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In February, Public Policy Projects (PPP) hosted their annual Patient Safety Forum in partnership with Patient Safety Learning. Held at the Royal College of Surgeons of England in London, it was attended by senior healthcare leaders, patient safety experts, representatives from the HealthTech industry, frontline healthcare professionals and patients. In this article, Patient Safety Learning reflects on one of the panels discussions—Aligning patient safety with productivity. Against a backdrop of long waiting lists and increasing financial pressures, improving productivity is a priority for healthcare leaders, commissioners and providers. The 10 Year Health Plan for England identifies this as a key issue of the NHS, setting a target to deliver a 2% year on year gain in productivity over the next three years. Productivity gains can sometimes be seen as running contrary to patient safety—a push to deliver more activity while cutting resources. However, at Patient Safety Learning we believe that creating a safer health system can be a key driver of productivity. Unsafe care and its consequences are inherently inefficient: it leads to longer stays, readmissions, litigation, staff turnover and reputational damage. At the Patient Safety Forum 2026 an expert panel was convened to discuss this topic, with the following members: Andi Orlowski, Director, NHS Health Economics Unit Professor Sanjiv Sharma, Group Medical Officer, Barts Health NHS Trust Stephen Rocks, Head of Secretariat for NHS Productivity Commission, The Health Foundation Gayathri Kumar, Lead Health Economist, NHS Health Economics Unit Panellists had a thought-provoking discussion about this topic. In this blog we reflect on the key takeaways from this panel. Scale of the challenge Andi Orlowski noted that while there had been many positive discussions at the Forum about improving patient safety, outcomes and experiences, the financial backdrop faced by the health service remains stark. He pointed to wider pressures on the Government to increase expenditure in areas outside of healthcare, such as defence, and the likely need for the NHS to do more work with the same money or less going forward. Panellists reflected on the scale of the productivity challenge faced by the health system. It was noted that since the onset of the Covid-19 pandemic, the NHS has grown in terms of staffing but productivity has fallen considerably in official measures. This is obviously not in itself a direct relationship, with the latter being associated with a range of issues varying from higher waiting list burdens to increased patient complexity. Stephen Rocks spoke about the work of The Health Foundation’s NHS Productivity Commission. This was established to provide evidence and solutions to boost productivity over the next decade. He was clear that patient safety should be seen as being aligned to productivity, with reductions in avoidable harm ultimately improving patient outcomes and by definition improving productivity. As part of its work, the NHS Productivity Commission held a public call for evidence this year. This invited a wide range of stakeholders to share their insights, ideas and expertise on the productivity challenge and how it could be tackled. Since the Patient Safety Forum took place a summary of its activities to date has now been published. Keeping sight of value A recurring discussion theme was that in looking to improve productivity in healthcare, we should not lose sight of value. By value, we mean whether patients achieve outcomes that matter to them, relative to the resources that have been used. What is meant by value in this context, however, can differ depending on perspective. Reflecting on this point, an audience member noted the importance of ensuring productivity discussions included the views of patients and frontline staff members. Gayathri Kumar concurred with this view, emphasising the importance of having deliberative conversations that include everybody who has a stake in decision making. Speaking about a practical example of this, she referred to the Health Economics Unit using the STAR (Socio-Technical Allocation of Resources) method to support Integrated Care Boards (ICBs). Taught through the Smarter Spending in Population Health programme, this is intended to help decision-makers to effectively assess their resources to see how they can create more value. This involves: Bringing together key stakeholders at decision conferences. Asking them to identify the criteria that matters to them and map the different interventions in a pathway. Subsequently working out what the value for money is, on both the financial side of things and in value terms. By coming together in this way, the aim is that decisions are not simply making assessments based on statistics divorced from patient and healthcare professional experience. It provides a way of identifying higher value interventions and services, crucial when there are only finite budgets available. Not just a financial focus Not simply focusing on financial improvements when thinking about productivity was also a key topic of discussion amongst the panel. Sanjiv Sharma from Barts Health Trust spoke about the importance of recognising the interrelationship of finance, quality and safety in healthcare, rather than framing them in oppositional terms. Avoidable harm in healthcare is not just a tragedy for those involved but comes at a huge financial cost. Sanjiv noted the Organisation for Economic Co-operation and Development (OECD) estimate that the direct cost of treating patients who have been harmed during their care in high-income countries approaches 13% of health spending. Reflecting on their work at Barts Health Trust, Sanjiv said that when they spoke about productivity they used a simple definition: using their resources to treat the highest number of patients in the safety way through the delivery of high-quality care. This moves slightly beyond a pure definition of productivity, also bringing in issues of quality, safety and access. Considering