The record
Each entry is one inquiry, investigation, policy review or national strategy. Open a review for the findings, the paraphrased recommendations, and the other reviews that share its themes.
Department of Health and Social Care
The national plan published in July 2025, written after the Darzi investigation. It is organised around three shifts: hospital to community, analogue to digital, and sickness to prevention. It also promises more public information on quality, a national maternity and neonatal investigation, and a more data-led CQC.
Dr Penny Dash
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.
Lord Darzi of Denham
Rapid investigation of the state of the NHS in England, published in September 2024. It diagnosed falling access, missed targets, a disengaged workforce, underinvestment in capital, and the unfinished business of social care. It was written to set the terms of a ten-year plan rather than to list new operational recommendations.
Dr Penny Dash
Review of whether CQC could do its job. An interim report in July 2024 and a final report in October 2024 found a regulator that had lost the confidence of providers and the public, with a failed IT transformation and unclear assessment.
Rt Hon Patricia Hewitt
Review of how integrated care systems were being overseen. It found too many national targets, too little autonomy, and prevention still losing out to acute pressure.
NHS England
The national plan for the decade from 2019: integrated care, out-of-hospital services, mental health, cancer, cardiovascular disease, maternity and a digital NHS. It assumed a funding settlement and a workforce to match.
NHS England and NHS Improvement
National strategy organised around insight, involvement and improvement. It set the direction for a new incident-reporting system and, later, the Patient Safety Incident Response Framework.
Professor Sir Mike Richards
Independent review of adult screening after a series of incidents in which people were not invited. It found ageing IT, split governance, and no single owner for making screening safe.
Dr Bill Kirkup
Independent review of a community trust where a bullying culture and an aggressive cost-improvement programme harmed patients and staff. Concerns were known and not acted on.
Sir David Dalton
Review of how NHS organisations might combine: groups, chains, acquisitions and management franchises. It was a response to trusts that could not sustain quality on their own.
Simon Stevens
The national strategy that replaced a single blueprint with new models of care: more prevention, more care out of hospital, and organisations working together. It was a plan rather than an inquiry, and it set the frame for the decade that followed.
Professor Don Berwick
National advisory group on the safety of patients, convened after Francis. It argued that the NHS should become a learning system, and that criminal sanctions should be reserved for wilful neglect rather than honest error.
Lord Darzi of Denham
The NHS Next Stage Review, led by a surgeon-minister. It argued that the next phase of reform should be organised around quality: safety, experience and effectiveness, with clinical leadership at the centre.
