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On the 14 May 2026 the UK Government introduced the Health Bill in the House of Commons, also known as the NHS Modernisation Bill. This new legislation is intended to introduce two significant changes, joining up health information and abolishing NHS England. This article pulls together a number of different reflections shared on this bill as it proceeds through Parliament. The Health Bill 2026-27 is a new piece of Government legislation which aims to: Improve patient safety and experience through a new single patient record, enabling joined-up, proactive care and empowering patients. Put power and resources in the hands of frontline NHS organisations by abolishing NHS England and stripping back national bureaucracy. Clarify the role of local health bodies, giving them real flexibility to design and deliver health services to best meet the needs of their local populations. Department of Health and Social Care The UK Government has published a collection of resources about the Health Bill, including fact sheets on the following topics: Single Patient Record Role and functions of the restructured Department of Health and Social Care Data and digital functions Oversight of the health system Integrated Care Boards as strategic commissioners Providers Patient safety Patient voice Patient Safety Learning Following the announcement of the NHS Modernisation Bill in the King’s Speech 2026, Patient Safey Learning published an article highlighting six key takeaways from this speech from a patient safety perspective. This includes reflections on specific provisions in the Bill including: Transferring the Health Services Safety Investigations Body functions to the Care Quality Commission. Creating a new single patient record. Transferring the functions of Healthwatch England to the Department of Health and Social Care and creating a new Patient Experience Directorate in the Department of Health and Social Care. Abolish NHS England and making several changes to the role of Integated Care Boards. The King’s Fund The health and care charity and think tank The King’s Fund have created on a new area on their website where they are sharing all their latest analysis, commentary and responses on the Health Bill as this legislation developments. This includes an article by their Chief Executive Sarah Woolnough setting out five tests for the NHS Modernisation Bill. Nuffield Health In this article, Becks Fisher, Director of Research and Policy at the Nuffield Trust, discusses key issues raised by the NHS Modernisation Bill. He considers this in the context of the departure of Wes Streeting MP as Secretary of State for Health and Social Care, and his replacement with James Murray MP. Health Service Journal In this episode of the Health Service Journal Health Check Podcast, Annabelle Collins and Dave West are joined by Hugh Alderwick, Health Foundation director of policy and research, to help unpick the 200-page legislation and what it will mean for the service. House of Commons This article provides a brief overview of patient safety issues raised in a debate in the House of Commons on Monday 1 June 2026, during the second reading of the Health Bill 2026-27. The second reading is the stage of the UK legislative process where Members of Parliament (MPs) debate the general principles and main purpose of a proposed piece of legislation. Carnall Farrar (CF) In a helpful infographic, CF’s snapshot of the NHS Modernisation Bill focuses on the provisions most relevant to NHS leaders and executives: what is changing, when, and what it may mean in practice.

The King’s Speech 2026 sets out the programme of legislation that the UK Government intends to pursue in its next parliamentary session. This blog highlights six key takeaways from this speech from a patient safety perspective. On Wednesday 13 May 2026, Kings Charles III delivered his annual speech in the Lords Chamber at the State Opening of Parliament.[1] Written by the Government and delivered by the Monarch, the speech presents opportunity at the start of a new parliamentary session for a government to set out its plans for the year ahead. This year’s speech includes two pieces of proposed legislation that have, potentially, significant implications for patient safety: NHS Modernisation Bill Public Office (Accountability) Bill In this blog, we highlight six takeaways from these proposed bills from a patient safety perspective. 1. Future of the Health Services Safety Investigations Body The NHS Modernisation Bill includes several changes to the patient safety landscape in England. These involve the implementation of several key recommendations put forward in Dr Penny Dash’s Review of patient safety across the health and care landscape last year.[2] This includes the recommendation to transfer the Health Services Safety Investigations Body (HSSIB) functions to the Care Quality Commission (CQC). In our response to the Dash Review, we stated our belief that HSSIB has an important independent role in the health system which should be retained.[3] There are understandable concerns about the potential for its independence to be compromised by its functions being transferred to the CQC.