an example of an improvement made without a pure financial focus, he cited the introduction of digital push notifications at Barts Health Trust to improve attendance at outpatient appointments. He said that by using these over a 12-month period they had managed to reduce non-attendance from 12.3% to 10.3%. While this may sound like quite a small percentage, the gain from this was not simply an improvement in attendance. Fewer wasted appointments had enabled them to create a significant number of new appointments, effectively delivering more care while expending a similar resources. This activity links to national proposals around improvements to the NHS App, with plans to use push notifications more widely to remind patients about upcoming appointments and relay important messages. Sanjiv also shared an example from a clinical productivity programme at Barts Health Trust looking at how outpatient clinics operate in the context of breaking down long waiting lists. In particular, looking at how the clinics can be organised more efficiently to better use the time of the most highly remunerated part of the workforce (consultants) so that more patients can be seen in normal working time. He noted this not only can save money on additional working hours, but also reduces the risk of consultants becoming overworked or burned out. More broadly, Sanjiv noted that when considering how healthcare can increase productivity, it is also important to recognise that there are limits to this. He spoke about the need for more honest conversations in wider society about what we can expect from healthcare, with our ageing population in the UK driving ever increasing demand on the system. 10 Year Health Plan As noted earlier, the 10 Year Health Plan for England sets specific goals for productivity improvements in the NHS. But how will this be measured and assessed? Gayathri noted that the answer to this was complex, as it depends on the perspective you take. She noted that if you were planning to take a societal perspective or NHS and broader perspective, you would consider the system impacts. Wider than this, she emphasised the importance of bringing together stakeholders from across different parts of care pathways so they can make things better—delivering both cost savings and improved patient outcomes. Andi reflected positively on the work Gayatri and her colleagues had done in this area. He noted that their work around the three shifts in the 10 Year Health Plan had involved reviewing over 6,000 papers to find which were cash-releasing by seeking the evidence base in the published literature and the grey literature. He noted that in many cases, performing these interventions would not achieve savings as often it results in moving pressures around the system. For example, increasing activity in an acute organisation saves money there, but transfers in activity in primary care which increases costs there. The importance of looking at the system as a whole was emphasised. Digital developments Panellists also discussed how digital advances can unlock productivity gains in the NHS. An example provided was switching to digital communications in full; for instance, stopping the use of paper letters. It was noted that this is quite a simple change, but can potentially unlock huge cost savings, while in turn reducing or enabling the re-direction of administrative resources in other areas. However, how this is delivered in practice requires considerably effort to change how healthcare organisations work, with far more complexity sitting behind such proposals than may first be apparent. The example of using artificial intelligence (AI) more was also highlighted, which is another key element of the 10 Year Health Plan. It was noted that while currently our approach to the application of AI in the NHS is a little uneven, it could potentially unlock significant improvements in processes if applied correctly in future. Role of Integrated Care Boards Whether ICBs could play an important role in improving productivity was also discussed by the panel. With a renewed focus on their strategic commissioning role, there is significant potential for ICBs to drive forward NHS productivity. Stephen Rocks suggested that they could potentially help look at improving productivity through the lens of their role in maximising population health management. He said he would welcome seeing more work at an ICB level that could help us to understand how well their areas are doing in terms of outcomes, and considering going forward if there is potentially more of a role for outcomes-based contracting rather than paying through block contracts or for activity targets. Importance of leadership One final key area of reflection from panellists was how leadership relates to improving productivity in healthcare. Stephen Rocks said that The Health Foundation had recently held a event with people sharing their success stories in other sectors which bore out the importance of this. They noted that this stressed the importance not only of those at the top of the organisation, but also the vital role of middle management. He reflected that the people at the top set the vision, at the bottom are the ground people doing things, and in the middle you're having to respond to people and understand their concerns as well as trying to carry out that vision. Investment was needed across all these levels. Sanjiv Sharma also noted the need to balance this focus on helping those in leadership roles be the best they can be. Sanjiv emphasised the importance of having proper support mechanisms in place as too often we create environments in the healthcare system where people are faced with a “just get on and do it attitude”. Share your insights What are your views on how best to align patient safety and productivity? Share your thoughts on this article and the issues raised by commenting below (sign up first for free). Find out more about the Patient Safety Forum 2026 You can read more about different discussions and panel sessions at this year’s event in the below: Safe systems, safe cultures: reflections from the Patient Safety Forum 2026 Patient voice, safety and the NHS 10 Year Plan: Reflections from the Patient Safety Forum 2026 Designing AI with patient safety at its core: Reflections from the Patient Safety Forum 2026 Inside the NHS quality debate: Key takeaways from Penny Dash’s keynote at the Patient Safety Forum 2026

