Summary
On the 18 August 2026 the Health Services Safety Investigations Body (HSSIB) published a new report looking at patient safety risks related to advice and guidance (A&G) services in the NHS in England. In this article, Patient Safety Learning sets out its reflections on the report’s findings.
Content
HSSIB investigates patient safety concerns across the NHS in England and in independent healthcare settings where safety learning could help to improve NHS care.
Their latest report, Electronic patient record systems – electronic referrals for ongoing care: advice and guidance, explores the patient safety issues relating to A&G services. A&G enables healthcare professionals in primary care (such as general practice) to seek specialist advice from secondary care. It is often undertaken via the NHS electronic referral service, a digital platform also used for referring patients to NHS hospitals.
Patient Safety Learning welcomes the publication of this report. We contributed to this during its consultation stage and in this article we set out our reflections on the findings.
HSSIB report
The use of A&G services has significantly increased in recent years. A&G can help to enable quicker access to specialist advice and tests/treatments, reducing unnecessary hospital appointments.
HSSIB’s new report found strong support for A&G services where they work well. However, it also found evidence that poorly designed or inadequately monitored pathways have contributed to physical harm, delayed and missed diagnoses, and, in some cases, to delays in cancer care.
Key findings from the investigation included:
Where A&G services improved communication between general practice and specialist services, they had positively influenced patient care. However, there was limited data on patient safety outcomes.
There was evidence that A&G services had contributed to near misses and incidents of patient harm, both physical and psychological, where they had been poorly implemented or monitored. Harm included delayed or missed diagnoses and delays to care and treatment.
There were significant gaps between how some local A&G and single point of access processes had been implemented and national expectations. This included local pathways that required GPs to use A&G rather than making direct referrals, and referrals for specialist assessment being declined despite persistent clinical concern.
Issues with the NHS electronic referral service, including interoperability problems and delays to planned system upgrades, made it harder to track patients through pathways and share clinical information consistently.
Safety recommendations
Following their investigation findings, HSSIB made two safety recommendations:
NHS England/Department of Health and Social Care should undertake a rapid evaluation of advice and guidance processes.
We welcome this recommendation; in particular the statement that this rapid evaluation should be completed and have its findings addressed before any further expansion of A&G services.
HSSIB’s investigation identified incidents where issues with A&G services have contributed to significant patient harm. They state that the extent of these patient safety issues cannot be determined, in part due to limited safety data. They note the challenges Integrated Care Boards (ICBs) face in seeking to support A&G implementation and expansion while also managing the associated risks to patient safety.
In our view, this is a description of an unassessed and actively expanding risk. We agree that there is a clear case for not proceeding with the expansion of A&G until the patient safety risks identified have been assessed and mitigated.
On the specific point of the scale of this risk, the report notes difficulties in capturing this in the national Learn from Patient Safety Events (LFPSE) service, particularly in primary care. We believe there should also be specific action to tackle the technical and practical barriers to LFPSE reporting from general practice by NHS England. There also may be value in looking at other sources of data that could shed some light on the scale of this problem. This could include Coroner’s Prevention of Future Deaths reports, Ombudsman reports, Trust Patient Safety Incident Response Framework reviews and ICB serious incident records.
NHS England/Department of Health and Social Care, in collaboration with relevant Royal Colleges, should commission the development of A&G request and response templates and support their effective implementation in practice.
We also welcome this recommendation. We agree that the variation in quality of clinical information exchanged can be a hazard when no one is examining the patient, and templates could assist with this. We would add that templates should include:
Prompts for red flag risks—whether symptoms, co-morbidities or other patient risk factors.
What has or has not been assessed, and what should prompt re-referral.
Safety observations
HSSIB also made two safety observations:
Organisations involved in the design and provision of healthcare education can improve patient safety by addressing gaps in knowledge and skill across the multidisciplinary workforce for the undertaking of asynchronous clinical consultation tasks.
