Opinion piece: Patient Safety Review by Dr Penny Dash

I read the review of patient safety by Dr Penny Dash [published in July 2025]. You can find it here:

https://assets.publishing.service.gov.uk/media/686bd5d52cfe301b5fb6780c/dhsc-review-of_patient-safety-across-the-health-and-care-landscape.pdf

I made six pages of notes as I read it and have a few comments as you can imagine. I think the best thing for me to do at this stage is provide some high level key messages from my perspective. I will try to restrict myself to ten of them, I mean who wants six pages!

1. Scope: It is not a patient safety review – it is a quality review. By dressing it as a patient safety review, it neither does justice to either patient safety or quality or the other dimensions of quality. The argument seems to be that too much effort and resources have been given to safety rather than the other dimensions of quality and that has been to the detriment of those other aspects of quality. Why is the answer [or this is how it feels] ‘do less on safety’ more on other areas of quality rather than can we do ‘as much on the other dimensions as we do on safety’. For what it is worth, my view is that safety is by far the most important of the six dimensions of quality.  It’s the underpinning of the other five.
2. Content: Forgive me, but it feels like it is written by, edited by, pulled together by individuals who are not patient safety experts. I apologise sincerely to those involved if I have done them a disservice. Maybe that was purposeful so that a ‘fresh eyes’ approach could be taken but it appears to diminish the science of safety and all that it is. The review mainly focuses on the ‘once things have gone wrong’ approach to safety. The quantification of harm, (which is pretty weak) and the approach we have taken to date which is to address individual harms one by one rather than the too difficult systemic issues. In the language of safety and human factors the review feels too often the ‘world of safety as imagined’ rather than the ‘world of safety as done’.
3. What is safety: It would be better if there was at least a nod to the work of safety over the last decade or so that has helped shape our thinking. The understanding we now have about the differences between healthcare and other high risk industries. The way in which safety is much more concerned with helping people work safely, asking ourselves…How do healthcare practitioners work safely every day — and how can we make that easier and more reliable? Safety is about looking at all outcomes, good and bad and what leads to those outcomes, it is not simply about error and harm.
4. Safety expertise: The work of safety experts is to help people maintain safety and crucially understanding how healthcare practitioners are able to produce safe and reliable performances despite the fallible, imperfect systems, unrealistic rules and incompatible procedures. In this regard we have shifted towards system thinking and learning about the interconnectivity and interdependencies in the complex adaptive system that is healthcare.
5. Culture: I appreciate that ‘culture’ seems to get a bad press these days. I think that has arisen because it is easy to say ‘just change the culture’. It is hard to define, and hard to do. Break culture down and you can get started. The only reference to culture in the review is that of improvement rather than a culture of safety or the key components of a culture of safety which are; learning, building a restorative just culture, ensuring psychological safety, compassion, kindness and the ways in which this culture can be enhanced by relationships and helping people talk to each other. I the future landscape where would any of this be addressed?
6. Achievements to date: I am one of the first to say that there is still much to do and we should have improved more since around 2000. The book ‘Still Not Safe’ sums that up for all of us who have worked in safety for that time. However, it would be wrong to say improvements have been limited. Key point – organisational and cultural change takes time. A long time. It is worth thinking back to the 1990s and ask what is different now. Knowledge, expertise, understanding of what we now call patient safety is significantly better. There are patient safety researchers, people with masters and doctorates in the subject, thousands of articles and books. We simply did not have this just 25 years ago. We have more data than we could ever have imagined via the incident reporting systems at a local and national level. We have patient safety specialists and a growing understanding of how to improve safety and undertake investigations in NHS organisations. I would argue that we are too good at cutting things down when they are just getting going. I am biased but the National Patient Safety Agency was just findings its feet when it was abolished and this applies to a number of organisations in the NHS. I hope that this does not happen to HSSIB, which in my view should expand its remit not curtail it. HSSIB broadening its work into wider system management seems totally appropriate to me.
7. Standardisation: For many reasons we need to caution the view that standardisation is the answer or that Kaizen or Lean is the answer. This is ‘linear system thinking’. These concepts work mainly for production lines [I am sure there will be people who tell me otherwise]. They will only apply to small areas of healthcare. As I have said, we have systems that are a mix of complex adaptive systems, some that are complicated and some that are even relatively simple, but they are rare.  It is:
   • Complex because it is a system of many interconnected parts and simultaneous interactions and processes which are rarely linear and make it unpredictable. That means you cannot prescribe, precisely what people should do for every single practice or process or task.
   • Adaptive because the system can change its performance according to conditions and decisions and people often have to change their performance according to the conditions and situations they face
   • In short, no two days are the same.  There is a great quote, no man ever steps in the same river twice, for its not the same river and he’s not the same man (Ref: Heraclitus) – this is healthcare. It is a mix of wanted and sadly unwanted outcomes that are a result of a unique combination of events and conditions.  In fact incidents are so tricky to review because they are the inevitable outcome of a sequence of events that rarely if ever occurs in exactly the same way a second time.
   • Charles Vincent and Rene Amalberti have looked at this in detail and in their brilliant book Safer Healthcare (2016) described the complex adaptive system as having three areas; ultra safe, high reliability and ultra adaptive.  The book beautifully describes how the strategies to achieve ultra safe systems only work for routine, predictable care. An awful lot of what we do is ultra adaptive – where there is a need to accept that there are risks in healthcare. Where there is high uncertainty and it is here that skills, knowledge and expertise are probably more important that adherence to things like standard procedures.  These are the things you study when you study safety.
8. National versus local: Having worked in front line trusts, in a regional body, in the Department of Health and Social Care, in the National Patient Safety and in NHS Resolution in my career I know the benefits that national organisations can have in supporting front line organisations. At a national level we get the luxury of time and resources to work on things that front line organisations cannot do. We get to look at it from a much wider perspective and to think about how we can maximise the N in the NHS. It is one of the things the NPSA did well -in working with pharmaceutical companies, in designers of equipment and those in procurement to improve aspects such as packaging and safer equipment designs and looking at procurement for safety.
9. The future: I get no sense of the future for patient safety apart from moving some functions to sit with other organisations, getting rid of the National Guardians Office and Healthwatch (what?!) and a revamped National Quality Board. It is odd in the way the review seems to describe the NQB as an organisation but it is [as far as I am aware, not being on it] a meeting of a collection of senior leaders from across the NHS. I have sat on a few of these and I am not confident the meetings are the agent for change that this review expects. I am happy to be proved wrong.
10. The findings: The findings all seem to relate to quality [yes I know that quality has been defined as including safety] and patient / user experience. Even the patient safety experts in NHS England are moving to the patient / user experience department in transition before moving to the DHSC [as far as I can tell from this]. Does this include the national reporting system [LfPSE] and work on the patient safety incident response framework? I assume so.
11. What would I have said: I had to ask myself, if I had been asked to review patient safety in the English NHS, what would I have said? I think I am in danger of living in the past. because I would have said [I will keep it brief to the top three things]:
    • Since the early 1990s we have focused on incident reporting and incident investigation as a way to solve the issue of safety. This has become a bureaucratic treadmill which has created a culture of fear. I would redesign the incident reporting systems to make them far more purposeful in what they collect and what they do with the information. I would also significantly ramp up the expertise required to do any investigation. Our approach to date is to give the job to pretty much anyone who has (or usually hasn’t) the time. This is completely wrong. There is some work started which is trying to address this so that needs to continue.
    • In the last decade in particular we have genuinely started to understand what it takes to improve patient safety and how we can help people work safely in a much more positive and proactive way. I would want us (healthcare) to work alongside safety experts who are immersed in this ‘new view’ of safety thinking.
    • I would have said that we need [yes I am going to say it] an organisation like the National Patient Safety Agency. My view is that HSSIB could have been that organisation. I would have given them a much bigger remit. I also think we need national leadership which is within the DHSC and also sits outside of it. This is what I thought the patient safety commissioner was going to be and was somewhat surprised when the role was confined to medicines and medical products.

So there we have it. My only last thought is for those people who are working in patient safety, particular the bodies that have been reviewed. Having worked in organisations that have had to go through organisational structural change and even one that was abolished I know how hard that is. I wish them well.