[4] [5] More broadly, we know that many staff working in healthcare do not feel confident raising concerns. As NHS Staff Survey results continue to illustrate, nearly two-fifths of staff say they do not feel safe to speak up about concerns.[6] Recognising the importance of staff feeling able to speak freely in investigations, HSSIB currently conducts these using a ‘safe space’ approach. This prohibits, on a legal basis, the unauthorised disclosure of protected material. Even if this legal assurance is maintained under these proposed changes, there still may be concerns that moving HSSIB into the CQC could potentially undermine staff confidence that confidentiality will be maintained. 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 understand what the risks to patient safety are and the action needed to address these. We await further detail in the NHS Modernisation Bill on how these challenges will be addressed. 2. Embedding patient voice in national decision making Other notable recommendations from Dr Penny Dash’s review expected to feature in the NHS Modernisation Bill include: Transferring the functions of Healthwatch England to the Department of Health and Social Care. Developing a new Patient Experience Directorate in the Department. In our response to the Dash Review, we welcomed the proposal to create a new National Director of Patient Experience, alongside a Patient Experience Directorate. A new central body offers potential benefits for pooling expertise and resources. However, questions remain as to whether these changes could risk making the routes through which patient experience and concerns influence decision making less visible and more diffuse.[7] [8] [9] [10] It is vital that these changes improve the health systems capacity to listen and respond to patient experiences. We believe that an important element of this will be ensuring this new Patient Experience Directorate can benefit from regional and local experience and expertise. We would expect to see further detail setting this out in due course, considering how this will connect with local models for engaging with patients, families and carers. Specifically, we would also seek clarity on how this Directorate will work with local and national Patient Safety Partners, whose roles were not mentioned in the Dash Review. 3. Creating a new single patient record Another key strand of the NHS Modernisation Bill will be plans to create a new Single Patient Record. This is intended to “enable people to see their own health records securely on the NHS App, empowering them to make informed decisions about their own health”.[11] In our response to the 10 Year Health Plan for England, we stated our support for this initiative.[12] It is broadly acknowledged that if implemented effectively, this could make a real difference in improving joined-up communication in the NHS.[13] Patients not only need easy access to their records, but simple mechanisms to flag concerns and address any inaccuracies in a timely manner. Mistakes in records can create significant patient safety risks, and as illustrated by patient experiences shared with us on our patient safety platform the hub, amending these is often not a simple process.[14] 4. Introducing the Hillsborough Law The proposed Public Office (Accountability) Bill would put in place a new professional and legal Duty of Candour—meaning public officials must act with honesty and integrity at all times. This was previously announced in September 2025 and the Bill itself has already been tabled in Parliament.[15] We welcome this legislation. 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. The proposals in this new legislation have greater scope than the existing statutory Duty of Candour in the NHS, with a focus on systemic institutional behaviour. It is also notable that these provisions of the Bill will apply to the whole of the UK, not just England and Wales. 5. Abolition of NHS England The NHS Modernisation Bill will legislate to integrate NHS England’s functions into the Department of Health and Social Care, as first announced last year.[16] While we are still waiting further detail of what this will look like in practice, the existing National Patient Safety Team at NHS England is likely to be impacted by these changes. This Team is currently responsible for owning various patient safety programmes and policies and issuing safety warnings and recommendations. As stated in our response to the 10 Year Health Plan for England, an area of concern for us remains the lack of significant capacity to intervene if necessary for the purposes of improvement at a national level. Alongside this, there is also currently no national body able to commission or develop solutions that all organisations can use and adapt to improve patient safety. If healthcare providers identify a systemic issue that needs to be addressed because it affects other organisations, there is no national organisation that has the role or capacity to act on this. Instead, providers are left to find local solutions to system-wide concerns without a vehicle for widespread dissemination and evaluation. We believe this gap places a serious limitation on the healthcare system’s ability to reduce avoidable harm. It does little to address the inconsistencies in care across the country, with multiple different responses and workarounds to system-wide problems with varying levels