Meeting Notes

10th Meeting – Monday 14 July 2025

Attendees
Professor Henrietta Hughes (Chair – Patient Safety Commissioner)
Louise Ansari (Healthwatch England)
Rabbi Dr Harvey Belovski
Helen Buckingham (National Voices)
Saffron Cordery (NHS Providers)
Dr Mike Durkin (Imperial College London)
Ian Green (Chair, Shropshire, Telford and Wrekin ICB)
Rachel Power (Patients Association)
Apologies
Dr Habib Naqvi (NHS Race and Health Observatory)
PSC staff members in attendance
Rachel Downey
Mel Peffer
Tom Savage

Meeting Notes

1.	Welcome & apologies
1.1	The Chair welcomed everyone to the meeting. Apologies had been received from Habib Naqvi. Ian Green said he was now the Chair and Non-Executive Director of Shropshire, Telford and Wrekin ICB.
1.2	The Chair expressed her sincere thanks to Saffron Cordery who would be leaving NHS Providers in early August and this would be her last Advisory Group meeting.
2.	Note of the previous meeting (1 May 2025) agree meeting note actions and matters arising
2.1	There were no corrections to the notes of the last meeting (1 May 2025), which were agreed and would be added to the PSC website. All actions were complete or in hand (Saffron would follow-up if required on the comms action).
3.	Dash Review and the 10 Year Health Plan
3.1	The discussion started by the Chair and Members reflecting how the changes in the Dash Review and trailed in the 10 Year Health Plan were communicated to staff in the affected organisation, how they found out about changes and the unanswered questions that remain. First and foremost there was a need for staff to be supported, particularly in those organisations most impacted by the Dash recommendations.
3.2	There was a general discussion which covered elements of both the 10 Year Health Plan and Dash Review including, for example: the perceived power imbalance in the system; the importance of an independent patient voice; and the implications of the new proposed Directorate of Patient Experience located with DHSC and how long this might take to be fully established. It was noted that across all Dash recommendations there would a huge amount of work to do, to unpack what was required and transition towards implementation of the recommendations.
3.3	The Chair explained that the specific recommendation relating to the PSC hosting arrangements transferring to MHRA did not require any changes to legislation (unlike many of the other recommendations). The Chair viewed the new hosting arrangement as creating an opportunity to ensure the continued focus on patient voice in the work of the MHRA and help it achieve its patient safety mission. The Chair said her first three-year term as Patient Safety Commissioner was due to end in September and she was awaiting a decision on appointment for a second term as provided for in the legislation.
4.	Chair’s Update
4.1	Much of the discussion at this shorter meeting of the Advisory Group focused on the implications of the recently published Dash report and its recommendations. Other updates from the Chair included: The ongoing work to promote and help embed the Patient Safety Principles, including with regulators, the health inequalities team at NHS England, the NHS constitution team, and those working on the assisted dying bill. The Chair was pleased to see elements of the principles reflected on the 10 Year Health Plan. Speaking engagements since the last meeting had included: Presenting to the Shelford Group Medical Directors The Clinical Pharmacy Congress The IHPN/CQC Patient Safety Conference Running a workshop at the International Forum on Quality and Safety in Healthcare: Utrecht, with Chris Subbe and Merope Mills) Building Trust Brown Bag Lunch session at the Nuffield Trust Panel session at the Integrated and Personalised Medicine Congress on tackling overmedicalisation in primary care The Chair was involved in work with the Royal College of Psychiatrists and NHS England on antidepressant de-prescribing. The Chair was pleased to see that the refreshed Accessible Information Standard (AIS) was due to be published and PSC had input in the context of the Safety Gap report.
5.	Forward look including transition planning post-Dash
5.1	Items included: In September the Chair intended to publish a paper on the impact of the Patient Safety Commissioner role in the first three years since it was first established and reflect where she had seen changes. The Chair said she expected a clearer understanding of the MHRA hosting arrangement recommendation would emerge in the coming weeks, including what it would mean and look like for those affected including for the Advisory Group going forward. The Chair reiterated she saw it as an opportunity to make more progress on medicines and medical device safety for the benefit of patients and the public. The PSC was currently responding to another Rule 9 request from a public inquiry to submit a written witness statement. PSC was due to speak on a panel at HSJ Congress in September. This year’s World Patient Safety Day would be held on 17 September with the theme – ‘safe care for every newborn and every child’. PSC was due to meet the CEO of the Canadian Health Standards Organization & Accreditation.
6.	AOB
6.1	None
7.	Next Meeting
7.1	The next meeting was already in diaries for Thursday 23 October. The Chair thanked everyone for their support.

9th Meeting – Thursday 1 May 2025

Attendees
Professor Henrietta Hughes (Chair – Patient Safety Commissioner)
Louise Ansari (Healthwatch England) – joined remotely
Helen Buckingham (National Voices) – joined remotely
Saffron Cordery (NHS Providers) – joined remotely
Dr Habib Naqvi (NHS Race and Health Observatory) – joined later, remotely

Apologies
Rabbi Dr Harvey Belovski
Dr Mike Durkin (Imperial College London)
Rachel Power (Patients Association)
Ian Green (Chair of Salisbury NHS Foundation Trust)
PSC staff members in attendance
Rachel Downey
Mel Peffer
Tom Savage
PSC staff members in attendance
Rachel Thomsen (PhD Student)