We agree with the rationale behind this observation. However, we would note that without this action being owned by specific providers of healthcare education, such as NHS England, it is unlikely to result in any meaningful change.
Organisations can improve patient safety by ensuring the mandated requirements for digital clinical risk management for the deployment of the electronic referral service are achieved.
This observation relates to one of the most significant findings of the report. The investigation “found that none of the providers it engaged with could provide evidence that clinical risk management requirements under DCB0160 had been met for electronic referral service”. DBC0129 and DCB0160 are the NHS standards that provide essential requirements for manufacturers of health IT systems and healthcare providers in assessing and managing clinical risks to ensure the safety of digital solutions in the NHS.
This would appear to suggest that the implementation of the electronic referral service into local care pathways had not been risk assessed. That is, the national digital system for sharing clinical decisions between organisations, at scale, is operating without formal assessment of the hazards it introduces into those pathways. We believe this is alarming and should not just be a safety observation, but is instead be considered a greater cause for concern that NHS England needs to respond to directly and immeidately. How was a live clinical decision system allowed to be implemented without a signed off risk assessment and who should be responding at pace to address this significant failure?
We would also note a missing part of this picture is the DCB0129, that the supplier of the electronic referral service would also be required to produce and maintain a clinical safety case and hazard log. We believe there needs to be clarity as to whether the DCB0129 for this system exists. If it does not, we think that there should be a safety recommendation directly for NHS England, to include publication of the hazard log and associated mitigations so that deploying organisations have something on which to build their local DCB0160 work on.
Role of patients
HSSIB’s report mostly speaks passively about the role of patients in the A&G process.
In many cases, we believe that patients may be aware that A&G has taken place. They may assume they have been referred and are waiting for an appointment, when in fact a specialist opinion has been sought and given without the patient being seen, examined or spoken to. This could mean that the patient:
Does not know that a specialist has formed a view about them.
Does not know what information about them was shared, or how complete it was.
Have no means of correcting any mistakes in the documentation.
If a patient erroneously believes that they are going to have an appointment with a specialist made for them, they may wait rather than returning to their GP when symptoms change.
The report includes cases where patients experience anxiety while waiting for responses to requests for advice about symptoms or signs of concern, and patients feeling dismissed when specialists declined to see them.
We believe there needs to be greater clarity for patients, which could include:
Knowing when A&G is being used instead of, or before, referral.
The outcome of the A&G request being communicated to them.
Explicit safety netting, including what to do and who to contact if symptoms persist or worsen while awaiting a response.
There is a route for a patient to ask for reconsideration where they remain concerned.
Other areas for consideration
In addition to the points above, we believe that the following issues should be noted and actioned by NHS England:
The report found repeated examples of A&G cases where delays ranged from weeks to more than six months. We think it would be worth considering whether there should be a nationally defined maximum response time for A&G requests. This could include a default fail-safe: where the maximum is exceeded, the request converts automatically to a referral rather than requiring the GP to notice, chase and resubmit.
It would be beneficial to clarify clinical responsibility and accountability in A&G. This should cover who holds responsibility for the patient while advice is awaited, what the responding clinician is accountable for, what documentation is required, and what happens where the requesting clinician does not agree with the advice given. This unresolved accountability is itself a significant patient safety risk.
The report identifies that electronic referral service functionality and usability affected users’ ability to share high-quality information and to monitor and track patients. It states that there are planned upgrades, but these have been delayed. Given the findings of this report, we believe greater clarity and clear timescales for action are needed around this.
Concluding thoughts
We believe it is vital that patient safety considerations are hardwired into the implementation of policies such as A&G via the NHS electronic referral service. New systems should be risk assessed before being widely implemented, including consideration of potential unintended consequences. Where risks are identified, the necessary changes to the processes should be made before wider implementation.
Given the nature of the patient safety issues raised by HSSIB’s investigation, we would expect NHS England to issue its response to this report as soon as practical. This should include their reflections on the safety recommendations and observations and a timescale for subsequent activities seeking to address these points.
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