Safety management

Background

In October 2023, we published Safety management systems: an introduction for healthcare. This report provided an overview of how safety management systems (SMSs) operate in other industries, where SMSs are a regulatory requirement.

An SMS is a proactive approach to managing safety which sets out the necessary organisational structures and accountabilities to manage safety risks. It requires safety management to be integrated into an organisation’s day-to-day activities.

An SMS explainer video was produced to introduce the principles described in the report. We are now exploring the extent that these principles are used or could be used to inform safety management across the healthcare system.

Everyone working in healthcare has some measure of responsibility for patient safety. When an organisation is accountable for patient safety, they should ensure that systems and processes are in place to effectively manage safety. This includes healthcare providers and integrated care systems (ICSs).

ICSs bring together providers and commissioners of NHS services across a geographical area to plan care in order to meet the needs of people. An ICS aims to join up hospital and community-based services, physical and mental health, and health and social care to improve long-term outcomes and minimise inequalities. Many patient safety risks go beyond organisational boundaries and may not be managed effectively without a clear safety management process. Gaps in responsibility and accountability can have serious consequences for patient safety.

Summary of investigation

This investigation considers how safety management is coordinated and integrated across the healthcare system. We have ensured that the patient voice is represented and that challenges to safety management are understood by hearing from patients that may have been harmed and those working within the system.

We have reported on pathways of care for the health needs of patients that require multiple contacts across different healthcare settings and providers. Contacts with the healthcare system were mapped with a detailed account of organisational patient safety accountabilities. We explored recurring risks when patients receive care from multiple services, and considered vulnerable patients.

We collected a diverse range of views to identify opportunities for the improvement of safety management. As part of the evidence collection, we interviewed NHS staff, patients, and carers. We spoke to patient groups to determine methods of engaging with patients that encounter multiple organisations to address their healthcare needs.

Safety recommendations

Department of Health and Social Care

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 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

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

HSSIB suggests safety learning for Integrated Care Boards

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.

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