Mark Hughes

The Maternity Incentive Scheme (MIS) is a financial incentive program designed to enhance maternity safety within NHS Trusts. It rewards Trusts that can demonstrate they have implemented a set of core safety actions, ultimately aiming to improve the quality of care for women, families and newborns. This report from NHS Resolution provides an overview of the national results from year 6 of the MIS.  The report summarises its key points as follows: 120 Trusts submitted for MIS Year 6. MIS payments into the scheme ranged from £140k to £3.86 million. 102 Trusts achieved full compliance (10/10) after validation – the highest since the scheme began. No Trusts were downgraded following external verification suggesting improved data integrity and/or supportive validation processes. 18 Trusts were upgraded following external verification. Trusts appear to have improved openness in self-declaration. Safety Action (SA) 8 (Multi-Professional Training) had the lowest compliance, often due to incomplete training coverage across all required staff groups. Challenges with anaesthetic and obstetric compliance. SA1 (Perinatal Mortality Review Tool [PMRT]) continued to be a challenge for some Trusts, with delays in completing factual questions and lack of evidence of multidisciplinary review within expected timeframes. SA2 (Maternity Services Data Set [MSDS] submission) achieved 100% compliance, reflecting strong engagement with national data requirements. All non-compliant Trusts in Year 6 submitted fully costed and sustainable safety improvement plans. Implementation will be overseen by Integrated Care Boards (ICB). Four appeals were submitted by Trusts in relation to their compliance outcomes. One appeal was upheld, resulting in a change to the Trust’s compliance status. Three were not upheld as the original decisions were found to be consistent with the standards and evidence.

This article outlines Patient Safety Learning’s response to the UK Government’s announcement that it plans to bring forward secondary legislation to implement a statutory barring system for NHS leaders. These plans were announced as part of the Government’s formal response to the outcome of its public consultation on how to strengthen the oversight and accountability of NHS managers in England, published on 21 July 2025. Patient Safety Learning welcomes new proposals set out by the Government this week to introduce professional standards for, and regulation of, NHS managers. We believe there is a clear case for the regulation of NHS managers, for the protection and benefit of both staff and patients. All staff have an important role to play in ensuring patient safety. As we see all too often in the outcomes of patient safety scandals and inquiries, there are too many instances of managers not acting on serious safety issues and suppressing concerns raised by those speaking up. We have also been highlighting these problems as part of a new interview series on the hub this year, Speaking up for patient safety.[1] [2] Regulation of managers is an important step forward in tackling these issues, introducing greater accountability in how organisations respond to patient safety concerns. Below we note our reflections on other aspects of the Government’s response to its consultation earlier this year on regulating NHS managers. Barring system and sanctions We welcome the proposal to introduce a statutory barring system for removing unfit managers in the NHS. We also support the proposed use of sanctions on managers who do not meet required standards. However, as noted in our consultation response, there will need to be clearly defined standards and effective oversight mechanisms so that all inappropriate behaviour is captured. We currently see evidence of managers weaponising other mechanisms against whistleblowers raising safety concerns, such as vexatious referrals to regulatory bodies. Scope of regulation The Government has stated it will initially introduce regulation for NHS bodies for board-level leaders and their direct reports, but notes: “… we will consider whether to extend scope of regulation to other senior managers. This achieves the overarching objective of preventing unfit NHS managers from occupying senior leadership roles and enables initial implementation to focus on the parts of the NHS that are most ready for this new regulation.” Patient Safety Learning believes this regulation should be extended to all senior managers (approximately bands 8d to 9) and mid-level managers (approximately bands 8a to 8c). Furthermore, all staff, including managers at all levels, should have competencies and behaviours regarding patient safety, in addition to any individual regulatory requirements. Duty of candour The consultation response states: “The government will