Review of patient safety across the health and care landscape

Today Dr Penny Dash’s independent review of patient safety across the health and care landscape has been published. The review maps the broad range of organisations that impact on quality and focuses on six key national organisations that have an impact on safety. Based on the findings, this review makes recommendations on whether greater value could be achieved through different approaches or delivery models. 

This briefing sets out NHS Providers’ views on today’s report, our influence so far, and a summary of key findings. Please contact Isabelle Brown (isabelle.brown@nhsproviders.org) if you have any comments or questions.

Commenting on the government-commissioned review by Dr Penny Dash, NHS Providers Chief Executive, Daniel Elkeles, said:

“Keeping patients safe is paramount.

“Dr Dash is spot on. Regulation is important but must focus on issues that really matter and continued improvement.

“Today running an NHS trust is like playing in a match with lots of referees, all with different rules, on the pitch. Right now, services are hampered by the sheer number of visits, inspections, audits and reports by several different, not joined-up, bodies resulting in lots of separate recommendations requiring staff to check what others are doing – taking many doctors and nurses away from looking after patients.

“The system has been too complex for too long. This review is an important step in simplifying and streamlining how patient care is regulated without ever compromising safety.

“Trusts welcome this review. A revamped National Quality Board will set clear, robust, consistent priorities and ensure that NHS services are held accountable for providing high-quality care, and we welcome proposals for trusts to appoint a senior executive responsible for ‘patient experience’.

“We welcome too proposals to streamline the complaints process.  If something goes wrong NHS trusts are determined to put in place measures quickly to improve the quality and safety of patient care.”

This review provides welcome acknowledgement that the safety oversight system has become more complex over time. The Francis public inquiry pointed to the challenge presented by the complex regulatory and oversight system, which has contributed to regulatory fragmentation, ambiguity and overlapping responsibilities between bodies. 

The expanded remits of the CQC, Health Service Safety Investigation Body (HSSIB), and the Patient Safety Commissioner, as outlined by Dr Dash, highlight existing gaps in the regulatory and oversight system for patient safety. It is essential that the Dr Dash’s proposed changes to the landscape are closely monitored and evaluated once implemented to determine whether those gaps are being addressed or continue to persist, and to understand whether they have led to improved safety in the system. Consideration also needs to be given to how organisations were designed, for example, in HSSIB’s independence reflecting its unique legal powers to hold protected materials.

The government has accepted Dr Dash’s recommendations, and as these are taken forward, we encourage further engagement with the sector to ensure that the new arrangements add value and do not add additional burden to an already pressurised system. Additionally, any changes to the system must also be accompanied by clear information for patients, families and carers which clearly lays out what the changes mean for them. This is particularly important in considering the reallocation of Healthwatch’s responsibilities. 

Most importantly – and as Dr Dash notes – there must be cohesive, joined-up working across all the remaining organisations that regulate and oversee patient safety, with a clear accountability framework that is well-communicated. ICB and trust leaders need a clear understanding of regulatory requirements and priorities, and the multiple sets of standards that exist currently create a confusing, noisy and complex regulatory environment. This work must be seen as the starting point of simplifying and rationalising the patient safety landscape, and making it more effective for patients, rather than simplification of the system being the end goal.

Our influence so far

• We were grateful to have had the opportunity to discuss the work with Dr Penny Dash directly, where we advocated for a consistent, coherent narrative on quality of care from national bodies and underlined the need for a simpler regulatory system.
• NHS Providers is a member of several cross-system working groups, allowing us to inform this review. Of particular note, we are a member of HSSIB’s Recommendations to Impact group, which sought to ‘diagnose the problem’ in relation to recommendations and then consider next steps to help improve recommendations made into the system. We represented the trust perspective in the challenges presented by the current regulatory system for patient safety, and the feasibility of the suggested proposals to tackle the challenges. 
• Our Good quality regulation report in March 2024 highlighted many of the issues later confirmed by Dr Dash in her first report into the effectiveness of the CQC. We also responded to Dr Penny Dash’s first report on the ‘significant internal failings’ found at the CQC, highlighting that the CQC must concentrate more on support and improvement. 

