Review of patient safety across the health and care landscape

A revamped, revitalised and reinforced NQB should be responsible for developing a comprehensive strategy to improve quality of care that is in line with the aims of DHSC and the NHS in England. This strategy should build on: This strategic approach should: More specifically, NQB should set out a vision of quality of care that: It should also build expertise in assessing healthcare value, including a more comprehensive assessment of: NQB should develop an overarching strategy for how improvement and innovation can best be supported across health and care, recognising: When it comes to data, NQB should: The organisation should be tasked with: This prioritisation should be based on high-quality analysis, including the evidence base for likely benefit, cost and cost-effectiveness, and fit with strategic priorities. As part of this, the NQB should: Responsibility for building and maintaining the register should sit within DHSC .

CQC should remain the independent regulator and oversight body across the health and care system. However, it needs to adopt tailored approaches to assessments by sector and within sectors, taking into account the structure of commissioners (including private health insurers) and providers, as described in more detail in the previous review into the operational effectiveness of CQC . As part of its assessment framework for larger organisations, it should focus on the role of boards, governance and accountability systems. It should assess boards on their ability to improve all aspects of quality of care while effectively balancing risks across organisations and wider health and care systems. For those (usually smaller) organisations where lack of governance structures may be more of an issue, it should offer a more customised approach. For all providers, it should draw on comprehensive and detailed data to meaningfully identify risks.

Most investigations into safety incidents should continue to be managed within provider organisations and commissioners ( ICBs ), with support from regions where required, to ensure they are: HSSIB should operate as a dedicated, expertise-led investigation facility that can be used in a responsive way to minimise the number of externally commissioned reviews and inquiries that might otherwise be required. HSSIB should collaborate with DHSC (through NQB ) to agree the scope of any investigations it carries out. Recommendations arising from all investigations should be considered as part of the clearing-house function of NQB . Consideration should be given to the role of HSSIB in improving the quality of other investigations (for example, service reviews led by royal colleges or the Parliamentary and Health Service Ombudsman). The functions of HSSIB should be transferred to CQC . It should continue to operate as a discrete branch within CQC and retain its independence for providers.

The original function of the Patient Safety Commissioner - to promote the safety of and enable the user voice to feed back on adverse impacts of medicines and medical products - should be hosted by MHRA , which has direct responsibility to monitor medicines and medical devices. This move would: The wider remit adopted by the Patient Safety Commissioner should be integrated into a new directorate for patient experience within NHS England (later transferring to the new structure within DHSC ) to support improvements to patient safety and patient experience, including: This should be reflected in a significantly enhanced profile for the patient voice and the introduction of a new board-level director of patient experience. The directorate should also take responsibility for advocacy support for people wishing to complain, which is currently carried out in local authorities. It is notable that the executive team of NHS England (and providers within the system) lacks a director of customer experience or similar. This is in contrast with other large-scale consumer-focused organisations, which do not outsource their customer experience function.

The statutory functions of Local Healthwatch relating to healthcare should be combined with the involvement and engagement functions of ICBs to listen to and promote the needs of service users. This should incorporate PPGs and patient or user engagement teams in provider organisations. This will: Local patient and user engagement teams would be supported by the new patient experience directorate within DHSC . The statutory functions of Local Healthwatch relating to social care (a very small proportion of the work of Local Healthwatch) should be transferred to local authorities in order to improve the commissioning of social care. The combined functions should: The strategic functions of Healthwatch England should be transferred to the new directorate for patient experience at DHSC . The directorate would have an explicit responsibility to: This would allow the existing deep patient advocacy expertise of Healthwatch England and Local Healthwatch to have a greater impact, thanks to:

There is a need to strengthen the importance of listening to and acting on staff voice, as identified in the recent publication of the National State of Patient Safety 2024 , which highlighted the recent NHS Staff Survey results and the need for greater confidence in the system. Staff should be supported and encouraged to share concerns about quality and safety as part of a data, evidence and learning-led culture that fosters improvement. The currently variable priority and quality of systems when it comes to supporting the freedom to speak up [footnote 68] needs to be addressed by organisations through the work of Freedom to Speak Up Guardians. The functions of the National Guardian’s Office could be more aligned with other staff voice functions in NHS England, such as the NHS England Freedom to Speak Up case management function (currently in the workforce, training and education directorate) and NHS England’s own internal Freedom to Speak Up function. This would:

Ultimately, it is only the providers of care and commissioners (including NHS England and DHSC ) who can improve quality of care. Far greater emphasis and attention should be given to how: There is a need to clarify governance and accountability throughout the system with a much stronger role and accountability for boards. DHSC , NHS England, commissioners in local authorities and ICBs and providers should demonstrate clear and aligned governance and accountability structures including: Commissioners and providers should operate effective quality and safety management systems that cover all aspects of quality, including efficiency or use of resources and people management. Examples of quality management systems from other providers and sectors could be built on. Commissioners and providers should be incentivised to engage in large-scale improvement activities that include more systematic sharing of best practice and support standardisation of processes and practices to:

Technology - in particular the use of AI - has the potential to significantly improve the safety, effectiveness and responsiveness of care delivery, and the use of resources. This will potentially result in major gains in health outcomes, life expectancy and quality of life. There are multiple examples of where technology is already improving safety and wider quality of care. These include the use of: Technology can improve safety, outcomes and user experience - as well as the efficiency of care delivery by freeing up resources to enable higher volumes of effective care to be delivered. Technology can also enable the user voice - for example, allowing for feedback to be given through the NHS App or QR codes. A central repository for all patient and user experience data would provide real-time feedback to inform policy and service design. There is a wealth of data that is produced and collated by the NHS. Every contact an individual has in a primary care and acute setting is recorded, and improvements to data quality could and should be made, particularly across mental health and community care. This should be used to far greater effect to improve safety and wider quality of care.

Adult social care functions differently to healthcare. A significant proportion of social care is organised privately and paid for by self-funders, while publicly commissioned care is the responsibility of local authorities. However, within this complex delivery chain, there is an opportunity to set out ‘what good looks like’ (building on work by NICE, SCIE and CQC ) and: Consideration should be given to consistent data sets, which all social care providers should collate to ensure a clear and consistent approach to data management across health and social care. Further opportunities to ensure effective commissioning of adult social care, as set out in the previous review into the operational effectiveness of CQC , should also be considered. A national strategy for quality of social care will need to align with or be embedded into the Casey Commission .