ICBs do not have visibility of some patient safety risks, according to a new report by the Health Services Safety Investigations Body (HSSIB).
The report said that although NHS England’s oversight framework states that an ICB ‘proactively manages system and provider risks’, that there are concerns ICBs are not able to see all the risks across the system.
It said: ‘Cross-organisational safety risks are not always being escalated to ICBs and there may be limited resources and capability to identify, define and investigate such risks.’
It added that there were challenges with the national learning service for the NHS, Learn from Patient Safety Events (LFPSE), meaning that system-level risks may not be visible to ICBs, and that often effective sharing was dependent on ‘good relationships’ being in place.
ICBs also reported ‘reduced visibility of incidents’ following the implementation of the Patient Safety Incident Response Framework (PSIRF), published in August 2022. ICBs told the investigation that the previous framework, called the Serious Incident Framework 2015 (SIF), had allowed CCGs to have ‘greater visibility’ of risks.
The report said: ‘Some patient safety specialists described PSIRF as having “eroded assurance activities and patient safety oversight”. Many of the ICBs reported that they now “feel detached from the incidents that happen” and that sometimes the first they heard of an incident having occurred was a request for a media statement.’
However, the authors added that the PSIRF was developed as a response to ‘identified weaknesses’ in the SIF, including ‘misaligned oversight and assurance processes’.
It added: ‘The limitations associated with the SIF equally did not allow ICBs to have full visibility of cross-organisational risks.’
The report recommended that the Department of Health and Social Care (DHSC) and NHS England use the findings to inform its 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,’ it said.
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 ICBs 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.’
She added: ‘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.’
In October, it was revealed that ICBs must identify digital clinical safety officers to support general practice in implementing digital tools safely.
Last month it was revealed that property failures result in 5,400 incidents in the NHS per year.
