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Stefan Peil summarises a pilot study he has done to see whether a structured systems model can support the preparation of a morbidity and mortality (M&M) conference discussion. The example used is a coronary angiography risk scenario to explore whether a model-based representation of patient safety knowledge could serve as a reliable basis for an artificial intelligence (AI)-assisted decision template. The work was produced to address a practical problem in patient safety: relevant information for M&M preparation is often spread across diagrams, reports and team knowledge, which can slow and make shared understanding less consistent. The pilot study, therefore, examined whether systems modelling could help organise, make transparent and reuse safety relevant information in a more structured way. The full study is attached at the end of this page. The challenge The identified challenge was the lack of a structured, reusable approach to preparing patient safety discussions for M&M conferences. The aim was not to automate clinical judgement, but to test whether a model-based risk analysis derived from team knowledge could serve as a structured input for drafting an M&M decision template. M&M preparation often relies on fragmented information and informal interpretation. In complex clinical environments, such as coronary angiography, risks do not arise from a single isolated factor. They emerge from the interaction between tasks, people, technology, information flow and organisational conditions. In this specific pilot example, the safety concern was a risk scenario in coronary angiography in which cognitive overload during real-time decision-making and escalation could contribute to complications not being detected in time. This formed the basis for testing whether a structured model could provide a clearer and more traceable starting point for discussion. Method and measures To explore this, a systems model based on Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 was created in Systems Modeling Language (SysML) using SPARX Enterprise Architect. The objective was to represent the work system, the contributory task factor, the resulting risk and the proposed measures in a traceable form. The model focused on one coronary angiography scenario. The critical task factor was described as cognitive density in real-time decision-making and potential escalation. In the model, this contributed to the risk that complications would not be detected in time. The text states an impact on quality of care, an occurrence rating described as relevant and an overall risk class of moderate. The proposed measures were: pre-procedure briefing risk-adapted staffing standardised laboratory layout regular simulation drills. The intended achievement was a more structured, transparent and reusable basis for M&M preparation and discussion. Outcomes and lessons learned The pilot showed that a structured model can be a useful way to organise safety-relevant knowledge. Because the model linked work system elements, risks and measures in a traceable way, it provided a clearer starting point for discussion than unstructured text alone. The practical process tested in this pilot was: defining a relevant patient safety scenario in coronary angiography modelling the work system and the contributory task factor linking this to a patient safety risk documenting possible mitigating measures using the model as the basis for an AI-assisted one-page decision template. One important observation was that the AI-generated output reflected the underlying model's content. This suggests that a structured model can support more consistent synthesis than relying only on memory or informal interpretation. The text does not describe multiple alternative technical approaches in detail, so it cannot be stated from the source whether other options were formally compared or ruled out. It also does not state direct patient involvement. Staff involvement is referenced indirectly by using team knowledge as an input to the model. The text does not report formal measurement tools, outcome metrics, time savings, patient safety indicators or model costs. Therefore, no validated impact measurement can be claimed from the source. A key lesson learnt was that AI can assist with drafting and synthesis, but cannot replace clinical judgement, governance or safety review. Any output generated from the model still needs to be checked against the source material and reviewed by responsible clinical and patient safety leads. Impact This work is only a prototype, not as a formal effectiveness study. As a result, the impact that can be claimed is limited. The main result was that the structured model appeared to support: clearer organisation of safety-relevant knowledge better traceability between work system factors, risks and proposed measures a more consistent starting point for multidisciplinary discussion reuse of modelled information for drafting a one-page M&M decision template. At the same time, the the study is explicit about what was not demonstrated. The pilot did not test whether the approach: improved patient outcomes reduced harm shortened preparation time in routine practice improved care delivery in a measurable way. A further limitation was that only a single, limited example was used, and some information was withheld for data protection reasons. This means the results were narrower than would be needed for broader implementation decisions. What worked was the structured linkage between the work system, contributory factors, risks and measures. What remains uncertain is whether this translates into measurable operational benefit in routine clinical governance. A likely barrier to improvement is the need for continued expert review, because AI-generated output cannot be used without clinical validation and governance oversight. If repeated, the next stage would need a clearer evaluation design, including defined measures of clarity, consistency, usability and possibly preparation time. Next steps The next step is a practical pilot in real clinical governance settings. A suitable next-stage comparison would be conventional M&M preparation versus model-supported preparation in a small, clearly defined pilot. The proposed questions for the next phase are: Does the approach improve clarity and shared understanding? Does it help teams identify contributory factors more systematically? Does it support consistency and traceability of measures related to patient safety? The study does not provide evidence of long-term organisational change, staff reaction, patient impact statistics or system-wide implementation results. Therefore, those elements cannot yet be stated as outcomes. However, based on insights from the pilot study, the anticipated longer-term value would be to make patient safety knowledge: more structured more reusable easier to discuss across professional groups more clearly linked to the wider work system rather than to isolated errors. A sensible next step would, therefore, be a controlled local test with defined governance, clinical review and evaluation criteria before any broader adoption.