• This review follows Dr Dash’s 2024 review into the operational effectiveness of the Care Quality Commission. The primary focus of this successor review is assessing whether the current organisations associated with patient safety oversight and regulation deliver effective leadership, listening and learning. 
• This review looks at the following organisations: Care Quality Commission (CQC), including the Maternity and Newborn Safety Investigations programme; the National Guardian’s Office (NGO); Healthwatch England and the local Healthwatch network; the Health Services Safety Investigations Body; the Patient Safety Commissioner; and NHS Resolution. 
• The review identifies the following organisations as responsible for the quality of care at different levels: NHS England; the Department of Health and Social Care (DHSC); the UK Health Security Agency (UKHSA); local authorities; Integrated Care Boards (ICBs); private health insurers; and healthcare providers. 
• Those seeking to influence the activities of services are identified as: statutory regulators; information and standards organisations; quality improvement, safety investigations and advisory bodies; royal colleges; professional peer review bodies; patient advocate organisations; national advisory groups; professional associations and societies; and voluntary sector organisations.
• The review encourages the DHSC to continue its review into the wider arm’s length body landscape to identify duplication, gaps and opportunities for transformation beyond the scope of this review. 
• The government has accepted all nine recommendations made by Dr Dash in full. The review’s findings are summarised below, along with our view on each of the recommendations. 

There has been a shift towards safety (vs other areas of quality of care) over the last 5 to 10 years, with considerable resources deployed, but relatively small improvements have been seen.

• Patient safety has commanded significant resource from both independent organisations and DHSC with recommendations often including calls for increased staffing levels. This review has found that these have potentially contributed to the considerable growth in hospital staffing and funding in the last decade. 
• An increased focus on safety over the last 5 to 10 years has seen less attention and resource in other aspects of quality of care, which Dr Dash identifies as: effectiveness; user experience; equity; and the leadership and management of care delivery.
• This review suggests a general principle that health systems should seek allocative efficiency, deploying resources to yield the largest benefit and recognise that when resources are use in one area, the opportunity to use them in another beneficial way is lost.  

There has been limited strategic thinking and planning with regard to improving quality of care.

• The last comprehensive strategy aiming to improve quality of care was ‘High quality care for all: NHS Next Stage Review’, published in 2008, which aimed to shift resource from acute care into the community. However, Lord Darzi’s 2024 investigation of the NHS in England found that the strategic intention to shift spending from reactive acute care into the community had moved in the opposite direction. 
• This review has found that the significant number of organisations and professional bodies publishing recommendations at both a local and national level, often without reference to wider system strategies, makes strategic planning to increasingly complicated.
• There is a National Quality Board (NQB), which was formed in 2009, but to date it has not developed a comprehensive quality strategy.

A large number of organisations carry out reviews and investigations. A very high number of recommendations have been made to the NHS that often lack any cost-benefit analysis.

• The significant number of national bodies conducting inquiries and reviews has led to an overwhelming number of recommendations. Each of these national bodies, inquiries and reviews considers different elements of safety, sometimes in response to previous problems and cases of unsafe care. However, the disparate nature of them results in the lack of a coherent national message, and a lack of ownership. The recommendations also vary significantly in quality and often lack data around the expected impact or cost of implementation. 
• The large number of recommendations causes confusion, increase training requirements, require more and more clinical staff to move into supervisory roles to oversee the implementation of recommendations and yet have a questionable impact on the safety and wider quality of care. 
• There has been some work to try and combat the issues caused by the significant volume of recommendations. HSSIB has also convened a Recommendations to Impact collaborative group to consider the large number of quality and safety recommendations being made, which made several observations on the challenges presented by the recommendations system. 

