Writing
Reflections by Dr Marion Lynch
Where Are the Nurses, the Women, and the Equity Lens?
A Critique of the 2025 Patient Safety across the Health and Care Landscape.
Patient safety is one of the most urgent and enduring priorities in health and care for the United Kingdom in 2025. It is, in fact, the bedrock of quality healthcare. Yet, in today’s Review of Patient Safety Across the Health and Care Landscape (2025), there are glaring omissions that I cannot let go unchallenged, the absence of nursing voices, women, and that equity analysis we are all asked to consider when developing strategy. I am therefore curious as to who is shaping this safety narrative, and wondering does it matter?
I will start with nursing. Why is the RCN not listed as one of the Royal Colleges contributing? Nursing is described as a safety critical profession. Nurses are the largest professional workforce in healthcare. We are at the bedside, in homes, in communities, and leading systems. We monitor vital signs, catch early signs of deterioration, prevent errors, advocate for patients, de-escalate crises, and hold continuity where fragmentation reigns. And we lead on safety and quality within systems. We are not an “optional extra” in patient safety. Yet, I am not able to see the nursing voice or nursing knowledge contribution within this review.
Secondly, and even more troubling: where are the women? Given that 90% of nurses are women, and the majority of the health and social care workforce is female, this question matters deeply. When women, and professions largely composed of women are absent from leadership conversations about safety, the resulting strategies risk being partial, skewed, or even unsafe. Remember we had this in COVID when those making the high-level decisions were not representative of all of the population.
The Patient Safety Review sets out to assess the current patient safety landscape and provide recommendations for structural improvements across the NHS and wider health and care system. On the surface, it presents a well intentioned, systemic view and integrates patient safety and patient experience. As with the NHS 10 Year Plan Fit for the Future it is leveraging Artificial Intelligence (AI), improving complaint handling, and is focussing on amplifying the patient voice. But a closer, gender transformative analysis reveals troubling disparities which make me wonder about what sort of equity thinking that has informed the recommendations to improve quality and safety across the system.
1. Nursing Absence from Key Contributions
The Royal College of Nursing (RCN) is conspicuously missing from the list of professional contributors. In contrast, a multitude of other Royal Colleges are named. This exclusion is not benign. It symbolically and practically marginalises the profession most embedded in day-to-day safety practices. Maybe the RCN was consulted and not listed, a common issue for nursing leaders, and an issue itself.
2. Gender Imbalance Among Expert Voices
Of the fourteen named “experts in safety” contributing to the review, are only five women? And of those is only one, Donna Ockenden, an expert in nursing and midwifery? There may be more women, I do not know all of those involved, but there are definitely more male than female expert views in this report. Given that safety events often disproportionately affect women (as patients) and more of the staff involved in health and social care are women, I wonder if this imbalance matters more than optics? I believe that it does because representation shapes the questions asked, the assumptions made, and the solutions proposed.
3. Advisory Board Demographics
Does the Review’s advisory board comprise twenty men and nine women? Again, maybe this is not accurate number but there is definitely an underrepresentation of the very people (nurses and female healthcare professionals) most involved in operationalising safety. This is not only statistically troubling, it suggests that gender and profession have not been considered as critical dimensions in understanding patient safety. Was there a Gender Equality and Social Inclusion (GESI) assessment?
Does it Matter?
Yes, this matters. If we are to reduce harm and improve care, we must draw on the full diversity of experience, expertise, and voice at all levels, whether defining the issues or designing the solutions. Having a lack of diversity in the design thinking is what got us to this problem in the first place. Again, I quote Audre Lorde, “The master’s tools will never dismantle the master’s house.” The gendered and professional imbalance in this Review speaks to a broader systemic issue, the consistent undervaluing of nursing knowledge and female leadership in safety critical discourse. This discourse matters as this is where it is decided what matters most.
I am curious about three points.
1. Nursing is a Safety-Critical Profession
The Review itself refers to improving data-sharing, enhancing analytics, and reducing paperwork burdens. These are sensible aims. But look at the examples provided of non useful safety issues: fire safety training for GPs, end of consultation forms for psychiatrists. No mention of the nurses, nor the good things that could be spread, early warning scores nurses escalate, the infection prevention protocols we lead, the way we prevent harm and falls, or the families we support through crises and so prevent complaints. Where is the data from the daily safety work of nursing mentioned in this new approach?
