Review of patient safety across the health and care landscape (7 July 2025)

Summary

This report sets out the findings of a review of patient safety across the health and care landscape in England, commissioned by the Secretary of State for Health and Social Care (DHSC) and chaired by Dr Penny Dash. The review looked at six specific organisations that were established to either assure—or contribute to improving—the safety of care, while also making reference to the wider landscape of organisations influencing quality of care.

You can read Patient Safety Learning's response to this here.

Content

Ten main findings of the review

• There has been a shift towards safety (versus other areas of quality of care) over the last 5 to 10 years, with considerable resources deployed, but relatively small improvements have been seen.
• There has been limited strategic thinking and planning with regard to improving quality of care.
• There are a large number of organisations carrying out reviews and investigations. A very high number of recommendations have been made to the NHS, most of which lack any cost-benefit analysis.
• A large number of organisations look at user experience or advocate on behalf of the ‘voice of the user’, yet few boards in the NHS have an executive director for user or customer experience.
• The current system for complaints and concerns is confusing and may lack responsiveness.
• Some of the organisations under review have expanded their scope.
• A greater strategic focus on care delivery and management is needed to improve quality of care.
• The National Guardian’s Office duplicates work carried out by providers.
• Insufficient use is made of the NHS’s data resources to generate insights and support improvement.
• There is insufficient focus on developing a national strategy for quality of social care.

Five key conclusions of the review

1. Action is needed to address gaps in functions. In particular, a strategic approach to improvement and innovation in quality of care (including safety) is needed that: considers allocation of resources to maximise health outcomes; co-ordinates and prioritises the many recommendations and ‘asks’ of providers.
2. There is a need to streamline, simplify and consolidate functions where considerable duplication and overlap currently exist—specifically when it comes to: user, patient or community engagement; capturing and learning from user or patient experience, or the ‘voice of the user’; investigations.
3. Too many functions sit outside of the commissioners and providers of care who are ultimately responsible for improving quality (including safety). This results in limited impact from the very many inquiries, reviews, investigations and resulting recommendations that are made.
4. Within commissioners and providers, there needs to be a far greater focus on: building skills and capabilities' effective governance structures; clearer accountability for quality (including safety) of care.
5. CQC was established as the independent regulator of health and care. It needs to rebuild public, professional and political confidence, and should also house functions where independence is required.

Nine recommendations

• Revamp, revitalise and significantly enhance the role of the National Quality Board.
• Continue to rebuild the Care Quality Commission with a clear remit and responsibility.
• Continue the Health Services Safety Investigations Body’s role as a centre of excellence for investigations and clarify the remit of any future investigations.
• Transfer the hosting arrangement of the Patient Safety Commissioner to the Medicines and Healthcare products Regulatory Agency (MHRA), and broader patient safety work to a new directorate for patient experience within NHS England, transferring to the new proposed structure within DHSC.
• Bring together the work of Local Healthwatch, and the engagement functions of integrated care boards (ICBs) and providers, to ensure patient and wider community input into the planning and design of services.
• Streamline functions relating to staff voice.
• Reinforce the responsibility for and accountability of commissioners and providers in the delivery and assurance of high-quality care.
• Technology, data and analytics should be playing a far more significant role in supporting the quality of health and social care.
• There should be a national strategy for quality in adult social care, underpinned by clear evidence.