A large number of organisations look at user experience or advocate on behalf of the 'voice of the user', yet few boards in the NHS have an executive director for user or customer experience.

• A large number of patient surveys are carried out each year by multiple organisations at national and local levels. However, the fragmented nature of these efforts and challenges with data governance limit their representativeness and strategic impact. In some geographies, local Healthwatch organisations and charities have sought to align approaches and resources to amplify patient voice, but this is not consistent across the country and the lack of coordination makes it hard to draw comprehensive, actionable insights.
• Many providers and commissioners of services involve users or patients and wider communities in the design and improvement of services. This happens at multiple levels, from setting high-level plans to redesigning care pathways – nationally, regionally, sub-regionally and locally. 
• There has been increasing interest over the last 30 years in exploring outcomes of care from a patient or user perspective, rather than from a clinical or medical perspective, known as patient-reported outcome measures (PROMs).
• Most NHS boards – provider and commissioner – lack an executive director for user or customer experience. This is in contrast with other consumer-facing industries. 
  
  

The current system for complaints and concerns is confusing and may lack responsiveness.

• This review has identified a 38% increase in complaints received by NHS organisations over the last decade.  There are also more than 70 different types of channels or organisations that offer a place for patients or users to share feedback, either formally or informally, about the quality of healthcare services.
• The publication of new NHS Complaint Standards in 2021 is applicable to all NHS providers and was intended to introduce a more consistent approach to complaint handling across the country. However, this guidance is non-binding and there has not been sufficient time to assess its impact. Additionally, many complaints are not handled within the statutory six-month timeframe, and given that complaints data is not centrally collected, wider lessons often cannot be learned. 
• The review argues that complaints, concerns and patient feedback require greater emphasis from boards, teams and individual clinicians to ensure improvements in care and service delivery are implemented. 
  
  

Some of the organisations under review have expanded their scope. 

• Some organisations in the review have expanded their scope – and this has not necessarily been driven by an overarching strategic vision or in co-ordination with other bodies.
• HSSIB has broadened its work into wider system management, the Patient Safety Commissioner has taken on a wider role as an advocate for wider patient safety themes beyond medicines and medical devices, and the CQC has expanded its remit into developing tools to support ICB better understand the health needs of communities.

A greater strategic focus on care delivery and management is needed to improve quality of care. 

• While standards and monitoring are emphasised, there is relatively little support for day-to-day management and improvement of care. Providers and their boards are responsible for delivering high-quality safe care, but this does not happen consistently due to a range of factors including: 
  • Lack of standardisation in operating processes and service models, meaning individual providers create their own solutions, leading to inefficiencies and wide variation in quality. This differs from the approach taken by other high-risk industries, such as aviation, where standardised processes are used to ensure safety and performance. 
  • Lack of strategic investment in core management functions, such as operations, HR, procurement and estates. Effective operational leadership can drive improvements in all domains of quality but lacks the necessary support and resourcing. 
  • Technology is underutilised and while some innovations are beginning to be deployed, adoption is inconsistent. There is significant opportunity to deploy technology more consistently. 
  • Governance structures also vary widely in in effectiveness with boards differing in their understanding of quality-related risks and in their ability to balance them across organisations or systems. Weak performance management, limited accountability mechanisms and inconsistent modelling of high-quality behaviours contribute to variability. Early emphasis placed on the role of boards has diminished in recent years.
  • Measurement and feedback mechanisms are lacking across the system, and performance appraisal processes are often too limited or generic to drive meaningful change.
  • Staff training and credentialing remain inconsistent, particularly where education is delivered externally to providers. 
  • The role of commissioners in driving quality remains under-defined. Clearer expectations around contracting, oversight, and assurance are needed to ensure quality is embedded in commissioning practice.
  • The review concludes that alongside clearer expectations for quality delivery, a national quality improvement infrastructure is needed.

The National Guardian's Office duplicates work carried out by providers. 

