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This report shares learning gained through examination of a regional care pathway – that is, a pathway of assessment and care for patients with a particular health condition – during a Health Services Safety Investigations Body (HSSIB) rapid response investigation pilot. The investigation aimed to investigate safety concerns shared with HSSIB about the safety and effectiveness of a care pathway that spanned multiple organisations and where specialist services were centralised to a single site. The pathway had been redesigned with engagement from the organisations, the public and staff to reduce inequalities. It was intended to improve patient outcomes and ensure efficient use of resources across the region. The investigation provided insights into how the governance of care pathways, including oversight and risk management, is achieved, and how cultural and communication challenges between organisations impacted on patients receiving appropriate care. The investigation identified differences between how the redesigned pathway was expected to operate and how it worked in practice. These differences affected staff wellbeing and led to concerns about risks to patient safety, including delays in access to specialist care. The learning in this report is shared to support organisations and integrated care boards (ICBs) to adopt effective change management processes that are informed by patient safety considerations when designing, implementing and overseeing care pathways. Findings A cross-organisation implementation board oversaw the redesign and initial implementation of the care pathway. Support and oversight from the ICB was time limited, ending before the project had been fully implemented, which impacted on the operationalisation of the service. A business case for implementation of the pathway was approved but not fully realised. This created expectations for how the pathway would operate that were not met in practice. There was no shared view across organisations about what the redesigned pathway could offer patients in reality. This limited the organisations’ ability to understand the risks across the pathway and to mitigate them to as low as reasonably practicable. There was no single guidance document shared between organisations, and there were inconsistencies in the documentation used to support decision making about whether patients should be provided with specialist care. Organisations held different perceptions of the risks to patient safety created by the redesign of the pathway. This impacted on clinical decision making and led to disagreements between teams. Organisational oversight of the pathway after its implementation was limited due to disengagement among staff and the absence of a collaboratively agreed evaluation plan. The data collected about the care pathway differed across organisations and was not routinely shared between them. This led to a difference in understanding about how the care pathway was working in practice and where improvements could be made. The ICB had limited ability to support ongoing improvement of the care pathway and had limited access to information about the quality and safety of the pathway in practice. Differences in the perceived purpose of the pathway led to barriers to collaborative learning and improvement of the pathway. These included examples of incivility among staff, which is known to impact on staff wellbeing and patient outcomes. HSSIB suggests safety learning for integrated care boards Safety learning for integrated care boards ICB/2026/019: HSSIB suggests that integrated care boards proactively identify the impact of commissioning decisions on pathways prior to implementation and develop mitigations to reduce any potential impacts on patient safety and equitable access to care. Safety learning for integrated care boards ICB/2026/020: HSSIB suggests that integrated care boards support organisations to effectively evaluate the implementation of new care pathways. Local-level learning prompts HSSIB investigations include local-level learning where this may help organisations and staff identify and think about how to respond to specific patient safety concerns at the local level. HSSIB has developed the following prompts to support local-level learning for NHS trusts when collaborating with other organisations across a regional care pathway. Safe implementation of the care pathway How do you identify and resource dedicated support to implement new care pathways? How do you ensure appropriate tools and resources are used to support the design and implementation of the care pathway? How do you identify and mitigate unexpected challenges to patient safety arising from the care pathway’s implementation? How do you identify and mitigate any mismatch between the expectations of patients, families, carers or staff and what the pathway can deliver in practice? How do you ensure that implementation of a care pathway is effectively evaluated to improve safety and learning? How do you identify and mitigate potential harm caused when implementing a new care pathway? The care pathway in practice How do you identify and manage incivility between staff across different organisations? How do you facilitate shared learning opportunities for staff across different organisations? How do you ensure information and documentation used to support the care pathway are aligned across different organisations? How do you enable staff to understand the context in which the care pathway may work in different organisations? How do you engage staff to understand the different requirements for electronic systems that may exist across the care pathway? How do you support interoperability of electronic systems to enable effective information sharing across different organisations? How do you enable new technology to be adopted and used across different organisations? How do you consider relevant tools and guidance when developing work processes across different organisations? Oversight of the care pathway How do you ensure shared governance forums are appropriately established and resourced, and are effective? How do you ensure concerns about the care pathway are escalated and acted on by senior and executive leadership teams across different organisations and the integrated care board? How do you ensure consistency in how data is collected and shared across different organisations, including with integrated care boards? How do you ensure that risks to the care pathway are identified and mitigated to as low as reasonably practicable across different organisations? How do you ensure messages about the care pathway are effectively shared and understood by staff across different organisations? How do you identify and facilitate proactive communication with a point of contact at the integrated care board with oversight of the care pathway?

