All Activity

This week the new Quality strategy for NHS-funded care in England has been issued. This has been published by NHS England on behalf of the National Quality Board (NQB), the principle national forum for quality across the healthcare system in England. The NQB brings together leaders from NHS England, the Department of Health and Social Care (DHSC), arm’s length bodies and clinical leadership. In this article, Patient Safety Learning sets out its initial reflections on the new Quality Strategy. On Tuesday 14 July 2026 a new Quality Strategy was published by the NQB. This document is intended to provide a structured approach to making quality the organising principle for all NHS activity over the next 10 years. At Patient Safety Learning, we believe that improving patient safety in inextricably linked to this aim. The new Strategy builds on last year’s Review of patient safety across the health and care landscape in England. We agreed with the Review’s recognition of the need to coordinate and rationalise the patient safety landscape. However, we have also expressed concerns about some of its content. In particular, we contested its argument that patient safety has been significantly over prioritised in recent years at the expense of other aspects of quality. As noted in our response to the review, we do not believe the examples it gave provided compelling evidence of this. Furthermore, we strongly believe that you cannot build an effective, efficient and responsive NHS on an unsafe system. In the coming weeks we will publish a more detailed analysis of this new Quality Strategy; however, in this article we will share our early reflections on the direction and content. Where we agree and welcome its approach We welcome the publication of the new Quality Strategy and the opportunity that it presents to improve patient care, experiences and outcomes. Priorities We are supportive of the six priorities identified by the new Strategy, and particularly the inclusion of a specific reference to patient safety. The priorities it includes are as follows: Improving outcomes and reducing unwarranted variation across major conditions and priority groups through implementation of the National Cancer Plan and modern service frameworks. Making sustained improvements in maternity and neonatal services. Strengthening patient safety across all settings. Improving experience of care and restoring trust in NHS services. Reducing inequalities across safety, effectiveness and experience. Monitoring clinical and population health outcomes. Clarifying who is responsible and accountable for quality Given the number of organisational changes in recent years, we are pleased to see the Strategy provides a clear outline of roles and responsibilities for quality management among different parts of the health system. Identifying patient safety risks We welcome proposals to explore how artificial intelligence and other advanced digital technologies can help the NHS learn more quickly when things go wrong and identify emerging risks earlier. Updating the Patient Safety Strategy We await with interest the publication a reviewed and refreshed NHS Patient Safety Strategy. Looking ahead to this: It is positive that there is a recognition of the need to integrate digital safety considerations into the updated document. We would echo comments made in by the Health Services Safety Investigations Body (HSSIB) about reviewing the Patient Safety Strategy with a view to bringing together quality management and safety management. The Quality Strategy rightly acknowledges these as different but connected approaches. We believe these should be brought together, as part of an integrated quality and safety management system. Where we have concerns Recognition and prevention of avoidable harm We are disappointed that in setting the context for this Strategy, the scale and persistence of avoidable harm is not mentioned. Given the findings of numerous public inquiries and rising clinical negligence costs, the omission of avoidable harm as a factor for consideration is a significant oversight in our view. We are also disappointed that there is also no explicit ambition to reduce avoidable harm, beyond the following statement: “Improving safety in healthcare involves reducing the risk of unintended and unexpected harm to patients, while recognising that all care carries some level of risk. It does not mean eliminating all risk or pursuing zero harm.” We have concerns that this could, understandably, be considered alarming by many, including those patients and families where harm is preventable but is not being prioritised. We also have concerns about how this approach sits along the statutory obligations of providers to provide safe care and treatment (set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). National learning and improvement Patient Safety Learning believes that there needs to be structured systematic approaches to learning about the cause and contributory factors of avoidable harm. We need to better understand the action that is needed to develop solutions and improvement action in the NHS. Accompanying this, there should be capacity at a national level to: Share widely learning from investigations and learning responses to patient safety incidents. Intervene if necessary for the purposes of improvement. Develop solutions to improve safety and share these systematically. The Strategy does not appear currently to envision any such role for either the DHSC, NHS England or the NQB. The absence of this national capacity is a gap we also highlighted in our responses to Penny Dash’s patient safety review and the 10 Year Health Plan last year. Culture We believe there needs to be a transformative effort and commitment to creating a safety culture in the health service. We are disappointed that this has not been given greater consideration in the Quality