• The National Guardian’s Office (NGO) is responsible for leading, training and support a network of Freedom to Speak Up Guardians. Given that the National Guardian network has now been established, with clear routes for staff to escalate concerns set out by the government, there is not a clear need for an independent oversight body. 
• There will still be a need to ensure a level of independence to support Freedom to Speak Up functions. The role of Freedom to Speak Up Guardian is played by a senior non-executive director in many organisations, and the review recommends that this should continue.
• The NGO’s placement within the CQC results in it being too distant from the people it needs to support and influence, and placing the responsibility of Freedom to Speak Up Guardians with commissioners and providers should allow for a more rapid response and raise the profile of staff voice. It should be a core function of the CQC to ensure these functions are being carried out in all commissioners and providers. 

Insufficient use is made of the NHS's data resources to generate insights and support improvement. 

• The review calls for more data sharing across organisations to build on the work already being done to collect and review data for clinical audit purposes. There is also considerable scope to use advanced analytics to generate insights and support organisations to focus on the most significant challenges to improving care.
• Difficulty in accessing national data collections is impeding research into developing better diagnosis, prevention and treatment strategies and assessing their effectiveness and safety through clinical trials. 

There is insufficient focus on developing a national strategy for quality of social care. 

• The lack of national attention to the quality of social care is evident in the limited data around quality of care in social care, and a lack of agreement on metrics which would best define quality in adult social care. 
• The review also highlights the lack of evidence around how best practice is disseminated amongst providers, and opportunities to share the beneficial impact of initiatives are limited. 

1. Action is required to address gaps in functions. There is a particular need for a strategic approach to improvement and innovative quality of care which considers allocation of resources and prioritises the large volume of recommendations to providers. 
2. Streamline and simply functions where duplication and overlap currently exists, specifically around patient and community engagement, capturing learning from patient experience, and investigations.
3. Too many functions sit outside of the commissioners and providers of healthcare, limiting the impact of inquiries, reviews and investigations and prevents recommendations being effectively implemented. 
4. Greater focus on building skills, effective governance structures and clearly accountability for quality and safety of care within commissioners and providers. 
5. The CQC, as the independent regulator of health and care, needs to rebuild public, professional and political confidence and house functions where independence is required. 

Recommendation 1: Revamp, revitalise and significantly enhance the role of the National Quality Board

Key points

• The review calls for a refreshed National Quality Board (NQB), which will be responsible for developing a comprehensive strategy to improve quality of care and will develop an overarching strategy for how improvement and innovation can best be supported across health and care. The NQB will also set out a vision of quality of care that describes what good looks like for the various dimensions of quality and recognise the need to balance priorities across dimensions.
• The proposed quality strategy will cover measurement and analysis of the current quality of care, evidence and examples of high-quality care and recommendations from previous reviews and inquiries. The strategy should also recognise the importance of balancing all dimensions of quality, build on the principle of healthcare value so that outcomes and costs are continually optimise and ensure resources are allocated to maximise life expectancy and quality of life. 
• The NQB will agree key national quality metrics and lead a data strategy using advanced analytics to improve accuracy and better use existing NHS data. The NQB will also oversee and manage the recommendations coming into the system; maintaining a repository of recommendations from multiple sources and operating a clearing house function to co-ordinate and prioritise recommendations. 
• Dr Dash suggests that the NQB could be co-chaired by the chairs of CQC and chair of NHS England, transitioning over time to the lead non-executive director for quality on the board of DHSC, and be directly accountable to the Secretary of State for Health and Social Care.
• Outside of the review’s recommendations, the review has considered the role of NHS Resolution and recommends it continues with its role as already established. However, more work needs to be done to ensure lessons learnt from its reviews are shared more widely, and that this is considered within the remit of a revamped NQB.

