HSSIB’s latest report has found that integrated care boards (ICBs) do not have visibility of some patient safety risks, which impacts on their ability to effectively deal with those risks to keep patients safe.
The investigation also found that there is variation in how risks are escalated to a regional and national level, and how responses to escalations are fed back, meaning that patient safety across multiple service providers is not adequately managed.
The report sets out an investigation which considers how safety management is co-ordinated and integrated across the health and care system. HSSIB looked at the safety management activities of ICBs as they have oversight of multiple healthcare providers in their area. In order to understand the organisational patient safety accountabilities and responsibilities, HSSIB spoke to staff working in multiple ICBs plus a number of national organisations across the health and care system. This included speaking to national healthcare organisations, and regional teams in NHS England about how patient safety risks are escalated to them and how they are managed.
This is the second report exploring safety management and whether the principles adopted in other industries may assist in the management of safety in health and care. This investigation follows HSSIB’s first report which describes Safety Management Systems (SMS) principles.
The insights from national teams and ICBs informed the development of the investigation’s eight findings. A key message coming from the investigation is currently there are no overarching principles that all health and care providers and ICB’s can use which enable a consistent and collaborative approach to safety management. This created a difference in understanding between organisations, including accountability for patient safety within organisations.
To illustrate the impact gaps in safety management can have on patients and their carers, the report tells the story of Ros and Norman. Norman is a carer for this wife Ros, who suffers from a number of health conditions and therefore her care is managed by multiple providers. Ros and Norman’s experience with cross-organisational care is documented in the report with Norman feeling he had had to act as a co-ordinator for Ros’ care as a result of organisations not communicating effectively with each other. This has led to a considerable burden being placed on him and led him to “feel overwhelmed.”
HSSIB’s report also highlighted that patients and carers are an important source of feedback to ICB’s about patient safety risks but this can create inequalities as some people are more able than others to make their voice heard. Norman told the investigation that he was getting the care Ros needed through his actions and that he was aware of other patients whose families did not have as strong an advocate as him.
The report makes one recommendation focused on the findings of the investigation being used to inform the development of the 10-Year Health Plan and the NHS Quality Strategy. The intention is to encourage further exploration of how safety management principles could be applied in health and care settings. The report also contains safety suggestions for ICBs which focus on visibility and management of patient safety risks and also the development of patient safety capability and expertise.
Sian Blanchard, Head of Patient Safety Insights at HSSIB said “Safety management across organisations in healthcare is complex– as our report emphasises there are multiple providers involved in one geographical area. We were told by those working in Integrated Care Boards about the challenges faced in delivering cross-organisational care and in how they monitor, escalate and respond to safety risks. It is crucial that lines of responsibility and accountability are defined including at a national level, and those we spoke to welcomed any further work on establishing approaches that would help them to manage recurring or emerging risks more proactively.
“Any opportunity to improve safety management should be examined because as we see through our investigations, safety incidents and patient harm happens as patients transition between health and care providers. This was clear in Ros and Norman’s case, with Norman telling us that “twice in 3 years Ros has been harmed due to the system not working together”.
“The report provides valuable evidence which we have specified should feed into high-level plans and strategies for the NHS. We know that safety learning hasn’t always been sufficiently embedded in healthcare as in other industries. The work we have done is aimed at ultimately encouraging different organisations, including national bodies, to work together with the common goal of improving how safety is managed, for the benefit of patients, families, carers and staff across the country.”