support a regulatory system for NHS leaders that gives consideration to the relevant legislation underpinning the statutory duty of candour. We are clear that there should be consistent and correct application of the existing statutory duty of candour across the NHS to increase accountability, openness and honesty. This should support the NHS to develop a just and learning culture where providers do not seek to blame individuals for what went wrong but acknowledge what happened and try to understand why it happened, how future risks can be reduced and how the needs of the patient and staff can be met in order to help them recover.” Patient Safety Learning believes it should be a requirement to be honest and transparent with patients and their families when something goes wrong, and this should be fundamental for all staff. This is an essential requirement for creating a transparent learning culture in an organisation focused on improving patient safety and reducing avoidable harm. We therefore support the principle that individuals in NHS leadership positions should have a professional duty of candour as part of the standards they are required to meet. However, we would note there remains a significant gap between what is said and understood regarding duty of candour, and what takes place in practice at many healthcare organisations. Clear evidence of this was found in the findings in last year’s call for evidence on statutory duty of candour.[3] These wider issues regarding the operation of duty of candour will need to be addressed if it is to apply in a meaningful way for NHS managers. We also note that it is difficult to envision the statutory duty of candour working as intended in organisations where blame culture and a fear of speaking up persist. As outlined in our report last year, We are not getting safer: Patient safety and the NHS staff survey results, the NHS needs to introduce clearer requirements and plans to help organisations create and maintain safety cultures.[4] Without addressing the pockets of negative culture that exist in the NHS, this will continue to act as a limit on the proper application of the statutory duty of candour. Managers being asked to act in an inappropriate manner by an organisation with a toxic culture and leadership should also have protections and be able to raise themselves concerns about inappropriate behaviour. Responding to patient safety concerns The Government states in their response that: “We will support a regulatory system that holds NHS leaders accountable for the mechanisms in their organisations associated with recording and responding to patient safety concerns to support organisational learning. This would be integral to the management and leadership framework being developed by NHS England, including professional standards and a single national code of practice. Mechanisms to advance patient safety should recognise the importance of staff and patients being able to freely raise concerns with management (without any negative consequences) and support the NHS to develop a just culture.” Patient Safety Learning believes all staff in health and care have a responsibility to record, consider and respond to any concern raised about the healthcare being provided, or the way it is being provided, in the best interest of patients. However, in practice, existing processes do not always support this. An example of this can be found in our blog earlier this year on reporting patient safety incidents and corridor care.[5] Taking this example, the existing incident reporting mechanism, the Learn from Patient Safety Events (LfPSE) service, heavily relies on digital tools for incident reporting. These infrastructure limitations impact in a range of areas, one of which can be the accessibility and ability to capture incidents comprehensively using the LfPSE service. This issue is amplified when working in overcrowded and chaotic environments like corridors, where staff may not have easy access to appropriate IT. Existing processes need to function, and staff need to be properly supported before expectations are applied. References Peter Duffy and Helen Hughes. Speaking up for patient safety: A new interview series about raising concerns and whistleblowing. Patient Safety Learning, 15 January 2025. Peter Duffy and Helen Hughes. Key themes from our ‘Speaking up for patient safety’ interview series. Patient Safety Learning, 14 May 2025. Department of Health and Social Care. Findings of the call for evidence on the statutory duty of candour, 26 November 2024. Patient Safety Learning. We are not getting safer: Patient safety and the NHS staff survey results, 26 March 2024. Patient Safety Learning. The crisis of corridor care in the NHS: patient safety concerns and incident reporting, 6 February 2025.

