Source · Select Committees · Public Accounts Committee
Recommendation 2
2
Accepted
Establish a national framework for patient safety with clear targets and improved complaints system.
Recommendation
The NHS has not done enough to tackle the underlying causes of harm to patients. The Department and NHS England’s approach to patient safety lacks coordination. Patients often pursue legal action to get answers and accountability due to a confusing and unresponsive complaints system. Neither the Department nor NHS England know how 3 much cost the NHS incurs treating patients it has harmed each year, but research suggests it could be significant. There is also evidence to suggest that a better initial response to harm, such as timely apologies or explanations, could reduce both the number of claims and cost of clinical negligence. We were also told during our informal private roundtable that effective compassionate, local resolution is both ethically right and fiscally responsible. Recent reviews have found that the NHS is overwhelmed by safety recommendations that it cannot action and one person we spoke to as part of our roundtable referred to the NAO’s findings on this as the NHS drowning in recommendations. Despite the Department’s stated commitment to improve patient safety and reduce harm, it has yet to outline any of the specific measures it will take to achieve this. It is also not clear how the abolition of NHS England will impact future patient safety arrangements and the little progress made to date. recommendation a. The Department must set a national framework for improving patient safety with clear targets for annual improvement. b. The Department must review the NHS complaints system and improve the number of cases that are resolved without recourse to litigation. c. The Department should estimate and track the costs to the NHS of treating avoidable harm. d. The Department should write to the Committee to set out progress in implementing the Dash Review and its assessment of the impact of abolishing the Health Services Safety Investigations Body (HSSIB) on patient safety. e. The Department and NHS England should have a clear system of accountability fo
Government Response Summary
The government states it has already implemented a national patient safety framework (2a) and reviewed the complaints system (2b) through the NHS Patient Safety Strategy (2019). For estimating costs of avoidable harm (2c), it explains that comprehensive tracking is not feasible but can demonstrate costs avoided through safety improvement work.
Government Response
Accepted
HM Government
Accepted
The government disagrees with the Committee’s recommendation The wider question around the health economics of patient safety will be explored as part of the forthcoming update to the NHS Patient Safety Strategy by working with academics and health economists to better understand how to cost patient safety. The department does not believe a system to track the costs to the NHS of treating avoidable harm would be financially or logistically feasible. Calculating costs of treating ‘avoidable’ harm would be very complex. There is no single, cost-effective mechanism for identifying ‘avoidable’ harm in healthcare. A methodology to calculate could be based on ‘events prevented x average Healthcare Resource Group tariff price for the relevant admission type’, however this does not represent the full economic or opportunity cost of care and estimation of ‘events prevented’ would be very challenging. Further, calculating this for all types of harm across the NHS would require significant investment in clinical review capacity, financial analytics and back-office support in NHS organisations to calculate costs associated with incidents. This does not align with the government’s 10 Year Health Plan and ongoing approach to workforce. However, the department can demonstrate costs avoided through the patient safety improvement work outlined in recommendation 2a above and in the evidence previously provided on progress made against the NHS Patient Safety Strategy. 2d. PAC recommendation: The Department should write to the Committee to set out progress in implementing the Dash Review and its assessment of the impact of abolishing the Health Services Safety Investigations Body (HSSIB) on patient safety. The government agrees with the Committee’s recommendation in July 2025. The report contained nine recommendations which the government accepted in full and are reflected in the 10 Year Health Plan). Progress is being made on implementing the recommendations. The recommendation to abolish the Health Services Safety Investigations Body and transfer functions to a discrete investigation unit of the Care Quality Commission requires primary legislation to implement. The department is aiming to simplify the patient safety landscape to make it easier for patients to navigate and to be clear where responsibility and accountability sit at all levels of the system. Protecting patient safety functions is integral to this work. Alongside introducing the relevant primary legislation, the department will develop a detailed plan to ensure the patient safety functions of HSSIB are protected throughout the organisational transition. A full impact assessment in line with HM Treasury's Green Book standards and an equality impact assessment are being produced. These will be published on the government website when legislation is introduced in Parliament. 2e. PAC recommendation: The Department and NHS England should have a clear system of accountability for patient safety, learning from mistakes and sharing what works, implementing best practice across the NHS streamlining patient safety alerts and recommendations from national bodies. The government agrees with the Committee’s recommendation Recommendation implemented NHS England is required to collect information about what goes wrong in the health service, using this to provide advice and guidance ‘for the purposes of maintaining and improving the safety of the services provided by the health service’ (Health and Social Care Act 2012). The Learn from Patient Safety Events service (LFPSE) now learns more from than 3 million patient safety incidents recorded each year through the development of machine learning and AI tools for analysis. LFPSE reviews hundreds of incidents weekly to look for new and under recognised risks that can be acted on including through issuing National Patient Safety Alerts, or developing national guidance in collaboration with partner organisations, such as royal colleges and the Medicines and Healthcare products Regulatory Agency. This saves an estimated 160 lives per year and £13.5 million in treatment costs per year through risk mitigation. The way the NHS responds to patient safety incidents has been reformed through introducing the Patient Safety Incident Response Framework (PSIRF). The PSIRF is a contractual obligation for all Trusts, supporting safety learning with a reduction in bureaucracy, greater patient and family involvement and more effective, timely learning through proportionate responses focused on driving improvement. The NHS has clear accountabilities for patient safety as set out in National Quality Board guidance. The changes the department is making as a consequence of the 10 Year Health Plan and Penny Dash’s review of patient safety across the health and care landscape will improve quality and safety by clarifying where responsibility and accountability sit at all levels of the system.