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This blog provides an overview of a discussion at a Patient Safety Management Network (PSMN) meeting on Friday 29 May 2026. At this session members shared their views on the proposed transfer of the Health Services Safety Investigations Body (HSSIB) functions to the Care Quality Commission (CQC). The PSMN is an innovative voluntary network for patient safety managers and everyone working in patient safety. It has over 2000 members from more than 650 different organisations. Created by and for people working in patient safety, it provides a weekly drop-in session with guests to talk through issues of importance, offers peer support and creates a safe space for discussion. You can find out more about the network here. Last summer the Department of Health and Social Care (DHSC) published the findings of its review of patient safety across England, chaired by Dr Penny Dash.[1] This review proposed several changes which sought to coordinate and rationalise patient safety roles and responsibilities. One of those recommendations was that the functions of HSSIB should be transferred to the CQC. HSSIB investigates patient safety concerns across the NHS in England and in independent healthcare settings where safety learning could help to improve NHS care. It is currently an executive non-departmental public body sponsored by DHSC. Transferring HSSIB to the CQC Plans to implement this Dash Review recommendation were included in the new Health Bill, announced in the King’s Speech at the beginning of May.[2] Setting out the rationale for this change, DHSC states: “Abolishing HSSIB and transferring its functions to CQC will simplify the patient safety landscape. System users will be clearer about who does what in the system and how to effect change. It will increase the effectiveness of patient safety recommendations and lead to more consistent system-wide learning and tangible improvements in patient safety outcomes. Having CQC undertake investigations (through a discrete function) will mean that the prominence of the investigation recommendations will be increased by virtue of being part of the sector’s regulator. The safety recommendation will therefore be heard clearly by providers across the system.”[3] In a fact sheet concerning the patient safety aspects of the Health Bill, DHSC advises that as part of these changes: The transfer of investigation functions includes retaining the ‘no blame, safe space’ model, which prohibits the unauthorised disclosure of protected material obtained during investigations. The prohibition on sharing protected materials outside of the investigation function will continue when performed by CQC. Powers currently held by HSSIB safety investigators will be carried over to CQC, including powers of entry and the ability to demand and secure documents and other evidence. HSSIB’s role in education and training in patient safety investigation skills for NHS and healthcare staff will also transfer. Concerns raised about this transfer There have been points of concern raised about this proposed change since it was first announced in the Dash Review last year. These have included: Concerns highlighted by Professor Carl Macrae that these changes risk setting back progress in the systematic improvement of quality and safety.[4] A warning from Sir Bernard Jenkin MP that these changes could undermine public confidence in investigations.[5] The All Party Parliamentary Group on Patient Safety calling for these changes to be stopped and HSSIB retained as a separate body.[6] Evidence provided by the CQC to the Health and Social Care Select Committee suggesting the changes will create a conflict of interest in protecting the safe space between their proposed investigatory and regulatory arms.[7] Network discussion After a brief presentation providing the background context of the Dash Review and the changes proposed in the new Health Bill, PSMN members had an open discussion about this topic. At the start of the conversation, it was notable that when asked, around one third of the 130 attendees answered that they had not been fully aware of these proposals. This included the implications for NHS organisations of recently announced changes to HSSIB’s education and training programme, discussed in more detail later in this blog. As the conversation progressed, it touched on the following areas. Independence Several network members emphasised the importance of HSSIB’s independence as a national patient safety investigator. Some of these comments mirrored the points highlighted by the CQC in their response to the Health and Social Care Select Committee mentioned earlier in this blog. There were suggestions that there was an inherent conflict of interest between the roles of investigator and regulator, and that the two needed to remain separate. One attendee said that these could only co-exist in one body if a formal division existed between the functions. They argued that once an inspection culture drifted into the investigation body, much of the value of the latter would be lost. Attendees also expressed concerns about whether staff could be confident that their disclosures to the investigator would not be shared with other parts of the CQC. Specifically, it was suggested that if investigations were seen as a potential trigger for future inspections, this could deter staff from being open in disclosures to safety investigators. One network member also queried how the leadership of the CQC in future would be able to appropriately govern the organisation if, to maintain confidentiality, they there were restricted in their oversight of the HSSIB investigations component of this. Education and training There were a lot of reflections about the role that HSSIB has played to date in providing patient safety training for NHS staff. As a result of recently confirmed changes following on from its new strategy, Building investigation excellence, HSSIB has announced the conclusion of its previous education programme. This had provided a range of training courses for NHS staff, which have had more than 40,000 participants since 2023.