Jump to content
  • Patient Safety Learning – The elephant in the room: Patient safety and Integrated Care Systems (11 July 2023)

    • UK
    • Reports and articles
    • New
    • Everyone


    In this report, Patient Safety Learning considers the roles and responsibilities of Integrated Care Systems (ICSs) in relation to patient safety, and how this fits in with the wider patient safety landscape in England. This article contains a summary of the report, which can be read in full here or from downloading the attachment below.


    Action is needed to ensure that ICSs are not ‘patient safety free zones’, says Patient Safety Learning.

    A year on from ICSs being placed on a statutory footing, a new report, The elephant in the room: Patient Safety and Integrated Care Systems, argues that there needs to be a greater focus on the role that they play in patient safety.

    The report sets out what we mean by avoidable harm in healthcare, outlining the scale of this problem and the need for a transformation in approach to improving patient safety. It also looks at the landscape of different coordinating groups and organisations in England that have roles and responsibilities to improve patient safety and reduce avoidable harm. What is revealed is a complex and fragmented environment, lacking strong measures for cross-organisational thinking and coordination to address complex systemic threats to patient safety.

    Considering the creation and initial development of ICSs, the report highlights how there has been little mention of their role in, or impact on, patient safety. It illustrates that although patient safety has not been set as explicit priority for ICSs, the delivery of safe care runs implicitly through each of their main aims. It goes on to consider the potential role that ICSs can potentially play in helping to embed and improve patient safety.


    Considering the steps that could be taken to address the current gap that exists between patient safety and ICSs, and the wider fragmentation of the patient safety landscape in which they operate within, the report makes the following recommendations:

    1. The Department of Health and Social Care and NHS England should consider introducing a fifth aim for ICSs making explicit their role in helping to improve patient safety and reduce avoidable harm.
    2. NHS England should update the NHS Patient Safety Strategy to account for ICSs being placed on a statutory footing in July 2022 and set out their roles and responsibilities in relation to this.
    3. The Department of Health and Social Care and NHS England should consider revising the remit of the National Patient Safety Committee to take on a greater role in coordinating and joining-up the existing patient safety landscape in England.
    4. The National Patient Safety Committee should regularly publish agendas, papers and the minutes of its meetings to help inform all bodies that may be impacted by this, such as ICSs and individual healthcare providers, and also patients and the wider public.

    Patient Safety Learning comment:

    Patient Safety Learning Chief Executive Helen Hughes said:

    “ICSs present a significant opportunity to drive improvements in patient safety in local health systems across the NHS. However, we think patient safety remains the ‘elephant in the room’ in the development of ICS roles and responsibilities. Currently there is not clear guidance or support to ensure that ICSs treat patient safety as a core purpose of healthcare. We believe they need to have specific aims for reducing avoidable harm and improving patient safety.

    There also needs to be clarity on where the patient safety role of ICSs fits into the wider healthcare system. The landscape of organisations with patient safety roles and responsibilities in England is fragmented and lacks coordination, often ill-suited to tackling complex systemic challenges to patient safety. We believe that the Department of Health and Social Care and NHS England need to consider how to better join-up this system, to promote cross-organisational working, coordination and ultimately reduce avoidable harm.”


    3 reactions so far


    Recommended Comments

    Am really disappointed about the outcome of this report. The concept that patient safety runs implicitly through systems and processes is questionable.

    I completely agree with all the recommendations made, particularly the 5th aim of patient safety.

    • 1 reactions so far
    Link to comment
    Share on other sites

    The excellent thing about this report is that it points out that patient safety being first and foremost requires getting so many practical actions right - not just saying patient safety comes first.

    In the commercial world saying putting profit as a priority, as many businesses do, is also meaningless when delivering on that requires getting so many practical actions right.

    • 1 reactions so far
    Link to comment
    Share on other sites

    This important report highlights the #patientsafety minefield that exists in the UK. It is characterised by a fragmented system with both overlaps and gaps, plus very few opportunities for inter-disciplinary / inter-organisational learning.
    - A Patient Safety Commissioner whose remit is limited to medicines and medical devices
    - A plethora of organisations that 'don't investigate individual concerns' (including Healthwatch and the Patient Safety Commissioner)
    - A lack of genuine patient involvement
    - A lack of ownership and leadership at the top
    #share4safety #health #healthcare #nhs #socialcare

    • 2 reactions so far
    Edited by Steve Turner
    Link to comment
    Share on other sites

    This report highlights and important problem which has implications well beyond the role of ICSs. I agree with the conclusion that safety should be a fifth aim of ICSs and I would extend that to include patient and staff safety.

    I am not sure the other recommendations will make a real difference. Clarifying and updating remits seems like housekeeping to me. One of the fundamental problems with ICSs is that they become simply another layer of bureaucracy and management. This report illustrates the risks confusion of purpose presents for patient safety. Why not recommend that some of these committees and bodies be abolished. Replace them with a clear role for ICSs to improve patient safety. 

    • 0 reactions so far
    Link to comment
    Share on other sites

    Create an account or sign in to comment

    You need to be a member in order to leave a comment

    Create an account

    Sign up for a new account in our community. It's easy!

    Register a new account

    Sign in

    Already have an account? Sign in here.

    Sign In Now
  • Create New...