Meeting Notes

1.	Welcome & apologies
1.1	The Chair welcomed everyone to the meeting. Apologies had been received from Harvey Belovski, Mike Durkin, Rachel Power and Ian Green.
2.	Note of the previous meeting (30 January 2025) agree meeting note
2.1	There were no corrections to the notes of the last meeting (30 January 2025), which were agreed and would be added to the PSC website. There were no actions or other matters arising.
3.	Chair’s Update
3.1	In a change to the previous agenda order circulated the Chair suggested she cover her general update first in case other members joined slightly later for the main discussion.
3.2	Today was the Team’s last day in 18 Smith Square due to the lease coming to an end and it not being possible to renew on a short-term basis pending the outcome of the Dash Review. Instead the team would have use of desk/meeting room facilities at 39 Victoria Street.
3.3	The Chair provided an update on activities since the last meeting adding that the current uncertainties had not stopped the team from pushing forward with work. Patient Safety Principles Much work had been undertaken, led by Tom Savage, around embedding the principles and this had included engagement with hospital chains in the independent sector, including Circle Health Group and Spire. Circle Health Group had adopted and incorporated the Patient Safety Principles into their patient safety strategy, and there had also been good engagement with the Independent Healthcare Provider Network (IHPN) who plan to run an event later this year based on the principles in action. Other engagement had included with NHS Providers, private health insurers AXA and Aviva, and with regulators – CQC, GMC, NMC and the Professional Standards Authority. International interest in the principles had come via the Patient Safety Movement Foundation (PSMF) including from a large US hospital chain. Safety Gap report The Safety Gap addresses safety and accessibility challenges faced by patients with sensory impairments when using medicines and medical devices. This work builds on previous research published by RNIB and RNID. The Chair explained the background to PSC’s work in this area, which had its origins in a piece of correspondence received, and had then led to the team commissioning an academic, Professor Mags Watson to undertake the research and produce the subsequent report, working closely with the RNIB and the Thomas Pocklington Trust. A launch event was held at the RNIB, and the report had been made available in several formats including easy read, Braille Ready Format, audio version and a BSL video of the introduction and recommendations. There had been good media coverage and follow-up interest, including from the Government’s British Sign Language (BSL) Advisory Board. The Report made four recommendations, and the Chair reported that already there were plans to restart the work via the UK Electronic Patient Information Task Force (ePIL) to digitise paper-based patient information leaflets and as part of this restart ePIL, working with patients, should examine how to maximise the benefits of this work for patients with sensory impairment. There followed a brief discussion about the currently paused Accessible Information Standard (AIS) which several members had an active interest in and were keen that it should not be watered down. Saffron Cordery said NHS Providers had an active comms director network group and that accessible information was a topic that comes up. *Action:* Saffron to link Rachel Downey with the group and also share the link to the Safety Gap report with them https://www.patientsafetycommissioner.org.uk/our-reports/the-safety-gap-report/ Martha’s Rule The Patient Safety Commissioner had committed to chairing the Martha’s Rule Oversight Group for one year, and the final meeting had been held in March 2025. Data shared at the final meeting had demonstrated good progress. The Commissioner highlighted the work led by NHSE to develop a Martha’s Rule communications toolkit and supporting materials which had been researched and tested. The work would continue to be led by NHSE/DHSC and there was currently funding for the pilot (143 sites) to continue. Redress report There was media coverage around the one-year anniversary of the publication of the Hughes report on redress for those harmed by valproate and pelvic mesh, which had been marked by a debate in Westminster Hall which saw a large number of MPs speaking passionately in support of their constituents and all those affected. A heartfelt apology was given by Minister Dalton on behalf of the Government, and this was warmly welcomed by the patients and families in attendance. Other updates The Chair had recently attended the Global Ministerial Patient Safety Summit in Manila and other speaking engagements since the last meeting included the Academy of Medical Royal Colleges Patient Safety Seminar, Digital Health Rewired conference, the Royal College of Surgeons of Edinburgh Patient Safety Group, the GS1 UK Healthcare conference, and the Community Pharmacy Patient Safety Group. The Chair highlighted that the 2024/25 PSC annual report was being prepared and expected to be laid in June. Work on responding to patient feedback and complaints, including use of AI and QR codes for real time feedback, was briefly touched upon. *Action:* Henrietta and Louise to have a catch-up call around complaints work
4.	Dash Review of patient safety across the health and care landscape (depending on publication date)
4.1	There was no date yet for the publication of the Dash Review, and this was discussed within the broader context of the recently announced NHSE/DHSC merger and ALB review, and the forthcoming 10 Year Health Plan.
4.2	The team was preparing a draft business plan and in doing so were taking a pragmatic, practical approach; and as a starting point reviewing the existing work, including recommendations and strategy and being realistic about the capacity for new work within current staff resources (three civil servants) and pending the Dash Review.
5.	Forward Look
5.1	Items included: Assessing the implications of Dash Review outcomes once published and any transition arrangements Finalising the 2024/25 annual report Interim, flexible business plan Presenting to Shelford Group CMOs Speaking at the Clinical Pharmacy Congress and the IHPN CQC Patient Safety Conference Delivering a workshop at the International Forum on Quality and Safety in Healthcare in Utrecht, with Chris Subbe, Merope Mills.
6.	AOB
6.1	Habib Naqvi reported that the NHS Race and Health Observatory (NHSRHO) would shortly be entering a partnership agreement with NICE to tackle persistent and systemic ethnic health inequalities. Habib also referred to NHSRHO’s Anti-Racism Principles having been adopted by CQC as both an employer and regulator and there were plans with the GMC to bring together all regulators at a roundtable.
7.	Next Meeting
7.1	The next meeting was in diaries for 24 July but would be revisited to ensure maximum attendance at the next meeting. *Action*: Secretariat to contact members for revised availability The Chair thanked everyone for their support, and the meeting finished early.

8th Meeting – Thursday 30 January 2025

Attendees
Professor Henrietta Hughes (Chair – Patient Safety Commissioner)
Rabbi Dr Harvey Belovski – joined remotely
Dr Mike Durkin (Imperial College London) – joined remotely
Dr Habib Naqvi (NHS Race and Health Observatory) – joined remotely
Rachel Power (Patients Association) – joined remotely

Apologies
Louise Ansari (Healthwatch England)
Saffron Cordery (NHS Providers)
Helen Buckingham (National Voices)
Ian Green (Chair of Salisbury NHS Foundation Trust)
PSC staff members in attendance
Mel Peffer
Tim Power – joined remotely
Tom Savage

Meeting Notes

1.	Welcome & apologies
1.1	The Chair welcomed everyone to the meeting. Introductions were made for the benefit of Tim Power from DHSC who would be providing interim assistance to the PSC in the interim, due to two members of the Team having moved at short notice back into DHSC to work on the assisted dying bill.
2.	Note of the previous meeting (7 November) agree meeting note actions and matters arising
2.1	There were no corrections to the notes of the last meeting (7 November 2024), which were agreed and would be added to the PSC website. Under action 2 – at the time of the last meeting it was thought that the Dash review would be published by now; this has not yet happened. There were no matters arising.
3.	Dash Review of patient safety across the health and care landscape
3.1	The Chair gave an overview of some of the history leading up to the Dash review, including PHSO’s 2023 report, Broken Trust. Following on from Dr Penny Dash’s review into the operational effectiveness of the CQC, last Autumn she was then asked to undertake an independent review of patient safety across the health and care landscape.
3.2	This latest review was looking at 6 organisations: Care Quality Commission (CQC) – including the Maternity and Newborn Safety Investigations programme; National Guardian’s Office (NGO) – hosted by CQC; Healthwatch England (HWE) and the Local Healthwatch (LHW) network – HWE is also hosted by CQC; Health Services Safety Investigation Body; Patient Safety Commissioner; and NHS Resolution (patient safety-related learning functions only, not clinical negligence functions).
3.3	Whilst MHRA and NHS England were not included in this latest review it was understood that the review team had spoken with both these organisations as part of the process. Members reflected on the process to date and it was noted that whatever the outcome there would be need to be a credible narrative making clear how any proposed changes would improve patient safety. It was hoped the Report from this latest review would be published soon.
4.	Update on Patient Safety Principles implementation
4.1	Tom Savage gave a brief update on work to implement the Patient Safety Principles, and the engagement to date with individuals and organisations to raise awareness, and to help ensure the principles are as integrated as possible into the health and care system.
4.2	This has included engaging with and presenting to regulators, providers, policy makers and professional bodies with examples including NHS Providers, CQC, Professional Standards Authority, Association of British HealthTech Industries (ABHI), Independent Healthcare Providers Network (IHPN), and different parts of the Department of Health and Social Care with policy responsibility for areas such as the MedTech Strategy, the 10-Year Health Plan and the NHS Constitution.
5.	Update on Accessible Medicines Project
5.1	The Chair reminded members this work was examining the barriers to patient safety in relation to the medicines and medical devices for patients with sensory impairment (hearing and/or sight loss/impairment), with a focus in particular on the experience of patients with visual impairment who have diabetes. The project was progressing well and the academic partner leading this work had prepared her draft report which was being reviewed for factual accuracy by those involved in the project. An update would be shared at the next meeting.
6.	Chair’s update
6.1	The Chair provided the following updates: The Chair informed members that she had recently been appointed as a Visiting Professor at the Institute of Medicine, University of Greater Manchester and was looking forward to delivering a lecture during induction week. The PSC’s 2024/25 Annual Report was being prepared for laying before Parliament before summer recess. The 7 February would mark the one-year anniversary of the publication of the Hughes Report on the options for redress for those harmed by pelvic mesh and valproate, and some media coverage was anticipated to keep the pressure on the call for redress. The Commissioner was due speak to Times radio, and there would also be coverage in the Sunday Times. The most recent Martha’s Rule Oversight Group had been held early that week and the Chair spoke of the early positive data from the 143 pilot sites. Meetings and presentations during the period since the last Advisory Group meeting had included: NHS Providers Conference, Liverpool National Pharmacy Association Visit to a Boots pharmacy Visit to Cromwell Hospital Launch of National State of Patient Safety 2024 Report Leng Review roundtable Patient Safety Leaders Awayday Health Equality Action Lounge event at Davos during the World Economic Forum
7.	Forward look
7.1	In addition to the ongoing work already covered, forthcoming events included a meeting with Sharon Hodgson MP the new Chair of the First Do No Harm APPG and various presentations on the Patient Safety Principles and Martha’s Rule.
8.	AOB
8.1	None. The meeting finished early.
9.	Next meeting
9.1	Thursday 1 May

7th Meeting – Thursday 7 November 2024

Attendees
Dr Henrietta Hughes (Chair – Patient Safety Commissioner)
Saffron Cordery (NHS Providers)
Baroness Julia Cumberlege
Dr Mike Durkin (Imperial College London)
Dr Habib Naqvi (NHS Race and Health Observatory)
Rachel Power (Patients Association)
Apologies
Louise Ansari (Healthwatch England)
Rabbi Dr Harvey Belovski
Helen Buckingham (National Voices)
Ian Green (Chair of Salisbury NHS Foundation Trust)
PSC staff members in attendance
Andrew Biden
Rachel Downey – joined remotely
Moore Flannery
Mel Peffer
Tom Savage – joined remotely

