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Safer care for all

Solutions from professional regulation and beyond

In our report - Safer care for all - (published in September 2022) we examine the current state of professional health and care regulation in the UK. However we go beyond this in identifying and proposing solutions to some of the huge challenges facing health and social care today.

Our report considers four main themes:

  1. Tackling inequalities
  2. Regulating for new risks
  3. Facing up to the workforce crisis
  4. Accountability, fear and public safety

Next steps for Safer care for all and how it ties in with our strategic direction

We published Safer care for all in September 2022. Since then we have been carrying out extensive engagement with stakeholders (including by consulting on our draft Strategic Plan) to develop our focus for the next three years and plan for 2023-24.

During 2023/24 we intend to focus on the interlinked issues of workforce, inequalities and accountability. A recurring theme in our discussions with stakeholders was that of culture in health and care. We realise that the PSA, alone, cannot tackle poor workplace culture or the problems associated with it, but we hope that with the ambitious aims we've set out in our strategic plan, we can make a start and work with others to to highlight improvements needed to assure better and safer care for all.

  1. Workforce – we know that workforce shortages impact patient safety as well as professionals’ workplace wellbeing. We want to focus on building the evidence base around the regulatory barriers. Working with regulators and wider stakeholders, we want to identify solutions to help create a more agile workforce as well as encourage innovation. We think this work will help us shape a practitioner regulatory strategy. We believe this is needed to support health and care workforce strategies across the four countries of the UK.  
  2. Inequalities – in addition to the work we are doing to revise our expectations of how regulators will meet Standard 3 as part of our performance review process (Standard 3 of our Standards of Good Regulation is focused on regulators understanding the diversity of their registrants, patients and service users and not creating barriers through any of their processes/disadvantage people with protected characteristics), We are also introducing a new EDI standard for the Accredited Registers. Our work in this area will focus on engaging and convening stakeholders on key issues where we can add value and support action. This will include disseminating our consumer research on perceptions of discriminatory behaviour in health and care and looking at barriers to complaints and the role of healthcare professionals in tackling health inequalities.
  3. Accountability – our main focus in this area will be to work with regulators to encourage clear messaging on the role of professional regulators when there have been serious failures of care. We also want to facilitate and encourage stakeholders to look at how to learn from serious patient safety incidents. This will include consideration of the wider issues we are aware of that may impact on professionals’ fear of regulation and wider accountability mechanisms, such as blame culture, barriers to candour and experience of ‘moral injury’ by healthcare professional involved in major failures of care.      
  4. Safety system – work in this area will be primarily focused on building our evidence base on how the functions proposed for the Health and Social Care Safety Commissioner might be delivered in different ways across the four UK countries and engaging with existing bodies fulfilling some or all of these functions across the UK. We want to explore how improvements in the safety system might be achieved. We also intend to engage with stakeholders on the case for a more coordinated approach to public inquiries and reviews (through a Commissioner role or otherwise).     

We will continue having conversations with stakeholders as we take forward this work through the year so watch this space.


Take a closer look at the four issues

Tackling inequalities

There are still unequal and unfair outcomes for protected groups in aspects of professional regulation. There is also a lot we still do not know about how inequalities affect all-important complaints mechanisms when care has gone wrong – or indeed what this could tell us about biases in care itself. Professional regulation must work to address its own issues, and support professionals to help tackle inequalities in the design and delivery of care. But as a sector, we also need to be better at hearing diverse voices, and collecting, analysing and sharing data.

>>Find out more

Facing up to the workforce crisis

Workforce shortages are putting patients and service users at risk across the UK. Engrained attitudes to professional regulation and qualifications aren’t helping. Is it time to rethink the contribution of professional regulation to workforce planning?

>>Find out more

Regulating for new risks

Changes in the way that care is funded and delivered are sometimes made with limited focus on the risks and impacts on patients and service users, and how to manage them. Reforming the regulators gives us an opportunity to address known problems, and may even build in some agility for the future – if we take the opportunity presented to us. But we also need better, more reliable ways to anticipate these changes.

>>Find out more

Accountability, fear and public safety

Just cultures and individual accountability are both essential to better, safer care, and must coexist. Professional regulation should be clearer about its role, to reduce unnecessary anxiety and inappropriate complaints. We need to find ways for these new approaches to safety such as ‘safe spaces’, to incorporate openness with patients, service users and families, and action against individuals where it is needed for public safety.

>>Find out more

Read all recommendations

You can find a table of all our recommendations here. This is not also a case of the 'we say, you do' - we have also committed the Authority to play an active role in tackling these challenges. These commitments are also listed in the table.

What would you like to read?

We have several versions available.  Not got time to read the report in full? You can read through the executive summary here. This encapsulates the four main themes set out in the report as well as the recommendations we have put forward. Even more pressed for time? Then read The essentials - this (very) short section tells you what the report is all about.

