Why Should Patient Safety be a Priority for Systems?

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Apr 13 2023 Featured

Following the recent publication of the Hewitt review we asked one of our Special Advisors, Professor Ted Baker, why, despite not featuring prominently in the review, patient safety should be a priority for systems.

Ted has had a long career in clinical and academic medicine, then in healthcare regulation and safety investigations. He has spoken out publicly before about the need for a new approach to patient safety, built on a radically different safety culture.

There will be a warm welcome for the Hewitt review from across the whole healthcare system. It is wide ranging and ambitious, and its recommendations reflect the growing consensus on the future for the new integrated care systems, which can be summed up as local autonomy with effective but enabling accountability. As the review says, this cannot be delivered by just a change of structures, there must also be a major change in behaviours and culture. System thinking and collaboration will be key, together with a focus on the needs of the local population, on health inequalities and on prevention of ill health.

At a recent Aqua Round Table made up of system leaders and safety experts, we considered how systems should tackle patient safety. While this is not prominent in the review, it is of course a fundamental part of quality, health inequalities and indeed the prevention of ill health. The Round Table identified several additional reasons why patient safety should be a priority for systems. First and foremost, it must be recognised that safety is a property of the whole system, not individual parts of the system. Safety risks in one part of a system-wide pathway are often manifestations of problems elsewhere in the system. They cannot be addressed by an individual service and must be managed consistently at system level. This understanding is an essential starting point for all the newly established systems.

Creating an environment which supports the provision of safe care is also key in engaging and motivating the workforce and in delivering efficient and economical care. The OECD estimates that 13-15% of healthcare costs are due to avoidable harm. Not attending to safety leads to poorer outcomes for patients, and more expensive care. This is why systems must not delegate safety to individual providers or confine management of it to sub-committees. It must be mainstream business, considered as central to every management decision. It must be built into the development of new models of care and must be central to systems’ plans to address inequalities in health outcomes in their local populations. It must involve patients and the local population. Understanding their experience of care and their priorities for safety are crucial for success. For too long we have regarded patients as passive recipients of safe care, rather than vital partners in ensuring safety. The population focus of integrated care systems that Hewitt advocates is a chance to change this for good.

System leaders have an unrivalled opportunity to drive improvements and to address the problems in care that now seem so intractable. Innovation and experimentation will be crucial. Nowhere will this be more important than in building a positive safety culture, ensuring strong and effective ways to manage patient safety across the system. The panel of experts convened for the Round Table worked to pull together seven safety themes for systems to consider:


  • A culture shift means embracing all those working across health and care to tackle the biggest system challenges.
  • A system safety culture needs to be collaborative, crafted, nurtured, and sustained, so all can flourish.
  • Improved culture is best supported by new ways of working within services, across the whole system.


  • Systems should ask searching questions about safety and be open to hearing the truth.
  • Leaders at all levels will need to demonstrate consistent behaviours to develop an effective safety culture across their system.

Systematic Management

  • Safety can be proactively managed in a consistent way across the whole system – it should be at the core of a system operating model.
  • Systems working together should develop a framework and principles to manage safety at a system level.
  • Strategic goals for system safety should be linked to data and health inequalities.

Model of Care

  • Developing collaborative relationships across whole pathways of care is essential to managing risk.
  • Listening to patients and people in local communities, and learning from them, will ensure that new models of care provide safe care.

Lived Experience

  • The voice of patients is crucial to setting the right safety priorities and establishing the right culture.
  • Patients can bring different experiences and expertise to the consideration of safety and help services make the changes they need.

Health Inequalities

  • Safety is central to considering health inequalities and ICBs can play a significant role, looking at the systems in place to reduce inequalities created by patient safety issues.
  • System leaders are encouraged to take a wider view of inequalities using NHSE Core20PLUS5 approach.
  • Learning from safety events, for those groups more likely to experience unsafe care, can be used to drive safety improvement for all.


  • Systems cannot deliver the change needed without developing innovative solutions to health and care problems.
  • Safety should be managed as a cross-cutting theme when new policies and pathways are developed.
  • Collaboration and improvement within systems is vital to learn from others and identify areas of best practice in patient safety.

As the review makes clear, Integrated Care Systems have a formidable agenda. Focusing on patient safety is an important part of this, done well it will help systems deliver the ambitious programme of improvement that the review lays out.

To read more about the Aqua Round Table’s assessment of safety at a system level, click here.

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