Is the patient voice fading? Reflections on patient safety in a changing NHS

Summary

Claire Cox, Associate Director at Patient Safety Learning, reflects on the changing landscape of health and care in the NHS and the impact this is having on patients' and families' voices being heard and acted upon.

Content

Over the past decade, there has been increasing recognition that patient safety is not only about systems, processes and data, but also about listening carefully to the people who use health services. Patients, families and carers often see risks first, experience harm directly and notice when care does not quite join up. They move across services and settings, observe patterns over time, and are frequently the first to recognise when something feels unsafe.

Their voice is a vital source of safety intelligence and an essential component of keeping people safe. And yet, at a time when patient safety is positioned as a core NHS priority, there are growing questions about whether the patient voice is becoming harder to hear. This question matters, not only in terms of experience and trust but because when patient insight is weakened or marginalised, opportunities to prevent harm may be lost.[1] 

A changing landscape

The NHS Patient Safety Strategy sets out a clear ambition to improve safety through better insight, learning and culture. Central to this was a commitment to partnership with patients, openness about harm, and a shift from blame towards learning and improvement.[2] This was followed by the publication of the Framework for involving patients in patient safety, which explicitly recognised that patients, families and carers have a role not only in their own care, but in shaping safer systems.[3]

However, alongside this, the wider health and care landscape has undergone significant structural change. Reforms have sought to simplify accountability, reduce the number of arm’s length bodies, and move towards more integrated system working through integrated care systems and integrated care boards (ICBs). While these changes aim to improve efficiency and population health outcomes, they also reshape how patient voice is gathered, represented and acted upon.

Most recently, Dr Penny Dash’s review of the patient safety landscape in England proposed further consolidation, including changes with direct implications for the visibility and independence of patient voice at a national and system level.[4] These proposals include:

• Transferring the hosting arrangement of the Patient Safety Commissioner to the Medicines and Healthcare products Regulatory Agency (MHRA).
• Creating a new patient experience directorate within NHS England, subsequently forming part of the Department of Health and Social Care following organisational merger.
• Abolishing Healthwatch England, with its strategic functions moving into the new patient experience directorate.
• Bringing together the work of Local Healthwatch, and the engagement functions of ICBs and providers.

While these changes are intended to support efficiency and clearer accountability, they also risk making the routes through which patient experience and concerns influence decision-making less visible and more diffuse. As responsibilities are absorbed into larger and more complex structures, there is a danger not by design, but by consequence, that patient voice becomes harder to translate into meaningful action, particularly at a time when safety pressures are increasing.

Is the patient voice fading—and how do we know?

If the issue was only structural, it might be resolved through clearer governance arrangements. However, concerns about the patient voice appear to be wider and more deeply rooted.

From a patient and family perspective, there is growing evidence of frustration and fatigue in trying to be heard. Patients affected by harm often describe long, complex processes to raise concerns, repeated requests for evidence, limited feedback and a sense that responsibility is passed between organisations. Complaints processes are frequently experienced as procedural rather than relational and focused on resolution rather than learning.[5]

Families involved in high-profile patient safety cases have consistently reported that their concerns were raised early and repeatedly, yet were not taken seriously until harm became undeniable. These experiences are reflected in national reviews and the work of the Patient Safety Commissioner, which highlight systemic barriers to listening to patients and acting on their concerns.[1] 

There is also increasing confusion for patients about ‘where’ their voice sits in the system. As engagement functions are consolidated across providers, ICBs and national bodies, patients may be unclear who represents them, who holds power to act and how their insight contributes to improvement. This can be particularly challenging for people whose care spans multiple organisations or pathways.

Importantly, these challenges are not evenly distributed. People who already face barriers to accessing care: including those with disabilities, learning difficulties, language barriers or complex needs, often experience the greatest difficulty being heard, increasing the risk of avoidable harm and inequity.[3]

Taken together, these experiences create a perception that, while the language of partnership remains strong, the practical influence of patient voice may be weakening.

