A touch of Dash: A review of patient safety across health and care

An independent review of patient safety in England has been published, recommending steps to consolidate the regulatory and oversight system for care quality, with the emergence of the National Quality Board as a key player.

Dr Penny Dash’s review, commissioned by the Secretary of State for health and social care, assesses whether the current organisations associated with patient safety oversight and regulation deliver effective leadership, listening and learning. It follows Dr Dash’s 2024 review into the operational effectiveness of the Care Quality Commission.

This article sets out our thoughts on the review and a summary of the key findings and recommendations.

About this review

The Dash review focuses on six national organisations involved in patient safety, but the wider safety system includes 70+ organisations. It looks at whether there are overlaps and gaps in functions across the six organisations and makes recommendations as to their future roles.

• Care Quality Commission (CQC)
• National Guardian’s Office
• Healthwatch England and Local Healthwatch
• Health Services Safety Investigations Body (HSSIB)
• Patient Safety Commissioner
• NHS Resolution

Impact of quality (including safety) of care

There is no universally agreed definition of quality in health systems, it is recognised as ‘multi-dimensional’, including safety, effectiveness and patient experience, as well as equity and efficiency.

Safety is understood as ‘minimising harm that arises during the giving of care’.

The Review defined “safety” as:

"The avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare."

Of around 600 million patient interactions with the NHS a year, around 1 in 200,000 results in a safety investigation. International comparisons suggest that if the UK had performed at the level of the top decile of OECD countries in 2022 – there could have been 780 fewer deaths per year due to unsafe care.

The review explains that effective care means “Care that should be provided to evidence-based standards to people who need it. Ineffective care results in considerably more avoidable harm.”

"Of the avoidable deaths in 2022 in England and Wales, around 65% or 82,000 deaths could be attributed to conditions considered preventable."

Dash finds five core problems

• Action is required to address gaps in functions. There is a need for a strategic approach to improvement and innovative quality of care (including safety) which considers allocation of resources and prioritises the many recommendations to providers.
• Streamline and simplify functions where duplication and overlap currently exists, specifically around patient and community engagement, capturing learning from patient experience, and investigations.
• Too many functions sit outside of the commissioners and providers of healthcare, limiting the impact of inquiries, reviews and investigations and the resulting recommendations.
• Greater focus on building skills, effective governance structures and clearly accountability for quality and safety of care within commissioners and providers.
• CQC needs to rebuild public, professional and political confidence and house functions where independence is required.

A closer look at the findings

Significant resources have historically been focused on safety, over other care quality areas, yet improvements remain modest.

There has been limited strategic thinking and planning around improving quality of care:

• Last strategy on care quality was in 2008, which aimed to shift resource from acute care into the community. But Lord Darzi’s 2024 review found the opposite has happened.
• Numerous organisations and professional bodies publish recommendations at both local and national levels, frequently without reference to broader system strategies, which can add complexity to strategic planning.
• The National Quality Board established in 2009 has not yet developed a quality strategy

Too many organisations conducting reviews and investigations, with high number of recommendations that often lack any cost-benefit analysis.

• The Thirwall Inquiry has found that there have been 1,400 recommendations from 30 inquiries in England and Wales in the last 30 years
• Various reviews into maternity care since 2020 have resulted in 450 recommendations
• NHS England has undertaken reviews with the establishment of the Patient Safety Incident Response Framework and the Learn from patient safety events
• Annually 3,000 patient safety incident investigations are conducted by NHS Trusts
• Recommendations vary in quality and lack data around the expected impact or cost of implementation. Often recommendations cause confusions, increase training requirements and require clinical staff to move into supervisory roles to oversee implementation but have questionable impact on quality and safety.

Complaints system is confusing and lacks responsiveness.

• There has been a 39% increase in complaints in the past 10 years
• Over 70 different channels exist to offer a place for patients to share feedback on quality of care
• Complaints are often not handled within six-month statutory period, with missed opportunities for lessons to be the learnt
• Greater support from boards and clinical teams required

User voice fragmented.

