Review of patient safety across the health and care landscape: terms of reference (Department of Health and Social Care, 15 October 2024)

Summary

This is the terms of reference for an independent review of patient safety across the health and care landscape in England. The review will map the broad range of organisations that impact on quality and focus on six key organisations overseen by the Department of Health and Social Care, which have a significant impact on patient safety.

Content

The primary task of this review is to assess whether the current range and combination of organisations delivers effective leadership, listening, learning (including investigations and their recommendations) and regulation to the health and care systems in relation to patient and user safety (and to what extent they focus on the other domains of quality).

Based on this assessment, the review will make recommendations on whether greater value could be achieved through a different approach or delivery model.  

The review will also set out the wider landscape of quality, looking at health and social care. The mapping work will provide context for the review of the specific organisations named below. This work will also be used to more widely inform the 10-year health plan.

The main focus of the review will be on the following organisations: 

• Care Quality Commission (CQC) - including the Maternity and Newborn Safety Investigations programme
• National Guardian’s Office (NGO) – NGO is hosted by CQC and its work on staff experience should inform improvements in patient safety
• Healthwatch England (HWE) and the Local Healthwatch (LHW) network – HWE is also hosted by CQC. Its work, alongside LHW, on patient experience should inform improvements in safety
• Health Services Safety Investigation Body
• Patient Safety Commissioner for England
• NHS Resolution (patient safety-related learning functions only, not clinical negligence functions)