Failing to learn? The NHS is losing its capacity for system-wide safety investigation

The health system’s safety and regulatory infrastructure has long been overly complex, unnecessarily cluttered and in need of careful reform.^1,2 The publication of a review of the patient safety landscape by the Department of Health and Social Care (DHSC), led by NHS England’s new chair Dr Penny Dash, sets out dramatic and sweeping plans for reorganisation. ³ While change to the landscape is clearly needed, the Dash review is an earthquake. One change in particular risks setting back progress in the systematic improvement of quality and safety by a decade, and would be unthinkable in any other sector that manages serious risks to the public. The national independent body charged with conducting system-wide and learning-focused investigations into the most serious risks to patient safety is to be merged with England’s struggling^4,5 regulator of health and care providers, the Care Quality Commission (CQC). This institutional change will abruptly remove the health system’s nascent capacity for independent system-wide safety investigation, and will bring to an end England’s globally leading role in pioneering a model that is emulated internationally.^6,7

The foundational role of system-wide investigation

The agency in question – England’s Health Services Safety Investigation Body (HSSIB) – has a critical and unique role that many in healthcare are still unaccustomed to. Its remit is system-wide and learning-focused, conducting major investigations into system-spanning safety risks solely for the purpose of learning and improvement. ⁸ HSSIB is tasked with identifying and investigating the most serious risks to patient safety that span the healthcare system, such as workforce and skills shortages, the risks of widespread staff fatigue, and gaps in safety management – all subjects of recent programmes of investigation.^{9 –11} It is responsible for analysing how the challenges faced by those delivering care – and the terrible experiences of those harmed by care – are shaped by systemic issues like the design of equipment and policy, and the decisions of commissioners and regulators. And it is charged with publicly targeting improvement-focused recommendations to any and all organisations across the health system – including, crucially, the CQC, NHS England and the DHSC itself.^{9 –11}

The imperative of independence

HSSIB purposefully sits apart from the regulators, policymakers and providers it is required to investigate and hold to account for improvement. ¹² Its independence is crucial to its role, and it is unique as a permanent body that has the power to investigate issues that span the entire health system, and to regularly issue challenging public critiques of, and recommendations to, the likes of NHS England, CQC and DHSC. Or at least, it can for now. HSSIB’s independence also ensures that its investigations are conducted solely for the purposes of learning and do not attribute blame or determine liability, creating a safe space for learning that is entirely separate from the punitive or judgemental activities of regulators.^13,14 Similar independent investigation bodies are the bedrock of the safety landscape in other safety-critical sectors. (In aviation, the UK’s independent safety investigation body has existed for well over 100 years ¹² ; its independent counterpart in healthcare has not yet reached 100 weeks.) This is because it has long been understood in other sectors that safety and quality at the ‘sharp-end’ are shaped by complex systemic factors created at the ‘blunt-end’ that cannot be addressed by one individual organisation, one incident at a time.^12,14 System-wide improvement requires system-wide investigation, analysis and learning. And that requires leadership and coordination from a body that is independent, impartial and trusted. ¹⁴

A short history to a long problem

Healthcare has a long history of struggling to address systemic safety failures, relying on a parade of one-off reviews, special investigations and public inquiries, each announced in response to the most recent crisis.^12,15 HSSIB was established to change that, and its own history is both long and short. Its creation by the Government in 2023 followed years of work by patient campaigners, clinicians, parliamentarians and safety experts, ¹² and was a direct result of recommendations made by the Public Administration Select Committee inquiry in 2015 that such a body was urgently needed in healthcare, and its independence should be guaranteed by legislation. ¹⁶ An interim agency was set up in 2017 – the Healthcare Safety Investigation Branch – while primary legislation was prepared to establish HSSIB as a genuinely independent, system-spanning investigation body. ¹⁷

Shooting the messenger or missing the point?

Now, after a decade of development and barely 22 months of existence, the Dash review proposes to strip HSSIB of its independence and, as a consequence, its critical role of leading impartial and system-wide investigation of serious risks to care quality. This is a dramatically rapid demise, even compared with the historically short life expectancy of most English health bodies. ¹⁸ At worst, it suggests an institutional reluctance to countenance systemic improvement recommendations made by a genuinely independent body – the purpose of which is necessarily to be something of a thorn in the side of regulators and policymakers like CQC, NHS England and DHSC by constantly championing systemic improvements to protect the public. At best, it indicates a lack of widespread institutional comprehension of the role and purpose of a permanent, independent, impartial and system-wide investigative agency, that are so well-understood and respected in other sectors.

A newly fractured learning landscape

The proposal to subsume HSSIB as an arm of the regulator undoes years of steady progress at a stroke, and would be unconscionable in any other safety-critical sector. It will bring to an end England’s pioneering efforts to build a permanent capacity for independent, rigorous, system-wide and learning-focused analysis of the most pernicious threats to care quality. And, as part of the regulator, HSSIB will inevitably risk being viewed as doing the footwork of punitive regulatory enforcement, destroying the hard-won safe space that HSSIB – and its underpinning legislation – was beginning to create for open and honest learning.^13,17 Concerns have been raised in Parliament, ¹⁹ and as the dust settles it remains to be seen whether the landscape that emerges will retain any vestige of the independent, impartial and system-wide capability for learning that has so long been needed and hoped for in healthcare.

Declarations

Competing Interests

CM was a member of NHS England’s Patient Safety Investigation Branch Pilot Expert Steering Group (2014–2015); Specialist Advisor to the Public Administration Select Committee inquiry into investigating clinical incidents (2015); a member of the Department of Health and Secretary of State for Health’s Healthcare Safety Investigation Branch Expert Advisory Group (2015–2016); advisor to the HSIB establishment team (2016–2017); Associate Director of Research and Evaluation at HSIB (2017–2019); called to give evidence to the Joint Committee on the Draft Health Service Safety Investigations Bill (2018); National Professional Advisor for Patient Safety at the CQC (2021–2025); and was consulted during Dr Penny Dash’s review of the patient safety landscape. CM currently leads a project supported by the UK’s AI Safety Institute that includes HSSIB as a collaborator.

Funding

None declared.

Ethics approval

Not applicable. This commentary article does not report on research involving human participants or associated data.

Guarantor

CM.

Contributorship

Sole author.

Acknowledgements

Views expressed here are the author’s own and do not reflect the beliefs or opinions of any organisations the author is affiliated with.

Provenance

Not commissioned; editorial review.