Prioritising patient safety: Reflections on the Patient Safety Forum 2025

Summary

Last month Public Policy Projects, in partnership with Patient Safety Learning, held their Patient Safety Forum 2025, as part of a new patient safety policy programme between the two organisations. Taking place at the Royal College of Physicians in London, in attendance were senior healthcare leaders, patient safety experts, representatives from the HealthTech industry, frontline healthcare professionals, patients, policy makers and the media. In this article, Patient Safety Learning’s Chief Executive, Helen Hughes, and Director, Clare Wade, look back at the day and share their reflections on the event.

Content

Digital health technologies are likely to be central to the successful delivery of the UK’s forthcoming 10-Year Health Plan. However, if we are to fully realise the benefits of new devices and innovations, patient safety needs to be at the heart of their development, implementation and use.

In working towards this, it is vital that we bring together people from across the health and social care system who have the right knowledge, skills and experiences to contribute to this. We have therefore been delighted to partner with Public Policy Projects (PPP) over the past six months on a patient safety programme that culminated in our Patient Safety Forum on Thursday 27 February 2025.

Leading up to this event, between October and December 2024, we hosted with PPP three roundtable sessions discussing patient safety through the lens of technology, digital innovation and data-driven transformation. The outcomes of these events are summarised in a new report, Patient safety in the digital NHS: user-centric approaches to technology and transformation.[1] The key findings of this report were reflected throughout the discussions at our Patient Safety Forum:

• A lack of user-centric design and interoperability between digital technologies is limiting scalable digital transformation and putting patients at risk.
• Digital clinical safety is being developed across the NHS, but a lack of resource and siloed working limits the ability for consistent monitoring of digital systems.
• A lack of understanding of digital technology and data is often tolerated among NHS leadership and the workforce is not adequately trained and/or supported to utilise digital technology.
• Opportunities to learn from the NHS patient safety reporting system are limited by a lack of data transparency and capacity for analysis.
• Digital poverty presents inherent patient safety risks where non-digital routes of access are not maintained, meaning digital transformation risks inadvertently widening inequalities.

Introduction to the Forum

To begin the event, Helen Hughes, Chief Executive of Patient Safety Learning, welcomed participants, sponsors and panellists to the Patient Safety Forum. The goals of the event and our partnership with PPP were to:

• Ensure that technology introduced to service delivery is patient centred and safe.
• Embed a culture of patient safety within UK healthcare.
• Support patient safety being a core purpose of Integrated Care Systems (ICSs) and to ensure the patient voice is core to the design of safety at system level.

The initial keynote speech at the Patient Safety Forum was then provided by Jeremy Hunt MP, Chair of the All-Party Parliamentary Group on Patient Safety. He reflected on his first experiences of patient safety in his previous role as Secretary of State for Health and the scale of avoidable harm in the healthcare system.

Jeremy spoke about a report published in December by Imperial Institute of Global Health Innovation and the charity Patent Safety Watch, which had highlighted the gap in healthcare between the UK and best performing OECD countries.[2] The report  showed that if the UK matched the top 10% of OECD countries, this would equate to 13,495 fewer deaths per year. The report also underlined the cost of unsafe care in England, estimated at £14.7 billion per year.

He also talked about the areas that he believes should be key patient safety priorities, identifying the following four areas:

• Creating a centralised system to collate and prioritise patient safety recommendations.
• To improving and revitalise the Care Quality Commission.
• To tackle cultural issues in the NHS, with reform of the clinical negligence system an important element of this.
• Not normalising avoidable deaths.

Patient safety and Integrated Care Systems

Following the morning keynote address, the first panel session of the Forum focused on the need to position patient safety as a core purpose across ICSs. This featured the following participants:

• Helen Hughes – Chief Executive, Patient Safety Learning
• Sir Liam Donaldson – Chair of North East and North Cumbria Integrated Care Board (ICB), Special Envoy for Patient Safety, World Health Organization
• Kate Provan – Associate Director Clinical Effectiveness and Improvement, NHS Greater Manchester
• Matthew Mansbridge – Senior Safety Investigator, Health Services Safety Investigations Body (HSSIB)
• Tim James – Clinical Director and Nursing Executive, Oracle Health UK

Sir Liam Donaldson opened the first panel by explaining that when approaching patient safety as an ICB, it must be viewed through the lens of avoidable harm. Some of the issues discussed with the panellists were:

• The need to reduce variation across healthcare in how patient safety incidents and avoidable harm are both responded to and acted on.
• The difficulties of reducing avoidable harm while working against the backdrop of persistent blame cultures in parts of the NHS, which undermine efforts to learn and improve.
• The difficulties that organisations can face in attempting to respond to mismatched reporting requirements across various bodies in a complex operating environment.
• Errors occurring in weak systems, where services are performing at suboptimal level and with poor practitioner performance. We need to tackle the normalisation of deviation from good practice

At Patient Safety Learning, we believe that greater action is required to create clarity about the role of ICBs and ICSs in patient safety. We set this out previously in in our 2023 report, The elephant in the room: Patient safety and Integrated Care Systems.[3] A HSSIB investigation report published this year echoed these points, highlighting the lack of overarching principles for ICBs and ICSs to take a consistent approach to safety management. [4] [5]

With greater clarity around the roles, ICBs and ICSs have the potential to drive systemic improvements in patient safety. However, to do so effectively, they require enhanced tools, commitment and capacity that support patient safety.