On the 18 June 2026, the Health Services Safety Investigations Body (HSSIB) published a new report summarising a rapid investigation focused on patient safety issues within a regional care system. It looked specifically at a case where multiple organisations were involved in providing care across a care pathway. In this blog, Patient Safety Learning’s Associate Director Claire Cox sets out reflections on the report’s findings. The most recent HSSIB learning report on patient safety across regional care pathways offers an important, if uncomfortable, insight into the realities of delivering care across organisational boundaries. While framed as learning, the findings expose fundamental gaps in oversight, clarity and system leadership, which pose significant risks to patient safety. A care pathway is a structured, evidence-based framework that describes the sequence of care and interventions a patient should receive for a particular condition, population group or healthcare need. It sets out how different services and professionals work together to deliver coordinated, high-quality care across the patient's journey. The HSSIB investigation examined a redesigned regional pathway involving multiple organisations and a centralised specialist service. However, the report deliberately omits specific details of the pathway, organisations and patient group involved. While this is understandable from a confidentiality perspective, it creates a key limitation: without a clear understanding of the full patient journey, it becomes much harder to articulate where risks emerge, accumulate and, ultimately, result in harm. The invisible patient journey One of the most striking issues raised by the report is the system’s inability to fully understand or monitor patient harm across the pathway. This is perhaps unsurprising. Care pathways that span multiple organisations are non-linear, dynamic systems, where risks rarely arise at a single point. Instead, harm often reflects latent system failures, decisions, constraints or assumptions made early in the pathway that only manifest much later. The investigation highlights several critical system weaknesses: Differences between how the pathway was designed and how it actually operated. A lack of shared understanding between organisations about what the pathway could realistically deliver. Limitations in the technology and digital systems used to support the pathway. Limited data sharing and inconsistent performance insight across providers. These issues are particularly evident in the technology underpinning the pathway, where a lack of interoperability between organisational digital systems means critical patient information is not consistently shared or visible across services. In practice, this results in manual workarounds, duplication and reliance on incomplete data. The safety implications are significant: clinicians are often making decisions without a full understanding of a patient’s history, delays occur in accessing or transferring information and opportunities for proactive intervention are reduced. Collectively, this creates a scenario where no single organisation holds a complete picture of the patient journey, meaning emerging harm cannot be reliably identified. From a patient perspective, it is reasonable to expect far greater visibility of the pathway they are moving through—not just who is providing their care, but how that care is organised end-to-end. This includes clarity on what the pathway looks like, the key decision points that may affect their treatment, and how and when care may escalate if their condition changes. They might also reasonably expect to know how risks to their safety are being identified, shared and actively managed across organisations. Without this transparency, patients are effectively navigating a system that is opaque, fragmented and difficult to understand. In such circumstances, meaningful collaboration becomes extremely challenging. Shared decision making depends on a shared understanding of both the clinical situation and the system through which care is delivered. Similarly, where risks are not visible to patients, there can be no clear line of accountability for how those risks are mitigated. If care pathways are to function safely across organisational boundaries, they must be understandable not only to professionals within the system but also to the patients who rely on them. The accountability gap A consistent theme throughout the HSSIB report is the absence of sustained oversight. Although a cross-organisational implementation board initially existed, oversight from the Integrated Care Board (ICB) reduced before the pathway was fully embedded. The consequences were predictable: No shared governance framework post-implementation. No agreed evaluation plan. Limited escalation of risks. Disconnected data and performance monitoring. This reflects a classic system failure: accountability without ownership. If no organisation or system leader maintains end-to-end ownership of a pathway, then: Risks fall between organisational boundaries. Mitigations are inconsistent or absent. Learning is localised rather than system wide. As highlighted by another HSSIB report last year, there is a lack of clarity about how patient safety is managed between ICBs other healthcare providers, including lines of safety accountability. This leads directly to gaps in oversight of cross-organisational safety risks. Implementation versus reality: the risk of 'work as imagined' Another critical safety issue is the mismatch between the pathway as designed ('work as imagined') and its real-world operation ('work as done'). The report highlights: A business case that was not fully realised. Resource assumptions (e.g. bed