The Health Services Safety Investigations Body (HSSIB) has published a new report, Safety Management: Accountability Across Organisational Boundaries, highlighting significant challenges in managing patient safety risks across multiple healthcare providers. This report highlights that there exist no overarching safety management principles to ensure a consistent collaborative report across healthcare providers and ICBs.
The investigation examines how safety is managed when care transitions between providers, particularly within Integrated Care Systems (ICSs). It reveals inconsistencies in how patient safety risks are identified, escalated, and managed—often leading to delays in care, confusion over responsibility, and undue burdens on healthcare professionals and organisations.
The findings of the report include:
- A misalignment between national expectations and ICBs’ ability to manage patient safety risks effectively, due to resource constraints and data usability challenges.
- Variability in how patient safety risks are escalated at regional and national levels, with limited feedback mechanisms in place.
- A lack of integrated patient safety data, making it difficult for ICBs to proactively identify risks spanning multiple providers.
Key Recommendations
HSSIB has made a safety recommendation to the Department of Health and Social Care and NHS England to use the findings of this report to shape the upcoming 10-Year Health Plan and NHS Quality Strategy. This includes embedding safety management principles into healthcare to improve cross-organisational patient safety.
Additionally, safety learning points have been highlighted for Integrated Care Boards (ICBs), urging them to:
- Ensure collaborative working across health and care providers when commissioning services to improve patient safety.
- Develop greater expertise in analysing safety data and intelligence to identify and address risks across multiple providers.
The Patient Safety Commissioner welcomes this report and encourages policymakers, NHS leaders, and healthcare professionals to engage with its findings to help shape a safer, more transparent, and patient-centred healthcare system.
For the full report and recommendations, visit https://www.hssib.org.uk/patient-safety-investigations/safety-management/investigation-report/