of success. It is also a significant missed opportunity if we fail to take learning gained from provider organisations and apply this nationally for improvement in a meaningful way. This is an issue we think should be considered and addressed in the future merger of NHS England and the Department of Health and Social Care. 6. Changes to Integrated Care Boards Finally, the NHS Modernisation Bill will also include several changes for Integrated Care Boards (ICBs), including: Refine the membership of ICBs. Placing new requirements for mayoral nominees to be on ICBs. Confirming their role as strategic commissioners, by transferring responsibilities for all but the most specialised commissioning functions to ICBs. In a joint blog with the Advancing Quality Alliance (Aqua) earlier this year, we noted that there is huge opportunity for ICBs to drive a systemic approach to patient safety through their strategic commissioning responsibilities.[17] [18] [19] However, there is currently significant variation in ICBs involvement in safety management activities.[13] With the right support ICBs have the potential to develop an integrated and coordinated approach to safety, reflecting patient care pathways across systems and ensuring consistency and collaboration. We would hope to see this included in these changes considered in the provisions of the NHS Modernisation Bill, and in the forthcoming new NHS Quality Strategy. References Prime Minister’s Office. 10 Downing Street. Oral statement to Parliament: The King’s Speech 2026. 13 May 2026. Department of Health and Social Care. Review of patient safety across the health and care landscape. 7 July 2025. Patient Safety Learning. Review of patient safety across the health and care landscape: Patient Safety Learning‘s response. 15 July 2025. 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. Patient Safety Learning. Patient Safety Learning’s response to the NHS Staff Survey Results 2025. 13 March 2026. Martin G, O’Hara J. Hope over experience? Patient and staff voice in the NHS after the Dash review. 1 2025;390:r1514. Cox C. Is the patient voice fading? Reflections on patient safety in a changing NHS. Patient Safety Learning. 28 January 2026. Morris L, et al. The Kings Fund. The future of patient voice: learning from the Healthwatch model. 18 March 2026. Patient Safety Learning. Patient voice, safety and the NHS 10 Year Plan: Reflections from the Patient Safety Forum 2026. 23 March 2026. Prime Minister’s Office. 10 Downing Street. King’s Speech 2026: background briefing notes. 13 May 2026. Patient Safety Learning. 10 Year Health Plan: Patient Safety Learning’s response. 14 August 2025. The Kings Fund. The King’s Fund responds to the King’s Speech and the introduction of the NHS Modernisation Bill. 13 May 2026. Anonymous. The digitalising of patient records – why patients MUST be involved. Patient Safety Learning. 16 April 2024. House of Commons. Public Office (Accountability Bill), Session 2024-26. Last updated 5 May 2026. Department of Health and Social Care. World’s largest quango scrapped under reforms to put patients first. 13 March 2025. Patient Safety Learning and Aqua. Patient safety and the new NHS Quality Strategy. 25 February 2026. 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 carer systems. 11 July 2023. Health Services Safety Investigations Body. Safety management: accountability across organisational boundaries. 13 February 2025.

This webinar, hosted by the International Association of Medical Regulatory Authorities, will explore how medical and health profession regulators and broader patient safety systems can work more closely together to strengthen care and reduce harm to patients. It aims to help improve understanding of the opportunities to better connect people and system focused safety systems, including through potential partnership models, to best support and ensure a safe and competent health workforce. Speakers include: Helen Hughes, Chief Executive, Patient Safety Learning Dr Gerry Hickson, Vanderbilt University Medical Center Professor Martin Fletcher, IAMRA Board Member You can sign up for the webinar here. Related reading Professional regulation and patient safety systems: parallel planets or partners in improvement?

Training to support the development of core understanding and application of systems-based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: purpose of patient safety incident response framework introduction to complex systems, system thinking and human factors restorative just and learning culture duty of candour involving staff in incident response involving patients, families and carers in incident response improvement science and developing system improvement plans general response techniques interviewing and asking questions conducting observations, understanding work as done systems frameworks response types patient safety investigation planning, analysis and report writing commissioning and oversight of an internal investigation a high-level overview of system-based response tools. Who should attend? Lead investigators; Executives, commissioning, and service leads for investigations; Investigators supporting or overseeing patient safety incident investigations Register hub members receive a 20% discount. Email [email protected] for discount code.