Patient Safety Partners: opportunity and vulnerability

One element of the patient safety architecture that remains unchanged—and notably unaddressed in the Dash Review—is the role of Patient Safety Partners (PSPs). Introduced through the Framework for involving patients in patient safety, PSPs are patients, carers or members of the public who contribute to organisational governance and management processes for patient safety.[3]

The introduction of PSPs marked an important step forward. It acknowledged that people with lived experience, including those affected by harm, can offer valuable insight into safety governance, learning and improvement. In many organisations, PSPs are making a meaningful contribution, challenging assumptions and helping leaders to view safety through a patient lens.

However, the role also carries vulnerabilities. PSPs often work within complex governance environments and may lack clarity about their purpose, influence and impact. Demonstrating tangible change can be difficult, not because their contribution lacks value but because systems are not consistently designed to capture, evidence or feed back on that impact.[3]

There is also a risk that PSP involvement becomes inconsistent or symbolic, particularly under operational pressure. Without clear support, feedback loops and visible outcomes, PSPs may be left offering insight without knowing whether it has altered practice or improved safety.

Why patient voice matters for safety

Patient safety depends on the ability to detect risk early, learn from harm and create cultures where concerns are raised and acted upon. Patient voices often surface issues that are not immediately visible through metrics alone — such as communication failures, gaps in coordination or the cumulative impact of repeated small errors.[2]

History provides stark reminders of what happens when patient voice is not listened to. The cases involving hormone pregnancy tests, sodium valproate and pelvic mesh all demonstrate how patient and family concerns were raised over many years before being acknowledged. In each case, the consequences were profound, leading to avoidable harm and, ultimately, to the creation of Patient Safety Commissioner roles in England and Scotland.

When patient voice is weakly connected to influence, opportunities to prevent harm are lost. This is not about attributing blame or questioning the intent behind reform, but about recognising that structural change can have unintended consequences if patient involvement is not actively protected and strengthened.[4]

How should the system respond?

If there is a genuine risk that the patient voice is fading, the response needs to be deliberate and multi-level.

At provider level, organisations should embed patient voice within safety governance, including supporting PSPs effectively, and treat patient insight as a core source of safety intelligence rather than optional feedback.[2]

At system level, ICBs and commissioners play a critical role in ensuring patient insight informs system-wide safety priorities, clarifying accountability for patient voice across pathways, and maintaining trusted and independent routes for raising concerns.[4]

At a national level, there is an opportunity to articulate clearly how patient voice fits within the evolving patient safety architecture, ensure consolidation does not weaken independence, and align patient experience, safety and improvement more coherently.[4]

Policy in England has consistently emphasised partnership, co-production and learning from patients as foundations of safer care. The NHS 10 Year Health Plan reinforces this ambition, seeking to move towards a more patient-controlled NHS.[6]

The patient voice does not need to be loud to be powerful, but it does need to be heard, supported and acted upon. As the NHS continues to evolve, there is an opportunity—and a responsibility—to ensure that listening to patients remains central to patient safety. The question is not whether patient voice matters, but whether enough is being done to ensure it continues to shape decisions that keep people safe.

References

1. Henrietta Hughes. Government and NHSE need to start listening to patients. Health Service Journal, 2023.
2. NHS England. The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients. 2019. London: NHS England.
3. NHS England. A Framework for involving patients in patient safety. 2021. London: NHS England.
4. Department of Health and Social Care. The future of patient safety: Review of the patient safety landscape in England. 2024. London: DHSC.
5. Parliamentary and Health Service Ombudsman. Listening and learning: The role of complaints in improving public services. London: PHSO.
6. NHS England. The NHS 10 Year Health Plan. Fit for the Future. 2025. London: NHS England.

Join the Patient Safety Partners Network

In June 2023, Patient Safety Learning established the Patient Safety Partners Network. The network meets monthly in a virtual capacity and now include more than 150 Patient Safety Partners.

These meetings provide a supportive and safe space to:

• discuss the barriers and opportunities
• share successes
• discuss how they can use their collective voice to make a difference for patient safety.

Only Patient Safety Partners working with NHS organisations in England can join, although experts are often invited to present or discuss specific topics. 

If you are a Patient Safety Partner, you can find out more about the Patient Safety Partner Network, and how to join here.