Meeting Notes

1.	Welcome & apologies
1.1	The Chair welcomed everyone to the meeting and thanked members for their help, support and scrutiny. Apologies had been received from Louise Ansari, Harvey Belovski, Helen Buckingham and Ian Green. A short information paper had been circulated to supplement the agenda.
2.	Note of the previous meeting (18 July) agree meeting note actions and matters arising
2.1	There were no corrections to the notes of the last meeting (18 July 2024), which were agreed and would be added to the PSC website.
2.2	The actions from the last meeting were reviewed, some of which would also be covered during other agenda items. The Chair reminded members to notify any changes to their register of interest listing on the website.
2.3	Under action 3, the Chair had met with Baroness Finlay who had raised the assisted dying bill. Under action 4, the Chair thanked members for responding to the Principles consultation; under action 5 the Chair confirmed she had taken part in a Patients Association webinar during Patient Safety Week on 2 September. There were no matters arising.
3.	Patient Safety Principles
3.1	The Chair gave an overview of the Patient Safety Principles which had been published on 23 October and were intended to be: A guide to design and deliver safer care for patients Applicable to all leaders across the healthcare system A framework for working with patients as partners
3.2	Engagement work at the start of the project had reviewed existing principles that helped inform the basis of the public consultation which concluded on 6 September. Responses from 849 organisations and individuals were received, the majority of which were from the public/patients. There was a high agreement rate with the draft principles. The Chair explained that in addressing the responses the team had: adopted the term ‘patients and communities’ modified the language of principle 3 from that of ‘equality’ to that of ‘equity’ modified the wording of principle 5 to make it clear that workers should be encouraged and empowered to speak up included a reference in Principle 7 to compliance with the Caldicott Principles
3.3	Resources on the PSC website to accompany and help promote the Principles included an A3 poster, postcard and a toolkit – which encouraged discussion at team meetings, and suggestions to use the principles in job specifications, to check against and assess processes including complaints and incidents, and to be used as a way of assessing information and how we all engage and treat each other in the workforce.
3.4	The Chair said there had already been a lot of interest in and support for the Principles, as evident in the endorsements received. Discussions were underway to embed the Principles into: the Kings Fund’s programme of work via PSA into professional regulators guidance AvMA’s development of the Harmed Patient Pathway ABPI’s ePIL work · IHPN’s programme of work
3.5	There was some discussion around seeking support for the Principles to be embedded within the system of the 10-year health plan, the NHS constitution and the accountability processes – and what role members could play in adding their support and influence to the Principles, with the Chair suggesting individual members could write to Sally Warren. One member suggested they would use the Principles as a foundation piece to inform their own organisation’s strategy. The NHS Leadership competency Framework was mentioned, and the Chair said she would write to the workforce team at NHS England. There was also mentioned made of the ALB assurance framework, and the suggestion to contact to Ed Moses and Mike Richards. The Chair said she would arrange to meet with the new National Health Mission Champion, Laura Kyrke-Smith MP. It was agreed the Principles were a ‘must-do’; rather than a ‘nice to do’.
4.	Dash Review of patient safety across the health and care landscape
4.1	The Chair recapped the background to the Dash Review and gave her reflections so far. The Patient Safety Commissioner was one of 6 organisations within scope of this latest review, alongside CQC, the National Guardian’s Office, Healthwatch England, HSSIB and the safety and learning function of NHS Resolution. The Commissioner was having regular meetings with the Review team, including with other members of the bodies in the review. A first draft of the review report was expected in December. Several members mentioned they had either met with the review team or were due to do so. The review was collecting and synthesising a great deal of information and evidence and engaging widely. There was further discussion around the review and a broader discussion around a landscape where patient experience and safety are unhelpfully considered as two separate elements.
5.	Chair’s update
5.1	The Chair provided the following updates: Some difficulties were still being faced regarding the separation of the staff costs from non-staff costs but there did appear to be recognition from DHSC that this situation was not ideal and discussions were ongoing with a view to finding better solutions. On Martha’s Rule, 143 sites were participating, and some interesting feedback was emerging. The Commissioner continues to present widely on Martha’s Rule at speaking engagements. The Commissioner had a positive introductory meeting with Layla Moran MP, the new Chair of the Health and Social Care Committee On the Redress report – the team continue to engage and seek updates from the policy team at DHSC, but it was disappointing that redress for those included in the Hughes Report was not included in any budget announcement. Speaking events, visits and meetings since the last meeting had included: Healthcare leaders visits to BA and easyJet to learn from their safety management systems (SMS) HSJ Patient Safety Congress Patient Safety Summit, Mid and South Essex ICB followed by a visit to Broomfield Hospital Ministerial visit with Baroness Merron to the Royal Preston Hospital
5.2	It was noted that the function of the Patient Safety Commissioner had been seen across the world, as had the need for such a role in other countries and that Dr Hughes had set a model for other countries where there was evidently great interest in her role and achievements, including recent engagement with New Zealand, Northern Ireland and presenting in the USA, Chile and with the WHO.
6.	Accessible Medicines Project
	Andrew Biden gave an overview of a project he is leading which is examining the barriers to patient safety in relation to the medicines and medical devices for patients with sensory impairment (hearing and/or sight loss/impairment). The work includes focus groups with those who are also living with, or have experience with, diabetes and managing it using medication and/or medical devices (such as continuous glucose monitors). We are also working with a number of patient charities in this area. The end product will be a short research report with recommendations and the work is being supported by a researcher (13 days).
7.	Forward look
7.1	Forthcoming events include speaking at Moorfields Eye Hospital Clinical Governance awayday, a visit to Boots pharmacy, the NHS Providers conference and a visit to Cromwell Hospital. Ongoing engagement with the Dash Review and work to implement the Patient Safety Principles would continue.
8.	AOB
8.1	Baroness Cumberlege was due to retire from the House of Lords next month and this would be her last Advisory Group meeting. The Chair expressed sincere thanks for all her work in patient safety and her valuable contribution to the Group.
9.	Next meeting
9.1	Calendar invites had been sent out for meetings next year, but members would be emailed to check the suitability of those dates to secure maximum attendance. (Action) Thursday 30 January Thursday 1 May Thursday 24 July Thursday 23 October

Actions

	Action	Who
1	Email members asking them to confirm availability for 2025 meeting dates	Secretariat
2	Update Members on the findings and recommendations of the Dash Review, and the Ministerial response to the Dash Review (likely to be in the New Year, before the next Advisory Group meeting)	Secretariat

6th Meeting – Thursday 18 July 2024

Attendees
Dr Henrietta Hughes (Chair – Patient Safety Commissioner)
Louise Ansari (Healthwatch England) – joined remotely
Rabbi Dr Harvey Belovski
Baroness Julia Cumberlege
Rachel Power (Patients Association)
Apologies
Helen Buckingham (National Voices)
Saffron Cordery (NHS Providers)
Dr Mike Durkin (Imperial College London)
Ian Green (Chair of Salisbury NHS Foundation Trust)
Dr Habib Naqvi (NHS Race and Health Observatory)
PSC staff members in attendance
Andrew Biden
Rachel Downey
Megan Dunworth
Moore Flannery
Mel Peffer
Tom Savage