This training will support the development of expert understanding and oversight of systems based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: PSIRF and associated documents (PSIRP, PSII standards) oversight framework effective oversight and supporting processes related to incident response maintaining an open, transparent, and improvement focused culture importance of communication and involvement of those affected (preventing further harm) commissioning and planning of patient safety incident investigations complex investigations spanning different organisational, care setting, and stakeholder boundaries. Who should attend? Executives, commissioning, & service managers supporting service lead investigator roles The following only after attending the 2-day systems approach to patient safety incident response: All Executive, Commissioner and Service Leads for investigation; All Lead investigators conducting patient safety incident investigations investigators conducting Register hub members receive a 20% discount. Email [email protected] for discount code.

Training to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations. Being open and apologising when things go wrong. Challenges/complexities associated with cases where there is more than one investigation. Effective communication, including dealing with conflict and difficult conversations. Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation. Sharing findings. Signposting and support: including loss, trauma and stress. Who should attend? Lead investigators conducting patient safety incident investigations. Executive and service lead for duty of candour. Executive and service lead for patient safety. Executive and service lead for the supporting response to patient safety incidents. Investigators supporting patient safety incident investigations. Register hub members receive a 20% discount. Email [email protected] for discount code.

Protocols, targets and pathways save lives. They give us essential structure to deliver safe, high‑volume care with finite resources, and they have transformed the NHS for the better. But as the healthcare experience becomes increasingly streamlined, Hannah Little, Assistant Chief Nursing Officer at North Bristol NHS Trust, asks: who are we leaving behind? One size rarely fits all We often hear about what healthcare can learn from efficiency‑led industries such as automotive manufacturing, where success is defined by pace, scale and uniform outcomes. And indeed, cross‑industry learning has benefited the NHS enormously. But context matters. People are not cars rolling off a production line. We are complex, diverse human beings with individual social, psychological and clinical needs. And I wonder how far we can push a target‑driven model before we start hearing louder public concern about the fact that, in healthcare, one size rarely fits all. Finding the sweet spot As a nurse, I see individuals deliver personalised care brilliantly. I see colleagues who instinctively adapt, interpret and flex protocols to truly meet the needs of their patients and families. What worries me is not the people—it’s systems that increasingly constrains them. There is a 'sweet spot' between regulation, targets and national mandate on one side, and freedom to innovate on the other. That tension is necessary: too much control and we lose space for creativity; too little and we invite unsafe variation. When the balance is right, systems evolve safely, testing change within a clear structure while allowing for the flexibility that person‑centred care requires. The weight of national targets Standards and strong governance are essential to quality. But how do we ensure they don’t swallow the space needed for anything else? Over recent decades, the weight of national targets has grown heavier. The NHS Oversight Framework was intended to bring much‑needed clarity—a more focused set of national priorities that would reduce noise and strengthen local autonomy. At the 2026 Patient Safety Forum, national leaders spoke about a welcome cultural shift away from over‑mandating and toward local devolution. But this shift appears to be landing alongside a net reduction in resource and ever higher stakes to deliver. So instead of fewer mandates and more autonomy, we may be facing fewer mandates and less capacity for innovation. This raises a critical question: after the targets are met, is there enough resource left for the other things that matter? The things that support sustained performance? Targets tend to serve the 80% who fit neatly onto the healthcare conveyor belt. Without additional support for those who don’t, we risk widening health inequalities. Equity requires adaptability to be hard-wired into pathways—and adaptability requires headroom. The trade-offs Are we comfortable with where we are now? Has the pendulum swung into the place we need for 2026? Everyone recognises that resources are limited. But when limited resources necessitate laser focus on a small number of priorities, are the trade‑offs services have to make the right ones for population health? What will we think, looking back in five to ten years? Will we feel confident that a model which rewards optimising delivery for the majority was worth potentially widening the gap for those who didn’t fit standard pathways? Unlike other industries (e.g. Apple, which famously narrowed its product line to recover focus), healthcare cannot simply do fewer things well. Complex populations do not disappear because they fall outside a national priority. When centrally governed targets narrow without a corresponding rise in local capacity, the burden of adapting care falls to already stretched individuals. And when that happens, quality, equity and outcomes inevitably feel the strain. So what is the solution? If we care about equity and the safety and health of whole populations, resource to adapt and personalise care needs to be preserved. We need open, honest analysis of the trade-offs being made at policy level. Do we have the right set of priorities? Are we incentivising organisations to only pick low‑hanging fruit? And crucially: are we preserving the resource required to deliver personalised, equitable care? Passionate individuals cannot carry this burden alone. Flexibility must be designed into the system, not left to chance. And perhaps the answer is not fewer targets—but targets that incentivise equity as much as efficiency. Call to action Policymakers and senior leaders must prioritise embedding flexibility within national frameworks for all sectors by protecting resource for personalised care, incentivising equity alongside efficiency and enabling local systems to adapt. Without deliberate action, we risk incentivising services that work well for many, but fail those most in need.

