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Patient Safety in the NHS: Opening the Door to Change

The NHS (National  Health Service) in England is developing a new patient safety strategy which will be published in the Spring of 2019. A consultation paper is out and responses are invited until next month. The strategy will sit alongside the NHS Long Term Plan and hopefully will ingrain safety within it.

The consultation paper contains some thoughtful provisions to make the NHS safer. A focus on three principles that should underpin implementation of the strategy: a just culture, openness and transparency and continuous improvement. Proposals include clarifying and standardizing safety critical advice and guidance to the NHS.

The CQC (Care Quality Commission) view of NHS Patient Safety

The NHS patient safety strategy consultation document should be read alongside the CQC report on NHS patient safety. The CQC is the independent regulator of health and social care in England, and this report gives essential context to the NHS Patient safety strategy consultation and provides a  detailed account of why the NHS currently does not have the right approach to patient safety:

“While safety needs to be part of what everyone does, and part of the culture of trusts, it is clear that the NHS does not yet have the right approach.”

Also in the report is an examination and analysis of the underlying issues that contribute to the occurrence of Never Events. This analysis is also applied to a wider NHS care setting and important themes and recommendations for change are made.

Never Events continue to happen in the NHS, there were 468 incidents provisionally classified as Never Events between April 1, 2017 and March 31, 2018. Other figures are also presented.

There are approximately 2 million patient safety incidents reported to the National Reporting and Reporting System (NRLS) annually. Around 74 percent of these caused no harm to the patient. There were approximately 21,500 serious incidents reported in the NHS in England between 2017 and 2018.


Several important findings are made in the report.

Patient safety alerts are generally viewed in the NHS as an effective way of guidance dissemination. The job of implementing the guidance can however be unsystematic and can fall to multiple persons. This can lead to too many adaptations of the same guidance and inconsistency in approach. A greater standardization of processes is called for. Trust (hospital) management boards are also not consistently prioritizing meaningful discussions about Never Events and associated patient safety alerts.

A confused and complex patient safety environment

The report found that the current patient safety landscape in England is confused and complex, with no clear understanding of how it is organized and who is responsible for what tasks. The problem of NHS staff not learning from each other is stated.

The ability of NHS trusts to learn from incidents locally and at a wider level is also hampered, with slow and unresponsive reporting processes that can discourage staff from reporting incidents.

Education and training for staff on safety systems and processes

Patient safety education and training is an essential prerequisite for developing an ingrained patient safety culture in the NHS, but this is not happening on the scale that it needs to. The report states that patient safety training is not a priority for trust leaders in the same way that operational targets are.

Recommendations in the report also include that the National Patient Safety Strategy must support the NHS to have safety as a top priority. And that leaders with a responsibility for patient safety must have the appropriate training, expertise and support to drive safety improvement in trusts.


We can see from the reports discussed that the NHS is resolute in its desire to improve the safety of health care. The CQC report is the best that I have seen on NHS patient safety policy development and what needs to be done in order to develop an effective patient safety culture. The NHS has however been trying for years to develop an ingrained patient culture and this has proved exceptionally difficult. The recommendations made by the CQC and in the proposed new NHS patient safety strategy will hopefully help towards developing such an ambition.

John Tingle

John Tingle

John Tingle is a regular contributor to the Bill of Health blog. I am a Lecturer in Law, Birmingham Law School, University of Birmingham, UK; and a Visiting Professor of Law, Loyola University Chicago, School of Law. I was a Visiting Scholar at Harvard Law School in November 2018 and formerly Associate Professor at Nottingham Law School, Nottingham Trent University in the UK. I have a fortnightly magazine column in the British Journal of Nursing where I focus on patient safety and the legal aspects of nursing and medicine. I have published over 500 articles and a number of leading texts in patient safety and nursing law. My current research interests are in global patient safety, policy and practice, particularly in African health care systems. My most recent publication is: "Global Patient-Safety Law Policy and Practice," edited by John Tingle, Clayton O'Neill, and Morgan Shimwell, Routledge 2018.

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