Skip to main content

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

Safety nets and sledgehammers

May 1, 2024, 09:47 by Anna van der Gaag Visiting Professor, Ethics and Regulation, University of Surrey
In this guest blog, Anna van der Gaag, reflects on our recent timetable exploring how to bring the best of safety culture initiatives and the best of regulatory processes together to do more for patient safety

In March 2024, the PSA convened a roundtable discussion entitled ‘Accountability, fear and public safety’ to explore some of the recent NHS safety culture initiatives in England and their relationship with professional health regulation. Representatives from patient advocacy groups, NHS organisations and regulators took part. We began to explore how to bring the best of safety culture initiatives and the best of regulatory processes together to do more for patient safety. It was a wide-ranging discussion, with some predictable recurring themes.

Not all safety culture initiatives are the same. But all, whether it’s the Health Service Safety Investigations Body (HSSIB), NHSE’s Patient Safety Incident Response Framework (PSIRF), or Mersey Care’s just culture have a number of things in common. The first is a focus on learning from errors and understanding and acting with a focus on system failures rather than individual failures in order to make improvements. The second are myths and misunderstandings about what safety culture initiatives do. For example, much of the focus on HSSIB has been on the misperception that the intention is to exclude patients and families from all its investigations. Other misperceptions are that HSSIB can investigate serious misconduct, and that it prevents other investigations from occurring at the same time. Similarly, PSIRF, with its intent to focus on learning and compassionate engagement with all parties, has been misunderstood as a ‘less robust’ process than its predecessor, the Serious Incident Reporting Framework. We also heard from Mersey Care that just culture is often misunderstood as ‘zero blame’ culture, rather than an approach which seeks to balance safety, accountability, learning and fairness into one, building ‘safety from below’ rather than imposed from above. In short, ‘just culture’ does not equate with ‘zero blame’. There will often be individuals who must be held to account. But if staff feel safe, they will be inclined to be ‘candourous’ too.

Evidence from the Parliamentary Health Service Ombudsman (PHSO) and NHS Resolution suggested that, in many places, professionals do not feel safe or free to speak up or raise concerns. There was consensus that the most risky workplaces are often ‘anxiety spaces’ – characterised by high accountability and low levels of psychological safety. These workplaces tend to have low staff retention rates and poorer outcomes for patients.

All participants agreed with Action against Medical Accidents (AvMA) on what patients want – acknowledgement, apology (meaningful), accountability, action (learning so it doesn’t happen again), and access to justice (to put right the harm that has happened). Equally, AvMA said, accountability is not just about the individual, it is about systems, processes, leaders, management and governance. Sands (a charity saving babies’ lives and supporting bereaved families) pointed to the high levels of frustration when families see no change, and the same issues recur time and again. Patients and families want to be involved in the learning and to know their voice is valued and listened to.

Regulators at the roundtable welcomed the emphasis on patient involvement, alongside the focus on learning. They too pointed to misconceptions and misunderstanding of what regulators do. Fitness to practise should be one part of the safety system, but only a small part for a small number of individuals.

Common myths and misunderstandings: healthcare, safety cultures & regulation

  1. Just culture means zero blame and no accountability
  2. Regulation is ‘out to get’ health care practitioners
  3. Accountability always leads to sanction
  4. Accountability is only about people, not about systems, places and processes
  5. Health practitioners will lose their registration if investigated
  6. Healthcare comes without risk

If nothing else, this roundtable highlighted the complexities involved in delivering a safe, accountable system of health care. The pull of a just culture, towards learning and openness, against the push of regulation, which appears to want to hold individuals to account for mistakes and errors, seems irreconcilable. So where does this take us?

In essence all these new, and not so new (Dekker, 2012) safety culture initiatives are about creating a learning environment in which all parties are involved, respected, seen as equals, with a view to restoring and re-building what is broken. They tie in with the principles of speaking up, increasing cultural competence and striving for equality and diversity. These are all hugely important building blocks of better healthcare.

And here lies the contrast. Alongside this we have built a system of individual redress in UK health professional regulation that is adversarial for all parties. Regulating ‘in the public interest’ can engender the very thing that is toxic to learning and health care safety and improvement – fear, some would say terror, even (Berwick, 2013). Adversarial approaches by definition precipitate defensiveness, and defensiveness supresses learning. To add to the complexity, regulatory decisions that result in practitioner suspensions where there is no obvious risk to patients (GMC versus Arora) invite criticism and dismay in a regulatory process that seems out of step not only with the ambitions of safety cultures, workforce pressures and the enormous stresses of our post pandemic health care environments.

What is not talked about to any great extent with the public or health practitioners is that professionals in health care don’t turn up to work to do a bad job. Bad things happen. Some elements of health care are risky. There will be system failures and human error. Risk is inherent in healthcare, and this acceptance is essential to tackling patient safety issues – to allow both the organisation, and the staff involved to learn from mistakes.

The fear of regulatory action, even when it is not likely to occur, can have negative consequences for individuals, their colleagues. It can also run counter to maintaining a healthy organisational culture. The majority of failures are system failures that involve humans, not human failures that involve systems. The sharp end of regulation therefore should be reserved for the latter, and just culture approaches, which use a restorative response to harm and involve patients and families, for the former.

This roundtable discussion suggests that health professional regulation needs to be refined, re-purposed and refocused to go with the grain of improvement, compassion, restoration and learning. Regulators need to open the door to just cultures becoming the norm in health care whilst keeping the safety of patients and families paramount. Health professional regulators could do more through their communication and engagement to address regulatory myths, for example that referral to the regulator will inevitably lead to a sanction, or that regulators will, by default, blame individuals for system failures. Sharing data and insights, being clearer about expectations and outcomes of complaints, referencing safety cultures in standards and education and training, in short, using the evidence in more proactive ways to help with this. Perhaps most urgent is thinking about how to address the fear factor in fitness to practise processes, which contributes to distress, damage and in rare and tragic instances, the untimely death of practitioners.

Doing the best for patients, in a just culture environment, means early resolution and engagement with patients and families as soon as possible after an event, learning from errors. It does not equate to zero blame, however. Successful safety culture initiatives are mindful of the need to maintain accountability, and the cloak of anonymity should not be necessary in a strong just culture in which people feel able to speak candidly about mistakes.

In the very rare cases of deliberate harm, intent to deceive, boundary violations and exploitation of power, individual accountability and swift regulatory action will always be required.

What do we hear time and again from patients? They want to be listened to, they want transparency, involvement, shared learning and no-one experiencing the harm again. In rare instances, they seek punishment. Health care, like every other human service, needs strong safety nets to protect patients from poor care, deliberate harm. These are the finely crafted and co-designed standards on education, ongoing learning, competence and conduct. But these are not enough. For health care to thrive, we need a seedbed of trust. And for trust to thrive we need a workforce to feel safe at work, free to be honest when things go wrong, not to be blamed for system failures. Just culture environments have been shown to deliver positives – not only trust and learning, but also, crucially, better professional wellbeing, better patient outcomes and safer environments. If regulation is to stay relevant and respected it must go with this grain, and not against it.

There is more work to be done to bring the best of safety culture initiatives and the best of regulatory processes together to do more for patient safety.

Anna van der Gaag

Visiting Professor, Ethics and Regulation, University of Surrey


I would like to thank all those who attended the roundtable from AvMa, Sands, NHSE, NHS Resolution, HSSIB, Mersey Care, PHSO, GPhC, GOsC, HCPC, NMC, GMC and Dinah Godfree, Alan Clamp and colleagues from PSA in attendance.

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