When repeated harm occurs in healthcare, public debate often centres on identifying an individual responsible. Although accountability is essential, patient safety may be better served by asking another question first: Were there earlier signals that something was going wrong? This blog reflects the perspective of Aditi Desai, a surgeon with nearly three decades of clinical experience and an interest in patient safety systems, surgical quality monitoring and organisational learning. Recent high‑profile cases, such as the case of surgeon Yasser Jabbar at Great Ormond Street Hospital,[1] have prompted difficult reflection across the profession about how systems detect repeated patient harm. These situations understandably lead to questions about individual responsibility, but they also highlight the importance of recognising warning signals earlier. After nearly three decades in surgical practice, I have seen how outcomes can fluctuate. A surgeon may perform many procedures safely, then experience several complications in close succession. Some of this represents natural variation. But sometimes patterns emerge that should prompt earlier concern. Modern healthcare systems collect large amounts of clinical data, yet we rarely use it systematically to detect deteriorating performance early.[2] Risk‑adjusted monitoring of outcomes over time, combined with supportive mentoring and fair accountability, could help organisations intervene sooner, protecting both patients and clinicians. Improving patient safety requires moving beyond a simple choice between blaming individuals or fixing systems. Safer care depends on recognising both the human realities of clinical practice and the need for strong organisational oversight. Recognising the early warning signs of unsafe surgical practice Having practised surgery for more than 28 years, I have learned that clinical outcomes are rarely perfectly predictable. A surgeon may perform a hundred operations without complication. Then, within a short period, several adverse outcomes may occur—like unexpected bleeding, infection or an unintended injury during surgery. When this happens, patients suffer first and most. For clinicians, complications also carry a heavy emotional weight. Many doctors recognise the sleepless nights and intense self‑reflection that follow when a patient is harmed. In recent years, public discussions around cases of repeated patient harm have raised difficult questions about how healthcare systems detect unsafe practice. The case of Yasser Jabbar at Great Ormond Street Hospital, widely reported in the UK, has prompted reflection not only about accountability but also about whether earlier signals of unsafe care might have been detectable. The instinctive response is often to ask: “Who is the rogue clinician?” But from a patient safety perspective, an equally important question may be: “Where was the signal that care was becoming unsafe?” Distinguishing variation from unsafe care All clinical practice carries risk. Even highly skilled surgeons experience complications. Medicine is complex, and outcomes vary according to patient condition, procedural difficulty and chance. The real challenge is distinguishing between: Expected complication rates and natural variation, and Patterns that may indicate deteriorating performance or unsafe practice. This distinction is rarely straightforward. It requires careful interpretation of clinical outcomes and trends over time. The human side of surgical practice Medicine often expects clinicians to perform at a consistently high level throughout long careers. Yet surgeons, like everyone else, experience illness, fatigue, personal stress and periods of reduced resilience. Most clinicians continue working through these pressures because the culture of medicine places great value on strength, reliability and professionalism. Recognising this human reality does not diminish professional responsibility. Instead, it highlights the importance of systems that can identify when a clinician may be struggling and offer support or review before patient harm accumulates. The missing safety infrastructure Healthcare organisations collect vast amounts of data about procedures and outcomes. Yet in many systems, we still lack robust mechanisms that can: Risk‑adjust outcomes for patient complexity. Monitor outcome trends over time. Identify negative outliers early. Trigger timely peer review or mentoring. Such systems are not primarily about punishment. Their purpose is to protect patients while supporting clinicians to maintain safe practice. Moving beyond 'individual versus system' Patient safety discussions often frame harm as either the fault of an individual clinician or the result of system failure. In reality, safety depends on both. Strong systems should be able to detect emerging risks early, while still ensuring fair accountability when unsafe practice becomes clear. This approach aligns with the principles of a just culture, where organisations seek to understand and respond to risks rather than relying solely on retrospective blame.