If we ignore these frontline contributions, we risk designing systems that created the problem in the first place, what in global health we call structural violence, We risk creating a system that works for boards and dashboards, but fails at a human level, on wards and in people’s homes. Safety is not just a technical problem, it is a deeply human, relational practice. People need to feel safe as well as be safe. Again, in mental health this is often the issue behind the challenges faced. Nurses hold safety at a personal and system level and build the equitable and the moral architecture of a safe place, which is often invisible to others until it is missing.
2. Gendered Impact of Safety Failures
Patient safety events are not gender neutral. Women form the majority of carers, both unpaid and professional providing care. Women are more likely to experience diagnostic overshadowing, under treatment of pain, and dismissal of symptoms. The statistics in the report point to some racist stereotypes towards pain experiences but does not delve into equity. Equity is the least mentioned aspect of quality within the whole review. Omitting women’s voices in shaping safety policy thus compounds systemic inequity. It is disappointing that such an important quality based report has no gender and equality impact assessment (GESI) within it. Maybe because the expert voices were not aware of the need for such a critical lens on such work.
A gender-transformative approach to this Review would ask:
How does gender affect the types of safety risks experienced?
Who is burdened with the emotional labour of unsafe systems?
Whose expertise is recognised and rewarded in shaping solutions?
The Review does not ask these questions. Should it? I think so, and so I am asking them myself.
3. Patient Experience and Advocacy
The Review recommends integrating patient safety with patient experience under a new directorate within DHSC and aligning Healthwatch with this work. This is promising, particularly if done well. But again, I am curious, who will make this happen as near to the patient as possible?
The answer is perhaps nurses. We are the ones who translate complaint data into care changes, who sit with distressed patients and re-establish trust, who mediate between systems and individuals daily. Who do what metaphorically can be termed the ‘domestic work of safety,’ sit on committees, manage relationships and resources, monitor what is going on, make adaptations within systems, but never get the publication, the podium, the position of power. Maybe this is why we are not named in this Review. We are still invisible.
To create truly safe and person-centred care, we must not only amplify patient voices, as is advocated by this Review, but also support the voices of those who hear and respond to them every day.
Towards a More Equitable Safety Landscape
This Review represents an important step in reshaping patient safety for the next decade. But I worry that it also reflects an outdated paradigm, one in which safety is something done to patients, by policymakers and technology, now AI, rather than with people. It did not have the choir of contributions that would make safety and equity seen in multiple ways. The Review perhaps sees safety mostly through a medical lens and machine metaphor. This misses out those who are already acting on safety and most trusted to do so. To address this, I wonder if a gender-transformative approach for the Review could look like this:
Naming nursing as a safety critical profession in the body of the report.
Including the RCN and nursing academics in evidence-gathering.
Ensuring gender balance in advisory and expert panels.
Recognising the unique safety risks experienced by women patients and professionals.
Valuing relational, embodied, and experiential knowledge as vital safety intelligence as well as artificial intelligence.
I say this because having been in the system for more than 40 years I see safety and improving safety as more than merely metrics. It is about how we and those we care for and design systems for, make meaning of what is happening to us, how we form relationships, build trust, and create presence. It is about whose expertise is counted and whose lives are protected. To omit nursing, and to overlook gender is to build safety policy on the partial truths that got us to the unsafe place in the first place.
Where are the Nurses? And where are the Women? Where is Equity?
Not in the Review. We are in hospitals and homes, in clinics and communities. We are holding patients to ensure safety, noticing early warning signs, filling gaps in systems and forming systems to improve quality. But we are not, it seems, in this Review, at least not in the way we could be.
If we are serious about safety, we must be serious about equity, visibility, and voice.
That means recognising nursing as central, not peripheral. That means understanding safety through a gendered lens too. That means asking not only what goes wrong, but who is left out of the conversation, and at what cost, and why.
Equity is not an end point; it is part of the design. A GESI lens is needed on quality if we are to change the safety discourse and stop designing the system that gives us exactly what is designed to do (the old quality adage we learnt from Deming).
We need nurses and women so that we are asking the right questions and listening to the right voices, only then will we design and deliver safe care and systems that work.
Dr Marion Lynch RN RMN Global Health Consultant and Gender Activist.
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