capacity) that did not materialise. Divergent expectations among organisations about pathway capability. This is not a minor operational issue, it is a core patient safety risk. When services are designed based on assumptions that are not delivered in practice: Demand exceeds capacity. Access thresholds shift informally. ·Staff are forced into workarounds. Clinical decision-making becomes inconsistent. Over time, this creates unstandardised care and inequity of access, both of which were flagged as concerns in the investigation. Culture, communication and friction The report also surfaces issues that are often underplayed in pathway redesign, relationships and behaviours between teams. Findings include: Differences in risk perception between organisations. Disagreements affecting clinical decisions. Examples of incivility. Barriers to shared learning. Lack of interoperability between organisation digital systems. These are not 'soft issues', they are direct contributors to patient harm. Where communication breaks down: Information is lost or misinterpreted. Decisions are delayed. Trust erodes across organisational boundaries. In cross-system pathways, psychological safety and collaboration are as critical as infrastructure and process design. What could strengthen learning? While the report provides valuable system-level insights, there is an opportunity to go further in translating findings into practical improvement. Two approaches could add depth: 1. After Action Review (AAR) at system level A structured, multi-agency AAR could: Reconstruct the pathway end-to-end. Identify where assumptions diverged from reality. Surface latent conditions contributing to risk. Build shared understanding across organisations. This would move learning from 'what happened' to 'why it made sense at the time'. 2. Transformative (tabletop) simulation Given the complexity of regional pathways, simulation offers a powerful way to: Test proposed improvements in a safe environment. Explore system stress points (capacity, transfers, escalation). Identify unintended consequences before implementation. In effect, simulation allows systems to experience the pathway as patients do across boundaries, not within silos. The role of integrated care boards: a system risk? Perhaps the most significant implication of this report is what it reveals about the current maturity of system oversight. ICBs are expected to: Commission across pathways. Ensure safety across organisational boundaries. Use data to drive improvement. However, the report evidences: Limited access to consistent safety data. Reduced capacity following structural changes. Difficulty maintaining ongoing oversight of complex pathways. Again this is not an new issue and is a theme that we have seen in previous HSSIB investigations, including a report last year looking at the implementation of the Patient Safety Incident Response Framework. This raises a critical question: do current system structures have the capability and capacity to oversee patient safety at pathway level? If the answer is uncertain, then this is itself is patient safety risk, one that is largely invisible to the public. How might the emerging quality strategy address this? The forthcoming NHS Quality Strategy presents a critical opportunity to address many of the systemic issues highlighted in this report, particularly the fragmentation of safety across organisational boundaries. The 10 Year Health Plan stated that alongside the National Quality Board its aim would be to address a crowded and unclear quality landscape and provide a single and authoritative determination of quality. This aligns directly with the need identified here: clearer expectations, better measurement and more coherent oversight across systems. However, emerging national discussion suggests there are still important gaps to resolve, including concerns about whether patient safety will be given sufficient prominence, and whether expectations for providers and system leaders will be clear enough to drive meaningful change. If the Strategy is to respond effectively to the risks identified in this HSSIB investigation, it must move beyond treating safety as one dimension of quality and instead position it as a central organising principle of system design. This creates a significant opportunity to design cross-system safety into: service planning service delivery accountability frameworks performance management data capture and intelligence. Without this, there is a real risk that existing fragmentation is reinforced: where metrics are numerous but unaligned, accountability remains diffuse, and no single entity holds responsibility for understanding risk across the whole patient journey. Conversely, a coherent and safety-led strategy could provide the support needed for ICBs and providers to jointly own pathway outcomes, supported by shared data, stronger governance and clearer system leadership. The absence of prescriptive targets may offer flexibility but it also increases the importance of how strongly patient safety is prioritised and operationalised in practice. Final reflection This HSSIB report highlights a fundamental truth: patient safety does not solely reside within organisations; it resides within pathways. The 10 Year Health Plan for England envisions a significant shift in the coming years towards more neighbourhood and system-based models. As this transition takes place, the risks identified in this report will only become more pronounced. Without clear end-to-end ownership, shared data and intelligence, robust evaluation, and strong cross-system leadership, we risk designing pathways that look coherent on paper but are fragile in practice, and where safety is too often an afterthought. The forthcoming NHS Quality Strategy could potentially present a opportunity to tackle these issues, designing for safety, to ensure safe outcomes, processes and behaviours. The challenge now is not simply to learn from this report but to recognise that these issues are unlikely to be isolated. They are systemic and they demand a system-level response.