• Most NHS boards – provider and commissioner – lack executive directors for patient or user experience
• Some areas have local Healthwatch or charities that amplify the patient voice

Organisations expanding role creating more complexities.

• HSSIB has broadened its work into making more systemic recommendations
• Patient Safety Commissioner has taken on a wider role as an advocate for other patient safety themes beyond medicines and medical devices.
• CQC has expanded its remits to assessing Integrated Care Systems and now develops tools to support ICBs to better understand the health needs of communities.

Providers require greater strategic focus on care delivery and management is needed to improve quality of care. But this does not happen consistently due to a range of factors. Examples include:

• Lack of standardised processes and procedures
• Technology is underdeveloped and underutilised
• The role of commissioners in driving quality remains under-defined. Clearer expectations around contracting, oversight, and assurance are needed to ensure quality is embedded in commissioning practice
• Governance structures vary widely in effectiveness with boards differing in their understanding with boards eg. Smaller GP or dental practices and SMEs in adult social care and private healthcare.

National Guardian’s Office duplicates work carried out by Freedom to Speak Up Guardians.

NHS data underused - as one of the most data rich global health and care systems, there is potential to use technology and AI to generate insights to enable organisations to improve care and outcomes.

Lack of a national quality strategy for social care.

• Limited data around quality of care in social care or metrics to define quality of adult social care
• Lack of evidence of how to disseminate best practice or new initiatives, such as Care England’s decaf by default project

Leading to nine recommendations

A revamped, revitalised and reinforced role of the National Quality Board.

• Responsible for developing a national strategy to improve quality of care
• Set out a vision for quality of care that describes what good looks like 
• Agree national quality metrics and lead a data strategy to improve use of NHS data
• Manage recommendations coming into the system, maintaining a repository of recommendations coming from multiple sources and operate a ‘clearing house function’ to coordinate and priorities recommendations
• Co-Chaired by chairs of CQC and NHSE transitioning to the lead non-executive director for quality on the board of DHSC, and be directly accountable to the Secretary of State for Health and Social Care.
• NHS Resolution role to continue as established

Rebuild the CQC with a clearer remit and responsibility.

• Remain lead regulator of health and social care
• Board governance and accountability must be focus for the regulator
• Assessments should cover all five quality domains, including how risks are identified and managed, ensuring a more tailored approach to the smaller and less structured organisations

Clarify and consolidate HSSIB role.

• Collaborate with DHSC through NQB to agree scope of any investigations it carries out
• Functions of HSSIB should be transferred to CQC, retaining its independent, expertise led investigation facility

Patient safety commissioner functions.

• The role of the PSC (which is to represent patients affected by medicines and medical devices) should be hosted by the MHRA.
• Patient experience work should transition to the new DHSC directorate

Integrate local Healthwatch with ICBs relating to healthcare and local authorities for social care.

• The strategic functions of Healthwatch England should be transferred to the new directorate for patient experience at DHSC

Streamline staff voice.

• Freedom to Speak Up Guardians to be embedded in provider and commissioners to be supported by CQC

Reinforce the responsibility and accountability of commissioners and providers in the delivery of high-quality care.

• Clearer governance and accountability structures with strong roles for board and leadership to support reward and learning

Technology, data and analytics.

• Leveraging the use of technology and AI to improve safety and quality of care
• Align with Sudlow review to buold on the federated data platform

Agree a set of metrics to asses care quality in social care.

Comments

Dr Dash’s report is the starting point for simplifying the patient safety landscape, making it more effective for patients – and the NHS. Poor or inadequate management costs the NHS £5billion each year.

The government has accepted Dr Dash’s recommendations in full - many of which have been highlighted in the NHS 10-Year Plan and will need to be taken forward in the implementation of the plan.

Outside the 10-year plan and the Dash review, there are other areas that have been flagged for future consideration:

• Investigatory functions of the royal colleges, medical examiners and professional regulators
• DHSC ongoing work to review its wider arm’s length body landscape

Standing back from the review, it will be important to ensure that there is ongoing engagement with the sector to check that the new arrangements do ‘add value’ and do not add more burden to an already pressurised health and care system.