[8] There were many positive reflections about HSSIB’s previous programme of education and training. Comments included: Multiple attendees stating that they had heavily relied on HSSIB for providing training to support their staff in implementing and supporting their use of Patient Safety Incident Response Framework (PSIRF) tools and methods in their organisations. HSSIB courses were seen as high quality. Some members expressed concerns about the quality of alternative options from external private providers in comparison to this. Courses from HSSIB being free for NHS staff was particularly beneficial. Some attendees suggested that their withdrawal raised questions about whether there would be adequate funding available in future for staff to be trained in the same way by external providers. HSSIB courses were not only a helpful training resource but a useful opportunity to meet and collaborate with peers in other NHS organisations. An attendee from a private provider noted this would have less impact on them as HSSIB courses had not been open to them, so they had relied on in-house support. It was also noted that HSSIB’s new approach to education services intends to build on its previous programme through a new operating model, focused on targeted capability building and creating a greater range of accessible training resources. Investigation reports During the discussion, several meeting participants highlighted the value of HSSIB’s patient safety investigation reports. Members shared how they had used the findings and recommendations from these reports to inform safety improvement work in their organisations. One point of debate was whether this proposed change could potentially strengthen the value of these reports in future. Some attendees suggested that CQC branded reports might be perceived as more authoritative by decision makers, prompting greater action in response to their recommendations. The wider question was also raised of how patient safety recommendations are approached in healthcare—namely, the number of recommendations made and the difficulties translating these into practical improvements. It was noted this was likely to remain an issue, irrespective of this organisational change. ‘Safe space’ provisions Existing legislation concerning how HSSIB operates means that under its ‘safe space’ provisions, its investigation evidence and findings is subject to special protections. They cannot be disclosed without the HSSIB chief investigator’s consent, or without a High Court order that has assessed the public benefit of that disclosure. The intention of this is to ensure staff feel they can speak to investigators without fear that their evidence could be used against them in some way. A similar approach is used in other safety critical industries—for example, in the UK’s transport investigation branches. As noted earlier, DHSC has stated that, as part of these changes, ‘safe space’ provisions will be carried over as HSSIB’s functions move into the CQC as part of the Health Bill. However, network members still expressed significant concerns about this. For some, the questions were how fixed this would be, and whether the ‘safe space’ provisions in practice may simply be removed by the Government later once this transition was complete. Others reflected on the importance of these changes not simply being protected but being seen as protected. One suggestion was that retaining an independent identity and infrastructure for HSSIB as it moves to within CQC could be important in maintaining the perception of this. Patient Safety Learning perspective In our response to the Dash Review last year, Patient Safety Learning stated our belief that HSSIB has an important independent role in the health system which should be retained. We do not think, to date, the concerns shared by PSMN members in this discussion have been effectively addressed by those in decision-making roles when considering the future of the independent patient safety investigation capacity in the NHS. Fundamentally, if confidence in the independence and confidentiality of HSSIB’s investigations is undermined, whether in reality or perception, this could compromise understanding of what is really happening on the ground. HSSIB’s ability to do this is an essential prerequisite to understanding what the risks to patient safety are and the actions needed to address these. We will be raising these issues directly with DHSC, the Health and Social Care Select Committee, and Members of Parliament more broadly as the Health Bill progresses through Parliament. How to get involved Are you working in patient safety and interested in joining the PSMN? You can join by signing up to the hub today When putting in your details, please tick ‘Patient Safety Management Network’ in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected]. References DHSC. Review of patient safety across the health and care landscape. 7 July 2025. Patient Safety Learning. The King’s Speech 2026: Six key takeaways for patient safety. 15 May 2026. DHSC. Health Bill: patient safety – fact sheet. 19 May 2026. Macrae C. Failing to learn? The NHS is losing its capacity for system-wide safety investigation. Journal of the Royal Society of Medicine, 2025; 118(10). Health Service Journal. Merging watchdog into CQC will ‘destroy’ independence. 26 February 2026. Moore A. Patient safety: MPs urge Streeting to stop “forced merger” of agencies. BMJ, 3 March 2026. CQC. CQC written evidence to the Health and Social Care Select Committee on Health Services Safety Investigations Body transfer to CQC. 2 June 2026. HSSIB. Building investigation excellence: our strategy for strengthening the capability of healthcare investigations. 27 February 2026