You can also download:

There is also a Welsh translation available of front part of the report, including The essentials and the executive summary. You can download it here

We also have a Word version of the full report available. Please get in touch - using the email address below - if you would like a copy.

Please get in touch with us if you would like a Word version of the full report.

Starting the discussion

Safer care for all conference 

When we published Safer care for all in autumn 2022, one of our main aims was to start a debate on the issues highlighted and the recommendations we put forward in the report. To take the next steps we organised a conference. On 9 November 2022, over 250 attendees came together (virtually) to discuss issues highlighted in the report, including:

  • 'Does regulation need to change to deliver the workforce of the future?'
  • 'Do health/care professionals have a duty to tackle inequalities?'
  • 'Is regulation keeping patients safe?'
  • 'Are learning cultures compatible with individual accountability and openness when mistakes are made?'

The conference provided an opportunity to hear experts’ views as well as consider and contest the themes raised in the report. Speakers and delegates came from both professional and system regulators as well as patient organisations, the ombudsman, the NHS, health and care sector organisations and Chairs from major healthcare inquiries. You can find a summary of the main themes that came out of the discussions here.

Safer care for all guest blogs

We are also publishing a series of guest blogs written by stakeholders from across the sector. You can find all our guest blogs published to date below:

Read our blogs

Cultural Safety – seeking to turn the tide of health inequities in Aotearoa New Zealand

Jan 6, 2023, 10:50 by Joan Simeon, Kiri Rikihana, Richard Tankersley, Jane Dancer, at The Medical Council of New Zealand
In our latest blog, Joan Simeon, Kiri Rikihana, Richard Tankersley, Jane Dancer at The Medical Council of New Zealand, discusses the role of healthcare practitioners, and regulators in addressing health inequities in Aotearoa, New Zealand, and how the practice of cultural safety can improve patient outcomes.

Our report Safer care for all launched at a Parliamentary reception on 6 September. It highlights some of the biggest challenges affecting the quality and safety of health and social care across the UK today.

We want Safer care for all to start a debate on the issues highlighted and recommendations we have put forward in the report. As part of this debate, we are publishing a series of guest blogs written by stakeholders from across the sector. This blog is from Joan Simeon, Kiri Rikihana, Richard Tankersley, Jane Dancer, at The Medical Council of New Zealand.

Aotearoa New Zealand is hailed as a leader in positive relationships between its indigenous Māori people and the New Zealand government. Some would debate this; however, where this is true the common ground is hard won, and compromises in the name of progress have been made on both sides. Where it is not true, it is because the social and health inequities experienced by Māori whānau (families) and communities persist.


Māori constitute 16.5% of Aotearoa New Zealand’s population of 5 million and most of the Māori population is aged under 35. Poor health outcomes, and unfair and unjust disparities in access to healthcare, employment, and housing, stifle the potential of Māori communities to flourish.

Health regulators have a unique place in supporting health equity by promoting and evolving the practice of cultural safety.

Since 2015, Te Kaunihera Rata o Aotearoa | Medical Council of New Zealand ('Council') noted that the causes of health inequity, and the links with poor health outcomes, were well evidenced. Moreover, inequities could be improved or avoided through a coordinated approach by training and health providers and policymakers.

In Council’s 2015 discussion paper, we set out that while the causes of health inequity are complex, there are some aspects of inequity where the regulator or medical profession has significant control or influence, and therefore we have a responsibility to act. As the medical regulator we have a responsibility to support and strengthen cultural competence, improve cultural safety, and more importantly work towards better health outcomes for Māori.

Off the back of this early work, two aspects of health policy are becoming established in the regulation of health professionals in Aotearoa New Zealand. The first is recognising Te Tiriti o Waitangi – the 1840 founding document for Aotearoa New Zealand signed between the British Crown and Māori iwi (tribes).

The second is embedding the practice of cultural safety into accreditation standards across the medical education continuum – which reflects the recognition of cultural safety as a core element of patient safety throughout the health sector.

Te Tiriti o Waitangi

A sea change has taken place in the last 30 years. We recognise the unique importance of Māori culture and values, and the necessary decision-making role that iwi (tribal) groups should have in health and social services – a recognition, in part, of the agreement made under Te Tiriti o Waitangi. In 2019 the Waitangi Tribunal produced the Hauora (Health and Wellbeing) report on breaches of Te Tiriti o Waitangi in the primary health sector. It reported five principles that should be used in the design and delivery of health services.

