A damning report by Sir Stephen Bubb this week on the collective failings to improve care and support for people with learning disabilities has lessons for us all.
Following the Winterbourne View scandal in 2011, it seemed that the widespread shock would drive change. People would not continue to be housed in similar institutions.
Health ministers pledged far-reaching changes by summer 2014. But much still remains to be done.
So what has been blocking change? Clearly it has proved difficult turning a huge tanker round and providing better care and support in alternative settings. But we have also witnessed a failure by the NHS and local government in delivering change. And a failure by Ministers and their offices to make that change happen.
Underlying these systemic failings has been an institutional betrayal of people with learning disabilities and their families. At all levels they haven't been listened to and they haven't been given control over their own lives and how and where they live.
Can the system and all those involved in delivering care and support change? Of course it can - with the right leadership, higher priority and better commissioning of community-based alternatives. The starting point has to be acceptance of this latest report and its recommendations combined with a new determination to listen to people with learning disabilities and give them power and control.
It will also mean continuing to move further from a health or medical model of care to a social model. There are plenty of examples of how this has been done with other groups of people in care.
For the wider care system, this experience should make us all question the way we deliver care and support and how we listen to and involve other service users like older people and their families. As we know from reviews left on Good Care Guide, much care for older people is also not good enough.
A lot of the focus has been on inadequate and sometimes neglectful and abusive residential care. But with increasing pressure to support older people in their own homes (rather than expensive and often inappropriate residential or hospital care), we must focus more on care delivered in older people's own homes.
Homecare services have been squeezed repeatedly by cuts in local authority spending. Meanwhile some providers have responded creatively to the needs of older people who pay for their own care.
We need to ensure that all older people can get quality homecare, whoever is paying for it. And we need to ensure that we listen to older people and their families where homecare is failing, and support older people with better independent advocacy to raise their voices.
I hope everyone feels challenged by Sir Stephen Bubb's report. It's moments like these that can be pivotal in creating real and lasting change.