[3] A role for data, mentorship and oversight In other high‑performance fields, such as aviation and elite sport, continuous monitoring and coaching are routine. Medicine has traditionally been slower to adopt this approach. Yet supportive oversight and mentoring could help clinicians identify and address problems earlier in their careers or during periods of difficulty. Clinicians may benefit from ongoing coaching and feedback, not only during training but throughout their professional lives.[4] Surgeon and writer Atul Gawande, the WHO checklist pioneer, highlighted this idea in his TED Talk “Want to get great at something? Get a coach”, where he describes how even experienced surgeons can improve performance and safety through structured coaching and peer observation.[5] Looking forward Cases where repeated harm occurs inevitably raise questions about accountability. Where clear incompetence or unsafe practice exists, fair accountability is essential. But patient safety improves most when healthcare systems are able to recognise warning signs early, before serious harm accumulates. By combining risk‑adjusted data, supportive oversight and a culture of learning, healthcare organisations can better protect patients while supporting clinicians to maintain safe practice. Ultimately, safer care depends not only on responding to failure, but on building systems capable of recognising risk sooner. References Triggle N. Great Ormond Street doctor who botched surgery harmed nearly 100 children. BBC News, 29 January 2026. Royal College of Surgeons of England. Surgical outcomes data and transparency. Outcomes FAQ. NHS England. Being fair tool: supporting staff following a patient safety incident. 9 May 2025. Pradarelli JC, Yule S, Panda N, et al. Optimising the implementation of surgical coaching through feedback from practicing surgeons. JAMA Surgery, 2021; 56;(1): 42-49. doi:10.1001/jamasurg.2020.4581. Gawande A. Want to get great at something? Get a coach. TED Talk, April 2017.

Last month, Public Policy Projects 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 the recurrent theme of safe systems and safe cultures.  Safe systems and cultures formed an integral theme throughout the Forum. Across the discussions, one message stood out clearly—safety cannot be something we focus on only when inspections are approaching or when things go wrong. It has to be built into everyday practice. One speaker framed this idea simply—every day should be a CQC (Care Quality Commission) day. Not because staff fear inspection, but because the systems around them consistently support safe care. When systems work well, healthcare professionals can deliver the care they want to give without constantly battling the structures and culture around them. Yet the conversations during the day also highlighted how far many parts of the system still have to go… Fatigue—“I’ll sleep when I’m dead” A significant discussion focused on staff fatigue and the culture that has developed around it in healthcare. Rather than being treated as an exceptional risk, fatigue is something that is just expected. In some cases it has become a misplaced badge of honour—evidence of dedication to the job. The example phrase of “I’ll sleep when I’m dead” resonated with many. A response no doubt born from a sense of utter powerlessness and lack of evidence that things will change. But normalising exhaustion creates unsafe systems for both staff and patients. Senior Nurse, Maggie Pacheco, shared an example from her own experience. After working six consecutive night shifts she was asked to take on a seventh. It did not feel safe, and during that shift a near miss occurred. Her story reflected a wider reality—systems that rely on exhausted staff are systems that increase risk. Sue Strudwick, Patient Safety Partner, highlighted that fatigue also shapes how care is delivered. When staff are constantly depleted, the system pushes them into reactive responses rather than preventative thinking. Creativity, reflection and improvement require energy and time, both of which fatigue removes. If healthcare is serious about safe systems, then fatigue cannot remain normalised. Staff support must be prioritised and built into the design of rotas, policies and