Meeting Notes

1.	Welcome & apologies
1.1	The Chair welcomed everyone to the meeting and suggested round table introductions as the new Chief of Staff, Moore Flannery, was attending for the first time. Apologies had been received from Helen Buckingham, Saffron Cordery, Mike Durkin, Ian Green, and Habib Naqvi.
2.	Note of the previous meeting (11 April) agree meeting note actions and matters arising
2.1	There were no corrections to the notes of the last meeting (11 April 2024), which were agreed and would be added to the PSC website.
2.2	The Chair explained that since the last meeting a change in approach to the intended letter referred to in Action 1 had been necessary due a number of developments (including the subsequent confirmation of the Office’s budget, the announcement of a general election, and feedback from Advisory Group members). The Commissioner had instead written to Matthew Styles (Director General at DHSC) more broadly about the structure of the Office
2.3	Actions 3 and 4 would be followed up with Mike Durkin and the Commissioner hoped to meet with him soon.
2.4	The Chair asked Members to review their register of interests listing on the website, and check biographies were still current. Rachel Power suggested the register of interests form could be routinely circulated before each meeting to act as a prompt to check and update returns if needed. (Action)
3.	Chair’s update
3.1	The Chair provided the following updates: Following the General Election the Chair noted that the DHSC ministerial appointments announced recently were: Wes Streeting MP – Secretary of State for Health and Social Care Karin Smyth MP – Minister of State for Health (Secondary Care) Stephen Kinnock MP – Minister of State for Care Baroness Merron – Parliamentary Under-Secretary of State for Patient Safety, Women’s Health and Mental Health Andrew Gwynne MP – Parliamentary Under-Secretary of State for Public Health and PreventionThe Commissioner, being independent and not a civil servant, had been able to meet with both Baroness Merron and Karin Smyth when they were in opposition, and post-election and appointment to the DHSC Baroness Merron – now the lead minister on patient safety – had already been in touch with the Commissioner’s Office. There was some discussion about the recently announced Lord Darzi review and the development of the 10-Year Health Plan, and it was agreed patients needed to be central to both. Louise Ansari (Healthwatch) and Rachel Power (Patients Association) had contacted Lord Darzi’s office, and the Commissioner said the team supported the review were due to contact her. The speed and quick turnaround of the review in particular was noted. The Chair had been interviewed by the BMJ in May and the article was published on 10 July (Patient safety commissioner: “A relentless focus on NHS finance and productivity is failing patient safety” \| The BMJ) and had been picked up by some news outlets. The Chair drew members attention to the finance summary update and the constraints in the non-pay budget. Whilst there had been some helpful discussions with the sponsor team (for example funding around legal services when the Commissioner is required to provide evidence to public inquiries) and a meeting with Matthew Style, some fundamental conversations were needed as to how the Commissioner’s office can achieve its purpose and prioritise activities whilst operating within the existing constraints. The Chair confirmed that raising funding from other sources was not an option. The Chair would keep members informed of any developments and intended to put some options to the new Minister.There were further reflections, including on the potential for the landscape to change and how organisations could work together on themes rather than in isolation in a complex system to avoid duplication and gaps. What are the constraints national bodies have and how can agreement to foster better collaboration be achieved. On the redress report the Chair said she was awaiting an update from the DHSC policy team on the response to the report in the light of the previous government indicating a response in the summer. The Commissioner would then follow up with the new Minister as it was important the Department was transparent on this issue, so that patients and campaigners were not left in the dark. The Commissioner continued to chair the monthly Martha’s Rule Oversight Group with DHSC providing the Secretariat. 143 sites were on board as part of the rollout. There was substantial work ongoing around communications to develop materials to advertise and explain the initiative in hospitals across the country. The Commissioner had continued to promote Martha’s Rule at various speaking events. The Chair had attended a number of speaking engagements (some others could not go ahead during the pre-election period), visits and meetings with safety leaders and others including: The Ministerial Patient Safety Summit in Santiago, Chile (April) Series of meetings on work HSSIB was leading on recommendations to impact Visit to Belfast to speak at the Society for Acute Medicine’s spring conference and a networking event organised by the equivalent of CQC in NI (Regulation and Quality Improvement Authority – RQIA) IHPN & CQC Patient Safety Conference (15 May) APPG First do no harm meeting (21 May) Chaired a session at NHS Providers conference (23 May) There was a brief discussion around the culture of the regulatory landscape in the context of the CQC review and recently reported NMC situation.
4.	Annual Report (23/24) and Business Plan (24/25)
4.1	The Chair handed over to Rachel Downey who gave an overview of the 2023/24 annual report which would be published shortly, and included a foreword from Lord Darzi and introduction from the Commissioner. In addition to setting out the structure of how the office works, a year-at-a-glance and achievements, an integral part of the report throughout would be the reflections from others including Louise Ansari, and Patient Safety Partners. [Post-meeting update: Annual report published on website].
4.2	Julia Cumberlege asked about redress and offered to ask a question regarding progress in the House of Lords. It was agreed PSC’s office would contact the DHSC policy team first for an update on the response to the Commissioner’s report (Action).
4.3	Julia referred to there being 35 Bills in the King’s Speech and offered to review the list and prepare a half page on relevant areas where the Advisory Group could potentially input *(Action)*.
4.4	Moore Flannery gave an overview of the Business Plan for 2024/25, a draft of which was shared with Members at the April meeting, and would be included in the annual report. The business plan was made up of four self-contained projects which fit with the strategy, and were in addition to business-as-usual work. These were: The Principles of Better Patient Safety – a statutory responsibility (to be covered under agenda item 5) A collaborative project on accessibility barriers to safe healthcare in relation to medicines and medical devices for patients with sensory impairments A piece of work on closed loop medicines administration – to be scoped, some initial exploratory discussions had begun. The Patient Safety Atlas of Powers – to be scoped but broadly looking at setting out the powers and remits of the key patient safety organisations working in England In response to a question about the definition of a safety organisation under the Patient Safety Atlas of Powers project, the Chair cited previous work by Professor Charles Vincent and others who attempted to map the regulatory landscape and found that by 2019 there were 126 organisations with some regulatory influence on NHS provider organisations. The Chair emphasised that the CLMA project would consider any previous reports and what others have done before in order to define what the focus should be and to help frame the work. Input from Patients Association and Healthwatch would be sought when the scoping was more advanced. Mention was made of the rollout of artificial pancreas also known as a hybrid closed loop system.
5.	Update on public consultation on Principles
5.1	Andrew Biden provided some background to the public consultation on the ‘Principles of Better Patient Safety’, and explained that the under statute, the PSC had a requirement to prepare and publish a set of principles to govern the way in which the PSC will carry out their core duties – and consult on these. However, it had become clear – including from the numerous inquiries into patient safety – that greater value and impact would be achieved by broadening the audience of the principles to all senior leaders, with the aim of guiding decision making in the health system more generally.
5.2	Pre-engagement and testing of draft principles to inform what to consult on, rather than starting from a blank sheet, had taken place with various stakeholders. The public consultation would be open from 24 July to 6 September and available on the PSC website. Post consultation all responses would be analysed, and the principles adjusted if required, with an aimed for launch in October.
5.3	Advisory Group members were asked to help by responding to the consultation, publicising and sharing the consultation as widely as possible, and suggesting how best to embed the principles post-publication (Action). The Chair emphasised the need for patient safety to be embedded at the very top of organisations for accountability.
5.4	Rachel Power offered to include details of the consultation in the Patients Association’s weekly news and offered a blog. There might also be opportunities to have a webinar on the consultation during their patient partnership week (2 September) (Action).
5.5	It was noted that the Duty of Candour might act as a lever for the principles, but it was unclear what the status of that consultation was. It was also noted that the principles should be part and parcel of the NHS Constitution.
6.	Forward look
6.1	In addition to the forthcoming annual report and principles consultation, the team would be taking forward work in the business plan. The Chair said upcoming events included giving a keynote speech at the Patient Safety Movement Foundation’s 11th Annual World Patient Safety, Science and Technology Summit in Los Angeles, and a healthcare leaders visit to BA and easyJet. The HSJ Patient Safety Congress was in September and the Chair was pleased to report that this year’s conference included a leadership strand.
7.	AOB
7.1	Other areas briefly raised included: work on complaints; membership of the joint patient/public voice group convened by Louise Ansari (Healthwatch); and the current debate around the Physician Associate role.
8.	Next meeting
8.1	Thursday 7 November

Actions

	Action	Who
1	Routinely circulate the register of interests form when the meeting papers are circulated to prompt any updates.	Secretariat
2	Approach the DHSC policy team for an update on the response to the Hughes Report on redress.	OPSC
3	Review the list of Bills and list any relevant areas where the Advisory Group could potentially input.	Julia Cumberlege
4	Respond, publicise and share widely the Principles consultation and suggest how best to embed the principles post-publication.	All members
5	Consider opportunities to have a webinar on the consultation during the Patients Association patient partnership week (2 September)	Rachel Power/OPSC