At a Patient Safety Management Network meeting last year, Amy Wood gave a presentation on her experience of managing change in the NHS. Speaking about her time at Chase Farm Hospital, Amy presented to the Network how Chase Farm Hospital moved to a new hospital building and implemented a new Electronic Patient Record (EPR) system whilst ensuring patient safety was maintained. We asked Amy to share her insights in a blog for the hub. Amy highlights the challenges she faced, how she engaged staff, the issues that came up and key takeaways from it. Background Chase Farm Hospital, part of Royal Free London, is a small elective, surgical hospital. At the time, it was made up of old buildings, not fit for purpose, spread across a large area. Example of the old building From August to September 2018, we moved the hospital to a new building with theatres, including a barn theatre and a 50-bedded ward. The new hospital had been designed to be paperless and so we also had to implement a new EPR system at the same time. Example of the paper-based system before the move The challenges As with all big organisational changes, there was a lot of meetings held with various staff members. At the time, the Royal Free London was divided into business units, each with their own executive management teams. One of the challenges was that not all of the staff who worked at Chase Farm Hospital and who would be affected by the changes were managed by our business unit. This meant they weren’t always invited to meetings and they didn’t always hear the crucial information. We had to find ways to ensure that these staff not only heard the key messages but that they felt included in the process. The move meant there was going to be new ways of working required and, as expected, we encountered reluctance to change with some staff. Naively we saw this change as two different projects, not one big change. However, when we spoke with staff we realised that they saw the projects as one big change and that we were going paperless because we were moving to the new hospital building. This became apparent when we began to engage with staff in small groups or one on one. We had to weigh up change fatigue with the benefits achieved of finishing the project. Engaging staff There was a long period of working with staff beforehand. It took 5 years to build the new hospital building, so we had time. We knew that for this to work well we needed to engage staff. We made sure that we spent lots of time with staff preparing them and listening to their concerns. We recognised early on that most staff couldn't attend dedicated meetings as generally these are only attended by managers. This meant that messages were not always being conveyed to staff and that frontline staff were not given the opportunity to ask questions or raise concerns directly to the decision makers. We needed to meet staff where they were, so the governance team were asked by the medical director to block out time to go to clinical departments and admin offices to speak with staff directly. Why the governance team? Because we were already well-known to many of the staff and had a reputation for being people that they could be open and honest with. We had the skills to listen to staff concerns, reassure them, and tactfully reiterate their concerns to senior leaders and decision makers. Through this engagement, we were able to adjust communications and identify areas or individuals who may benefit from additional at-the-elbow support. There was involvement from staff in the design. The new building was designed to use space and resources more efficiently; some old workflows were not going to work in the new building. An example was that we moved to a ‘barn theatre’ with four surgeries going on at the same time in one operating theatre. In our old building, staff were used to single theatre rooms. We had to talk through the benefits of this with staff but also hear their concerns. Some people didn’t want to move, they liked their current set up and there was some anxiety about the move and the digitisation. We identified those who may struggle more and made plans to make additional support available to them if they wanted it. We found the influencers—those who were going to champion the move and the changes—and they helped us get their colleagues on board. For the EPR part of the project there were staff members who had a greater interest and underwent 'superuser' training to be able to support their colleagues. We provided additional at-the-elbow support to those that wanted it. We took staff around for tours of the new building and the layout at different stages. How did it go? Not everything will go as planned or expected. How you respond to these issues is important. There were issues daily and we made sure we did huddles and had floor walkers to capture these issues quickly, escalate them to those that can resolve them. Importantly, our floor walkers fed-back to staff so that they knew the issues were being addressed. The move occurred in a phased approach, with new services moving every few days. As each new service moved, their department leaders joined the huddles. There was shared learning between services, with early-moving departments helping those that moved in later. We continued to hold regular huddles until all initial snagging issues had been raised and resolved, just reducing frequency when it felt right. Department leaders were advised that they were welcome at all huddles but could stop attending