Recommendation 97

Transfer of the National Patient Safety Agency to a system regulator

Accepted in part
The National Patient Safety Agency’s resources need to be well protected and defined. Consideration should be given to the transfer of this valuable function to a systems regulator.

The functions of the National Patient Safety Agency were moved to NHS England in order to ensure that improving safety is core business for the NHS. The Department of Health and NHS England agree this vital function should continue to have its resources protected. The Mandate for NHS England includes the objective to continue to reduce avoidable harm and make measurable progress by 2015 to embed a culture of patient safety in the NHS including through improved reporting of incidents. NHS England will be held accountable for progress against the objectives and will use its position as the leadership body for the NHS to support quality improvement throughout the healthcare system, which by definition includes safety improvement.

Patient safety is a critical component of what an effective regulator seeks to secure, maintain and improve and is rightly at the heart of the Care Quality Commission’s new inspection regime. The Chief Inspector of Hospitals’ assessment will include an inspection for patient safety which will inform the ratings of all NHS providers. In addition, the Care Quality Commission and NHS England will work closely together to share information, including reported incidents from the National Reporting and Learning System, to support Care Quality Commission’s surveillance and inspection.

The government has considered the case for the transfer of the functions of the National Patient Safety Agency to a system regulator. These functions were primarily focused on learning, improvement and innovation rather than regulation and assurance. The core functions were to collect patient safety incident reports from all healthcare organisations, so that those reports could be analysed by safety experts in order to learn from what had gone wrong and then to use that knowledge to encourage patient safety improvement across the system. No system is ever 100% safe and patient safety demands an active commitment to continually reducing harm. Professor Don Berwick’s report, Improving the Safety of Patients in England, emphasises that regulation is a crucial component of patient safety, but is not sufficient alone to secure patient safety. Ensuring the continual reduction of harm to patients requires the underlying culture of the NHS to be devoted to learning, improvement and innovation, and delivering that is a role that goes much wider than the system regulator’s remit. The government believes this role rightly sit within NHS England.

In order to realise the Berwick report’s vision of the NHS as an organisation devoted to continual learning and improvement, NHS England and NHS Improvement Quality are leading to establish a nationwide patient safety collaborative programme and will bring a significant level of resource and support to patient safety and improvement science over the next 5 years. Each collaborative will be locally-led and nationally supported. They will be designed to inspire and support a culture of continuous learning and improvement of patient safety in the NHS and be expected to deliver on a set of core patient safety priorities as well as their own priorities. As set out in the NHS Mandate refresh, NHS England and NHS Improvement Quality will seek to finalise the design of the programme, put in place the support and development capacity and recruit participating organisations by spring 2014. NHS England is also working with others on the best ways to develop much greater patient safety capability in the NHS through the education and training of the healthcare workforce in patient safety skills.


In the wake of the Public Inquiry –  with the Care Quality Commission now making rapid progress to improve the rigour and effectiveness of its surveillance, inspection and ratings responsibilities for patient safety; NHS England now focusing primarily on the commissioning of safe services; the new development of the patient safety transparency website; and the launch of the new national Sign up to Safety Campaign – the Government agrees with Sir Robert that it makes sense to concentrate and consolidate national expertise and capability on safety within a single organisation that can provide strategic leadership across the whole healthcare system.

The Department of Health will therefore consider with relevant organisations the options for transferring NHS England’s responsibilities for to a single national body.