5th Meeting – Thursday 11 April 2024

Attendees
Dr Henrietta Hughes (Chair – Patient Safety Commissioner)
Louise Ansari (Healthwatch England) – joined remotely
Helen Buckingham (Nuffield Trust / National Voices)
Saffron Cordery (NHS Providers)
Baroness Julia Cumberlege
Dr Mike Durkin (Imperial College London)
Ian Green (Chair of Salisbury NHS Foundation Trust)
Dr Habib Naqvi (NHS Race and Health Observatory) – joined remotely
Apologies
Rabbi Dr Harvey Belovski
Rachel Power (Patients Association)
PSC staff members in attendance
Rachel Downey
Megan Dunworth
Mel Peffer
Tom Savage

Meeting Notes

1.	Welcome & apologies
1.1	The Chair welcomed everyone to the meeting. Apologies had been received from Harvey Belovski and Rachel Power.
2.	Note of the previous meeting (11 January) agree meeting note actions and matters arising
2.1	There were no corrections to the notes of the last meeting (11 January 2024), which were agreed and would be added to the PSC website. The actions had been completed.
2.2	The Chair thanked all members for agreeing to continue their membership of the Group for another term.
3.	Chair’s update
3.1	The Chair was pleased to report that Moore Flannery had recently joined as the new Chief of Staff and looked forward to attending future advisory group meetings. The Chair asked Tom Savage, who had recently joined the team as a policy officer, to briefly introduce himself.
3.2	The Chair provided the following updates: The wider resourcing issues discussed at the previous meeting remained unresolved, and in particular the Chair noted it was not sustainable that there was only one person to cover communications and engagement. There had been no response from DHSC’s Permanent Secretary to the letter the Commissioner had sent him in January. The lack of clarity well into the second year of the Commissioner’s term was noted and it was agreed the Advisory Group would write a letter to the Chair of the Health and Social Care Committee (Action). [post-meeting: it was decided this letter be sent in the first instance to the Secretary of State for Health and Social Care] The Chair provided an update on the redress project. The Commissioner’s report published in February had received wide ranging coverage in the media, and the Chair thanked Julia Cumberlege for the questions in the House of Lords. The Commissioner was awaiting a response from DHSC, and this was expected by 7 May (the three-month deadline given). The Commissioner had been asked to chair the Martha’s Rule Oversight Group which would meet every two months, with DHSC providing the Secretariat. NHS England had issued an expression of interest on 27 March formally inviting NHS providers of acute adult and/or children and young people’s inpatient care, with an existing on-site 24/7 critical care outreach team (CCOT) or paediatric critical care outreach team (PCCOT) infrastructure, to submit expressions of interest to participate in the first phase of the Martha’s Rule programme throughout 2024/25 (published on NHS England’s website – https://www.england.nhs.uk/patient-safety/marthas-rule/ ). The Commissioner’s recommendation to improve the safe use of the most potent teratogenic medications had been accepted by NHS England in a letter from the National Medical Director, Stephen Powis (https://www.patientsafetycommissioner.org.uk/our-work/recommendations/ ) In February the Commissioner sent a joint letter with Rob Behrens, outgoing PHSO, to the DHSC calling for an overhaul of the complaints system. Later on in the meeting the Chair also mentioned having written to Amanda Pritchard, NHS England CEO to request that an element of patient safety be included in the Planning Guidance. The Chair had attended a number of speaking engagements and meetings including: Hosting the HSSIB Board Development Day Meeting with members of the shadow Labour health team, including Karin Smyth MP Meeting with DHSC officials leading Declaration of Conflicts of Interest pilots Nuffield Trust Summit 1st meeting of the PSRC Network Advisory Board (SafetyNet), which Mike Durkin chairs. Decision making and consent virtual roundtable MedTech Programme Board and their patient engagement forum Meeting with RNIB – the accessibility of health care and information
3.3	The Chair was due to attend the Global Ministerial Summit on Patient Safety in Santiago, Chile the following week and had been invited to speak at the plenary Ministerial Day. The opportunities to learn from other counties and bring to bear external support and influence was noted. The Commissioner had connected patient groups in New Zealand and the United States. Louise Ansari was speaking with the equivalent of Healthwatch in Australia, and separately offered to connect the Commissioner with contacts for the WHO global framework for statutory bodies (Action).
4.	Business Plan
4.1	The Chair introduced the draft business plan which had been shared with members for information and outlined the four projects the Office intended to carry out that would support the strategic priorities: Public consultation on the Principles of Better Patient Safety The Patient Safety Atlas of Powers – which would pull together and clearly set out the remits and powers of the main safety organisations in the healthcare space, to identify common or overlapping objectives and powers, and to facilitate better working together. A collaborative project with groups of patients with additional needs on medicine and medical device patient safety. A report on closed loop medicines administration and the barriers to implementation.
5.	Principles consultation
5.1	The Chair reminded members that the public consultation on Principles of Better Safety was a statutory function that had previously been delayed due to resourcing constraints. It would be the primary activity for 2024/25.
5.2	Draft example principles with paragraphs had been shared with Advisory Group members drawing on existing work. The project would start by speaking with partner organisations, including some Advisory Group members, about the draft principles to seek their views/input prior to going out to public consultation.
5.3	Informal feedback to date had been positive. There was the suggestion that the principles could be made personal to different groups; that they should be clear, concise and transparent – with leaders in particular being clear about ‘what does this mean for me’. Mike Durkin offered to share similar work that had been done by the Patient Safety Movement Foundation (Action)
5.4	There was recognition that the essence of the principles exists in other forms, including in legal duties and the NHS Constitution, and it might be helpful to consider the next layer down in terms of activity and use case studies to illustrate the principles in action.
5.5	The need for the principles to endure over time was also considered and how to ensure they are ‘signed-up’ to and made relevant to all – or made more specific for different parts of the system.
6.	Forward look
6.1	Forthcoming activities in the short term included: Work proceeding at pace on the Annual Report to be laid before Parliament in July Response from DHSC on redress report Operationalising the business plan Principles consultation
6.2	The Chair asked members for suggestions for future collaborations or gaps. Suggestions included meeting with the CE of NICE and Mike Durkin offered to share contact details for the European Patient Safety Foundation (Action), and also suggested partnering with academic research groups.
7.	AOB
7.1	None
8.	Next meeting
8.1	Thursday 18 July

Actions

	Action	Who
1	Prepare 1st draft of letter for AG to send to the Secretary of State for Health and Social Care.	Secretariat
2	Connect the Commissioner to the WHO contacts referred to	Louise Ansari
3	Share work done by the Patient Safety Movement Foundation to feed into principles work	Mike Durkin
4	Connect the Commissioner to the European Patient Safety Foundation	Mike Durkin

4th Meeting – Thursday 11 January 2024 (virtual meeting)

Attendees
Dr Henrietta Hughes (Chair – Patient Safety Commissioner)
Louise Ansari (Healthwatch England)
Baroness Julia Cumberlege
Dr Habib Naqvi (NHS Race and Health Observatory) – until 11:30
Rachel Power (Patients Association)
Apologies
Rabbi Dr Harvey Belovski
Helen Buckingham (Nuffield Trust / National Voices)
Dr Mike Durkin (Imperial College London)
Ian Green (Chair of Salisbury NHS Foundation Trust)
PSC staff members in attendance
Andrew Biden
Rachel Downey
Mel Peffer

