On 7 July 2025 the Department of Health and Social Care published the report of Dr Penny Dash which was commissioned to review patient safety across healthcare.

The paper looked at 6 organisations and how they interact with the wider health landscape, these included:

• the Care Quality Commission:

• the National Guardian’s Office

• Healthwatch England and the Local Healthwatch network

• the Health Services Safety Investigations Body

• the Patient Safety Commissioner

• NHS Resolution

The review highlighted several critical issues within the health and care system, some of which are set out below:

Limited measurable improvement: Over the past 5 to 10 years, there has been a significant focus on allocation of resources on “patient safety”, yet improvements have been modest. Despite a substantial increase in staffing and funding in acute hospitals, progress in safety remains mixed.

Limited strategic planning: There has been insufficient strategic thinking and lack of a comprehensive approach.

Confusing and numerous recommendations: there have been numerous reviews, inquiries and an excessive number of recommendations (over 450 for maternity care in the past 5 years alone), that have created confusion for NHS staff.

Confusing complaints system: the system for managing complaints is fragmented, with over 20 different organisations potentially having input, resulting in delay and responses that vary in quality or are inadequate.

Poor use of data: despite the NHS having an abundance of data, it isn’t used correctly or maximised in order to provide key insights and support improvement.

Dr Dash makes a number of recommendations including the need for the Care Quality Commission (CQC) to regain public, professional, and political confidence. It is noted that at present too many functions currently reside outside the direct responsibility of care commissioners and providers, limiting the impact of inquiries and their recommendations.

The report also concludes that there needs to be clear focus on accountability for care and patient safety and considerably streamlining of roles which are duplicated. Guidance needs to be simplified and there is a critical need for a strategic approach to improve the quality of care and patient safety, with a focus on correct allocation of resources and key coordination of the multitude of recommendations given to providers.

The government recently announced its 10 year plan to reform the NHS based on a shift from hospitals to neighbourhood health hubs, a new focus on prevention and improved use of technology.

It’s abundantly clear the NHS needs considerable reform. As a society we deserve better and those dedicated to working tirelessly in the NHS need to be supported. It is hoped of course that the Health Secretary Wes Streeting and Department of Health and Social Care will look closely at the content of this report in implementing its reforms.