Strategy, despite the ambition being explicit in the NHS Patient Safety Strategy. There are significant changes needed to ensure that there is an open and fair culture with a focus on learning and improvement that does not blame healthcare staff for systemic failings. Organisations need to actively foster a patient safety culture, tackle blame and fear and promote a culture of safety improvement. Areas we believe need further consideration Involving and engaging with patients and families We believe there is room to develop in this Strategy to include greater detail on how patients and families can be supported and involved in improving quality and safety. The Quality Strategy tends to focus on the role of the new Directorate of Patient Experience in DHSC, and better use of patient feedback mechanisms. We believe there should also be a greater emphasis on listening to patients, families, including bereaved relatives. Their concerns can often highlight risks that organisations have not identified or before they are aware of them. The Strategy puts on a welcome emphasis on increasing transparency. We believe this should be accompanied by stronger commitments to ensure openness and transparency when harm occurs. This includes honest communication with patients and families following safety incidents, an ambition often stated but not delivered. Coordination and improvement We would welcome further information about the roles of: Regional teams “co-ordinating involvement and intervention where necessary”. System Quality Groups supporting the management of quality across organisational boundaries by identifying early warning signs and “co-ordinating system action required to improve quality”. If these bodies are to take important roles in these areas we would expect to see plans to ensure they have the appropriate capacity and support to function in this way. This is particularly important in the context of the changing roles and reduced resources with the current NHS organisational changes Monitoring recommendations There remain significant questions around how the NQB will undertake its new role maintaining and monitoring national recommendations arising from reports, reviews, inquiries and investigations. We understand the development of a new “recommendations hub”, mentioned in the Strategy, is already underway, and we await to see what this will look like in practice. There remain unanswered questions about how this will work in practice and what level of transparency there will be around which recommendations are prioritised for implementation. This will be important given concerns which have been raised about how the transfer of HSSIB’s functions to the Care Quality Commission may impact the independence of future investigations. Questions about implementation The new Quality Strategy contains a detailed list of requirements, opportunities, imperatives and suggestions. However, many questions remain about what its implementation will look like and the impact this will have on patient and staff safety. At Patient Safety Learning, we recognise challenges organisations face in implementing changes in quality and patient safety. We have been engaging with organisations through our “What Good Looks Like” for patient safety, drawing on our report A Blueprint for Action. We believe this framework could help to potentially underpin significant elements of the implementation of the broad commitments in the new Quality Strategy. While the existing Strategy does include some specific activities are accompanied with broad timescales, we would expect to see more developed plans subsequently setting out how this will be delivered. This should be accompanied with details on the initial areas that will be prioritised and what key success criteria will be for delivering quality and safety improvements.

We often hear from the Patient Safety Management Network that members are in interested in how others from different industries do things. In this hub top picks, we have pulled together useful websites on safety and investigations in other industries, including aviation, rail, nuclear and defence. Aviation safety Air Accidents Investigation Branch (AAIB) AAIB Reports Collection National Transportation Safety Board (NTSB) NTSB Aviation Accident Database ASRS - Aviation Safety Reporting System European Union Aviation Safety Agency (EASA) EASA Safety Publications Safety - International Civil Aviation Organization BEA Safety Hub - France Confidential Human Factors Incident Reporting Programme (CHIRP) SKYbrary Aviation Safety THE NIMROD REVIEW An independent review into the broader issues surrounding the loss of the RAF Nimrod MR2 Aircraft XV230 in Afghanistan in 2006 HC 1025 Aircraft Accident Report AAR 2/2023 - Sikorsky S-92A, G-MCGY Defence Defence Accident Investigation Branch (DAIB) Defence Safety Authority (DSA) Service Inquiries (SI) Ministry of Defence Service Inquiries Safety Assessment Principles (SAPs) - Office for Nuclear Regulation Guide to Service Inquiries Marine safety Marine Accident Investigation Branch International Maritime Organization Marine Safety Investigation Reports Nuclear industry safety International Atomic Energy Agency (IAEA) IAEA Safety Reports Series World Association of Nuclear Operators (WANO) The Public Inquiry into the Piper Alpha Disaster: Volume 1 Oil and gas and major accidents Energy institute Deepwater Horizon Investigation Report Rail safety Rail Safety and Standards Board (RSSB) Rail Accident Investigation Branch Reporting railway incidents - Office of Rail and Road Related reading See our Good practice from other industries category on the hub for more resources and reading. Do you have any safety resources from other industries that you have adapted to use in your organisation? We'd love to share them on the hub. Comment below (you'll need to be a hub member—sign up is free and easy to do) or email [email protected].