NHS Providers view

The rejuvenation of the National Quality Board, and the publication of a new Quality Strategy, is encouraging. The National Quality Board is uniquely placed to bring together key stakeholders to create a consistent and coherent narrative on quality. 

Trust leaders have told us that they would welcome a national quality strategy that takes an approach of the ‘centre in the service of the local’. A national strategy could helpfully recognise that the challenge isn’t so much to embed a focus on quality but rather to enable providers to achieve a shared focus across all priorities, including across finance, operations and quality. There is also an important role for the strategy in enabling, empowering and supporting frontline staff to drive quality improvement. This would help shift the mindset from controlling processes and structures to creating supportive and enabling conditions for improvement.  

The creation of a ‘clearing house’ function to distil and simplify recommendations made in national inquiries would be a welcome addition to the role of the NQB, particularly as it would ensure trust boards can easily understand the changes and the required actions resulting from a recommendation. This function would also help clarify the landscape, reducing the duplicative or contradictory recommendations that are made. To strengthen the support provided to trust boards, we would encourage the NQB to facilitate two-way communication with trusts in their implementation of each recommendation, so there is better understanding of the impact of implementing recommendations both in terms of the impact and from a cost/resource perspective. This learning would help shape future recommendations. 

With regards to the governance arrangements of the NQB, it may be worth considering how and whether the Board could be made more accountable to patients. It is also important that Dr Dash’s recommendation is for the NQB to ultimately be brought into DHSC. This enables quality to be treated in the same way as finance and other aspects of NHS policy – as opposed to a siloed issue to be dealt with by a separate body. 

Recommendation 2: continue to rebuild the Care Quality Commission with a clear remit and responsibility

Key points:

• The CQC should remain the lead independent regulator, setting clear, sector specific standards for quality and aligning with national strategy through a robust assessment framework. 
• Board governance and accountability must be a renewed focus, with the CQC assessing how effectively boards oversee quality, manage risk and drive improvement. 
• Assessment should cover all five quality domains, including how risks are identified and managed and ensure a tailored approach for smaller or less structured organisations. 

NHS Providers view

Trusts will welcome the push to define what good looks like from a regulatory perspective, and it will be helpful to have CQC regulatory standards aligned with NHS England and DHSC strategy. It is also encouraging that the CQC will look at boards’ ability to improve all aspects of quality of care while effectively balancing risks across organisations and wider health and care systems. It would be helpful to understand how this assessment will overlap with NHSE assessments on board capability so that there is a clear and non-duplicative regulatory approach. 

Recommendation 3: continue the Health Services Safety Investigation Body's role as a centre of excellence for investigations and clarify the remit of any future investigations

Key points: 

• Most investigations into safety incidents should continue to be managed within provider organisations and ICBs, with support from regions to make sure they are mobilised quickly, expertly and are rapidly resolved, where feasible, and lessons are learnt.
• NHS England, transferring to the new proposed structure within DHSC, should support excellence in investigation and learning throughout the health and care system.
• HSSIB should continue to operate as a dedicated, expertise-led incident investigation facility and should collaborate with DHSC (via NQB) to agree the scope of its investigations. HSSIB should also retain its role in upskilling health organisations in patient safety investigations. Recommendations from HSSIB should be considered as part of the ‘clearing house function’ of the NQB.
• Dr Dash considered whether the complex investigations carried out by MNSI should be incorporated into HSSIB to strengthen expertise as part of the wider review that is to be conducted regarding the future of the MNSI programme, but it was decided that this could be overly disruptive and risk delays to investigations.
• The functions of HSSIB will be transferred to CQC, and the organisation will now operate as a branch within the CQC, thereby retaining its independence. 

NHS Providers view

According to ‘Learning not blaming’, the government response to the Freedom to Speak Up consultation, HSSIB was established ‘to conduct independent, expert-led investigations into patient safety incidents’, and was placed on statutory footing by the Health and Care Bill to establish it as a non-departmental public body. Its statutory footing ensures independence, supports a legally protected ‘safe space’ for confidential evidence-gathering, and promotes learning rather than blame as well as consistency in safety improvement across the healthcare system. 