This week, the UK Government has published Fit for the Future — its 10 Year Plan for health in England. This sets how it intends to create a modern health service designed to meet the changing needs of the population. In this article, Patient Safety Learning sets out its initial reflections on the Plan. At Patient Safety Learning, we believe that patient safety is not just another priority; it is a core purpose of health and social care. While patient safety is considered at points in the new 10 Year Health Plan, we are disappointed that it is not recognised as a key theme that should run throughout this.[1] Patient safety is one component of a broader approach to quality, but the risk and impact of avoidable harm to patients should be a strong driver for change. The Plan acknowledges that “NHS' history is blighted by examples of systematic and avoidable harm”. It also highlights some of the key concerns that arise in patient safety investigations time and time again. However, this is focused specifically in the “A new transparency of quality of care” chapter of the report. The term ‘patient safety’ itself is only mentioned 11 times in the 168 page document. Despite the awareness of avoidable harm, and the hard work of many people in the health service, this continues to persist at an unacceptable level. Prior to the Covid-19 pandemic, NHS England stated in the NHS Patient Safety Strategy that there were around 11,000 avoidable deaths annually due to safety concerns, with thousands more seriously harmed.[2] In practice, this figure is now likely to be a significant underestimate given the ongoing enormous strain faced by the healthcare system in recent years. Every avoidable death and disability is an unnecessary tragedy for patients, families and healthcare professionals. As the Government takes forward the implementation of its 10 Year Health Plan, Patient Safety Learning will continue to make the case that the scale of avoidable patient harm needs to be acknowledged and tackled head on. From hospital to community At the core of the Plan is the creation of a Neighbourhood Health Service. The Plan sets out an aim that “care should happen as locally as it can digitally by default, in a patient’s home if possible, in a neighbourhood health centre when needed, in a hospital if necessary”. Moving towards a more community-based model of healthcare is an admirable ambition, and also a significant undertaking. It will require a major investment in the redesigning of healthcare systems and its workforce if it is to meet its aim that the majority of outpatient care will have moved away from hospitals by 2035. We believe it is important that the new services referred to in this Plan, “single neighbourhood providers” and “multineighbourhood providers”, have a clear focus on patient safety. When introducing these new providers we would expect to see clear plans to ensure they develop and maintain effective systems and processes to respond to and learn from patient safety incidents. This would include using existing NHS initiatives, such as the Patient Safety Incident Response Framework (PSIRF) and the Learn from Patient Safety Events (LFPSE) service, and actively engaging with patients, families and carers for feedback. From analogue to digital The 10 Year Health Plan places a strong emphasis on the use of new technologies to improve the performance of the health service, in particular artificial intelligence (AI). We believe it is important to recognise the need to embed patient safety throughout the life cycle of these new digital solutions and products. Patient safety must be at the heart of the initial procurement, design and configuration of new technologies. As they are subsequently rolled out, appropriate training and support should be provided to staff. Once in place, how they are operating in practice should be monitored, learning and acting on any risk assessments, incidents or near misses relating to this. In each of these stages, there should also be clear steps to involve and engage with both patients and frontline staff. We were pleased to see the importance of this acknowledged specifically in the Plan when outlining plans for the new My NHS GP tool, with it stating that “safety will be paramount, and it will be designed with clinicians”. We would like to see this principle applied across all these new technologies. The Plan also refers to a new AI-led early warning system to identify safety concerns across the NHS. We have set out our reflections on this proposal and how this might work in practice in a separate article this week.[3] Organisational changes The Plan also mentions a number of proposed organisational changes in the health service, due to be detailed further in the forthcoming report of Dr Penny Dash’s independent review of the patient safety landscape in England. We will await the publication of this report to see the full detail of this before commenting with a full response. However, we initially would note the following points: We welcome proposals to create a new National Director of Patient Experience. We have significant reservations about the role of the Patient Safety Commissioner being transferred to the Medicines and Healthcare products Regulatory Agency (MHRA) and the potential for this to undermine the role’s independence and credibility in the eyes of patients and the public. We wish to see further detail on proposals to transfer the functions of the Health Services Safety Investigations Body to the Care Quality Commission, to consider the potential implications this will have on its independence and investigation capacity. Financial sustainability The final chapter of the 10 Year Health Plan is dedicated to considering how the Government intends to put the NHS on a route to financial sustainability. We would highlight that the current scale of avoidable harm in the NHS comes at a huge financial cost to the healthcare system. NHS Resolution figures alone make this clear. In their last annual report, they estimate that the cost of harm covered by the Clinical Negligence Scheme for Trusts was £4,778 million in 2023/24.