When the Prime Minister asked me to look at how to improve the safety and quality of care in the NHS, I was honoured to have the chance to contribute to one of the world's biggest and best healthcare systems.
The NHS is a global icon and is admired by both patients and doctors everywhere who are inspired by the fantastic work that its dedicated nurses, doctors and a whole range of other healthcare workers do on a daily basis.
As part of my report I wanted to look not just at how to improve care for patients but also at how to help those dedicated staff do the best job they can.
In any organisation, mistakes will inevitably be made. But we shouldn't just accept that 'these things happen'. We need to find a way to make sure that they happen as little as possible and that when they do happen we learn from them to improve care for patients.
What the UK does have in the NHS is something that most other nations in the world don't have: a unified system of care that is completely capable of identifying its problems, admitting them, and acting to correct them.
With that in mind, I recruited a brilliant team of NHS and healthcare improvement experts to help me recommend some important ways that NHS leaders, clinicians, professional bodies and the Government can improve quality and safety of care.
With the help of these expert doctors, academics and most importantly, patient representatives who can draw on their own experiences of the NHS, I have come up with a number of recommendations on how the NHS can improve patient safety and care.
Firstly, our report recommends the NHS puts quality of care, and particularly patient safety, above all other aims. Patients should be at the centre of everything the NHS does, engaged both in their own healthcare and in the way the system works, from the frontline to Whitehall.
The best doctors and nurses are those that continue to learn and improve the way they care for their patients every single day. A culture of learning should be developed across the entire National Health Service, where all staff can update their skills continually and improve the care they give, in an atmosphere that is supportive and in a system that ensures staff are present in sufficient numbers.
The NHS should also make sure that it is always open and transparent about how good it is. Complaints systems should be continuously reviewed and improved. Supervisory and regulatory systems should be clear and in-depth.
We have proposed two new criminal offences around wilful neglect and mistreatment of patients and to make sure healthcare organisations don't withhold or obstruct relevant information. These reflect the fact that serious misconduct should attract appropriate sanctions, but it is vital that they are only used very rarely and in extreme circumstances - mistakes should never be punished.
Healthcare is complicated and even when everyone is working their hardest things can go wrong. I hope these recommendations will help staff and the NHS to minimise mistakes and learn from them. Over time I believe the NHS will improve and emerge as one of the safest healthcare systems in the world.