Managers are still treating patient safety as 'subordinate' to money despite the health service's £1.8bn underspend, according to the NHS medical director.

Sir Bruce Keogh's comments back up findings from HSJ's exclusive poll that revealed most trust boards are still prioritising other targets and finance over infection control.

Speaking at HSJ's Patient Safety Congress, organised jointly with sister title Nursing Times, Sir Bruce said: "Safety and quality are still subordinate to fiscal considerations at board level.

"For the first time now the health service has come in with a small surplus of£1.8bn and that gives us a unique opportunity to try to focus additional money on quality.

"The majority of trusts are in financial balance - most have a significant surplus. I'd like to see that issue of quality and safety at least receive the same level of attention, so the money is used for quality and safety."

Clinicians needed to raise concerns with managers but the NHS's traditional top-down command structure had resulted in "despondency", he said, with many health professionals feeling the system was "deaf".

Chief nursing officer Christine Beasley agreed trust boards were not giving safety the attention it deserved. "It's not all about saving, sometimes it's about investing too," she said.

Health minister Ann Keen had earlier urged boards to invite staff responsible for safety issues to board meetings in order to debate the challenges being faced.

Prime minister Gordon Brown made an appearance on the congress's opening morning, telling the audience the government was "grateful for everything you do". With life expectancy rising and more sophisticated treatments, it was important to work together to meet public expectations, he said.

"This comes down to personal care we can give people and that's why the whole basis of our reforms are to empower staff."