[4] In 2022, the OECD estimated that the direct cost of treating patients who have been harmed during their care in high-income countries approaches 13% of health spending.[5] Excluding safety lapses that may not be preventable, this figure is 8.7% of health expenditure.[6] In 2024/25, £181.4 billion of the total Department of Health and Social Care budget is being passed on directly to NHS England. Even saving 5% of this expenditure by reducing preventable harm would release £9 billion of funds to reinvest in service improvements and additional capacity. The above figures do not account for the wider societal costs of avoidable harm, including the loss of productivity in the population as a result of people being economically inactive, either from the direct impact of avoidable harm to patients or indirect impact to families, carers and employers. There is a financial imperative, as well as a moral one, to focusing on reducing avoidable harm in healthcare. What is clear though is that without improvements, funds that could be spent to proactively improve the volume, quality and safety of care will instead be wastefully spent on dealing with the cost of error and harm. Concluding comments As noted earlier, this is just an initial set of reflections on the 10 Year Health Plan and does not cover all aspects of the document or how it relates to patient safety in the NHS. While references to patient safety specifically are limited, we do welcome the ambition of this Plan to tackle some of the key underlying causes of avoidable harm in healthcare, including: Healthcare professionals not having the right information at the right time to make decisions on diagnosis and treatment. Insufficient incentives for delivering consistent high quality care. Not actively engaging patients or capturing patient safety outcome measures to drive change and improvement. In the coming weeks we will publish a more detailed analysis of the 10 Year Health Plan, along with a response to findings and recommendations of the independent review of the patient safety landscape in England when this is published. References Department of Health and Social Care. 10 Year Health Plan for England: fit for the future, 3 July 2025. NHS England. The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019. Patient Safety Learning. New AI system to identify patient safety issues announced: Patient Safety Learning’s initial reflections, 1 July 2025. NHS Resolution. NHS Resolution annual report and accounts 2023 to 2024, 23 July 2024. OECD and Saudi Patient Safety Center. The Economics of Patient Safety. From analysis to action, 21 October 2020. Helen Hughes. Improving patient safety: a financial imperative, Healthcare Financial Management Association, 17 May 2023.

The Department of Health and Social Care has announced that it is developing a world-first artificial intelligence (AI) early warning system to automatically identify safety concerns across the NHS. In this blog, Patient Safety Learning reflects on this announcement and how this might work. Within the NHS there are an increasing discussions about the potential opportunities that AI can present to improve the efficiency and effectiveness of healthcare treatment and outcomes. Recent examples of this include: Using time-saving AI-enabled ambient scribing products that can automatically listen and capture conversations.[1] Using AI tools that assist with diagnosis and decision making.[2] Applying new AI systems that can analyse data, such as patient and family feedback and experiences, revealing new insights which can be used to improve services.[3] In the most recent development, the Department of Health and Social Care has this week announced plans to create a new AI early warning system to flag safety issues in real time and trigger inspections. In the announcement it states that: “The new safety warning system, being developed as part of the government’s 10 Year Health Plan, will rapidly analyse healthcare data and ring the alarm bell on emerging safety issues. Work on rolling out the system is already underway. A new Maternity Outcomes Signal System will launch across NHS trusts from November, using near real-time data to flag higher than expected rates of stillbirth, neonatal death and brain injury.”