Meeting Notes

1.	Welcome & apologies
1.1	The Chair invited everyone to the virtual meeting. Apologies had been received from Helen Buckingham, Harvey Belovski, Ian Green, and Mike Durkin.
1.2	In his absence, the Chair extended warmest congratulations to Harvey Belovski on becoming an Emeritus Rabbi.
2.	Note of the previous meeting (10 October) agree meeting note actions and matters arising
2.1	There were no corrections to the notes of the last meeting (10 October 2023), which were agreed and would be added to the PSC website. The actions had been completed.
3.	Chair’s update
3.1	The Chair said Martha’s Rule, the Redress Project and the strategic priorities were substantive agenda items so would be covered later.
3.2	The Chair provided the following updates: The recruitment process was underway for the now vacant Chief of Staff post and discussions continued with DHSC on wider resourcing issues to enable the office to fulfil its statutory functions effectively. The lack of resourcing – particularly in data and policy functions – remained and the Chair had written to the Permanent Secretary at DHSC to highlight her concerns. Members offered their support and there was a discussion on possible escalation routes if no tangible response was received. The Chair reported that she had made a formal recommendation to NHS England that they have a fully funded and resourced system for improving the safe use of the most potent teratogenic medications, through a National Quality Improvement Programme for Integrated Care Systems, starting with the safe use of sodium valproate. The Commissioner believes that this should be implemented by September 2024 for sodium valproate, before expanding to cover any medication with a Pregnancy Prevention Programme by September 2025. The Chair was growing a network of health executives to have virtual monthly conversations about safety to identify gaps and share experience. The Commissioner had received a Rule 9 request from the Thirlwall Inquiry to provide a written evidence statement. The Chair updated members on some of the meeting/speaking engagements she had participated in to amplify patient voice, including: Race and Health Observatory Neonatal Report roundtable Hospice UK National Conference NHS Assembly MedTech Patient Engagement Forum Global State of Patient Safety Report launch MHRA Board meeting Medicines Safety Improvement Programme Board (MedSIP) MedTech Programme Board The Chair highlighted work to increase the prominence of the yellow card reporting functionality on EMIS to improve reporting activity in primary care.
4.	Advisory Group membership
4.1	The Chair noted this was the 4th meeting of the Group which had first met in March 2023 and thanked members for being a valuable source of advice, support, and assistance. The Terms of Reference asked members to serve initially for a one-year term with the option of re-appointment. Given the first year was approaching, the Chair suggested all members consider whether they wished to continue and in the coming weeks the Chair would arrange to have individual calls with each member to discuss the term served and whether they wished to continue or step down. Action: Secretariat to arrange 1:1s between Chair and members.
5.	PSC’s strategic priorities
5.1	The Chair thanked those members who had responded to the recent survey on her strategic priorities and that it was helpful to check alignment with others to ensure a common direction.
5.2	The three aims of the strategy were: To drive the alignment of the healthcare system to deliver a just and learning safety culture To support initiatives which amplify all patient voices and empower patients to make informed decisions about their care To advocate for partnerships which embed patient safety and patient voice throughout the healthcare system
5.3	There was general consensus that the survey had been helpful, and that the components of the strategy were sound. It also sparked thinking for other organisations represented on the Group on how to work jointly with organisations like the Patient Safety Commissioner in particular areas and how to support and help embed initiatives (e.g. patient safety partners). The importance of tracking delivery of the strategic priorities was raised, which the Chair agreed with.
6.	Redress Project update
6.1	An update on the Redress Project was provided indicating the report was being finalised and would be published on 7 February. The report would recommend a two-stage scheme and contain ten recommendations – the key pillars of a redress scheme.
7.	Martha’s Rule update
7.1	The Chair gave a brief update on Matha’s Rule and said an announcement was expected soon from NHS England, ideally before the first meeting of the working group later this month. Action: The Chair undertook to keep members informed.
8.	Forward look
8.1	Forthcoming activities in the short term included: Launch of strategic priorities Martha’s Rule Working Group (23 Jan) Sunday Times interview Launch of Redress Report (7 Feb) New Chief of Staff in post
9.	AOB (to be notified to the Chair before the meeting starts)
9.1	None
10.	Next meeting (Thursday 18 April) and future dates
10.1	An alternative date for 18 April meeting will be identified and circulated to avoid a clash with the Global Ministerial Summit on Patient Safety. Beyond April future meeting dates in the diary are: Thursday 18 July Thursday 7 November

Actions

	Action	Who
1	Arrange 1:1s between Chair and each member to discuss continuing membership	Secretariat
2	Keep members updated on the progress with the Martha’s Rule Working Group	PSC

3rd Meeting – Thursday 12 October 2023

Attendees
Dr Henrietta Hughes (Chair – Patient Safety Commissioner)
Rabbi Dr Harvey Belovski
Helen Buckingham (Nuffield Trust / National Voices)
Saffron Cordery (NHS Providers)
Baroness Julia Cumberlege
Dr Mike Durkin (Imperial College London) – joined remotely
Ian Green (Chair of Salisbury NHS Foundation Trust) – joined remotely
Chris McCann (Healthwatch England, on behalf of Louise Ansari)
Dr Habib Naqvi (NHS Race and Health Observatory)
Rachel Power (Patients Association) – joined remotely
Apologies
Louise Ansari (Healthwatch England)
PSC staff members in attendance
Andrew Biden
Rachel Downey – joined remotely
Gary Duncan
Megan Dunworth
Mel Peffer

Meeting Notes

1.	Welcome & apologies
1.1	The Chair invited everyone to the meeting and suggested round table introductions for the benefit of those attending for the first time.
1.2	Apologies had been received for Louise Ansari (Healthwatch England)
2.	Note of the previous meeting (22 June) agree meeting note actions and matters arising
2.1	There were no corrections to the notes of the last meeting (22 June 2023), which were agreed and would be added to the PSC website.
2.2	Actions from the previous meeting were reviewed and all were completed or in hand. There were no matters arising.
3.	Chair’s update
3.1	The Chair provided an update including: The Patient Safety Commissioner’s first annual report had been laid in Parliament and published on the website in July. As of yesterday (11 October) legislation came into force meaning sodium valproate will be dispensed in its original packaging to ensure patients always receive the safety information supplied on the label and in the Patient Information Leaflet alerting them to the risks if used during pregnancy. The Chair said this was a step forward and added that she wanted to ensure more action was taken regarding monitoring the safe use of sodium valproate and teratogens more generally and that she intended to make a recommendation to NHS England. The Chair reported positive progress being made on the Outcomes and Registries programme as part of the MedTech Strategy and she was pleased that patient voice was being incorporated at different points and they were developing patient reported outcome measures (PROMS). The Chair had met with the Secretary of State for Health and Social Care and discussion points had included Martha’s Rule, yellow card reporting, and training for non-executive directors. The Chair gave an overview of the series of sprints that had taken place in order to make Martha’s Rule a success. The 4th and final sprint was scheduled for next week, followed by recommendations to the Secretary of State. In discussion members raised a number of themes including patient power to raise concerns, the importance of culture and organisational development, how to make Martha’s Rule an embedded element within a broader umbrella of restorative culture, not done in isolation or as an add-on. The Chair had attended the WHO’s World Patient Safety Day 2023 Global Conference ‘Engaging patients for patient safety’, worked on the WHO Global Patient Safety Charter and had chaired a session on patient safety as a human right. She had also participated in a WHO ad hoc working group meeting for a report on “Patient experiences of harm: lessons for the health care system” The Chair offered to share other updates by email after the meeting. (Action)
4.	Redress Project
4.1	The Redress Team provided an update on the Redress Project. The background to the project was briefly described and would involve providing some advice to Minister Maria Caulfield MP outlining redress options for those harmed by pelvic mesh or valproate, followed by a public facing report on redress options to be published in early 2024. It will then be a decision for Government to consider the advice and set out next steps.
4.2	The small project team were working to a challenging timescale, with external expert support from Dr Sonia Macleod who had been the lead researcher for the First do no harm report. The project plan comprised 4 workstreams: research (desk-based research; engage (stakeholder engagement): draft (drafting of report); publish/persuade (comms, influencing, launch event).
4.3	The engagement workstream had included meeting with patients and patient groups, and a survey on the website seeking the views of those affected. The team had also met with other stakeholders with expertise or an interest in mesh, valproate and/or redress. One member asked whether it was possible to do something additional with the rich output from the survey in terms of transparency and further research opportunities, which the team took away to consider.
4.4	The team outlined possible ways Advisory Group members could advise and/or assist, including: Attending the public launch event (early 2024) Providing advice on how to publicise the report and project Sharing experience from members’ own work with the redress team Supporting the launch communications Lobbying on this issue and/or taking a public view on redress if able to do so Identifying colleagues or contacts to attend the launch event or support this work in another way Suggesting other people the redress team may want to engage with prior to publication to move through the stages of change model (Action)
4.5	Additional observations from members included a discussion on financial and non-financial aspects of redress. Whilst there were no guarantees if/how options presented would be taken forward by the Government it was clear there was a strong moral case and moral responsibility to act.
4.6	The Chair recorded her thanks for the excellent work the project team had done and the quality, depth, and compassion of the meetings held. Other members also commended the team for their phenomenal work, and the benefit for those who have been heard.
5.	Forward look
5.1	The focus for the coming weeks would be redress, and more immediately, Martha’s Rule. Following the final sprint on 18 October the Chair said she would share an update on Martha’s Rule with members by email. (Action)
5.2	Progress on recruitment of resource to undertake the consultation on the principles would be pursued with DHSC. Work had started recently on refreshing the strategic priorities for the next period and identifying overarching themes based on what the Commissioner had heard from patients and the public since taking up post. One member commented that the role of the Patient Safety Commissioner had shown its value with the work on redress and Martha’s Rule.
6.	AOB (to be notified to the Chair before the meeting starts)
6.1	One member raised whether there was any merit in having an APPG with a wider patient safety remit. The Chair observed that APPGs tended to have a very specific of focus, and that patient safety is a very broad area.
7.	Next meeting (Thursday 11 January 2024) and future dates
7.1	The next meeting is due to be held on Thursday 11 January 2024, and revised dates would be circulated for future meetings to take into account feedback received on the dates previously circulated. (Action)