Sebastian Gonzalez, hub topic lead and learning disability lead nurse at Barts Health NHS Trust, reflects on the lack of progress made in reducing health inequalities for people with a learning disability despite a number of reports and recommendations over the last few years. He highlights the new reasonable adjustment digital flag that is being implemented across the NHS, which allows the sharing of detailed information across the healthcare system about the reasonable adjustments individuals require. Sebastian asks you to explore what your organisation is doing to implement the reasonable adjustment digital flag to help identify and support patients with a learning disability. Since the publication of the Confidential Inquiry into Premature Deaths of People with Learning Disabilities (CIPOLD),[1] we have been aware of the profound health inequalities across the country. Currently, it is estimated that 1.5 million people with a learning disability live in the UK,[2] and more recent data show that, on average, adults with a learning disability die 19.5 years earlier than the general population and that 40.2% of their deaths are considered avoidable.[3] The National Confidential Enquiry into Patient Outcome and Death report The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) is a UK based charity that reviews the quality of healthcare in order to improve patient safety and outcomes. In 2026 they published a study report: Learning Together: A Review of the Quality of Care Provided to Adults with a Learning Disability When Admitted to Hospital Acutely Unwell (NCEPOD).[4] More than a decade after CIPOLD first exposed the health inequalities experienced by people with a learning disability, the findings of this report demonstrate that significant challenges remain and that further action is needed to improve patient safety and healthcare outcomes. The study focused on adults aged 18 years and over with a learning disability who were admitted to hospital as an emergency between 1 July and 30 September 2024. Data were gathered from a range of sources, including clinician questionnaires, primary care questionnaires, organisational questionnaires, surveys completed by healthcare professionals, patients and carers, and detailed reviews of patient case notes. Key findings: Incorrect use of the terms learning disability and learning difficulty. Underuse of flagging and alert systems. Failure to consistently implement reasonable adjustments. Poor adherence to the Mental Capacity Act. Limited involvement of people with a learning disability in their own care decisions. Unequal access to specialist learning disability services. A focus on flagging and alert systems The study found that hospital services often failed to accurately identify and flag people with a learning disability. One of the key expectations introduced in 2018 through the Learning Disability Improvement Standards for NHS Trusts was that organisations should have mechanisms in place to identify and flag patients with a learning disability, autism, or both, from the point of admission through to discharge. Yet, the report highlighted that while 89.7% of the organisations reported having flagging or alert systems in place, only 52.2% of patients had these alerts. The issues were compounded by the incorrect use of the term learning difficulty, an issue well known to people with a learning disability and those that support them.[5] Furthermore, the report identified a key link between the use of flags and the provision of reasonable adjustments, highlighting how adjustments were more likely to be made when patients had been accurately identified and flagged. Moving forward Throughout the years, several reports have provided evidence of the poorer outcomes experienced by people with a learning disability and have made recommendations on how to improve their care. Despite this, it remains clear that there is still a long way to go in reducing the health inequalities experienced by this patient group. While the process of identifying and flagging patients may seem administrative in nature, it represents an essential patient safety mechanism that helps ensure individuals receive healthcare that is reasonably adjusted to meet their needs. In addition, an effective flagging system enables organisations to monitor outcomes closely, including incidents involving this group of patients. This, in turn, can support more effective service planning and ultimately contribute to improved patient outcomes. The reasonable adjustment digital flag[6] being implemented across the NHS represents an opportunity to go beyond simply identifying and flagging patients. Not only does it allow for detailed information about the reasonable adjustments individuals require, but it also promotes the sharing of this information across the healthcare system. If your role involves improving patient safety, consider exploring what your organisation is doing to implement the reasonable adjustment digital flag, and