Response to Select Committee report: Government progress on patient safety recommendations

  • 22nd March 2024

The Health and Social Care Select Committee’s Independent Expert Panel produces reports which assess progress the Government has made against their own commitments in different areas of health and care policy. On the 22 March 2024 they published a new report evaluating the implementation of accepted recommendations made by inquiries and reviews into patient safety. This blog sets out Patient Safety Learning’s response to its findings.

Patient Safety Learning welcomes the Expert Panel’s new report today stating that Government action to improve patient safety “requires improvement”.[1]

Reviewing a list of recommendations pertaining to patient safety and whistleblowing in the NHS, the Expert Panel identified five recommendations across three broad policy areas for investigation:

  • Maternity safety and leadership
  • Training of staff in health and social care
  • Culture of safety and whistleblowing

It gave each individual recommendation a rating in the style used by national bodies such as the Care Quality Commission. Overall, it noted that:

“… despite good performance in some areas, the evidence we received has led us to rate the Government’s overall progress in the area of patient safety as ‘requires improvement’. Our rating partly reflects the length of time it has taken for the Government to make progress on fully implementing four of the recommendations which were accepted nine years ago, or longer. Progress is imminent in several areas, which is reassuring, but we remain concerned about the time it has taken for real action to be taken. In two cases, the promised guidance or legislation to implement the recommendation has been delayed.”[2]

Our submission to the Expert Panel

Patient Safety Learning submitted a response to the Panel as part of this review earlier this year. This focused on two areas:

1. Culture of safety and whistleblowing

The Panel was assessing the progress that had made in implementing a specific recommendation from the Robert Francis QC’s review into speaking up in 2015. This recommendation stated that:

“Every organisation involved in providing NHS healthcare, should actively foster a culture of safety and learning, in which all staff feel safe to raise concerns.”[3]

In our response we noted that blame cultures and a fear of speaking up continue to persist in significant parts of the NHS. We highlighted evidence of this drawn from staff survey results, patient safety scandals and the shocking experiences and testimonies of whistleblowers.

We acknowledged the positive development that NHS England, over the last two years, has introduced several new good practice resources aimed at helping organisations to foster a patient safety culture. However, we also pointed to concerns that there appears to be no clear system for ensuring implementation across the NHS with no public plans for monitoring and evaluation. This means that it is difficult to easily ascertain which organisations are aware of the guidance and have made commitments to implement this, what progress they have made and what impact it is having.

2. Inquiry recommendations and the implementation gap

We also highlighted issues beyond the individual recommendations being considered by the Expert Panel, concerning the implementation gap relating to patient safety inquiries and reviews more broadly.

The implementation gap is the difference between what we know improves patient safety and what is done in practice.[4] This gap between learning and improvement exists at multiple levels and in many different areas, as we have previously identified in our report Mind the implementation gap: the persistence of avoidable harm in healthcare.[5] In this report we looked at six specific areas where this gap exists on a policy level and acts as a barrier to patient safety improvement. One area we focused on specifically as part of this was patient safety inquiry and review recommendations.

In our submission to the Panel we set out that too often we see recommendations around specific areas of ongoing concern, such fostering a culture of safety and learning, failing to translate into meaningful changes and improvements on the ground. We noted that it is particularly difficult to assess the effectiveness of many recommendations, stating:

“As made self-evident by the need for the Select Committee to undertake this specific Expert Panel review, there is no central repository or responsibility across government for tracking whether recommendations have been implemented and ensuring that inquiries have an impact. We lack the tools to assess how effective inquiries recommendations are in addressing the patient safety problems they identify.

Without a publicly available central repository of recommendations and transparent reporting against this, we cannot easily identify how many inquiry recommendations are outstanding and how many have been implemented. We also cannot easily tell whether there are a number of overlapping recommendations on a specific theme or topic stemming from different inquiries, and whether there is a systemic approach in place to tackle these.

Simply put, there is currently no way a patient, member of the pubic, parliamentarian, policymaker, or journalist to assess what recommendations have been implemented, whether in full, in part of not at all, across the whole of the NHS or individual organisations.”[6]

Concluding comments

Public inquiries and reviews into serious patient safety issues should function as a key source of insight and learning that we can use to reduce avoidable harm in healthcare. However, they require system-wide commitment and resources, with effective and transparent performance monitoring to ensure that the accepted recommendations translate into action and improvement.

We welcome that the Expert Panel in its report has highlighted the importance of this, along with the need for great action and urgency in implementing patient safety recommendations. We await the Government’s response to this report with interest.


[1] House of Commons Health and Social Care Select Committee, Expert Panel: Evaluation of the Government’s progress on meeting patient safety recommendations, 22 March 2024.

[2] Ibid.

[3] Robert Francis QC, Freedom to speak up: An independent review into creating an open and honest reporting culture in the NHS, February 2015.

[4] Suzette Woodward, Patient safety: closing the implementation gap, 30 August 2016.

[5] Patient Safety Learning, Mind the implementation gap: The persistence of avoidable harm in the NHS, 7 April 2022.

[6] Health and Social Care Select Committee, Written evidence submitted by Patient Safety Learning (PSN0008), 24 January 2024.

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