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A new national patient safety strategy for the NHS

In July 2019, NHS Improvement published the first ever national patient safety strategy. Here, Matthew Fogarty from the national patient safety team in NHS England and NHS Improvement explains parallels between the new strategy and the Q community.

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As I’m sure you’re aware, earlier this month we published the first ever national patient safety strategy to support NHS staff and organisations to ensure wherever NHS care is delivered it is done so in the safest possible way.

Much like the Q community, the strategy embraces the principle of continuous safety improvement, underpinned by a safety culture and effective safety systems. And like Q, the strategy is for all parts of healthcare from hospitals to GP practices and community care.

It is not a document written by us telling the NHS and its staff what to do. It is rather a document that we curated in the national patient safety team on behalf of the NHS. This is reflected by the wide range of people who contributed to the drafting. It is a statement of our collective intent to improve safety by recognising that to make progress, we must significantly improve the way we learn, support staff and involve patients.

Key features include a safety syllabus and training for all staff, a requirement for all NHS organisations to identify a specialist to lead on patient safety, a new digital incident management system, a much clearer and more consistent approach to the involvement of patients in safety and a national patient safety improvement programme.

Much like the Q community, the strategy embraces the principle of continuous safety improvement, underpinned by a safety culture and effective safety systems. And like Q, the strategy is for all parts of healthcare from hospitals to GP practices and community care.

Although of course I hope you will all read the strategy from cover to cover (if you haven’t already done so!), one particular area I thought might be of interest to Q members is the introduction of patient safety specialists. And indeed I suspect many of you may be suited to these roles within your organisations.

We have not yet defined exactly who should be identified as an organisation’s safety specialist and what skills they should have or might need to develop. We did agree through discussion with the NHS and patients that we want these roles to be separate from executive teams. This is so the focus can be entirely on providing safety leadership, without the distractions from the other responsibilities of being a member of the board.

In some ways the concept is similar to designating someone a Caldicott Guardian, Director of Infection Prevention and Control or Freedom to Speak Up Guardian. But in contrast to some of these designations we want the introduction of the patient safety specialist concept to develop existing people and roles rather than create new posts. We know there are safety experts across NHS organisations. We want to link them up, support them and help them do their vital work. A national programme of training for patient safety specialists will be created as part of the national patient safety syllabus.

Patient safety specialists should have oversight of and provide support for safety activities across their organisations. Part of their role will be to ensure that systems thinking, human factors and just culture principles are embedded in all patient safety activity. However, they should not individually be accountable for patient safety within their organisation, and should instead support the fundamental principle that patient safety is everyone’s responsibility. Accountability remains with the board.

The parallel with Q continues in that to help the specialists thrive, we will support local, regional and national networking. Networks of specialists will allow them to learn from what peers are doing elsewhere, provide access to advice and help from others, and to share good practice to help the spread, adaptation and adoption of successful initiatives.

Our next task will be to define the kinds of skills and responsibilities that people believe are right for specialists.  If you have any thoughts or ideas around the creation of patient safety specialists we’d be keen for Q members to start a discussion by commenting on this blog.

We will then be asking all NHS organisations to identify at least one person to be developed as their proposed patient safety specialist and to notify the national patient safety team by April 2020.

We are indebted to the people who contributed to the NHS Patient Safety Strategy through the online consultation, workshops, stakeholder events, social media and other engagement activity. I therefore want to finish by thanking everyone that inputted into the process.

I also want to thank you in advance for your help in delivering this strategy, which we need every part of the NHS to embrace. If we get this right over the next five years and beyond, it will make a huge difference to how staff approach and engage with patient safety; and most importantly to the safety of patients both now and in the future.

You can find out more and download a copy on the NHS patient safety strategy from the NHS Improvement website.


  1. I would very much like to be involved and contribute to this programme I have spent 10 years as a Director of Safety and had oversight of and provided support for safety activities across my organisation. We created an academy to support the work (GSQIA) to support both safety and improvement, currently we are building our human factors faculty as part of the academy and have a specialist investigation team for all concerns including incidents, complaints, claims and inquests. Our improvement programme is based on Habits of an Improver and includes System thinking.

    Andrew Seaton

    1. Hi Andrew

      Thanks very much for expressing interest in being involved in the work programme relating to the development of  Patient Safety Specialists. We would be happy to meet to understand more about your work in Gloucester and discuss potential opportunities for engagement.


  2. Many thanks Matthew

    The idea of a patient safety specialist for each NHS organisation is a wonderful idea and long overdue - well done NHS England!

    That aside and just to issue a further challenge and give you a headache, is it going far enough?  If we are really to take patient safety (and other emergent outcomes) seriously in the NHS then do we not need to professionally develop ALL of the patient safety and clinical risk advisory workforce in the same way equivalents are in other safety-critical sectors such as transport and oil and gas?

    How do we ensure that they all have the relevant training, qualifications and competencies and access to appropriate CPD to keep up-to-date with modern Human Factors/Ergonomics and Safety Science thinking and methods and which are applicable for highly complex sociotechnical systems like healthcare?  This is an issue of international importance that goes beyond the NHS.

    What are the related learning needs of all of those who provide advice and practical support to healthcare teams and organisations on clinical risk and patient safety matters on a daily basis?

    If occupational health and safety specialists, for example, need to be qualified and be able to demonstrate 'competence' and are typically members of an appropriate professional body, is this not be an aspiration that we should be supporting for those advising on patient safety issues also?

    A great start, and lot questions and challenges, but I think we need to formally engage with other non-healthcare professional bodies and safety-critical industries to see how they recruit, train, support, develop and even regulate safety and risk specialists

    This is something we're floating in NHS Scotland - at a very, very early stage - but happy to keep you posted and/or discuss plans further

    best of luck


    1. Hi Paul

      Thanks very much for taking the time to comment and it’s good to know that you are supportive of the Patient Safety Specialist role. I briefly mentioned in my blog that another key feature in the strategy is the development of a patient safety syllabus and training in patient safety for all staff. This syllabus has been created with input from other non- health related industries. Heath Education England are leading on the development of the syllabus which will include human factors, safety management and the systems approach to patient safety. Through working with system partners HEE will ensure that training is available to staff at an appropriate level, from an introduction to patient safety for new staff  to specialist training modules for those with a more specialist role. There is a requirement in the strategy for all staff to receive training in the foundations of patient safety by April 2023.


  3. Hello Matthew,

    I was involved in one of the focus groups on the National Patient Safety Strategy and syllabus, and felt really encouraged by the proposed approach which just “makes sense”.  I am really keen to get involved in development of the Patient Safety Specialist role, and perhaps to be one.

    We have a fledging Patient Safety Faculty in North Cumbria, with a group of staff particularly interested in moving forward cross-cutting safety challenges, linking this to QI projects which as you mention absolutely makes that link between safety and QI so well covered in the strategy. The  concept of our faculty, is as you describe working out-with the formal assurance board structures to use influence and facilitation to assist in QI addressing safety issues.

    I absolutely believe that the Patient Safety Specialists need to be “front-line” staff of multiple professional backgrounds who are prepared to speak up and promote safety and quality improvement across healthcare. They will need to be influencers and I do think that the potential for a network to provide peer support and advice will be really beneficial, and patent representation will

    Thanks to all who brought the National Patient Strategy to fruition, we just now need to ensure that we really implement it and the syllabus right through the health-service, not just as a concept.


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