expectations. Structural change is required, not symbolic gestures. Staff safety as a foundation of safe systems The forum also highlighted the importance of ensuring that staff themselves feel safe at work. Healthcare workers continue to face violence, harassment, racism and sexual abuse in some workplaces. These experiences damage morale, wellbeing and the ability to focus on patient care. A safe healthcare system cannot exist if the people delivering care do not feel physically and psychologically safe themselves. Protecting staff is therefore not separate from patient safety—it is part of it. When silence signals risk Another strong theme was the importance of psychological safety, particularly when it comes to speaking up and raising safety concerns. Silence in an organisation is sometimes interpreted as stability. In reality, it can indicate the opposite. Panellists described the presence of “shut up signals” within teams and organisations—signals that speaking up is unwelcome or risky. These signals may appear through dismissive responses, defensive leadership or negative consequences after raising concerns. Once staff recognise them, they quickly learn that raising issues carries a personal cost. The impact on patient safety is significant. When staff do not feel able to speak openly about risks or mistakes, organisations lose their early warning systems. Problems remain hidden until they escalate into serious harm. Language and responses after incidents play an important role here. Punitive reactions can discourage openness and suppress learning. Safe cultures, by contrast, make it easier for staff to raise concerns and share information when something goes wrong. Many of the guests in our Speaking up for patient safety interview series highlight the same issues surrounding psychologically unsafe cultures, and the devastating impact this can have on patients and staff. From blame to systems thinking Closely linked to speaking up is the way organisations respond when incidents occur. Healthcare is a complex system where harm rarely results from a single individual’s actions. During the forum, Ted Baker, Chair of the Health Services Safety Investigations Body (HSSIB), highlighted the importance of shifting the question from “who is to blame?” to “how did the system allow this to happen?” Frontline staff frequently create workarounds to protect patients when systems or policies do not function well in practice. These adaptations often keep services running safely despite structural weaknesses. If organisations focus only on individual blame, they risk overlooking the system conditions that allowed harm to occur in the first place. A systems approach enables learning and improvement rather than fear and defensiveness. Leadership and culture change Underlying many of these issues is the need for a different style of leadership. Creating safe systems requires leaders who listen, collaborate and engage with those delivering and receiving care. Solutions are more likely to be sustainable when they are developed with frontline staff and patients rather than imposed from above. Working with patients, the public and Patient Safety Partners were repeatedly highlighted as an important part of cultural change. A healthcare system that values patient experience alongside operational metrics is more likely to identify risks early and respond effectively. What organisations measure also shapes their culture. When success is defined solely through activity and productivity, the human experience of care can easily be overlooked. Balanced measures that include safety and experience are essential for creating systems that truly support quality care. Culture is the system The conversations at the Patient Safety Forum made clear that safety cannot be separated from culture. Policies and processes matter, but the everyday behaviours, expectations and norms within organisations matter just as much. Safe systems are created when staff are supported rather than exhausted, when concerns can be raised without fear, and when organisations seek to understand system failures rather than simply assign blame. Changing culture is never quick or easy. But if healthcare systems want to improve patient safety, they must be willing to challenge the norms that have become embedded in everyday practice and redesign systems that allow safe care to happen consistently. Share your insights Have you seen patient safety affected either positively or negatively by culture and systems? Share your thoughts on this article and the issues raised by commenting below (sign up first for free). Or you can email our editorial team at [email protected].

