DHSC Review of patient safety across the health and care landscape

The DHSC published the Review of Patient Safety Across the Health and Care Landscape on Monday 7 July 2025.

Overview

This review of patient safety across the health and care system was commissioned by the Secretary of State for Health and Social Care, in response to concerns about the fragmented landscape of oversight bodies. It focuses on six national organisations and the broader functions that underpin quality and safety in care.

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We have closely reviewed the Executive Summary and key appendices, with a rapid scan of the full report. While patient voice is a distinct but related function to the VCSE sector, it remains especially important to LIOs; particularly those hosting local Healthwatch. We've summarised the key points here, but will look to national infrastructure bodies specialising in patient voice for more detailed analysis.

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The Six Organisations Reviewed

1. Care Quality Commission (CQC) - Independent regulator of health and care providers, including ICSs.

2. Health Services Safety Investigations Body (HSSIB) - Investigates serious safety risks; intended to replace reactive external inquiries.

3. Patient Safety Commissioner - Advocates for safer use of medicines and devices, now expanding into broader safety themes.

4. National Guardian’s Office - Oversees the Freedom to Speak Up guardian network, enabling staff voice within the NHS.

5. NHS Resolution (safety function only) - Supports learning from clinical negligence and safety incidents.

6. Healthwatch England and Local Healthwatch - Statutory bodies amplifying patient and public voice in care planning and quality.

Shortlist of Findings

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.

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

3. There are 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.

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.

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

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

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

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

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

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

Five Principle Conclusions from these findings:

1. Strategic Coordination Needed
   Gaps in functions must be addressed through a coordinated, strategic approach to improving quality and safety, particularly by aligning resources with outcomes and prioritising recommendations.

2. Simplify and Consolidate Functions
   There is duplication across engagement, user voice, and investigation functions. These should be streamlined to reduce inefficiency and confusion.

3. Shift Responsibility to Those Delivering Care
   Too many functions sit outside commissioners and providers, limiting their impact. Responsibility for improvement must rest with those delivering care.

4. Strengthen Governance and Accountability
   Providers and commissioners need to focus on governance, skills, and clear accountability to embed quality and safety throughout the system.

5. Rebuild Confidence in the CQC
   The CQC must restore trust and take on key functions requiring independence, reinforcing its role as a credible and effective regulator.

Recommendations

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1. Revamp, revitalise and significantly enhance the role of the National Quality Board (NQB).
   A new, strengthened NQB should develop a comprehensive national quality strategy, prioritise recommendations, and oversee implementation aligned to health outcomes and value for money.

2. Continue to rebuild the Care Quality Commission (CQC) with a clear remit and responsibility.
   CQC should remain the independent regulator, with a sharper focus on governance, risk balancing, and data-led oversight, particularly in supporting smaller providers.
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. ‍HSSIB should focus on serious, systemic investigations, while most reviews remain local. It should work with the NQB to prioritise and avoid unnecessary duplication.
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. ‍Split the role: MHRA should handle medical safety feedback, while broader patient experience functions move into a new DHSC-led directorate focused on improving complaints and engagement.
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. ‍Merge local Healthwatch roles with ICB engagement functions to streamline input from patients and communities into care planning—raising questions about local independence.
6. Streamline functions relating to staff voice. Embed the Freedom to Speak Up function into providers and commissioners directly, removing the need for a separate National Guardian’s Office and reducing duplication.
7. Technology, data and analytics should be playing a far more significant role in supporting the quality of health and social care.
   Invest in high-quality, shareable data and use AI and analytics to generate insights and drive safety, efficiency, and better outcomes across health and care.
8. ‍Reinforce the responsibility for and accountability of commissioners and providers in the delivery and assurance of high-quality care.
   Reaffirm that commissioners and providers are ultimately responsible for quality, and must strengthen internal governance, accountability, performance, and learning.

Other Elements to Note

Cost, Value and Impact

The report notes that the six organisations cost at least £60 million per year and at least £100 million more has been spent on DHSC-sponsored reviews and inquiries into patient safety (no time scales given for this spend). In comparison:

• Healthwatch England receives approx. £3.2m
• Local Healthwatch collectively costs £25.4m / year
• The five other organisations [combined] cost £31.4m / year

Although Healthwatch receives just under 50% of the combined spend on the six organisations reviewed, its work is uniquely rooted in local insight and community engagement. With the NHS 10-Year Plan focused on people, communities, and tackling health inequalities, it’s worth questioning whether centralising this function is truly the most effective; or cost-efficient as it risks undermining the very voices the system aims to prioritise.

Complaints and Insight

The report states that in 2023-24:

11% of healthcare complaints were escalated to the Parliamentary and Health Service Ombudsman, compared to 1.3% in rail, but is that a real comparison? A complaint about unsafe care is fundamentally different from a delayed train.

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Healthcare: Only 1.6% of NHS complaints referred to the Parliamentary and Health Service Ombudsman (PHSO) were upheld.

Social Care: Approx. 24% complaints referred to the Local Government and Social Care Ombudsman (LGSCO) were upheld.

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International health comparisons are limited, and no direct escalation rate comparisons appear to be available. However, we’re concerned that this may be used as a misleading metric of success.

A Focus on Recommendations 5 and 7

Recommendation 5 proposes merging Local Healthwatch’s healthcare functions with engagement teams inside Integrated Care Boards (ICBs); currently 42, but expected to reduce to around 26 in England. This would shift patient voice functions from place to system level, raising concerns about independence, visibility, and local responsiveness.

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Recommendation 7 reinforces that commissioners and providers are ultimately responsible for the quality and safety of care. It calls for stronger internal accountability, governance, and learning cultures, placing more onus on those delivering and commissioning services to act on safety concerns directly.

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Healthwatch’s statutory role currently empowers it to independently represent patient voice, including raising safety issues with those in power. Without this independence, it’s difficult to see how patient voice can meaningfully speak truth to the very system it may be harmed by. As responsibility for safety shifts more firmly to providers and commissioners, removing or centralising independent patient voice risks weakening the essential scrutiny and challenge needed to keep systems accountable.

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This also raises a key value-for-money question: can patient voice truly be delivered more impactfully and cost-effectively through centralised ICB structures than by resourcing independent VCSE organisations with trusted community links?

Conclusion

This review sets the stage for substantial changes to how patient voice is heard and acted on within the health and care system. While simplification and improved coordination are valid goals, the proposed shifts risk weakening the independence, local relevance, and legitimacy of those voices. For VCSE organisations, especially those involved in Healthwatch or ICS-VCSE Alliances, now is the time to reflect on what’s at stake; and to advocate for approaches that genuinely strengthen community voice, not just restructure it.

With thanks to Assura

Our health work is proudly supported by the Assura Community Fund. Their funding helps us strengthen the role of local infrastructure and the VCSE sector in health and care; supporting communities to thrive. You can learn more about the impact of the Fund here.

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