HSSIB Report – Recommendations but no action: improving the effectiveness of quality and safety recommendations in healthcare (16 September 2024)

Summary

Quality and safety recommendations are made to the healthcare system as a mechanism to drive improvements and/or mitigate an identified patient safety risk. These recommendations are made by many different stakeholders both within the healthcare system and outside of it, and can be directed towards any level of the healthcare system. This report by the Health Services Safety Investigations Body (HSSIB) is the output of work commissioned by the Department of Health and Social Care, which looks at how safety recommendations made to the healthcare system are developed, made and implemented.

Content

Findings

• Failure to implement actions following recommendations can impact public confidence in the healthcare system and compound harm to patients.
• The ‘noise’ created by the significant volume of recommendations being made to the healthcare system means that providers struggle to prioritise and implement recommendations, concentrating on those which are addressed directly to the provider, or where there are immediate patient safety risks.
• Some recommendations duplicate or contradict others. The development of a searchable repository which includes recommendations made across the healthcare system may help to reduce this.
• It may reduce the ‘noise’ and help with prioritisation if organisations refer to each other’s recommendations, or group together in support of one organisation’s recommendation rather than repeating it. The development of an agreed system to identify recommendations for cross-referencing would assist this.
• There is currently a lack of visibility of ongoing work across arm’s length bodies that would enable collaborative working on related workstreams. A searchable repository of ongoing work may assist this.
• Recommendations differ in terms of the evidence on which they are based, and their structure and language. This can affect their relevance and how they are interpreted.
• It is unclear how some recommendations are intended to impact the patient, which should be a key consideration in their development where possible.
• Most recommendations made to the healthcare system are not costed, either in relation to the cost of implementing the proposed actions or their longer-term cost effectiveness. This may affect providers’ ability to implement them and means there is a lack of information to support prioritisation decisions.
• Some recommendations may be of limited relevance to certain providers and could promote inequalities by negatively impacting certain patient groups if implemented. However, providers can feel they are not empowered to reject recommendations, especially those related to safety.
• Few recommendations require a formal response from the recipient organisation, and there is a lack of monitoring of the actions planned or taken to address recommendations. A monitoring system could help to track actions and identify opportunities for escalation where changes have not been made.

Recommendations

The Recommendations to Impact Collaborative Group recommend further work in this area to develop:

• guidance on the creation and implementation of recommendations
• a proposal for a repository for recommendations
• a proposal for a repository for ongoing workstreams
• a proposal for a monitoring system with a multi-agency board feeding into the Department of Health and Social Care to provide oversight and a route of escalation for recommendations that are not implemented.

Related reading

Patient Safety Learning, Mind the implementation gap: The persistence of avoidable harm in the NHS, 7 April 2022.