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Reviews / 2025

Independent reviewPublishedWhole systemEngland

Review of patient safety across the health and care landscape

Dr Penny Dash · work from 2024 · published 2025

What this was

Review of six organisations — CQC, HSSIB, the Patient Safety Commissioner, the National Guardian's Office, Healthwatch England, and the safety-learning role of NHS Resolution — and of the wider quality landscape. It found too much attention on structures, too little on outcomes, and so many recommendations from so many bodies that staff and patients could not tell what mattered. The government accepted all nine recommendations on 7 July 2025.

Why it sits in the hub

Dash asked for a clearing house: one place that collects recommendations, prioritises them, and checks whether they changed anything. This hub is a public version of that job, limited to landmark reviews rather than every local investigation.

Findings

  1. Finding 1

    Safety structures had multiplied, while strategic thinking about quality had thinned.

    Leadership and boardsRegulation and oversight

  2. Finding 2

    The volume of reviews and recommendations was itself a source of confusion.

    Learning from harmRegulation and oversight

Recommendations in this hub

The source reports 9 recommendations or essential actions. The notes below are a paraphrase, not the official text.

  1. 1AcceptedDHSC and NHS England

    Rebuild the National Quality Board so that it owns a quality strategy and a way to collect, prioritise and track recommendations.

    Accepted on publication. This is the official case for a recommendations clearing house.

    Leadership and boardsLearning from harm
  2. 2AcceptedCQC

    Keep rebuilding CQC as the principal quality regulator, with sector-specific assessment and a harder look at boards.

    Leadership and boardsRegulation and oversight
  3. 3AcceptedDHSC

    Keep HSSIB as a specialist investigation function, hosted inside CQC, with its independence from providers protected.

    Learning from harmRegulation and oversight
  4. 4AcceptedDHSC

    Move the Patient Safety Commissioner's medicines role to the MHRA, and wider patient-experience work into DHSC.

    Listening to patients and familiesMedicines and devices
  5. 5AcceptedDHSC and ICBs

    Join local Healthwatch with ICB and provider engagement, instead of running parallel listening structures.

    Integration and neighbourhood careListening to patients and families
  6. 6AcceptedDHSC and providers

    Simplify where the staff voice sits after the National Guardian functions move.

    Thirlwall later recommended that those functions go to the Parliamentary and Health Service Ombudsman instead.

    Speaking up
  7. 7AcceptedICBs and providers

    Put accountability for the quality of care back onto commissioners and providers.

    Leadership and boardsRegulation and oversight
  8. 8AcceptedNHS England

    Use data, analytics and technology as a main way of knowing whether care is good.

    Data and early warningDigital and information
  9. 9AcceptedDHSC

    Write a national quality strategy for adult social care, based on evidence.

    Data and early warningSocial care