how it identifies patients with a learning disability and ensures they receive the support they need. Small changes in these areas have the potential to make a significant difference to patient experience and outcomes. References Heslop P, et al. Confidential Inquiry into premature deaths of people with learning disabilities (CIPOLD) Final report. Norah Fry Research Centre, 2013. Mencap. Learning Disability Research and Statistics. Last accessed 5 July 2026. White SA, et al. LeDeR Annual Report Learning from Lives and Deaths: People with a Learning Disability and Autistic People. The Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London. Last update June 2026. Tavaré A. Learning Together A review of the quality of care provided to adults with a learning disability when admitted to hospital acutely unwell. NCEPOD, 2026. Mencap. Learning Difficulties: Types, Causes and Symptoms. Last accessed 5 July 2026). NHS England. The reasonable adjustment digital flag action checklist: what you need to do to achieve compliance. 25 March 2024.

NHS Resolution is an arm’s length body of the Department of Health and Social Care. It provides expertise to the NHS on resolving concerns and disputes fairly, sharing learning for improvement and preserving resources for patient care. It handles negligence claims on behalf of NHS organisations and independent sector providers of NHS care. Their annual report and accounts for 2025/26 reflects on the first year of their three-year strategy, Resolution Through Collaboration, providing an overview of the work of NHS Resolution over this period. Key points highlighted in this report include: There has been in increase in new clinical claims received, which totalled 15,236 in 2025/26 (up from 14,428 claims in 2024/25). 84% of clinical claims were kept out of formal court proceedings, providing earlier resolution for patients and healthcare staff, and saving costs. £3.2 billion was paid out in 2025/26 for compensation and associated costs on all of NHS Resolution’s clinical schemes (up from £3.1 billion in 2024/2025 and £2.8 billion in 2023/24). 40% (£1.3bn) of the total clinical negligence payments (£3.2bn) in 2025/26 related to maternity. This is a reduction from 42% in 2024/25. The estimated total cost of harm incurred in 2025/26 was £4.8 billion. The majority of this related to the main clinical scheme, the Clinical Negligence Scheme for Trusts, which was £4.5 billion. NHS Resolution’s provision for future liabilities as of 31 March 2026 was £60.3 billion.

I have spent almost three years as an NHS stop smoking advisor in Luton. A client called me five days after removing her nicotine patch due to a skin reaction. She had started smoking again. She was distressed and convinced she had failed. The answer to her question took me thirty seconds. She could have had it five days earlier if there had been anywhere to turn at the moment she needed it. That moment made me ask whether technology could do what the NHS structurally cannot. Provide trusted, clinically grounded support at any hour, in any language, in the moments when relapse is most likely to happen. So, I developed an AI-powered stop smoking support tool. This blog is about what building this innovative product taught me about patient safety. The gap that innovation has to fill Relapse in smoking cessation does not usually happen because someone stops wanting to quit. It happens in unguarded moments between appointments. At 11pm on a Saturday. After a stressful day at work. When something goes wrong with nicotine replacement therapy (NRT) and there is nobody to call. That structural gap is not a failure of the NHS. It is a limitation of what any appointment-based service can provide. Innovation exists to fill gaps that existing systems cannot reach. This was mine to fill. The innovation I built alongside my NHS role While continuing in my NHS role, I built an AI-powered stop smoking support platform delivered through WhatsApp. The choice of WhatsApp was deliberate. No app download is required. It works on any smartphone and is available in six languages. In Luton, where significant communities speak Urdu, Bengali, Arabic, Polish and Romanian as their first language, removing every possible barrier to access was a patient safety decision as much as a design one. The platform provides real-time nicotine craving support, NRT guidance, behavioural nudges, relapse prevention messaging and proactive check-ins. Every response is grounded in verified NHS clinical guidance using a technique called retrieval augmented generation, meaning the AI draws from a curated clinical knowledge base rather than generating health information from general training data. The innovation is not the technology itself. The technology exists. The innovation is applying it to a specific, underserved clinical gap with genuine patient safety discipline built in from the beginning. Why patient safety had to come before innovation Before I wrote a single line of code, I had to answer an