Clinical investigation booking systems failures: written communications in community languages
HSIB Legacy
Published
Communication and decision making
This investigation looks at the safety risk of booking systems failures. We explore the use of paper and hybrid booking systems and the production of appointment letters.
1 recommendation
5 observations
4 actions
1 of 1 responded
Safety Recommendations (1)
NHS England
R/2023/229
HSIB recommends that NHS England develops and implements a standard for healthcare providers on supplying written appointment information in languages other than English.
NHS England is conducting a strategic review and options appraisal by March 2024 to identify effective policy levers for improving community language translation services, which will include addressing written appointment information.
Thank you for completing this investigation and inviting NHS England to respond to the recommendation. We were deeply saddened by the investigation case and are aware of other safety investigations and Care Quality Commission (CQC) inspection reports that have raised community language translation and interpretation (CLTI) issues. CLTI services are critical for patient safety, supporting equality and reducing healthcare inequalities. NHS England recognises that current issues must be addressed, including those raised in the investigation and we are committed to proactively addressing these issues and improving CLTI services. We have carefully considered the recommendation to develop and implement a standard for healthcare providers on supplying written appointment information in languages other than English. We appreciate this could help improve services but are concerned it may not be at the pace and scale required. The Accessible Information Standard (AIS) Review, published later this summer, notes that while the content of the AIS is good, it has not resulted in enough change, and traction needs to be increased through other means. To ensure we identify the most effective policy levers or intervention(s) to address issues and improve CLTI services, we have committed to completing a strategic review this financial year. The review will consider the breadth and complexity of issues across the patient pathway and complete an options appraisal of potential interventions. Addressing issues with written appointment information will be a core component of the review. The review will inform how we best facilitate improvements to CLTI services and help ensure they meet the needs of communities and support equitable access, experience, and outcomes for all. This review will be led by the Healthcare Inequalities Improvement Team. We will work closely with the Patient Equalities Team, Patient Safety Team and a range of stakeholders including the Healthcare Safety Investigation Branch (HSIB). Thank you again, for your investigation and highlighting these important issues. Actions planned to deliver safety recommendation: 1) Complete scoping and options appraisal, by November 2023. 2) Agree recommendations, by March 2024. Response received on 24 July 2023.
Safety Observations (5)
It may be beneficial if the ‘preferred written communication method’ field of the Personal Demographics Service system is completed for patients who require written communications in a language other than English.
It may be beneficial if NHS trusts identify mechanisms to appreciate the language needs of their patient demographic and adjust the written communications accordingly.
It may be beneficial to clarify the roles and functions of national organisations in supporting the health inequalities landscape.
It may be beneficial for NHS healthcare providers to incorporate the NHS Service Standard into agreements with third-party developers of electronic clinical investigation booking systems.
It may be beneficial for NHS care providers to explore options for the translation of written appointment communications, including pre-attendance guidance, for patients whose preferred written language is not English.
Safety Actions (4)
It may be beneficial if the ‘preferred written communication method’ field of the Personal Demographics Service system is completed for patients who require written communications in a language other than English.
It may be beneficial if NHS trusts identify mechanisms to appreciate the language needs of their patient demographic and adjust the written communications accordingly.
It may be beneficial to clarify the roles and functions of national organisations in supporting the health inequalities landscape.
It may be beneficial for NHS healthcare providers to incorporate the NHS Service Standard into agreements with third-party developers of electronic clinical investigation booking systems.