Strategic commissioning has begun, but without proper allocative tools and co-design, the NHS risks cutting the services it needs to close the health inequalities gap, argues Andi Orlowski in this HSJ article.

NHS commissioning reforms repeatedly fail due to structural, financial and political barriers, raising doubts over whether latest changes can succeed. Drawing on Nigel Edwards’ analysis, this HSJ article highlights recurring problems, including overambitious scope, chronic skill and capacity gaps, information and power imbalances in favour of providers, repeated loss of institutional memory through reorganisation, misplaced financial risk, and political resistance to service change. While the new Strategic Commissioning Framework and the move to consolidated integrated care boards have sound principles, the author warns they will only succeed if there is genuine devolution to place level, clearer decision rights, a financial architecture that allows investment and savings to align, and an accepted, transparent approach to decommissioning services.

The 10 Year Health Plan sets out an ambition to build a truly modern NHS that delivers better treatment for patients and better value for taxpayers. To realise this vision, we must deliver services in new ways that better meet patients’ needs, and provide care as close to home as possible, in a way that is most convenient for them and gives them what they need when they need it. As set out in the Neighbourhood Health Framework, this will mean improving routine healthcare services, moving to a more proactive care model for people with multiple long-term conditions and delivering better alternatives to hospital care. Commissioning reform and development will support integrated care boards (ICBs) to become more expert strategic commissioners, moving to a population health approach that aligns incentives, reduces fragmentation and addresses the imbalance of resources. Commissioners will increasingly use population-based contract models to enable providers to work together to deliver joined-up care. Delivering this vision does not require disruptive organisational change. This publication sets out new population health delivery models to facilitate this change, supporting ICBs to commission providers around the needs of defined populations. ICBs – working with partners, including local authorities and health and wellbeing boards – will agree neighbourhood footprints that form clearly defined populations. Single neighbourhood, multi-neighbourhood and integrated health organisation contracts will be commissioned around these populations. Single neighbourhood providers (SNPs) will deliver services, through integrated neighbourhood teams, within a defined single neighbourhood, enabling primary care to take on new neighbourhood services that are not contracted through today’s general practice contracts – General Medical Services (GMS), Personal Medical Services (PMS) or Alternative Provider Medical Services (APMS) – which will continue to be determined nationally and commissioned locally. Multi-neighbourhood providers (MNPs) will co-ordinate the consistent delivery of services across multiple neighbourhoods. This may include delivering services directly at a larger scale than a neighbourhood or by ‘filling in’ services where an SNP is not willing or able to. Integrated health organisation (IHO) contracts will give providers a whole population health budget for a geographically defined population, underpinned by a contract. The model will empower highly capable providers to lead change through their understanding of local population need, knowledge of activity and costs, and ability to engage frontline clinicians in service redesign. IHOs will undo needless NHS fragmentation and create incentives to invest in community-based preventative care.

Since its introduction in 1990, the commissioning layer of the NHS has been the most reorganised part of the health service, and it is changing once again. In this article for the Nuffield Trust, Nigel Edwards reviews the lessons to learn from the past and describes what needs to happen for ICB-led strategic commissioning to succeed where previous models have fallen short.

This webinar was part of a series of evidence events hosted by the Health Foundation's NHS Productivity Commission. The NHS Productivity Commission has been established with the aim of providing evidence and solutions to boost NHS productivity growth over the next decade. The Commission is drawing on experience and insights from the NHS, the wider economy and health systems in other countries.   In this event we hear from an expert panel about what we can learn from international evidence and best practice. 

This toolkit summarises good practice for Integrated Care Boards (ICBs) and primary care commissioners and providers regarding the provision of primary care services for people seeking asylum who are living in initial and contingency accommodation. It aims to ensure equality in access to services and improved long-term health outcomes for residents in Home Office accommodation, minimising health inequalities and encouraging collaborative working with accommodation providers and other local stakeholders.

Increasing numbers of people are at risk of developing frailty. People living with frailty are experiencing unwarranted variationin their care. This toolkit will provide you with expert practical advice and guidance on how to commission and provide the best system wide care for people living with frailty.