uncomfortable question. What could go wrong if this AI got something wrong? In a stop smoking context the risks are real and specific. A pregnant client might ask about NRT safety. Someone in mental health crisis might reach out through the tool. A user might receive confident sounding information that is clinically incorrect. These were not hypothetical concerns. They were situations I had encountered as a human advisor. I completed a full clinical hazard log covering fifteen clinical and technical risks before the platform went live. I built human escalation logic as the first feature not the last. When the AI detects language suggesting crisis, risk or a clinical situation beyond its scope, it immediately directs the user to their advisor, a crisis line or emergency services. The innovation only works if the safety net is stronger than the gap it is trying to fill. The innovation lesson I learned from getting it wrong My first multilingual responses were translations of English text rather than naturally generated responses in each language. They were grammatically correct but culturally flat and in some cases confusing. For communities in Luton where English is not the first language this was a patient safety issue not just a usability one. A client who misunderstands health information because the language feels unnatural may make the wrong decision at a critical moment. I rebuilt the language handling so the AI generates responses directly in each language as a native speaker would write them rather than translating from English. Sometimes the most important innovations are not the ones you planned. They are the ones you discover by getting something wrong. What this innovation does not yet know I am currently preparing the AI-powered stop smoking support tool for a pilot with NHS stop smoking services in Luton in partnership with University of Bedfordshire and Luton Borough Council Public Health. The evaluation will compare quit rates against NICE benchmarks and traditional support methods. But I want to be honest about what this innovation does not yet know. Whether AI can fully replicate the human connection that makes stop smoking support effective. How clients with complex needs will interact with the tool in real-world conditions. What risks will emerge in practice that did not appear in design. Innovation in health is not finished when the technology works. It is finished when the evidence says it is safe, effective and reaching the people it was built for. We are not there yet. The pilot is where that work begins. Opinions expressed in blogs and other content are those of the author. Patient Safety Learning welcomes sharing content and opinions that promotes safer patient care and for the reduction of avoidable harm. The views expressed on the hub however do not necessarily represent Patient Safety Learning's views or values. References to a specific product or service does not imply a recommendation or endorsement.

Public Policy Project (PPP)’s fourth annual Wound Healing Forum will convene clinical experts, system leaders and industry partners for the sector’s preeminent arena co-creating policy thinking, championing innovation and driving systemic change for patients. The growth and engagement of our audience has allowed expansion the offering at the Forum, with two dedicated tracks in addition to plenary keynote sessions. In 2026, it will offer for a greater diversity of nuanced discussions, with attendees able to curate their experience and contributors freed to get into the critical minutia. The Theatres This year’s forum will feature two full-day theatres; System Innovations and Policy Movements, offering an expanded programme of discussions spanning system transformation, emerging policy priorities, and practical strategies to enhance wound care delivery and outcomes. System Innovations Theatre: Sessions in the System Innovations theatre will explore the latest approaches to transforming wound care delivery across the UK. Focused on service redesign, person-centred care models, and the adoption of new technologies, practices and ways of working. Sessions will highlight practical examples of innovation in action, showcasing how teams are improving efficiency, reducing variation, and enhancing patient outcomes through system-wide change. Topics include: Judicious use of AI in wound care Patients as true co-creators of good care The potential in strategic tissue viability Moving from repetition and resistance, to regeneration and resolution. Policy Movements Theatre: Sessions in the Policy Movements theatre will examine the evolving policy landscape shaping wound care across the UK. Examining how NHS reforms create opportunities and challenges, understanding impacts of regulatory developments, and finding in-roads to effect policy directions. Topics include: Pain as policy priority Ceasing the window of political opportunity Speaking across disciplines and interests Workforce planning now and for the future Register