Culture and regulation

The second panel session at the Forum focused on how patient safety improvement could be driven forward and supported through culture and regulation. This featured the following participants:

• Sue Holden – Executive Chair, Advancing Quality Alliance
• Dr Alan Clamp – CEO, Professional Standards Authority for Health and Social Care
• Norman MacLeod – Patient Safety Partner
• Moyra Amess – Director - Assurance and Accreditation, CHKS

A key element of this panel discussion was how to create a psychologically safe culture in healthcare. This extended not just to creating a culture of incident reporting, but also ensuring staff and patients see clear examples of those reports being acted on for improvement. Psychological safety is when someone feels they are safe to speak up with ideas, questions, concerns or mistakes without fear of being punished or humiliated. We have a number of different resources available on this topic on the hub, our platform to share learning for patient safety.

To overcome blame cultures in the NHS, the panellists all emphasised the importance of kind leadership: “Leaders have an active choice to be kind in healthcare, and it makes such a difference, it is hard in a pressurised system, but it is a choice we can all make.” Panel members also discussed some of the challenges for regulators and regulation, highlighting the following points:

• Regulators must prioritise safety over regulations.
• The need for the regulatory environment to continually evolve to meet new patient safety opportunities and challenges, such as the growing use of artificial intelligence (AI) in healthcare.
• Being clear on how to understand ‘what good looks like’, what organisations are doing to work towards this and how this is measured.
• Not subsuming safety within quality.
• Being alert to system failure in healthcare like the frogs in a saucepan analogy—the water heating slowly to the point of catastrophic harm because we have tolerated normalised deviance.
• Insight through triangulation of data—patient and, staff perspectives and experience and data.

Harnessing information and sharing for patient safety

The next panel session at the Forum was on the opportunities and challenges presented by the development of new systems for sharing and utilising patient data to improve outcomes. This featured the following participants:

• Professor Sam Shah – Professor of Digital Health, College of Medicine and Dentistry, Ulster University
• Jonathan Webb – Head of Safety & Learning, NHS Wales
• Professor Maureen Baker CBE – Former Chair, Professional Record Standards Body
• Mark Linggood – Director of Product Management, RLDatix

A key area of discussion in this session was on the use of AI and the need to understand the advantages and limitations of this in improving the sharing and use of healthcare data. This included the use of AI in diagnostics, sentiment analysis and how it can support deeper organisational learning.

Panel members also highlighted the following points:

• The need to improve interoperability—the ability of different systems, devices, applications or platforms to work together and exchange information effectively. This still presents significant barriers to sharing data in real-time.
• Difficulties that patients and families face in navigating the NHS and having control over their own care. This has recently been the subject of a new blog series we have published on the hub.
• The importance of clinical engagement in the design and procurement of digital systems. 
• That the digital safety standards are essential and need to embraced, supported and championed by system regulators such as CQC, which unfortunately isn’t the case.

Improving how we can share and use patient data, and the implications of this for patient safety, is an area we have previously looked at in detail around electronic patient record (EPR) systems. While EPR systems have the potential to improve patient treatment, increase efficiency and reduce the costs of healthcare, their implementation also comes with serious patient safety risks. In July last year, we published a new report on this topic, Electronic patient record systems: Putting patient safety at the heart of implementation.[6] This outlined the key patient safety risks associated with choosing and introducing new EPR systems and identifies 10 principles to consider for safer implementation.

Health inequalities and patient safety

The focus of the final panel session of the Forum was on the connection between health inequalities and patient safety. This featured the following participants:

• Jono Broad – President Elect - Patient Safety, Royal Society of Medicine
• Sandra Igwe – Chief Executive, The Motherhood Group
• Professor Habib Naqvi MBE – Chief Executive, NHS Race and Health Observatory
• Jacob Lant – Chief Executive, National Voices

Health inequalities often result in poorer outcomes for some patient groups, including impacting on their safety during care and treatment. Discussing these issues, panel members made the following points:

• Research has found that, in too many cases, black mothers are treated in an inhumane way by maternity healthcare professionals, including examples of the barriers in providing pain relief and a lack of empathy.
• The need to do more to ensure appropriate minority representation in healthcare organisation staffing and leadership.
• Addressing racial biases in medical devices, such as the accuracy of pulse oximetry, and recommendations of the Government’s review of unfair biases in their design and development more broadly.
• Vulnerable groups have longer wait times—as services do not cater for their needs, a ‘one size fits all’ strategy doesn’t work in healthcare.
• Health inequalities can lead to a breakdown in trust by communities, which leads to further patient safety issues if patients are reluctant or fearful of accessing services.