The Patient Association's response to the PHSO: Complaint Standards Framework. Summary of core expectations for NHS organisations and staff. See also Patient Safety Learning's response to the framework.

This guidance wriiten by the Royal College of Nursing, is for health care professionals, service providers and those involved with planning and commissioning services. It sets out the RCN’s perspective on contemporary and future children and young people’s nursing services in the home and community setting. It also underlines the increasingly crucial role played by community children’s nurses as they provide integrated care closer to home. It explores the legislative and policy agenda, defines the role of the CCN, sets out the core principles of providing care, considers variations in how the needs of families are assessed across the four countries of the UK and outlines examples of current models of care and service delivery.

Dr Matt-Inada-Kim, National Clinical Lead for Sepsis and Deterioration, shares the proforma he has developed to document management and treatment for the deteriorating patient for the new CQUIN, coming soon. This proforma ensures that all the CQUIN data is captured when it comes to audit. He has shared his accompanying slide set explaining about the CQUIN.   CQUIN.pptx CQUIN.pdf

The NHS has recently conducted a consultation on its updated Standard Contract for use in 2020/21. Once finalised this contract is published by NHS England and used by commissioners to contract for all healthcare services other than primary care services. The contract is regularly updated to reflect changes in legislation, policies and technical improvements. In this year’s consultation there have been several changes proposed that specifically relate to patient safety and in this blog we outline the main patient safety changes proposed and detail Patient Safety Learning’s formal consultation response. Medical Examiners of Deaths Proposed Change: We propose to include a new requirement for acute providers (NHS Trusts and Foundation Trusts only) to establish a Medical Examiner’s Office, in accordance with guidance published by the National Medical Examiner. The Office will, initially, review those deaths occurring on the Trust’s premises and not referred to the coroner, ensuring that the certification of death is accurate and scrutinising the care received by the patient before death. Patient Safety Learning supports this proposal. We welcome the decision to make the establishment of a Medical Examiner’s Office a requirement for acute providers. This proposal was first recommended following the Shipman Inquiry (2002-2005) and recent media coverage has revealed that a significant number of NHS trusts have still yet have appoint a Medical Examiner. Medical Examiners can play a key role in improving patient safety in cases where the patient’s death was the result of avoidable harm. They can provide vital insights into these cases and help to identify effective remedial actions to prevent their recurrence, as well as sharing this information for wider learning beyond their specific trusts. Patient Safety Incident Response Framework Proposed Change: The NHS Patient Safety Strategy indicates that the current NHS Serious Incident Framework and Never Events Policy Framework will be replaced, over the next two years, by a new single Patient Safety Incident Response Framework. To accommodate and signpost this planned change, we propose adding a specific reference to “successor frameworks” to the existing requirements relating to the current Frameworks. Patient Safety Learning supports the proposal to update requirements. We welcome the review of these frameworks and the development of a new Patient Safety Incident Response Framework (PSIRF). However, we have concerns about the delay in its release, which was initially expected towards the end of 2019 and now instead subject to a limited release this year with pilot organisations, rather than being shared more widely. We are also concerned about the lack of stakeholder engagement in this process, particularly for patients and families. Despite providing a valuable source of information when incidents occur, they are often not included in investigation processes. The failure to include and listen to patients and families in investigations can often result in more harm and increasing the likelihood of complaints and litigation. In updating these processes therefore it is vital their views are taken into account. National Patient Safety Alerts Proposed Change: The National Patient Safety Alerting Committee is establishing new, co-ordinated and accredited arrangements for the issuing of National Patient Safety Alerts to providers. We propose to include a new requirement for providers to ensure that they can receive each relevant National Patient Safety Alert, identify appropriate staff to coordinate and implement actions required within the timescale the Alert prescribes, and confirm and record when those actions have been completed. Patient Safety Learning supports this proposal. We welcome steps to ensure providers have appropriate arrangements in place to coordinate and implement actions required by national patient safety alerts and record when these have been completed. A recent report by Action Against Medical Accidents, An organisation losing its memory?, has indicated that a number of trusts have experienced significant delays in introducing safer practices highlighted by national patient safety alerts. They found in many cases that the trusts experiencing delays ‘indicated that they were in the process of improving internal systems for overseeing the implementation of patient safety alerts’. It is a positive step to see this is now being added to the NHS Standard Contract as a formal requirement for them to do so. However, we have concerns beyond the scope of these contractual obligations that this process does not appear to be monitored at a national level. While these measures place specific responsibilities on providers, we are not clear on what, if any, oversight arrangements will be put in place to accompany these. We think such national monitoring and public reporting is essential and would look for this to be implemented as a priority. Patient Safety Specialists Proposed Change: The NHS Patient Safety Strategy envisages the establishment of a network of patient safety specialists, one in each provider, to lead safety improvement across the system. We therefore propose to include a requirement on each provider to designate an existing staff member as its Patient Safety Specialist. Patient Safety Learning supports this proposal. We support this proposal in principle but have reservations about how this will be implemented in practice. The requirement to appoint a Patient Safety Specialist, as set out in the NHS Patient Safety Strategy, currently lacks detail about the nature of this role. What do we mean by a ‘Safety Specialist’? What knowledge and training should they have? Will the appropriate governance arrangements be in place to make sure their voice is heard by the organisation’s leadership? We think these arrangements should be specified, resourced, monitored and transparently reported. We will be responding to the separate consultation on this which opened on the 30 January 2020 in more detail. Common sources of harm to patients in hospital/Safety Thermometer Proposed Change: Feedback suggests that the existing Contract requirements on use of the Safety Thermometer are creating too great a bureaucratic burden, and not facilitating learning. We therefore propose to remove the specific requirements relating to use of the Safety Thermometer and, instead, introduce a higher-level obligation on acute providers to ensure and monitor standards of care in the four clinical areas which the Safety Thermometer addresses – venous thromboembolism, catheter-acquired urinary tract infections, falls and pressure ulcers. At Patient Safety Learning we believe that the health and social care system should develop models for measuring, reporting and assessing patient safety performance. This data should be gathered centrally and then used for learning and to implement actions that improve care. With regards to the removal of Safety Thermometer requirement, while we recognise that it has been noted that this has not been effective in facilitating learning, we would expect the newly proposed measures to follow these principles. We would also expect patient safety measurement to apply to all NHS organisations, rather than being an obligation limited to acute providers.

