The CQC find that safety culture within NHS organisations is challenging, with mixed messaging from the centre and a lack of dedicated resources.

policy digest

29 / 01 / 2019

Opening the door to change: NHS safety culture and the need for transformation

CQC, December 2018

In this report on safety culture within the NHS, the Care Quality Commission seeks to establish how guidance from central bodies is regarded by trusts, how effectively trusts implement this guidance, how other system partners support trusts with implementation and what the sector can learn from other industries. The report finds a number of serious barriers that are preventing trusts from improving safety for patients and makes 7 recommendations to overcoming these.

Drawing on a series of examples from across the system, the authors focus on challenges for trusts, challenges for the whole system and challenges for the workforce.

NHS Trusts

  • The current practice of trusts receiving patient safety alerts from a range of different organisations is confusing and does not provide trusts with a clear set of actions to take.
  • Many trusts do not have the resources or time to consistently implement changes in response to patient safety alerts
  • Some level of standardisation in the processes available to staff wishing to register concern about safety would encourage them to speak up
  • Standardisation of practices, subject to professional judgement might improve safety in a more consistent way.

Whole system

  • The current landscape is confused and muddled, with many different organisations taking responsibility for safety and trusts complaining that they receive multiple messages on certain issues.
  • There is a lack of learning from incidents at a local and national level which is hampering significant progress.
  • Varying cultures between different trusts mean that information is not always shared, and trusts are not incentivised to collaborate to learn from incidents.
  • Better technology is needed to enable reporting and learning to take place across the system.


  • Patient safety needs to be an essential thread which runs through every aspect of a medical professionals’ career.
  • Greater clarity is needed on the role of different stakeholders: medical regulators, membership bodies and educations bodies in educating and training medical staff on patient safety.
  • Trusts are often unwilling or unable to release staff for safety training, this is hampering consistent progress.
  • The NHS workforce lacks a common understanding of patient safety and safety culture.

The report ends with 7 key recommendations which it states will be critical to improving patient safety culture within the whole system.

  1. NHS Improvement (NHSI) should work more closely with Health Education England to ensure the NHS workforce has a common understanding of patient safety and Health Education England should develop specialised training for staff to undertake as part of their clinical education or through separate training.
  2. The upcoming National Patient Safety Strategy shout set out a clear vision for patient safety with clarification on the roles and responsibilities of all national and local stakeholders.
  3. Leaders on patient safety must be given adequate training to drive safety in their trusts and should actively feedback into NHSI to enable learning across the system.
  4. NHSI should work with professional regulators, royal colleges, frontline staff and patient groups to develop a framework for identifying where processes and practices in trusts could be standardised to improve safety.
  5. The National Patient Safety Alert Committee should work to align patient safety alerts and outputs of all bodies with a stake in safety to better enable trusts to take appropriate action in response to alerts.
  6. NHSI should work with royal colleges and professional regulators to review the Never Events framework – with a particular focus on leadership, culture and barriers to improving safety such as human behaviours.
  7. CQC should improve the way they assess and regulate safety to ensure the NHS workforce has a common understanding of the steps necessary to improve safety.

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