Closing remarks

At the end of the Patient Safety Forum, Dr Penny Dash, Chair of NHS North West London and the incoming Chair of NHS England, gave a keynote address.[7]

Penny set out how she had approached her independent review into the patient safety landscape, commissioned by the Government to be published ahead of the 10-Year Health Plan.[8] [9] She noted the overcrowded and fragmented patient safety landscape, highlighting that her team had identified over 127 organisations in England involved in patient safety to some degree.

Penny emphasised that quality should encompass productivity and efficiency as well as safety and effectiveness. She said: “We know that well-managed services lead to more efficient use of resources–that in itself is a big quality opportunity. We can actually do things for less that frees up money for more care.” Looking forward, she said she hoped the NHS would be given a “balanced scorecard” to measure quality, alongside the priorities in its annual planning guidance. She said there were many metrics available, but they could be “presented and brought into board papers” better than they were.[10]

Reflections from Patient Safety Learning

This was the first face-to-face event as part of our new patient safety policy programme with PPP. We had a magnificent line up of speakers with expert chairing of panels and a great turn out on the day. The Forum was significantly oversubscribed and we had a long waiting list that we had to close. We are sorry that not everyone was able to attend, next year we plan to make the event even bigger and better.

We have received enthusiastic feedback from panellists, sponsors and participants, many saying that this was the best event on that topic that they’d ever attended. There was huge energy in the auditorium with conversations during the breaks that were equally inspiring, with people keen to push ahead on improving patient safety in their own organisations. There was also a supportive theme that ran throughout the discussions, with a number of panellists and participants stressing the need for greater kindness and empathy in the health service.

Helen’s thoughts

One personal story shared at the Forum that really resonated with me was shared by Sue Holden, Executive Chair, Advancing Quality Alliance.

She recalled a time early in her career as a midwife when she had met with parents to share information as to why their newly born baby had suffered severe avoidable harm during the birth. At the end of the meeting, which she said had been at times challenging and emotionally hard for all, the father of the baby showed Sue two envelopes that he’d previously prepared. On opening the one passed to her, Sue found a financial donation to the hospital’s fundraising appeal. When she asked what was in the other one, the father explained that he was a solicitor and it was a prepared letter outlining the clinical negligence action he would have taken if faced with a lack of information and defensiveness. Sue described how this has always stayed with her, and I felt that this is a strong metaphor for the choices we all make for patient safety.

It made me think, how often do we, as clinicians, patient safety experts or organisational leaders, look the other way? Do we just follow process? Or do we embrace honesty, integrity and justice, putting patients and families at the heart of the work we need to do to take action for improvement. Many of the Forum participants shared their challenges in doing the right thing, raising questions about organisational culture and behaviours that don’t prioritise patient and staff safety.  As Penny Dash said, we must role model the behaviour we want to see in others. We must listen and act with kindness. And as Sir Liam said, “'find harm', go looking for it, use data and analysis to understand it and address it.”

Clare’s thoughts

At a time when the NHS is grappling with the toughest challenges in its history, it was heartening to have so many enthusiastic, positive delegates join us last Thursday. Connections were made and reignited, and conversations about issues and how to combat them were shared. Although everyone is in no doubt of the hill we all have to climb, there was a collective voice keen to find solutions and make change happen. I met new people, listened to different perspectives and drew energy from being in such a positive space. Our keynote speakers offered their insights, and panel members brought opinions from their own experiences encouraging us to challenge beliefs. It's important that we all take these opportunities to refresh, engage and reenergise. Thank you to everyone who joined us, we hope to see you again soon.

References

1. Public Policy Projects. Patient safety in the digital NHS: user-centric approaches to technology and transformation, 28 February 2025.
2. Imperial Institute of Global Health Innovation & Patent Safety Watch. National State of Patient Safety 2024: Prioritising improvement efforts in a system under stress, 12 December 2024.
3. Patient Safety Learning. The elephant in the room: Patient safety and integrated care systems, 11 July 2023.
4. HSSIB. Safety management systems: accountability across organisational boundaries, 13 February 2025.
5. Patient Safety Learning. Patient safety across organisational boundaries: Patient Safety Learning’s response to HSSIB investigation, 13 February 2025.
6. Patient Safety Learning. Electronic patient record systems: Putting patient safety at the heart of implementation, 31 July 2024.
7. Department of Health and Social Care. Dr Penelope Dash confirmed as new chair of NHS England, 3 March 2025.
8. Department of Health and Social Care. Review of patient safety across the health and care landscape: terms of reference, 15 October 2024.
9. Patient Safety Learning welcomes a new review of patient safety across the health and care landscape, 15 October 2024.
10. Health Service Journal. New NHSE Chair seeks ‘clear accountability and responsibility’, 4 March 2025.