Actions

	Action	Who
1	Provide any further updates to Members by email after the meeting, including on Martha’s Rule	PSC
2	Advise and assist the redress project team (para 4.4 suggestions)	All Members
3	Circulate revised dates for meetings in 2024	Secretariat

2nd Meeting – Thursday 22 June 2023 held at 18 Smith Square

Attendees
Dr Henrietta Hughes (Chair – Patient Safety Commissioner)
Louise Ansari (Healthwatch England)
Rabbi Dr Harvey Belovski
Helen Buckingham (Nuffield Trust / National Voices)
Baroness Julia Cumberlege
Dr Mike Durkin (Imperial College London) – joined remotely
Ian Green (Chair of Salisbury NHS Foundation Trust) – joined remotely
Dr Habib Naqvi (NHS Race and Health Observatory)
Rachel Power (Patients Association)
Rachel Downey (Secretariat)
Mel Peffer (Secretariat)
Apologies
Saffron Cordery (NHS Providers)

Meeting Notes

1.	Welcome, introductions and apologies
1.1	The Chair welcomed everyone to the meeting and invited Louise Ansari and Harvey Belovski to introduce themselves.
1.2	Apologies had been received from Saffron Cordery (NHS Providers)
2.	Note of the previous meeting • agree meeting note • actions and matters arising
2.1	There were no corrections to the notes of the last meeting (23 March 2023), which were agreed and would be added to the PSC website.
2.2	Actions from the previous meeting were reviewed and matters arising included: • It was agreed that the current membership provided a wide range of views and would remain at 10 (including the Chair) for the time being. Going forward members could flag any substantial gaps in response to issues arising. • The Chair reminded members of the importance of completing and returning the register of interests form as soon as possible, if not already done so, for adding to the website (Action) • The Chair confirmed that the list of parliamentarians that Julia Cumberlege had suggested for inviting to a meeting aligned well with the list the Commissioner’s Office had identified. • Ian Green will follow-up to help facilitate the Commissioner attending a meeting of NHS Chairs/Chief Executives.
3.	Terms of Reference sign-off
3.1	There was some further discussion on the Terms of Reference. The Chair confirmed the accountability routes of her Office. Members were not accountable for the policies, financial or other management aspects of the OPSC and had no assurance role. The Commissioner’s financial accountability is through DHSC; operational accountability is to the Chair of the Health and Social Care Committee.
3.2	Final changes agreed to the Terms of Reference: • Indicate that any technical expertise regarding medicines or devices would be sought externally on an ad-hoc basis if required. • Add ‘England’ to clarify the scope applies to England only. • Add ‘where required’ to paragraph 4 in the role section.
3.3	The amended Terms of Reference would be circulated for final sign-off via email and published on the website before the next meeting (Action).
4.	Chair’s update
4.1	The Chair provided an update, including: • The team now had desk space within the NHS Confederation and it felt that the office had moved out of the initial ‘set-up phase’. • The Chair thanked Julia Cumberlege for asking the recent questions in the House of Lords on sodium valproate. • Launch of PSC website. • The Commissioner had published a new resource for patients with complications from pelvic mesh which was co-produced with campaign groups and was available on the PSC website. Rachel Power offered to include a link on the Patients Association website (Action). • The Commissioner had been invited to join the MedTech Strategy Programme Board, and had also been working to support patient involvement in the Outcomes and Registries Programme. • Two staff had joined the team to work on the redress project, and the Chair said she was keen to understand redress in its totality, including restorative practice. An expert would input to the project. • The Chair had attended the recent Patient Safety Movement Foundation summit which had included inspirational patient speakers, the sharing of excellent examples of good practice, and there had been much interest in the PSC role and several offers of help. • There had been no further update from DHSC on confirmation of budget allocation or resourcing, which put at risk the Commissioner being able to fulfil all her statutory obligations, including the consultation on principles.
5.	Website
5.1	Rachel Downey (Head of Communications and Engagement) explained that the website had gone live in the last couple of weeks and was still very much in development mode and would incorporate feedback from the focus groups that the Patients Association had facilitated.
5.2	Rachel gave a demonstration of the website and feedback from members and other points of discussion included: • The suggestion that signposting links should direct users to the relevant page of external websites, rather than the default homepage. • Add captions to photos • Move the section on the Advisory Group from ‘our work’ to ‘about us’ • Add an explanation about pelvic mesh to the webpage text introducing the resource • Rachel will commission blogs from all members to include their voices on the website (Action). • Part of the development plan will consider the naming of sections, and sub-sections (e.g ‘Resources – innovations’). • There was a discussion around not promoting or endorsing initiatives/innovation (e.g that have a commercial element). • Positive comments were received on the visual approach and identity. • A continuous programme of user testing and having relevant, fresh and reliable content would be important.
5.3	Rachel said the driver to get the website up quickly was the pressing need to have a platform to publish. A development plan could now be implemented that would include sections on patient stories and patient resources, including where people can go for help. Video and audio content would be included recognising different mediums can appeal to different audiences and help support literacy. Mike Durkin suggested the Patient Safety Movement Foundation would be able to provide support on video content.
5.4	Rachel welcomed any future feedback and views on the website as it continued to develop and grow.
6.	Engagement
6.1	Rachel Downey introduced the next agenda item to generate a discussion about how to best achieve engagement with very limited resources yet maximise opportunities for the Commissioner to hear directly from patients.
6.2	Louise Ansari offered use of the Healthwatch networks to facilitate meetings and Habib Naqvi said NHSRHO had a number of forthcoming report launches that would include engagement opportunities. Rachel Power offered support and the Chair said she was keen to take part in similar events to the Patient Association’s ‘Patient Partnership Week’ and ask what matters to patients, hear examples of both good and bad experience and pull out what it was that made a difference. Rachel Power had attended an event organised by the Healthcare Partnership Network (HPN) and would follow-up with Rachel afterwards. It was agreed to make the Commissioner aware of opportunities in members own organisations and elsewhere for engagement.
7.	Forward look
7.1	Items covered included: • World Patient Safety Day was being held on 17 September this year with the theme ‘Engaging Patients for Patient Safety’, and the Chair asked Members to help promote it. • Members would be asked to engage with Rachel regarding contributing a guest blog for the website. • An update on the redress project would be provided at the next meeting. • The Annual Report would be laid in Parliament in July before summer recess.
8.	AOB
8.1	Julia Cumberlege shared a report on progress with the IMMDS recommendations, which would be circulated to Members afterwards (Action).
9.	Next meeting
9.1	Thursday 12 October 2023

Actions

	Action	Who
1	Reminder to complete and return register of interests form if not already done so	All members
2	Help facilitate the Commissioner attending a meeting of NHS Chairs/Chief Executives	Ian Green
3	Circulate amended Terms of Reference for final sign-off via email	Secretariat
4	Add link to new resource for patients with pelvic mesh to the Patients Association website	Rachel Power
5	Members to engage with Rachel Downey on contributing a guest blog for the website	Rachel Downey, All members
6	Circulate the report on IMMDS recommendations that Julia Cumberlege shared at the meeting	Secretariat