Rosie Benneyworth (interim CEO of HSSIB) has previously noted HSSIB is “very keen to be a supportive organisation and that people see the real value in getting involved in our investigations. We don’t want to be an organisation that is having to compel people to get involved in talk[ing] to us.” The move back to CQC needs to be considered carefully in order to maintain trust in HSSIB’s work and use of its legal powers, and in turn the impact of its investigations. We would encourage early clarification of how HSSIB’s safe space protections will be preserved and how its role will remain distinct from CQC’s regulatory remit. 

Recommendation 4: transfer the hosting arrangement of the Patient Safety Commissioner to MHRA, and broader patient safety work to a new directorate for patient experience within NHS England, transferring to the new proposed structure within DHSC

Key points

• The role of the Patient Safety Commissioner (which is to represent patients affected by medicines and medical devices) should be hosted by the MHRA.
• The wider remit of the Patient Safety Commissioner (covering patient experience and engagement) should be embedded in a new NHS England directorate for patient experience, later transitioning into DHSC. This directorate will lead on patient engagement, complaints learning and advocacy support, be led by a Board-level Director of Patient Experience and ensure the patient voice is central to care design, feedback and safety improvement.
• The new directorate could include work on building on the NHS Complaints standards to support organisations to proactively use feedback from complaints to improve services

NHS Providers view 

The incumbent Patient Safety Commissioner has meaningfully expanded the areas considered by the role beyond its statutory functions. The Commissioner has filled a critical gap in representing patients across the full spectrum of quality and safety issues. We welcome Dr Dash’s recognition of the value of this broader role and consideration of how this can best be articulated at the national and local levels. 

We welcome the introduction of a national board-level Director of Patient Experience, particularly as it ensures a clear national commitment to focusing on patient experience. We would encourage the Director of Patient Experience to work closely with the Patient Safety Commissioner. There must also be mechanisms to ensure that the Director of Patient Experience can hear directly from patients on their most pressing issues and the importance of independence in holding the system to account must also be considered. 

We also welcome the review’s commitment to strengthening the complaints process. Complaints are too often an untapped patient safety resource. It is vital for trust boards to properly engage in issues and concerns raised by patients and their families. We hope that DHSC’s national work on complaints will support consideration of widespread or systemic issues, and that this includes feedback from staff as well as patients.

Recommendation 5: bring together the work of Local Healthwatch, and the engagement functions of integrated care boards (ICBs) and providers, to ensure patient and wider community input into the planning and design of services

Key points

• 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 patient participation groups and patient or user engagement teams in provider organisations.
• 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 to improve the commissioning of social care.
• The strategic functions of Healthwatch England should be transferred to the new directorate for patient experience at DHSC. The current role of Healthwatch England to provide advice to the Secretary of State should also move to the new patient experience directorate in DHSC. 
• ICBs and local authorities (for social care) will be responsible for listening to communities and users and ensuring strategies and plans consider patient, user and community input. 
• As part of its wider responsibilities, a core function of CQC should be to assess whether every ICB and provider is listening to patients and users effectively, using existing local networks.
  
  

NHS Providers view

The failure to listen to patients and their families can have catastrophic consequences. Healthwatch was introduced to strengthen the voice of patients and the public in healthcare, following failures in the system to act on concerns. The introduction of the organisation was triggered by the desire for a more visible, powerful, professional and independent body to represent the public in a more decentralised system, further to the Health and Social Care Act 2012, with the broad direction of travel now also being towards decentralisation.

While it is right that ICBs and local councils embed patient voice to carry out their functions, removing the independent body that is responsible for representing patient voice carries risk. It should also be recognised that in a time where there have been significant cuts to ICB funding, there may be reduced internal capacity to properly focus on hearing and addressing patient concerns. Local Healthwatch branches have also done significant work to engage with more vulnerable groups in local populations. Without this proactive outreach approach in systems, there is a risk that these voices are ignored or under-represented. 