Commissioning is the continual process of planning, agreeing and monitoring services. Commissioning is not one action but many, ranging from the health-needs assessment for a population, through the clinically based design of patient pathways, to service specification and contract negotiation or procurement, with continuous quality assessment. There is no single geography across which all services should be commissioned: some local services can be designed and secured for a population of a few thousand, while for rare disorders, services need to be considered and secured nationally.

In this guest blog from NHS England, the Director of Policy for National Voices throws his support behind NHS England’s refreshed statutory guidance on the importance of involving patients and the public in commissioning.

This document provides information about NHS England’s and NHS Improvement’s funding in 2019/20. It sets out how NHS England and NHS Improvement will support The NHS Long Term Plan through distribution of funding, people and resources, to transform local health and care systems.  This document explains how patients are informed, involved and consulted in the development, improvement and delivery of health and care services.

This guidance aims to support integrated care boards (ICBs) in planning and commissioning services to manage infectious disease outbreaks. With over 10,000 outbreaks managed annually in England, these incidents can strain NHS resources and exacerbate health inequalities, especially among vulnerable populations.ICBs are responsible for developing health plans, managing budgets, and arranging services. The guidance emphasises the importance of activities like diagnostic testing, clinical assessment, vaccination, and post-exposure chemoprophylaxis to prevent illness and reduce transmission.Clear prior arrangements with providers are crucial for timely responses and minimizing disruptions to routine services.This guidance is intended to help ICBs prepare their response to infectious disease threats up to and including NHS incident response level 2, ranging from individual exposures to localised outbreaks.It should be used alongside national legislation and policy and operationalised through commissioning arrangements with local providers in conjunction with local outbreak plans and multiagency memorandums of understanding.

Richard has a learning disability and has spent time in hospital. His mum shares his story through this video about their journey to find the Right Care in the Right Place.

Independent Healthcare Providers Network (IHPN) has released a report on Community Health Services called 'What does good look like', which includes an overview of community health services in England, along with sixteen case studies from IHPN member organisations.   The case studies cover areas including workforce, service demand, quality, commissioning challenges, and what is new in the community services space.