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MedLed, in partnership with Midlands Air Ambulance Charity, is hosting a Human Factors & Patient Safety for Clinical Leaders course this June and spaces are now open to the wider healthcare sector. Human Factors & Patient Safety for Clinical Leaders is a 2-day face-to-face course built with pre-hospital care as its foundation: the high-stakes, time-pressured, operationally complex environment where Human Factors challenges are most visible. But the principles apply across all of healthcare, and we now have spaces available for clinical and non-clinical professionals beyond the pre-hospital community. What's covered? How human capabilities and limitations influence leadership, management, and the quality of care. Systems thinking and models of safety, moving beyond individual blame and the flawed concept of human error. Why practice doesn't always make perfect and how to recognise error-provoking conditions. The relationship between stress, physiological needs, and performance. Strategies for leading high-performing teams, including ad hoc teams under pressure. How to create an environment of psychological safety for your team. Register

Deborah Dover is an NHS Consultant Child and Adolescent Psychiatrist, a Topic leader for the hub, and a Director of Patient Safety. In this blog, she tells us more about the Patient Safety Director role and how it can be a powerful driver for safety improvement. When I joined East London NHS Foundation Trust (ELFT) as their first Director of Patient Safety, I quickly discovered that people were curious about what the job actually involves. Safety is something we all care deeply about, but the work behind building safer systems can sometimes feel hidden in the background. So, I wanted to share a little about what the role looks like in practice, why it matters, and how we’re trying to shape a more proactive and connected approach to safety across the organisation. Why the role matters Healthcare is delivered in busy, complex environments, and even with talented, committed teams and individuals, NHS systems often are far from reliable, and variation is commonplace. Safety science and systems thinking can really help us understand how to create safer and more resilient care. But historically most clinicians and leaders haven’t had formal training in these areas, and often the work of designing for safety isn’t owned by anyone at senior level. That’s where a dedicated leadership role can make a difference. Safety becomes much more than responding to incidents — it becomes something deliberately designed, coordinated and supported across the whole organisation. My path to the role I became the trust’s Director of Patient Safety in 2022 after several years in a neighbouring trust, supporting safety and improvement as a Deputy Medical Director and Associate Medical Director for Quality Improvement. As part of my induction, I attended the Institute for Healthcare Improvement’s Executive Patient Safety programme. Seeing how common Chief Safety Officer roles are in US healthcare, made me realise the opportunity there is for the NHS to go further in benefitting from senior, specialist leadership for safety. The role and its purpose Before I joined ELFT, the trust had undertaken an external review of patient safety, led by safety expert, Professor Carl Macrae. One of his recommendations was to introduce a board level role to take a more coordinated approach to safety. That review gave us a strong starting point to build from and using it as a foundation, I led the co design of an ambitious whole trust Safety Plan. The plan brings together work on patient safety, workforce safety and upstream, population level factors that influence safety. It’s built on a few important ideas: that equity and safety are inseparable; that patients and carers bring expertise we must include and that a compassionate, just culture underpins reliable care. There is also recognition of the importance of learning from all outcomes, not only when things go wrong and that safety systems must be future focussed, using intelligence to problem-sense, anticipate safety risks and respond to issues in a nimble way. Nationally, the introduction of the Patient Safety Incident Response Framework (PSIRF) has been a helpful enabler. It has supported our ongoing journey to ensure positive safety cultures, move toward systems thinking and forward-looking learning, and to involve patients and carers. Alongside this, we’ve been working on strengthening our focus on reliability, measurement for learning and anticipating risks early. What difference does a Director of Patient Safety make? Having a dedicated safety director is helping us bring clarity, focus and alignment to safety work across the trust. It has strengthened the links between safety, improvement, workforce wellbeing and population health and has supported us to build capability in safety science, so teams have what they need to improve. We now have a strong network of Patient Safety Specialists across services, alongside an in-house Lead Patient Safety Partner who brings her own lived experience and coordinates further service user involvement into our safety systems. Our online Safety Learning and Training Hub is making safety knowledge more accessible to all, with systems thinking also now woven into our leadership and improvement programmes. We are continuing to strengthen our approach to just and equitable culture, and are working to improve how we support both staff and service users after safety events. Recently we’ve begun collaborative research, learning from the way our safety system works, and how we can go further to integrate the key aspects within our Quality Management System to support proactive, whole system safety. We are also increasing our focus on population level safety insights and social determinants of safety outcomes, in line with our ambition for whole community safety. Our aim of safer care, safer people and safer lives across our communities is supported through all of this work. A call to action For organisations thinking about creating a Director of Patient Safety role, I would strongly encourage taking that step. As Ted Baker, Chair of HSSIB, recently said: “Safety is not just one of the domains of quality. It is the foundation on which other aspects of quality are built.” If safety is foundational, senior leadership for safety must be too.