Safety management
Published
NHS staff
Patient safety themes
Patient and family
Continuity of care
This investigation considers how safety management is coordinated and integrated across the healthcare system. It looks at accountability beyond organisational boundaries and involving NHS staff and patients.
1 recommendation
2 observations
2 actions
1 of 1 responded
Safety Recommendations (1)
Department of Health and Social Care
R/2025/057
HSSIB recommends that the Department of Health and Social Care, working with NHS England, uses the findings of this report to inform the development of the 10 Year Health Plan and NHS Quality Strategy. The intent of this recommendation is to encourage further exploration of how the safety management principles described in this report might be applied in health and care settings to improve patient safety.
The Department states the 10 Year Health Plan is in development, to be published after the summer spending review, and the NHS Quality Strategy is planned for autumn publication. Both will be informed by evidence and safety management principles.
The Department is currently in the process of developing the 10 Year Health Plan, which will be published following the spending review in the Summer. The plan will set out how we will deliver an NHS fit for the future, creating a truly modern health service designed to meet the changing needs of our changing population. The plan is being co-developed with the public, staff and patients through a thorough and detailed engagement exercise, which was launched in October 2024. Alongside considering the three big shifts needed to transform care - moving care from hospitals to communities, from analogue to digital and from sickness to prevention, it will also ensure continued progress on fundamentals such as patient safety. We are grateful to the Health Services Safety Investigations Body for the detailed and considered response to the Change NHS consultation, which covered Safety Management Systems. NHS England’s Quality Strategy, planned for publication later in the Autumn of this year, will set out a framework to manage quality, including safety, and be informed by evidence and good practice, such as safety management principles. Response received on 24 June 2025.
Safety Observations (2)
Health and care organisations can improve patient safety by working together to identify the challenges with the practical use of the Learn from Patient Safety Events service to enable the identification of risks that span multiple providers. This is intended to identify the requirements and support needed to improve risk management.
Health and care organisations can improve patient safety by having clear lines of safety accountability and assurance of risk management processes. Currently patient safety risks are not managed in line with established UK government risk management principles.
Safety Actions (2)
HSSIB suggests that integrated care boards seek assurance of how health and care providers will work together when commissioning services, so that patient safety can be managed across health and care providers. This is to help support the visibility and management of patient safety risks across an integrated care system.
HSSIB suggests that integrated care boards develop their patient safety capability and expertise to ensure they can effectively analyse safety data and intelligence about patient safety risks. This would help to identify and understand patient safety risks that exist across multiple providers in order to proactively investigate and manage these risks.