In this Byline Times article, the family of 18 year-old Mollie McAinsh describe her treatment in an NHS hospital after they sought help for her life-limiting ME. Millie developed the condition after a viral illness in 2019 and became increasingly unwell. When she was no longer able to feed herself, she was admitted to the Royal Lancaster Infirmary, where her family believed she would have a feeding tube fitted and then be sent home. However, while in hospital her mother was banned from visiting and Millie was sectioned under the Mental Health Act. The article looks at the issues facing people with severe ME and examines the history of how the illness has been perceived, which many believe has resulted in the wrong treatment being offered to ME patients.

This report is aimed at people who are working with those who have a learning disability, in the role of commissioners or providers of services. It was produced on behalf of the Hampshire Safeguarding Adults Board by a multi-agency group and seeks to understand why people with a learning disability are at greater risk of choking, looking at what can be done locally in Hampshire to improve outcomes for people who are at risk of choking, in any care setting. The report makes a number of recommendations based on common sense and good practice. Recommendations Adults with a learning disability should be supported to take up annual health checks. Adults with a learning disability should be supported to attend a dentist for regular check ups. Social workers, as part of their annual review of placements, must check that individuals are receiving dental checks. All Primary Care Services in Hampshire are provided with information and web links for the National Patient Safety Agency (NPSA) ‘Ensuring safer practice for adults with learning disabilities who have dysphagia’. Health Commissioners ensure that there is sufficient Speech and Language Therapy resource within the community to respond to requests for assessment of learning disability clients identified as at risk of choking. The consent of the person with learning disability must be obtained before any medical investigation or assessment is carried out. All services providing for clients with a learning disability should use an Eating and Drinking Difficulties Screening Tool, which will indicate whether a choking risk exists and a referral to the GP is needed. All services providing for clients with a learning disability, who have a known risk of choking, should use the appropriate documentation in order to ensure the appropriate referrals are made. All Services providing for clients with a learning disability should ensure that they follow the instructions provided by the Speech and Language Therapist following an assessment. All services providing for clients with a learning Disability who are at risk of choking as a result of challenging behaviour or deliberate self- harm, should refer the individual to the Learning Disability Health Team for a formal assessment. If staff or carers identify that someone is at risk of choking from food or other objects in their mouth, a Mental Capacity Act assessment needs to be considered to support appropriate decision making. If clients, as a result of their behaviours and the consequent risk of choking, are prevented from accessing areas within a residential setting then an application should be considered from the care provider to the Supervising Authority (Local Authority) under the Mental Capacity Act Deprivation of Liberty Safeguards. If staff or carers identify that someone is at risk of choking, they must consider a referral to an advocacy organisation for an advocate to support the person with decision making in relation to eating and drinking plans. All carers and staff should be involved in the care planning process for people at risk of choking, particularly those who will be implementing the plan. Staff should be aware of the consequences of not following an agreed eating and drinking care plan. Care plans to support people at high risk of choking should be reviewed at least every 6 months or after any change in the person’s health or care. Staff induction training in all learning disabilities settings should include choking recognition and First Aid treatment of choking. All trainers to increase the emphasis on responding to choking incidents in First Aid training for services that provide care for people with learning disabilities. In line with the NPSA recommendation, regular practices or drills for staff around responding to a choking incident should be carried out as part of First Aid response training. The Group recommend a standard training matrix which should be used by all those providing care for those with a learning disability. The four Hampshire Safeguarding Adults Boards should seek to influence the Department of Health to consider a national data collection about choking deaths in people with a learning disability in order to understand the problem and guide improved practice. All Primary Care Services in Hampshire are sent the NPSA Learning Disability Dysphagia Protocols for GPs. The four Hampshire Safeguarding Adults Boards undertake a communications campaign to raise awareness around the issues of choking. A ‘Health passport’ is developed for every person with a learning disability to ensure that information around health risks including risk of choking is available to be shared between providers, with the person’s consent. All choking incidents involving people with a learning disability should be reported and investigated appropriately.

Infant mental health describes the social and emotional wellbeing and development of children in the earliest years of life. It reflects whether children have the secure, responsive relationships that they need to thrive. However, services supporting infant mental health are currently limited; only 42% of CCGs in England report that their CAMHS service will accept referrals for children aged 2 and under. This briefing by the Parent-Infant Foundation is aimed at commissioners looking to set up specialist infant mental health support. The guidance covers the following areas: What is infant mental health? Why does infant mental health matter? What are specialised parent-infant relationships teams? What infant mental health provision exists in the UK? Who needs infant mental health support? What impact has COVID-19 had on infant mental health?