1st Meeting – Thursday 23 March 2023 held at 18 Smith Square

Attendees
Dr Henrietta Hughes (Chair – Patient Safety Commissioner)
Helen Buckingham (Nuffield Trust / National Voices)
Baroness Julia Cumberlege
Dr Mike Durkin (Imperial College London)
Ian Green (Chair of Salisbury NHS Foundation Trust)
Rachel Power (Patients Association)
Gary Duncan (Secretariat)
Mel Peffer (Secretariat)
Apologies
Louise Ansari (Healthwatch England)
Rabbi Dr Harvey Belovski
Saffron Cordery (NHS Providers)
Dr Habib Naqvi (NHS Race and Health Observatory)

Meeting Notes

1.	Welcome
1.1	The Chair warmly welcomed everyone to the first meeting of the Advisory Group and thanked everyone for agreeing to join the group.
1.2	Apologies had been received from Saffron Cordery (NHS Providers), Louise Ansari (Healthwatch England), Rabbi Dr Harvey Belovski, Dr Habib Naqvi (NHS Race and Health Observatory).
2.	Round table introductions
2.1	The Chair invited round table introductions. Members’ biographies would be circulated after the meeting and made available on the Commissioner’s website (once live) *(Action)*.
2.2	The Chair said there was one vacancy on the Group remaining and asked members to consider and provide suggestions after the meeting, perhaps someone with a background in research/science or other areas not represented on the group. (Action).
2.3	The Chair asked members to complete and return the register of interest form (*Action)*.
3.	Purpose & role of the Advisory Group
3.1	The Chair introduced the Terms of Reference which had been circulated before the meeting, indicating that the group was a statutory requirement to provide her with advice and assistance and to encourage good practice in involvement with patients.
3.2	Scope of the Patient Safety Commissioner The Group discussed the scope of the Commissioner’s role, and it was acknowledged that many other issues had already been brought to the Commissioner’s attention outside the scope of First Do No Harm. Role of the Advisory Group There was agreement that the wording in the terms of reference facilitated the statutory requirement of the group to advise and assist. There was a suggestion that temporary sub-groups possibly focussing on research and communications could be considered. The Group’s membership, biographies, terms of reference, meeting notes and other documentation will be published on the website (once live) to ensure openness and transparency. Offers of help were received from the Patients Association and National Voices to host on their website and include updates in their communications.
3.3	The Chair suggested additional comments on the Terms of Reference could be emailed after the meeting with a final version of the Terms of Reference signed off at the next meeting in June, and thereafter to be reviewed at the end of the first year. (Action).
4.	Scene setting – the first 100 days
4.1	The Chair reflected on some of the challenges faced during the initial set-up period including negotiating practicalities such as securing office space, staff resources, procuring a website, and in doing so having to work through government department processes and the inherent complexity and time-consuming nature of the various approvals required.
4.2	Resourcing was discussed; the original set-up budget/resourcing was considered insufficient going forward and a headcount of only four staff was very modest compared with some commissioner offices. The budget for 2023/24 had not yet been confirmed by the sponsoring department (Department of Health and Social Care) and this was cause for concern. The Chair said she intended to write to the Department after the Advisory Group meeting and would raise resourcing again (Action).
4.3	The Chair described some of the work that had been done and was ongoing including: Work to avoid sodium valproate being dispensed in white boxes, including raising concerns to the General Pharmaceutical Council who then wrote to all community pharmacists. Engaging with NHS England and keeping visible the pressing need for this to be resolved, including raising delays with the white box consultation with the responsible DHSC Minister. Redress – the Commissioner had been asked by Minister Caulfield to look at redress for those harmed by pelvic mesh and sodium valproate, and since December there had been a process of negotiation with DHSC to agree the precise scope of the work to ensure that it is patient focussed, and to secure additional resource, including expertise in the area of redress. The work would start once resource was in place.
4.4	There was a general discussion around engaging stakeholders and the need for the Commissioner role to influence in a really strong way. The Chair had met with patient groups, visited clinics and spoken at numerous types of events which had been well received. The Chair had met regularly with various leaders in the healthcare system to help amplify patient voice including different directorates in NHSE, MHRA, professional regulators, parliamentarians, officials, and trade bodies. Building networks of allies was seen as important, including the informal network of patient safety leaders. It was noted that extending reach and awareness of the role needed to be at a manageable pace given existing resources.
4.5	There was a suggestion that engaging parliamentarians from both houses was useful, and Baroness Cumberlege offered to convene a small group, starting with the Lords to meet with the Commissioner and help apply pressure where action was needed *(Action)*.
5.	Priorities: pelvic mesh, sodium valproate, culture change
5.1	The Chair ran through some slides, introducing her current three priorities: culture change, pelvic mesh and sodium valproate. The slides would be circulated after the meeting *(Action)*.
5.2	The Chair described her three focused elements of culture change as: a psychologically safe environment where people can ‘speak up, listen up, follow up’, consent, and conflicts of interest.
5.3	The journey of consent and supported decision making were mentioned, and the need for all healthcare professionals to be aware of and follow current legislation.
5.4	The Chair said she was in touch with the policy team at DHSC leading on the conflict of interest pilot, but there was some concern raised at the meeting about progress of the pilot.
5.5	From the slides, the Chair gave some examples of actions against each of the three priorities, including: Campaigning to improve the use of yellow card reporting, including design of the patient information leaflet and packaging, and raising awareness. Seeking to understand how organisations listen to patient voices, for example with a patient director at board level and through having patient stories at the top of their meeting agendas. Working with NHS England to ensure patients are aware they have a choice of specialist mesh removal centres. Helping the NHS England team leading on the registries work to have input from patients by connecting them with patient groups. Co-producing resources for patients and GPs on pelvic mesh complications. Working with health leaders to ensure that all relevant patients are on a Pregnancy Prevention Plan (PPP) and given the necessary information.
5.6	It was thought important that identifying a patient director at board level did not end up as just a tick box exercise. It was queried whether complaints learning was brought to Boards and also if measuring patient experience was taken to Board level. One member indicated he had commissioned work to review how their Board was working and Ian Green offered to help facilitate the Commissioner speaking at a future NHS Chairs & Chief Executive meeting (Action).
5.7	The Chair explained that achieving the ambitions outlined in the slides would take leadership, listening and partnership, and that she was keen to understand and map out the powers held by different organisations across the health system. The group thought it sensible to focus on a few areas until more resources were made available.
6.	Statutory requirements
6.1	The Chair’s Chief of Staff briefly described the Commissioner’s statutory requirements, all of which would benefit from some level of input and review by Advisory Group members. Consultation on principles of better patient safety Publication of a business plan, currently with DHSC Annual report (to be laid in Parliament – before summer recess)
7.	Next steps & actions – discussion
7.1	There followed a final short discussion; points raised included: The benefit of learning from other countries and systems, including fragile, vulnerable and conflict states, and recognising that within our own systems and services there are vulnerabilities – where can we make the most impact in these areas. How can we best learn across our own system and elsewhere. Engaging with integrated care system leaders would be beneficial to learn about good practice.
7.2	The Chair thanked the offers received to host communications until such times as the Commissioner’s website was live, and in the meantime twitter would be used to announce the group had been established and met for the first time.
8.	AOB
8.1	None. For future meetings the Chair asked that she is made aware of any other business before the meeting starts.
9.	Next meeting
9.1	The next meeting was scheduled on Thursday 22 June, but depending on availability, particularly those not in attendance at today’s meeting, an alternative date may need to be found.

Actions

	Action	Who
1	Circulate Members’ biographies and the slides to the Advisory Group.	Secretariat
2	Provide suggestions for the remaining vacancy on the Advisory Group.	All members
3	Complete and return register of interests form	All members
4	Provide any further comments on the Terms of Reference by email – by end of April	All members
5	Write to DHSC after the Advisory Group meeting to raise budget/resourcing for 2023/24	Henrietta Hughes
6	Convene a small group of parliamentarians to meet with the Commissioner	Baroness Cumberlege
7	Facilitate the Commissioner attending a meeting of NHS Chair/Chief Executives.	Ian Green