The HSSIB has flagged patient safety risks across regional care pathways, stressing that unclear roles, limited oversight and inconsistent information sharing can limit how risks are managed.
The Health Services Safety Investigations Body (HSSIB) has issued a learning report following a pilot last year of a new rapid investigation process that examined a redesigned regional care pathway.
It warns that unclear roles, limited oversight and inconsistent information sharing are all factors that can affect risk management across the NHS.
Regional care pathways assess and care for patients with a particular health condition. This one was redesigned alongside healthcare organisations, staff and the public to reduce health inequalities, improve patient outcomes and ensure efficient use of resources.
However, the HSSIB investigation has found that the Integrated Care Board (ICB) and NHS trusts involved – which it isn’t naming – didn’t share an understanding of how the pathway should operate in practice. It also identified gaps in how safety is managed across organisational boundaries, with risks not always shared, accountabilities unclear and oversight arrangements limited.
This, the HSSIB has found, reduced how far the ICB was able to manage patient safety proactively.
Information sharing
Further gaps in understanding came from variations in data collection and limited information sharing, with no single guidance document shared between organisations and organisations holding different perceptions of patient safety risks. As a result, none of the organisations involved had a full picture of patient safety, with clinical decision-making impacted and teams disagreeing.
“Where there is no shared understanding of roles, responsibilities and risks, it becomes harder for NHS staff to make consistent decisions about patient care,” warned Deinniol Owens, deputy director of investigations at the HSSIB, adding that patient safety should always be at the fore of decision-making and proactively monitored across pathways.
The report, released earlier in June, is for ICBs, provider organisations and specialised commissioners involved in delivering and commissioning regional care pathways in England.
Now, the HSSIB is encouraging ICBs to ask and answer questions about the care pathway going forwards, including on identifying dedicated support for new pathways and using appropriate tools and resources.
It is also urging NHS leaders to clarify accountability, improve data sharing and support a more coordinated approach to managing patient safety across these regional care pathways.
Earlier this year, the HSSIB revised its strategy to strengthen investigation capability in England.
