Review of patient safety across the health and care landscape: Patient Safety Learning's response (15 July 2025)

Summary

This month the Department of Health and Social Care (DHSC) published the findings of a review of patient safety across the health and care landscape in England chaired by Dr Penny Dash. This review looked at six specific organisations involved in assuring and contributing to the safety of care, while also considering the wider landscape of organisations influencing the quality of care. This article sets out Patient Safety Learning’s response to this announcement.

Content

You can read Patient Safety Learning's full response to the review in the briefing paper here.

Commenting on this, Patient Safety Learning’s Chief Executive Helen Hughes said:

“We agree with this review’s overarching recognition of the need to coordinate and rationalise the patient safety landscape in England. The existing structure of our health system is often ill-suited to tackling complex challenges to patient safety and addressing the underlying systemic causes of avoidable harm, and steps to address this are welcome.

However, we would strongly contest its assertion that patient safety has been significantly over prioritised in the past 5 to 10 years at the expense of other aspects of quality. Patient safety is not just another priority; it should be a core purpose of health and care. You cannot build an effective, efficient and responsive NHS on an unsafe system. We need to address the cause of avoidable harm not just understand why it happens and then drive the delivery of consistent high quality care and patient safety.”

The briefing can be summarised by the key takeaway messages below:

Where we agree

• The review’s assertion that the past 5–10 years have not seen a significant improvement in patient safety. Despite the hard work of many people and organisations, avoidable harm continues to persist at unacceptable levels.
• There is a need for a strategic focus on improving quality of care, including patient safety. Relatively little support goes to the day-to-day management and improvement of care.
• Its recognition that quality is multi-dimensional. It includes safety, effectiveness and patient experience, accessibility, equity and efficiency.
• There is a need to better assess and manage the balance of risks within organisations and across systems. This includes better cost-benefit analysis of actions to improve the quality of care and ensuring that there are no unintended consequences to patient safety of poorly implemented recommendations.
• The current system for complaints and concerns is confusing and lacks responsiveness, as has been identified in many reports in the last two decades.
• There is a need to coordinate and rationalise patient safety roles and responsibilities.

Where we disagree

• The review’s argument that patient safety has been significantly over prioritised in recent years at the expense of other aspects of quality. We do not believe the examples given provide compelling evidence of this.
• The review’s suggestion that spending on patient safety inquiries is evidence of a system that over prioritises patient safety. Inquiries stem from failures in safety. It is not credible to suggest that this expenditure equates to investment in safety improvement. Inquiries do not represent an investment in improving patient safety, they are instead seeking to provide a better diagnostic of why harm occurs. We need to address the cause of avoidable harm not just understand why it happens.

Proposals and suggestions we welcome

• The recommendation to reinvigorate and repurpose the National Quality Board (NQB). In particular, the suggestion that the NQB should be responsible for developing a comprehensive strategy to improve quality of care (including patient safety) and the need for a focus on improvement and innovation.
• The retention of the role of the Health Services Safety Investigations Body (HSSIB) as expert investigators. We would like to see further detail on how its operational independence is maintained as it transitions to the Care Quality Commission (CQC) and in what form its valuable education programmes will continue.
• The creation of a new National Director of Patient Experience, also referenced in the 10 Year Health Plan. We look forward to seeing more detail of the scope and responsibilities of this role alongside a new Patient Experience Directorate.
• The emphasis on the use and importance of Patient-Reported Outcome Measures (PROMS) and Patient-Reported Experience Measures (PREMs).
• Support for effective risk-informed decision making with organisation boards responsible for all areas of performance. We believe patient safety has to be a core purpose, not one priority of many, and with clear accountability for patient safety in all roles across the whole organisation.
• Acknowledgement of the value of embedding a culture and capacity for continuous improvement.
• Recognition of the need for significant investment in digital and data capacity, alongside a strategy for using technology effectively.
• Recognition that there should be a national strategy for quality in adult social care.

Areas that need further review and consideration

• We believe there needs to be a transformative effort and commitment to creating a safety culture in the health service. We are disappointed that culture has not been a key issue considered by this review. There are significant changes needed to ensure that there is an open and fair culture with a focus on learning and improvement that doesn’t blame healthcare staff for systemic failings. The existing network of Freedom to Speak Up Guardians working with individual healthcare providers is identified by the review as being able to contribute to a strengthened safety culture. However, this is not in itself sufficient. Organisations need to actively foster a patient safety culture, tackle blame and fear, and promote a culture of safety improvement.
• One significant gap in the current patient safety landscape in England is the lack of structured systematic approaches to learning and solution development. In the absence of this, insights from good practice and investigation into patient safety incidents tend to be retained solely within individual organisations. Lessons learned need to be disseminated for rapidly resolved improvement, as recommended by the review.
• We have significant reservations about the role of Patient Safety Commissioner being transferred to the Medicines and Healthcare products Regulatory Agency (MHRA) and the impact of this on the role’s credibility and independence.
• Currently everyone who uses or works in the healthcare system, including patients, families, carers and healthcare staff, can raise issues that HSSIB may seek to investigate. We would like to see a commitment to retain this in some form as HSSIB transitions into its new hosting arrangement with the CQC.
• The review does not reflect on the future role of NHS England/DHSC on patient safety, nationally nor regionally, other than in chairing the reinvigorated NQB. National NHS leadership, arm’s length bodies, system and professional regulators, Royal Colleges, standard setting organisations, peer review bodies, advocates and advisory bodies, commissioners and providers, etc, should be designed into an effective operating model for quality and patient safety. This is an area where the revitalised NQB could take a leadership role in future. This could involve designing this into an effective safety management system, with clarity of each organisation’s role and contribution to the reduction of avoidable harm
• Although the review recognises that the quality of social care needs to be addressed, no specific recommendations are made in relation to this.
• There are a number of recommendations, that if not implemented as intended, might diminish independent voices in raising concerns about patient safety. It is essential that patients, families and carers and staff can speak up and be listened to.