HSSIB investigation report: Safety management: accountability across organisational boundaries (13 February 2025)

Summary

This is one of a series of Health Services Safety Investigations Body (HSSIB) investigations exploring safety management and whether the principles adopted in other industries may assist in the management of safety in health and care.

The aim of the investigations is to help improve patient safety in relation to the management of patient safety risks across organisational boundaries. This has been explored through an understanding of the pathways of care for patients whose care involves engaging with providers in primary, secondary and community care and with integrated care systems (ICSs). This report makes reference to processes which exist within the health and care system relating to the management of safety.

You can read Patient Safety Learning’s response to this report here.

Content

This investigation explored the experiences of Ros, and her husband and carer Norman, to demonstrate the gaps in patient safety management when patients’ care is managed across multiple providers in an ICS.

The investigation engaged with patient safety and quality teams within Integrated Care Boards (ICBs) to understand how patient safety risks were managed at this level of the health and care system. The investigation also engaged with NHS England regional and national teams to understand the risks that were escalated to them and how they were managed.

Findings

• There are no overarching principles that all healthcare providers and ICBs can use which enable a consistent and collaborative approach to the management of patient safety.
• There is a difference in the perception of how patient safety is managed between ICBs and national health and care stakeholders, including the lines of safety accountability.
• National organisations’ expectations of how ICBs manage patient safety are not in line with what ICBs can currently achieve due to challenges with resourcing and the usability of safety data.
• Patient safety risks may be escalated from the regional to the national level but there is variability in how these risks are managed at a national level and how responses to escalations are fed back.
• Cross-organisational safety risks are not always being escalated to ICBs and there may be limited resources and capability to identify, define and investigate such risks.
• Learn from Patient Safety Events (LFPSE) is the national learning service for the NHS; however, challenges in the usability of LFPSE data means that system level risks may not be visible to ICBs and the wider health and care system.
• Existing informal ‘good relationships’ between individual providers and an ICB facilitate the effective sharing and management of risks. Where these ‘good relationships’ do not exist or change, formal governance processes do not always ensure information sharing continues.
• Patients and carers are an important source of feedback to ICBs about patient safety risks across organisational boundaries. However, this can create inequities as some people are more able than others to make their voice heard.

Recommendations, observations and suggestions

HSSIB makes the following safety recommendation:

• Safety recommendation R/2025/057: HSSIB recommends that the Department of Health and Social Care, working with NHS England, uses the findings of this report to inform the development of the 10 Year Health Plan and NHS Quality Strategy. The intent of this recommendation is to encourage further exploration of how the safety management principles described in this report might be applied in health and care settings to improve patient safety.

HSSIB makes the following safety observations:

• Safety observation O/2025/061: Health and care organisations can improve patient safety by working together to identify the challenges with the practical use of the Learn from Patient Safety Events service to enable the identification of risks that span multiple providers. This is intended to identify the requirements and support needed to improve risk management.
• Safety observation O/2025/062: Health and care organisations can improve patient safety by having clear lines of safety accountability and assurance of risk management processes. Currently patient safety risks are not managed in line with established UK government risk management principles.

HSSIB makes the following safety suggestions:

• Safety learning for Integrated Care Boards ICB/2025/011: HSSIB suggests that integrated care boards seek assurance of how health and care providers will work together when commissioning services, so that patient safety can be managed across health and care providers. This is to help support the visibility and management of patient safety risks across an integrated care system.
• Safety learning for Integrated Care Boards ICB/2025/012: HSSIB suggests that integrated care boards develop their patient safety capability and expertise to ensure they can effectively analyse safety data and intelligence about patient safety risks. This would help to identify and understand patient safety risks that exist across multiple providers in order to proactively investigate and manage these risks.