It is right that providers and ICBs are held to account on listening to patients and service users effectively, and more information on how the CQC will do this would be welcome. Dash suggests that DHSC should assume responsibility for collating learning from complaints and other mechanisms on a national basis, and it will be important that they are held to account for doing so effectively by parliament. 

Recommendation 6:  streamline functions relating to staff voice

Key points

• There is a need to strengthen the importance of listening to and acting on staff voice. 
• 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 needs to be addressed by organisations through the work of Freedom to Speak Up Guardians.
• The distinct role of the National Guardians Office is no longer required. The responsibilities of the National Guardian for Freedom to Speak Up in the NHS and National Guardian's Office should be incorporated into providers. The functions of the National Guardian's Office could be more aligned with other staff voice functions in NHS England.
• A core function of CQC should be to assess whether every commissioner and provider has effective Freedom to Speak Up functions, with the right skills and training.
   

NHS Providers view

The NGO has played a key role in encouraging staff to speak up. Dr Dash’s report rightly notes, however, that staff confidence in speaking up has not improved, suggesting further work is needed on building psychologically safe environments to enable speaking up. 

While it is reassuring that FTSU guardians will remain within trusts, it is concerning that these roles will no longer have the support of a National Guardian. The NGO sets national standards, offers guidance and monitors the function of FTSU guardians. There is a risk that the efforts of FTSU guardians will become fragmented and more vulnerable to local pressures. Indeed, within his report ‘Freedom to Speak Up’, Sir Robert Francis notes the importance that FTSU guardians have a network ‘to share good practice and to identify common issues and themes’. It is therefore vital that trust boards continue to support their FTSU guardians, and the links with the DHSC patient experience directorate also need to be further understood.

Recommendation 7: reinforce the responsibility and accountability of commissioners and providers in the delivery and assurance of high-quality care

Key points

• The review reaffirms that providers and commissioners (including NHSE, DHSC, ICBs and local authorities) are ultimately responsible for delivering and enabling high-quality care across all sectors. There is a need for clearer governance and accountability with a stronger role for boards, aligned leadership and positive role modelling from top to bottom and systems for continuous measurement, reward and learning. 
• 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:
  • maximise the quality-of-care delivery
  • minimise harm
  • improve operational effectiveness
  • manage costs
• To incentivise high-quality care, Quality Accounts could be reenergised, and national audits and improvement programmes (such as GIRFT) could be used more by boards of commissioners and providers to identify improvement opportunities. 
• The skills and capabilities of commissioner and provider leadership teams need particular attention – particularly in terms of using data, engaging with patient feedback, co-designing services and allocating resources based on quality. 
• Relative roles of different organisations and accountability structures within NHS England are being considered as part of the revised operating model described in the 10 Year Health Plan, and through the integration of NHS England into DHSC.
  
  

NHS Providers view

Strengthening board level responsibility and aligning governance across the system would be welcomed by trust leaders, and the review rightly emphasises the role of national bodies and boards in role modelling positive actions from top to bottom. The national bodies play a vital role in shaping the values, behaviours, and practices of the sector, and behaving with integrity, transparency and accountability sets the tone for the rest of the sector. 

It is also encouraging to see the important role of relational enablers to quality (such as reward mechanisms and commitment to learning) are captured, with the role of commissioners and providers made clear. Inquiries have repeatedly noted the role that culture plays in the delivery of high-quality care. Promoting a safety-focused organisational culture is a key enabler of patient safety and quality improvement, and commissioners and providers have both an individual and a collective role to play in proactively engaging with and promoting this. This can be done by being considered in terms of what behaviours are rewarded, what culture-related indicators are measured and the values that are modelled. 