On 3 July 2025, the UK Government published its 10 Year Health Plan for England. In the following months there has been much commentary on the practical implications of this and how it will impact patient safety, and healthcare more broadly.  This article brings together reflections from organisations and individuals on the Plan’s vision for the future of the NHS. The 10 Year Health Plan for England identifies four major challenges shaping the future of healthcare in England: An ageing population living with multiple health conditions. Changes in illness, with more than a quarter of the population having a long-term health condition. Higher public expectations of how the NHS should provide services. Increases in cost, with health spending in England meeting the Organisation for Economic Co-operation and Development (OECD) average but achieving worse outcomes. To take on these challenges, and act on the opportunities available, the 10 Year Health Plan reimagines the NHS through three radical shifts: 1. Hospital to community- envisioned by the initiation of “a historic expansion of provision in people’s neighbourhoods. By bringing more integrated services into local communities, patients will have more power to tailor care to their individual needs and more convenient access.” 2. Analogue to digital - transforming the NHS “from being a bricks and mortar service to a digitally led one, where patients can access care online and offline 24 hours a day, 365 days a year. By embracing the digital revolution, we will give patients the ability to control their appointments, choose their providers and access the help they need to manage their health and their care.” 3. Sickness to prevention - with a goal to “halve the gap in healthy life expectancy between the richest and poorest regions, while increasing it for everyone, and to raise the healthiest generation of children ever. This will boost our health, but also ensure the future sustainability of the NHS.” Commentaries on the Plan and its implications for the future of health and care Below are several different perspectives on the 10 Year Health Plan for England that we have added to the hub: Patient Safety Learning In our response to the Plan we highlighted that although it disappointingly does not recognise patient safety as one of its core themes, it does set out a welcome ambition to tackle some of the key underlying causes of avoidable harm. We sought to elaborate on this, setting out why patient safety needs to be at the core of the delivery of this new Plan. Much of the focus of our response concerns two of its three radical shifts: “Hospital to community” and “Analogue to digital”. Our response notes: In seeking to create a Neighbourhood Health Service, service redesign and plans should ensure that patient and staff safety is core to how care is delivered, unnecessary hospital admission is prevented and early discharge is supported. If the NHS is to become a fully digitally enabled service, patient safety will need to be at the heart of the introduction, implementation and operationalisation of new technologies and innovations, particularly AI-enabled care. A strong emphasis is placed on patient choice in the Plan, but relatively little is said about the role of patient and public involvement in shaping healthcare services—beyond engagement through new digital portals. Coupled with the proposed centralisation of patient experience functions within the Department of Health and Social Care there are valid concerns this could weaken the strength and independence of the patient voice. The absence of considering and responding to problems with NHS culture is a significant oversight in the 10 Year Health Plan. If the healthcare system is to truly be transformed over the next decade, then we cannot simply proceed by ignoring these issues or assuming they will resolve themselves. The Plan does not address the absence of systematic approaches to sharing learning about avoidable harm, the inadequacy of joined up approaches and user-centred design in solution development. Read more here. From analogue to digital: Tackling inequality and digital exclusion in the future NHS In this blog, Katie Heard from the Good Things Foundation considers the digital implications of the 10 Year Health Plan. She reflects on the benefits and risks for those who are digitally excluded, what more can be done and how existing resources can help support further progress. Read more here. Compassionate leadership and the 10 Year Health Plan: address moral injury In this blog Naja Felter and Alistair Thomson, noting the recognition of moral injury in the 10 Year Health Plan, make the case for compassionate leadership. They highlight there is ample evidence for the impact of this style of leadership in health and social care, including higher quality care, greater patient satisfaction, lower levels of workforce stress and burnout, and improved financial organisational performance. Read more here. Dazed and confused? Policy ideas behind the 10-Year Health Plan In this article, Phoebe Dunn, Nicholas Mays and Hugh Alderwick ask whether the 10-Year Health Plan is a coherent blueprint for ‘reimagining’ the NHS, or a collection of ideas pulling in different directions? They identify five policy ideas that seem to guide key proposals in the Plan, draw on evidence about their potential impact, and stand back to see what it all adds up to for the NHS. Read more here. Patient Power: energising the 10-Year Health Plan through patient partnership This is a video of a Patients Association online event that considered what needs to be done to ensure patient partnership is in the foundations of the 10 Year Health Plan. The session explored what meaningful patient agency looks like in practice, drawing on real-life insights from the Patients Association helpline and focus groups. Watch the recording. How will waiting times in community health services affect the shift towards neighbourhood health? Community services are under growing strain, with more than 1.1 million people waiting for care, and the steepest rise among children and young people. In this Quality Watch article, Jessica Morris notes that focus to date has largely been on efforts to improve waits for hospital care, but as neighbourhood health services are rolled out, addressing pressures on community services will be essential if the ‘hospital to community’ shift is to become a reality. Read more here. Podcast: Alan Milburn on the 10-year health plan In this podcast, The Health Foundation speaks to Alan Milburn about the future of the NHS and his thoughts on the government’s 10-Year Health Plan. Alan was Secretary of State for Health from 1999 to 2003, during the Blair governments, with his tenure seeing the development of the NHS Plan (2000) and record levels of investment. As Lead Non-Executive Director at the Department of Health and Social Care, Alan also had a hand in writing and developing the new plan. Read more here. What does the NHS 10 Year Plan mean for dementia? In this article, Alzheimer’s Research UK reflects on what the Plan means for people affected by dementia. It considers how it will potentially impact dementia diagnosis, new treatments, improving brain health and prevention. Read more here. Share your views with us What is your opinion on the 10 Year Health Plan? In the coming months we would like to feature more perspectives on how ideas and proposals flowing from this Plan are impacting how the NHS approaches patient safety. We would welcome your views and experiences of this. You can comment below (sign up to the hub first for free) or email the team directly at [email protected] to share your views.

Harnessing the contribution of support staff, and the wider population, is crucial in both determining the success of service transformations and shaping health outcomes. The fourth seminar in the Health Education England series will discuss the importance of whole system design and transformation and maximising everyone’s contribution to promoting and protecting the public’s health, as well as the significance of encouraging new and emergent roles and routes into health and care systems. Register