Dr Penny Dash has published her review into patient safety across the health and care landscape, in which she has revealed 10 main findings, has drawn five main conclusions and made nine recommendations:

10 main findings of the review

Finding 1: 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.

Finding 2: There has been limited strategic thinking and planning with regard to improving quality of care.

Finding 3: There is a large number of organisations carrying out reviews and investigations. A very high number of recommendations have been made to the NHS, most of which lack any cost-benefit analysis.

Finding 4: 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.

Finding 5: The current system for complaints and concerns is confusing and may lack responsiveness.

Finding 6: Some of the organisations under review have expanded their scope.

Finding 7: A greater strategic focus on care delivery and management is needed to improve quality of care,

Finding 8: The National Guardian’s Office duplicates work carried out by providers.

Finding 9: Insufficient use is made of the NHS’s data resources to generate insights and support improvement.

Finding 10: There is insufficient focus on developing a national strategy for quality of social care.

Five conclusions of the review

Dash stated: “I have drawn five principal conclusions from the findings.”

1. Action is needed to address gaps in functions. In particular, a strategic approach to improvement and innovation in quality of care (including safety) is needed that:

• Considers allocation of resources to maximise health outcomes.

• Co-ordinates and prioritises the many recommendations and ‘asks’ of providers.

• There is a need to streamline, simplify and consolidate functions where considerable duplication and overlap currently exist – specifically when it comes to:

• User, patient or community engagement.

• Capturing and learning from user or patient experience, or the ‘voice of the user’.

• Investigations.

3. Too many functions sit outside of the commissioners and providers of care who are ultimately responsible for improving quality (including safety). This results in limited impact from the very many inquiries, reviews, investigations and resulting recommendations that are made.

4. Within commissioners and providers, there needs to be a far greater focus on:

• Building skills and capabilities.

• Effective governance structures.

• Clearer accountability for quality (including safety) of care.

5. The Care Quality Commission was established as the independent regulator of health and care. It needs to rebuild public, professional and political confidence, and should also house functions where independence is required.

Nine recommendations

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

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

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,

Recommendation 4: Transfer the hosting arrangement of the Patient Safety Commissioner to the Medicines and Healthcare products Regulatory Agency, and broader patient safety work to a new directorate for patient experience within NHS England, transferring to the new proposed structure within DHSC.

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

Recommendation 6: Streamline functions relating to staff voice.

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

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

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

Reacting to the report David Hare, chief executive of the Independent Healthcare Providers Network (IHPN), said: “Delivering safe, high-quality care is the number one priority for independent healthcare providers and IHPN, on behalf of the sector, welcomed the opportunity to input into Dr Penny Dash’s review as part of its expert advisory group.

“As anyone who works in the health service will attest to, there is a real need for a much more simplified and strategic approach to looking at the quality, safety and effectiveness of healthcare providers and the wider health care landscape.  The report’s recommendation signalling a fundamental change to the role of the National Quality Board is therefore a real opportunity to look across the whole system – including in the independent sector – to drive meaningful improvement and innovation in healthcare.”

“The report is also right to emphasise the need for commissioners to take a much more active role in ensuring healthcare providers deliver the highest quality patient care – helping give patients confidence that poor performance will not be tolerated – with a new director of Patient Experience at DHSC putting the patient voice back at the heart of decision-making.”

Read the full review here