when they felt it was no longer of benefit to them. We did the same thing when we went live with the new EPR system. Once staff were in the new building, we asked them how it was working. On paper we had great pathways that would work well but in reality in some places the pathways were not working. Luckily the flexibility of the design of the hospital and the honesty of the staff in raising when workflows didn’t work meant that we were able to review and amend pathways. There were still things that we didn’t pick up on. Some staff weren’t happy. But we listened. It was important that the leadership team listened and were responsive to the feedback. We had good relationships with the CEO and Medical Director and we were able to talk to them and feed back. They took this onboard really well and discussed how to address it. It’s important the leaders are visible to staff and do walkabouts. Even though the staff may not always tell them how they felt, it was still important they were seen. Some staff were initially suspicious of the governance team being in their departments, particularly in clinical areas and with staff that did not know us previously. There was concern that we may be there to audit them or tell them off. We addressed this by introducing ourselves and explaining why we were there. Something that really helped us gain trust was being able to fix something for staff, either in the moment or by raising it to the team that could fix it. Importantly, we always tried to feedback directly to staff so that they knew that we had listened and were trying to help them. There were also patient facing elements. We had factored in the obvious changes that would affect the patients; for example, with the check-in process, and this was worked through. However, other factors had not been considered; we recognised early on after the move that more support was needed for patients to navigate the pathways and the changes that impacted them. Key take aways Team approach – decision makers, experts and influencers. Staff engagement – do not expect staff to come to you, you need to go to them. Plan for issues – how are you going to pick up issues and feedback to staff. The project doesn’t end at implementation. To earn staff trust – listen and fix something for them. Going live isn’t the end. There has to be continued conversations and observations. Find the truth. The new Chase Farm Hospital Patient Safety Management Network You can apply to join any of our networks by signing up to the hub today. When you complete the registration form you’ll see a section called ‘Join a private group’, please tick the box by the relevant Network. If you are already a member of the hub, please email [email protected].

The RiskReimagined 2026 Conference is a premier event for sharing best practice and innovation, designed to help NHS professionals move from awareness to applied implementation. Delegates will gain hands-on frameworks, tested delivery models, and peer-derived insights on embedding safe, equitable, and sustainable transformation within their organisations. Dedicated Skill Clinics provide practical tools, checklists, and implementation templates for enhancing governance, risk oversight, and incident response. Lessons Learned Sessions offer candid reflections from NHS leaders on real-world challenges, course corrections, and successes. This is not a showcase of what to achieve, but a skills exchange on how to achieve it, translating national ambition into measurable improvement. This year’s event is structured around clear outcomes. Delegates will leave understanding: Evolving governance for safer care: clarifying responsibilities for safety oversight at system level and strengthening board leadership, accountability, and assurance around quality and risk. Applying AI and early warning systems: improving early identification of emerging risks and embedding proactive approaches to risk management into everyday clinical practice. Building a learning culture from incidents: encouraging open reporting, meaningful follow-up, and consistent learning from incidents, including effective use of PSIRF, HSSIB insights, and safer medicines management. Strengthening the Estate infrastructure: addressing weaknesses in estates, equipment, and organisational preparedness, while strengthening plans to maintain care during disruption. Improving continuity and trust in patient information: supporting joined-up care through better stewardship, sharing, and governance of patient records, enabling a single, trusted view of the patient journey. Building workforce risk capability: through targeted training, multidisciplinary governance structures, and safety leadership aligned with People and Quality frameworks. Why attend: Earn 8 CPD Points by attending. Build professional confidence through applied, hands-on learning. Access ready-to-use frameworks for governance, interoperability, and workforce transformation. Hear real experiences from peers and leaders driving NHS improvement. Leave with practical artefacts, toolkits, and action plans for local rollout. Join a community of NHS professionals committed to capability-building and sustainable delivery. Who would benefit: This conference is ideal for Board Members, Chief Executives, Governance and Quality Leads, Patient Safety Managers, Risk and Assurance Directors, and ICS Executives driving NHS transformation. It will also benefit clinical and operational leaders, CCIOs, CIOs, service managers, and workforce planners seeking practical guidance on embedding safety, accountability, and resilience. Suppliers, digital partners, and academic collaborators will gain insight into implementation priorities, workforce skill gaps, and the real-world enablers shaping the next decade of NHS transformation. Register