This year will mark the publication of the first comprehensive Quality Strategy for the NHS in over fifteen years. In this blog, Patient Safety Learning and the Advancing Quality Alliance (Aqua) set out the need for safety to serve as a golden thread woven throughout the Strategy. The 10-Year Health Plan for England presents a significant opportunity to improve patient care, experiences, and outcomes. It is expected that the forthcoming NHS Quality Strategy will seek to deliver these improvements by placing a system wide focus on quality. We believe that improving patient safety is inextricably linked to this aim. Level of avoidable harm Prior to the Covid-19 pandemic, NHS England stated in its Patient Safety Strategy that there were around 11,000 avoidable deaths annually due to safety concerns, with thousands more patients seriously harmed.[1] Separately, a 2026 report from the Institute of Global Health Innovation has suggested that 22,789 lives could be saved if the UK matched the rate of treatable mortality of Switzerland.[2] In practice, both these sets of figures are likely to significantly underestimate the scale of harm given the ongoing enormous strain faced by the healthcare system in recent years. Particularly when also considering the pressures in service provision in primary care, emergency and urgent care and discharge planning with social care. This is an unnecessary tragedy for patients, families, and healthcare professionals. Cost of unsafe care This level of avoidable harm is also accompanied by a huge financial cost. The Organisation for Economic Co-Operation and Development (OECD) has estimated that the direct cost of treating patients who have been harmed during their care in high-income countries approaches 13% of health spending.[3] Excluding cases of avoidable harm that may not be preventable, this figure is 8.7% of health expenditure. NHS Resolution estimated that the “annual cost of harm” of clinical negligence claims alone in England in 2024/25 was £4.6 billion.[4] The problems created by unsafe care also undermine efforts to improve quality by increasing productivity. Avoidable harm and its consequences are inherently inefficient, leading to longer inpatient stays, higher staff turnover, reputational damage and reduced trust by patients and the public in the NHS. Improving safety to deliver improvement Patient Safety Learning and Aqua believe that improving patient safety should be a key cornerstone for creating a more effective and productive health system. This means that we should be designing for safety, to ensure safe outcomes, processes, and behaviours. We should know ‘what good looks like’ for safe care and apply this knowledge rigorously and transparently.[5] This should include: Improving the quality of patient safety reviews and investigations. Sharing learning widely and translating this into tangible improvements. Nurturing an open and restorative culture in the NHS. Listening to patients, families, and staff, to better understand risk, take action to prevent harm and give redress and support to people harmed. Board level oversight and reporting of safety incidents, reviews and learning applied. Greater use of technology, data and analytics to significantly improve the safety, effectiveness and responsiveness of care delivery.[6] We also believe it is important to embrace safety science and not oversimplify complex issues. We must respond to delivering safer ‘work as done’ and not be comforted by revising unrealistic and unachievable ‘work as imagined’.[7] Moving towards a safer healthcare system Leadership will be essential to driving these safety improvements. The creation of a new Quality Strategy presents a valuable opportunity for organisational and system leaders to embrace an integrated approach to patient safety. They should encourage a culture of openness and transparency among staff and patients regarding safety issues and related recommendations, while ensuring that safety and quality remain balanced priorities. We need to find better ways of working within organisations and across patient pathways and systems to design and deliver safer outcomes. We too often remain siloed in our response to avoidable harm and must share and work together to design system-wide solutions. There is a huge opportunity for Integrated Care Boards (ICBs) to drive a systemic approach to patient safety through their strategic commissioning responsibilities.[8] [9] There is however currently significant variation in ICBs involvement in safety management activities.[10] We believe they could take on a clear leadership role for system safety. This could have the potential to develop an integrated and coordinated approach to safety, reflecting patient care pathways across systems and ensuring consistency and collaboration. Patient Safety Learning and Aqua look forward to reviewing the Quality Strategy and contributing to its implementation, ensuring that patient safety is integral to how we design and deliver a transformed health care system. Get in touch For organisations wanting to engage in our work and networks, please contact us at: Aqua: [email protected] & 0161 206 8938 Patient Safety Learning: [email protected] References NHS England. The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients. July 2019. Institute of Global Health Innovation & Patient Safety Watch. National State of Patient Safety 2025: Prioritising improvement efforts in a system under stress. 29 January 2026. OECD and Saudi Patient Safety Centre. The Economics of Patient Safety. From analysis to action. 21 October 2020. NHS Resolution. NHS Resolution annual report and accounts 2024 to 2025. 17 July 2025. Patient Safety Learning. ‘What Good Looks Like’ in patient safety. Last accessed 23 February 2026. Alex Kafetz. Why data on quality of care is now more important than ever. 17 February 2026. Claire Cox. Putting the writing on the wall: Explaining work as imagined vs work as done. 1 August 2023. Aqua. What Should Safety Look Like at a System Level. 6 April 2023. Patient Safety Learning. The elephant in the room: Patient safety and integrated care systems. 11 July 2023. Health Services Safety Investigations Body. Safety management: accountability across organisational boundaries. 13 February 2025.