[4] The Department says that this new Maternity Outcomes Signal System will use near real-time data to flag higher than expected rates of stillbirth, neonatal death and brain injury. While it has an initial focus on maternity, the Department has indicated that when fully implemented this could be applied to hospital databases across other types of injuries and incidents. Patient Safety Learning welcomes this announcement. While significant efforts have been made to collate useful patient safety data, too often organisations, both at a local and national level, remain often data-rich and information poor. Any technological developments that can be applied to reveal the systemic causes of patient safety failure in a consistent and compelling way are to be commended. However, we do have a number of questions stemming from today’s announcement and about this new Maternity Outcomes Signal System. How will it operate in practice? Today’s announcement leaves open several practical questions about how the Maternity Outcomes Signal System will function, including: What data will this AI model be trained on? This will be critical to informing how it performs in practice. This can also affect bias and data, potentially overrepresenting certain groups or viewpoints, which can exacerbate and entrench health inequalities. Will these data include a patient’s clinical records? If so, how will patients provide consent for their data to be used in this way? Indeed, how will patient, family and carer insights be sought to inform such analysis? And how will staff-reported data, including whistleblowing testimonies, be captured? How much medical terminology will this new AI understand? Does it ‘get’ subtle semantic differences? This issue is currently being debated around the accuracy of AI-enabled ambient scribing software in taking patient records. How will alerts in the system operation? How will they be raised and to who? Will alerts be graded in severity? How will alerts be acted on? A key problem in patient safety remains “the implementation gap”; the difference between what we know improves patient safety and what is done in practice.[5] We already have findings from a wide range of different investigations and inquiries, with accompanying safety actions and recommendations; however, putting these into practice remains difficult. As we noted in our report Mind the implementation gap: The persistence of avoidable harm in the NHS, this is in part because we often lack systematic approaches to implementing and evaluating safety recommendations.[6] If a new AI early warning system is to be effective, it must be matched by the appropriate mechanisms to act on its findings and subsequently check that these actions result in improvement. The initial announcement states that where concerns are raised “the Care Quality Commission (CQC) will deploy specialist inspection teams as soon as possible to investigate and take swift action”. It’s interesting that the immediate response is not for the organisation itself to undertake an investigation but for this immediately to be escalated to CQC, the systems regulator. We would like to see greater clarity on the criteria for triggering an investigation, but also: What these investigations look like in practice. For instance, how might they consider not only systemic issues but, where appropriate, matters of staff competence that could be of concern to professional regulators. What the threshold for investigations will be and the capacity being planned at CQC to meet the demand. How implementation of the changes they may mandate are responded to (are they observations, recommendations for directors?) and how will responses be monitored and evaluated. What steps are put in place if the situation does not improve following these investigations. How will learning be shared? We would also like to see greater detail on how learning will be shared from this new system. Also is it anticipated that its findings and alerts could connect to existing reporting and investigation frameworks, such as the Learn from Patient Safety Events (LfPSE) service, the Medicines and Health products Regulatory Agency (MHRA) Yellow Card Scheme and the Patient Safety Incident Response Framework (PSIRF). Where safety alerts flag issues for the CQC to respond, the problems identified and action taken to address them may be applicable elsewhere in the NHS, the independent sector and across the UK. There needs to be mechanisms in place to enable the sharing of this data. Concluding thoughts In summary, we welcome this statement of commitment to patient safety and the use of emerging technologies to ensure healthcare better proactively assess risk and respond to it to prevent avoidable harm. As with all innovative initiatives, there will be many issues to work through to turn concept into practical reality. Patient Safety Learning looks forward to hearing more about this journey and would welcome the opportunity to directly engage and support this development, including using the insights and expertise from its extensive patient safety networks of clinicians, patient safety experts and patient safety partners. References NHS England. Guidance on the use of AI-enabled ambient scribing products in health and care settings, 27 April 2025. Sunny Deo. One size does not fit all. How AI and better data can help us embrace complexity in diagnosis and treatment. Patient Safety Learning, 6 May 2025. Ben Kenyon. From pain to progress: How NHS trusts are tackling the complaints crisis with AI. Patient Safety Learning, 23 June 2025. Department of Health and Social Care. World-first AI system to warn of NHS patient safety concerns, 30 June 2025. Suzette Woodward. Patient safety: closing the implementation gap. The King's Fund, 30 August 2016. Patient Safety Learning. Mind the implementation gap: The persistence of avoidable harm in the NHS, 7 April 2022.