The review rightly highlights the need to balance operational effectiveness, harm reduction, cost management, and quality improvement. A national focus on outcomes would support the work to balance these considerations. 

These recommendations, while directionally sound, may introduce new layers of expectation without corresponding investment. Delivering stronger systems, advanced data use, and more sophisticated commissioning demands capacity many organisations may currently lack. 

Recommendation 8: technology, data and analytics should be playing a far more significant role in supporting the quality of health and social care

Key points

• Technology – particularly the use of AI – has the potential to significantly improve the safety, effectiveness and responsiveness of care delivery, and the use of resources. 
• There are already multiple examples of where technology has improved the quality of care, including chatbots, falls detection, drug interaction alerts, automated monitoring (e.g. blood pressure, ECGs, CTGs), AI diagnostics, and robotic surgery. 
• Better use of existing NHS data – especially when linked across primary, secondary, mental health and community care – would support personalised care, identify at risk populations and improve the safety of care along with outcomes and resource use. 
• To unlock this potential, high-quality, shareable data, alignment with the Sudlow Review, investment in digital infrastructure (e.g. federated data platform), clear accountability, and fit-for-purpose regulation are all essential, as highlighted in the 10YHP. 
  
  

NHS Providers view 

We agree that data and analytics can likely play a more significant role in supporting quality of care, and many trusts are already leveraging this technology. We also note the need for enabling staff capability and funding. Staff will require additional training, and systems must be reviewed and upgraded to support better data linkage. Additionally, AI tools must enhance not replace the empathy, the relationships and the human judgement that underpins trust in the NHS. At its core, the NHS is a people-focused system. 

Recommendation 9: there should be a national strategy for quality in adult social care, underpinned by clear evidence.

Key points

• While adult social care functions differently to healthcare, there is an opportunity to set out what good looks like (building on work by NICE, SCIE and CQC) in developing and agreeing metrics to assess quality of care, disseminating best practice and ensuring appropriate governance structures.
• 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.
  
  

NHS Providers view

We welcome the focus on defining and measuring quality in adult social care and would enable far greater clarity for healthcare providers in how best to plan more coordinated care pathways. As Deborah Rozansky, Director of Policy, Research and Information at SCIE notes, ‘rather than being viewed solely as a partner to the NHS, social care must be recognised as a central force for promoting population health and supporting people to live better lives’. 

The review lists a series of next steps in implementing the recommendations in this report. These include:

• Several areas have been highlighted in the 10YHP and will need to be taken forward in the implementation of the plan. This includes:
  • Being clear in how management and governance mechanisms within commissioners and providers need to evolve to ensure robust governance structures and systems 
  • Considering how more standardised operating processes and models of care will be developed and implemented across all providers.
  • Detailing how a rapid acceleration in data and technology can be realised to support safer, high-quality care
• Outside of the 10YHP, other areas have been raised for longer-term consideration. These include consolidating investigatory functions of the royal colleges, medical examiners and professional regulators into a wider investigatory function, the role of national clinical directors in setting standards and identifying which metrics to use and the role of MHRA and NICE in assessing new technology. 
• DHSC should continue to explore options to review its wider arm's length body landscape to identify areas of duplication, gaps and opportunities for transformation, beyond the 6 organisations looked at by this review.
• Some primary and secondary legislation will need to be changed to enact some of the recommendations and further work to implement the change will be needed. 
• Throughout the course of this review, the very large number of requirements, regulations, roles and organisations that purport to address safety have been raised, including new roles that have emerged in the last few years, the extensive mandatory training for all staff and extensive paperwork to be completed by all staff. It is suggested that further work is carried out to quantify the cost-benefit of all of these, led by NQB.

• Department for Health and Social Care: Review of patient safety across the health and care landscape
• NHS Providers: Interim report into the operational effectiveness of the CQC
• NHS Providers: Reviews into CQC’s operational effectiveness and single assessment framework
• NHS Providers: On the day briefing – 10-year health plan