practical undertaking.
It deals with uncertainty in which mistakes are inevitable - but this isn't a message anyone wants to hear. Positive change won't happen if we continue to exist in a risk-averse bubble.
As Professor Eileen Munro of the London School of Economics put it recently, defensive care practice doesn't avoid risk, it simply displaces it - usually onto those using the services.
Time sensitive
What is needed is something in very short supply in the health service - time.
It takes time to develop expertise and build relationships based on intelligent kindness, not just technical skills.
It takes time to build critical reasoning skills and provide effective supervision.
It takes time to allow staff doing a difficult and stressful job to reflect, offload and be mentored by those with more experience.
In an era of unprecedented NHS reform, how can we find the time?
I believe we need a greater focus on helping the workforce develop the skills, knowledge and personal qualities required to meet care needs, support new staff more and improve opportunities for career progression
Workforce development takes time and money, but it is an investment that could support safer and better care, and mutual respect between patient and carer or doctor.
Old fashioned?
Don't get me wrong; improved processes can help, too.
We need data in healthcare but what we want and need are useful, practical tools that help learning and improve care.
This learning should involve ongoing feedback from patients, which is acted on by people like me.
What's the bottom line? A health service in which the treatment and care of people - not systems and processes - are at the heart of what we do.
Does that seem terribly old fashioned?
It sounds an awful lot like what I came into medicine for 40-odd years ago, but which I have seen start to drift away.
I will be accused of being simple minded, but a just culture should replace a blame culture.
This will require a major shift in approach towards positive risk taking and being open and honest with ourselves and with our patients that not everything can be "cured".
It's not too late, but policy makers will have to be brave to think and act in the long term. But is anybody listening?
