This thought-provoking book examines breakdowns in the quality of health and social care over the past decade, exploring governance failures and the challenges of achieving lasting change.


Failures in care have been manifest across many different settings. Drawing on examples from care of older people and end-of-life care, as well as from learning disabilities, mental health, maternity care and services for vulnerable children, Neil Small shows that the same sorts of problems are evident across these settings and that they are occurring up to the present day. Discussing culture change alongside levels of funding and the impact of prevailing political and economic orthodoxies, and through the lens of shifts of trust in society, this book argues that the concept of culture must be cast much wider than organisational and professional cultures if change is to be secured.


This book engages with how to improve quality of care in the NHS and welfare systems more generally. Its case examples are from the UK but the issues of governance, culture change and shifts in the social contract that failures illuminate have an international relevance. It is important reading for those with an interest in health, social care, political science, and sociology.




Chapter One


The presenting problem

More detail about the argument to be made (and some underlying assumptions.)

Plan of the Book.

Chapter Two: Mid Staffordshire, the Francis Report and its aftermath


The picture emerges.

The Francis Reports.

What had caused the "scandalous decline in standards"?

A profusion of reports – broadening the scope of concerns beyond Stafford and considering how things might change.

Culture change.

Governance – the role of individuals and of external scrutiny

The response.

The state of the NHS at the time of the Francis Report


Chapter Three: The fall of the Liverpool Care Pathway and the challenges of end-of-life care.


Criticisms of the Liverpool Care Pathway.

What problems were there in end-of-life care?

The governance of end-of-life care.

Protocols, guidelines and guidance.

Cultures of care and the challenge of change.

Progress made in implementing change in the short term


Chapter Four: Are problems new and are they widespread?


Is history repeating itself? Inquiries are a form of palimpsest.

Learning disability.

Widespread problems and resistance to change.

Care of older people outside the NHS

Care of vulnerable children.

Continued failings in the care of children.

Private sector provision in childcare.

Trust, the social contract and sexual abuse


Chapter Five: How the NHS and social care change and why they often don’t.


How failures come to wider attention

Routes to prevent and rectify failures from established structures and procedures: anticipatory governance.

Changing culture(s)

It’s the money.


Chapter Six: Conclusions.

Considering change in the NHS

Why is it difficult to ensure effective governance and to change culture?



Afterword: "good" care in (sometimes) "bad" institutions.