This article provides an overview and transcript of a recent interview given by Patient Safety Learning’s Chief Executive, Helen Hughes, to BBC London, reflecting on the news that a patient’s death was contributed to by a cyber attack on a NHS pathology provider in June 2025. With increasing use of digital technology throughout health and care, cyber attacks present a significant and growing risk to patient safety. Patient Safety Learning believes it is vital that NHS organisations not only invest in cyber security for themselves, but are also vigilant in checking the cyber security protocols of key system suppliers. It is also important that: Organisations have robust plans to recover services, prioritising patient safety, so that when attacks do happen they can be mitigated as soon as possible. There is clear communication with frontline healthcare professionals and patients as to what is happening if there are any disruptions, and what plans are being put in place to address this. Learning from these incidents is shared widely both between Trusts and nationally to improve defences against future incidents across the NHS. In addition to recorded cases of harm, incidents may have resulted in further patient harm that is more difficult to capture. Disruption caused by cyber attacks often results in significant delays to care and treatment, with longer waits having a particularly serious impact on patients with chronic conditions and worsening health. The impact of these delays will only be seen over time. Healthcare providers need to closely monitor any patient safety risk associated with these delays and ensure that there are appropriate escalation routes to minimise future harm. June 2025 cyber attack Last summer a ransomware attack on the Synnovis pathology system saw more than a thousand operations cancelled as the laboratory used by two major hospitals, King’s College Hospital NHS Foundation Trust and Guy’s and St Thomas’ NHS Foundation Trust, was unable to report. One year on from this event, the NHS confirmed that nearly 200 patients were harmed in connection with this attack.[1] King’s College Hospital has subsequently confirmed that one patient had "died unexpectedly" during the cyber attack.[2] Quoted by BBC News, a spokesperson for the trust said a number of contributing factors led to the patient's death, including "a long wait for a blood test result". BBC interview Below is the transcript of an interview on BBC London Evening News on the 26 June 2025 between our Chief Executive, Helen Hughes, and Senior Broadcast Journalist and Presenter Victoria Hollins, responding to this news. You can watch the interview starting at 18 minutes and 38 seconds on BBC iPlayer here. Victoria Hollins: Next, a ransomware attack last June on pathology services in the NHS in London has now been linked to the death of a patient. The attack, which targeted Synnovis, a private firm managing blood tests for the NHS, saw more than 10,000 appointments cancelled at the two worst affected trusts in London. Well earlier I spoke to Helen Hughes, who is Chief Executive of the charity Patient Safety Learning, the charity that campaigns to improve patient safety. I began by asking for her reaction to the news that the ransomware attack had been linked to a patient's death. Helen Hughes: I mean it’s just horrible, isn’t it, to hear that someone’s death has been contributed to by this. At the time of the ransomware attack there was an expectation that it wouldn’t cause much harm, there may be some inefficiency and some delays in treatment, but it wouldn’t have as significant effect as it has. It’s horrifying that someone’s death should emphasise how important it is that we get cyber security right in healthcare. Victoria Hollins: And getting it right, how is the NHS doing on that? Does it prioritise cyber security, and the patient experience as part of that? Helen Hughes: You know, we do hear very much about how importantly the NHS is taking cyber security and the investment they're making. There are concerns within the NHS that the investment isn’t coming through quickly enough, and I suppose the risk that has been evidenced by this patient death might help release some of those resources. So it is taken seriously. The more the NHS relies on digital services, and that’s a good thing, because that really helps conditions and patients have the right information at the right time, but it does evidence the vulnerability. So it is important, and I’m sure people will be just really quite upset on the impact this has had because it's clearly not what people go to work to do. You know, IT experts, Chief Execs, Cyber Security Leads, are trying to avoid this happening but I suspect the risks are increasing, so they need to be more mindful. Victoria Hollins: And the NHS is of course so big and is using so many different parties, it's not just the NHS is it? Is that a concern for patients? Helen Hughes: There was at the time because with this particular incident it was a third party supplier of pathology services, and there are a lot of services, diagnostic services, admin services, a whole range of services that supply to the NHS under contract. So, the NHS firewall is a very secure vehicle for protecting the NHS, but when you buy in services from other third parties, the security of those and the risk assessment and the management and the contract management of those needs to be as good, if not better. References Health Service Journal, Nearly 200 patients harmed in major cyber attack, 18 June 2025. BBC News, Ransomware attack contributed to patient’s death, 25 June 2025.