BackgroundProblems of quality and safety persist in health systems worldwide. We conducted a large research programme to examine culture and behaviour in the English National Health Service (NHS).MethodsMixed-methods study involving collection and triangulation of data from multiple sources, including interviews, surveys, ethnographic case studies, board minutes and publicly available datasets. We narratively synthesised data across the studies to produce a holistic picture and in this paper present a high-level summary.ResultsWe found an almost universal desire to provide the best quality of care. We identified many ‘bright spots’ of excellent caring and practice and high-quality innovation across the NHS, but also considerable inconsistency. Consistent achievement of high-quality care was challenged by unclear goals, overlapping priorities that distracted attention, and compliance-oriented bureaucratised management. The institutional and regulatory environment was populated by multiple external bodies serving different but overlapping functions. Some organisations found it difficult to obtain valid insights into the quality of the care they provided. Poor organisational and information systems sometimes left staff struggling to deliver care effectively and disempowered them from initiating improvement. Good staff support and management were also highly variable, though they were fundamental to culture and were directly related to patient experience, safety and quality of care.ConclusionsOur results highlight the importance of clear, challenging goals for high-quality care. Organisations need to put the patient at the centre of all they do, get smart intelligence, focus on improving organisational systems, and nurture caring cultures by ensuring that staff feel valued, respected, engaged and supported.

AimsTo synthesize data from published studies and international experience to identify evidence of potential benefits and drawbacks of direct patient reporting of suspected adverse drug reactions (ADRs) by patients. MethodsStructured search of MEDLINE, CINAHL and PsycINFO supplemented by internet searches and requests for information to key contacts. ResultsSeven studies (eight papers) were included in the review. None of the studies concerned spontaneous reporting by patients. Information on patient reporting systems was obtained for six countries, with summary data repor ted by four. Patient reports identified possible new ADRs that had not previously been repor ted by health professionals. The quality of patient reports appears to be similar to that of health professional reports. There is some evidence that patients report an ADR when they consider their health professional has not paid attention to their concerns. Patient reports may, at least initially, be more time consuming to process. ConclusionsOverall, the evidence indicates that patient reporting of suspected ADRs has more potential benefits than drawbacks. Evaluation of patient reporting systems is needed to provide further evidence.

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The World Union of Wound Healing Societies (WUWHS) is proud to partner with the Lindsay Leg Club Foundation and endorse this document on patient-centred care. The topics covered in the document have been produced by experts in this field who have participated in the Lindsay Leg Club symposium on patient advocacy held in Florence during the WUWHS conference in September 2016. The content covers several aspects that we face every day during our clinical practice. Patients asking for our expertise not only in managing chronic wounds, but also to have optimal interaction and collaboration with the wound care team treating their condition. The key point is always to put the patient at the centre of wound management. This goal is described here, from different points of view with a focus on the holistic approach to care that considers the patient's needs as a whole rather than treating wound problems in isolation. My role as a WUWHS President will be to make sure that the document receives worldwide distribution in different settings, from scientific societies to political organisations, with the aim of raising awareness on patient advocacy, and to obtain enough credit and understanding to be able to negotiate better quality health-care services, together with the highest standards. With my wound care team, at the University of Pisa, have been working, in the last few years, under the umbrella of the European Commission on a research project regarding telemonitoring of patients by means of biomedical sensors. We think that this is a fascinating area of wound care practice in relation to patient-centred care, where there is space to improve service to patients in isolated geographical areas not able to reach specialist hospitals. I am sure we will be able, in the not too distant future, to cover the care needs of these patients. I wish this group great success in the years to come and consider this a brilliant initial initiative for us to demonstrate the desire to act on patient advocacy supported by a strong communication strategy across wound care worldwide.

Editor-Partnership with patients in sharing medical decisions is an idea of paramount civil importance for modern health systems, as raised in correspondence in the eBMJ. 1 Partnership stems, on the one hand, from the reasons underlying the right to informed consent to medical practices and the humanisation of the approach to patients and, on the other, from the development of advocacy in health promotion and self determination of civil rights. Such a profound innovation increases the complexity of and turbulence in organisations and has cost implications. Firstly, the medical profession needs to be trained in this aspect. Education should not be restricted to questioning current medical practices to improve human contact with patients but should embrace specific epidemiological knowledge on risks and outcomes as well as evidence based medicine. These disciplines should, despite their limits, play a pivotal part since they hold the information everyone needs to formulate an opinion. Secondly, all services will clearly become more costly since doctors will require more time for each patient. In some cases time will increase only minimally; in others it will increase considerably. The time devoted to patients will in no case fall. Thirdly, the breakdown of barriers between patients and doctors will remove inhibition and increase the possibility of legal wrangling. Fourthly, increased interplay between the roles of doctor and patient will probably unveil the limits of medicine, revealing that it is not an exact science as believed by most of the general population. The crude impact of predictive medicine may drive more people towards alternative or supernatural practices. Fifthly, boundaries, including legal limits, need to be outlined for the role of patients' relatives. Special attention should be paid to patients who are unable to communicate competently, who are medical or surgical emergencies, and who are psychiatric cases. Lastly, as outlined above, cultural change, fostered by health and political institutions through complex educational strategies, is required. Balancing the interactions between doctors and patients is a noble and pressing idea. But partnership is not a magic formula. The ground is not quite ready. Massive long term financial and cultural investment is required to realise this opportunity fully-but on the understanding that all patients have the right to delegate decisions to their doctor when this is the most comfortable solution for them.