These principles are now beginning to be included into legislation, strategic planning, and operational service delivery. For example, the Health Practitioners Competence Assurance Act 2003 already requires that responsible authorities address the needs of Māori people, and in doing so the Medical Council of New Zealand is supporting the principle of equity by examining and redesigning our regulatory system (including quality improvement, notification, governance, and data systems) to support more equitable outcomes for Māori. This progresses opportunities for more equitable outcomes to develop for all and advances a more culturally safe regulatory system. 

The Treaty of Waitangi Principles derived from WAI 2575

Tino rangatiratanga: The guarantee of tino rangatiratanga, which provides for Māori self-determination and mana motuhake in the design, delivery, and monitoring of health and disability services.

Equity: The principle of equity, which requires the Crown to commit to achieving equitable health outcomes for Māori.

Active protection: The principle of active protection, which requires the Crown to act, to the fullest extent practicable, to achieve equitable health outcomes for Māori. This includes ensuring that it, its agents, and its Treaty partner are well informed on the extent, and nature, of both Māori health outcomes and efforts to achieve Māori health equity.

Options: The principle of options, which requires the Crown to provide for and properly resource kaupapa Māori health and disability services. Furthermore, the Crown is obliged to ensure that all health and disability services are provided in a culturally appropriate way that recognises and supports the expression of hauora Māori models of care.

Partnership: The principle of partnership, which requires the Crown and Māori to work in partnership in the governance, design, delivery, and monitoring of health and disability services. Māori must be co-designers, with the Crown, of the primary health system for Māori.

Cultural safety

“Cultural safety requires health practitioners to examine themselves and the potential impact of their own culture on clinical interactions. This requires health providers to question their own biases, attitudes, assumptions, stereotypes and prejudices that may be contributing to a lower quality of healthcare for some patients. In contrast to cultural competency, the focus of cultural safety moves to the culture of the clinician or the clinical environment rather than the culture of the ‘exotic other’ patient.” Curtis, E., Jones, R., Tipene-Leach, D. et al, 2019

Curtis, E., Jones, R., Tipene-Leach, D. et al. Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. Int J Equity Health 18, 174 (2019). 

The term cultural safety was coined by nurse academic and practitioner Irihapeti Ramsden, ONZM 1946- 2003. 

“Cultural Safety is therefore about the nurse rather than the patient. That is, the enactment of Cultural Safety is about the nurse while, for the consumer, Cultural Safety is a mechanism which allows the recipient of care to say whether or not the service is safe for them to approach and use. Safety is a subjective word deliberately chosen to give the power to the consumer”.

Council considers that as a medical regulator, it has a key role in cultural safety and health equity. This is demonstrated with one of our key strategic directions (known as pou or pillars)  focused on the promotion of equity of health outcomes.  We intend that we will see an improvement in the experience of cultural safety amongst Māori receiving health services from doctors. We will also see an increased support for Pasifika and disabled people and in time a more diverse and inclusive medical workforce.

Our statement on cultural safety sets standards that all doctors must adhere to. In addition, Council uses its regulatory levers in setting accreditation standards across the medical education continuum, from medical school, through prevocational medical training, vocational training and continual professional development programmes, to ensure there is a focus on cultural safety and health equity in all training and education programmes. The accreditation standards also focus on steps to encourage Māori trainees into training programmes and to support them once they are there, such as actively monitoring cultural loading and providing appropriate pastoral care.

We have captured baseline data about the state of cultural safety for patients, as delivered by doctors in a report called Cultural Baseline Safety Data Report - October 2020 that will be used for future evaluation and to help Council consider if it is achieving the goal, it set out.

This recognises that cultural safety theory and practice is central to the quality and safety of a doctor’s practice. Whether a doctor is successful or not in their cultural safety practice is in the “eye of the beholder” (the patient) or reflected in the comfort of the patient and their family.

The practice of cultural safety can be demonstrated by the following examples: 

  • A surgical team taking time before the surgery proceeds for the patient’s adult son to lead the group in a karakia /wayclearing prayer to settle the patient.
  • A doctor recognising and acknowledging a patient’s cultural need to schedule breast cancer surgery at a time that aligns with her practice of following the maramataka (Lunar calendar).
  • A health professional using indigenous introduction methods (where are your people from? how are we connected?)  to build rapport and trust with the patient and their whānau (family) before a consultation begins.
  • Non-indigenous and indigenous doctors speaking up against institutional racism and championing system change within their institution toward an anti-racist system.

These examples speak to a clinician’s insight and knowledge about their own power relationships as a clinician and to overtly acknowledge the patient’s culture and world view.

The historical dominance of the medical paradigm is no longer the only factor in the clinical relationship – and there is now space for the patient’s values. An important addition is that systematic fairness can be at the centre of the clinical conversation, therefore reducing bias and the perpetuation of inequities.

Get in touch

Contact us if you would like to join the discussion about how we can work together to make health and social care safer for all. You can get in touch by emailing