Patient Safety The review was asked to consider whether
there are overlaps and gaps in functions across organisations, and make recommendations as to the future roles of the organisations. Dr. Dash’s report found that:
l There has been limited strategic thinking and planning with regard to improving quality of care.
l 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.
l 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.
l The current system for complaints and concerns is confusing and may lack responsiveness.
l Some of the organisations reviewed have expanded their scope of work beyond the original remit. While this is done with the admirable intention of improving the safety of care delivery, it can create further complexity, recommendations and confusion.
l A greater strategic focus on care delivery and management is needed to improve quality of care.
l The National Guardian’s Office duplicates work carried out by providers.
l Insufficient use is made of the NHS’s data resources to generate insights and support improvement.
l There is insufficient focus on developing a national strategy for quality of social care.
She concluded that action is needed to address some of the gaps in functions. In particular, a strategic approach is needed with regards to improvement and innovation in quality of care
(including safety). There is a need to streamline, simplify and consolidate functions where considerable duplication and overlap currently exist. Furthermore, 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. Within commissioners and providers, there
needs to be a far greater focus on: l building skills and capabilities l effective governance structures l clearer accountability for quality (including safety) of care
Lastly, she states that the CQC was established as the independent regulator of health and care. Dr. Dash said that it needs to rebuild public, professional and political confidence, and should also house functions where independence is required. She goes on to make nine recommendations
in the report: 1. Revamp, revitalise and significantly enhance the role of the National Quality Board
2. Continue to rebuild the Care Quality Commission (CQC) with a clear remit and responsibility
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
4. Transfer the hosting arrangement of the Patient Safety Commissioner to the Medicines and Healthcare products Regulatory Agency (MHRA), and broader patient safety work to a new directorate for patient experience within NHS England, transferring to the new proposed structure within DHSC
5. Bring together the work of Local Healthwatch, and the engagement functions of integrated care boards (ICBs) and providers, to ensure patient and wider community input into the planning and design of services
6. Streamline functions relating to staff voice 7. Reinforce the responsibility for and accountability of commissioners and providers in the delivery and assurance of high-quality care
8. Technology, data and analytics should be playing a far more significant role in supporting the quality of health and social care
9. There should be a national strategy for quality in adult social care, underpinned by clear evidence
Commenting on the report, Matthew Taylor, chief executive of the NHS Confederation, said: “Patient empowerment is crucial to the success of the government’s Ten-Year Health Plan. It is absolutely vital that when things do go wrong there are ways
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www.clinicalservicesjournal.com I September 2025
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