“The NHS has developed a widespread culture more of fear and compliance, than of learning, innovation and enthusiastic participation in improvement.” It also said “Virtually everyone in the system is looking up (to satisfy an inspector or manager) rather than looking out (to satisfy patients and families)” and “managers ‘look up, not out.’”

The Institute for Healthcare Improvement (IHI), a US organisation, report on the NHS ( quoted by Brian Jarman in the BMJ. BMJ 2012;345:e8239 doi: 10.1136/bmj.e8239 (Published 19 December 2012)).