Source · HSSIB Patient Safety Investigation
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
HSSIB’s introductionWe've identified patient safety risks across regional care pathways, linked to unclear roles, limited oversight and inconsistent information sharing which can limit how risks are identified and managed across NHS organisations.
Published 18 June 2026
Published
Communication and decision making
Access to care
Continuity of care
Indexed content
22 learning prompts
Learning Prompts
How do you identify and resource dedicated support to implement new care pathways?
How do you ensure appropriate tools and resources are used to support the design and implementation of the care pathway?
How do you identify and mitigate unexpected challenges to patient safety arising from the care pathway’s implementation?
How do you identify and mitigate any mismatch between the expectations of patients, families, carers or staff and what the pathway can deliver in practice?
How do you ensure that implementation of a care pathway is effectively evaluated to improve safety and learning?
How do you identify and mitigate potential harm caused when implementing a new care pathway?
How do you identify and manage incivility between staff across different organisations?
How do you facilitate shared learning opportunities for staff across different organisations?
How do you ensure information and documentation used to support the care pathway are aligned across different organisations?
How do you enable staff to understand the context in which the care pathway may work in different organisations?
How do you engage staff to understand the different requirements for electronic systems that may exist across the care pathway?
How do you support interoperability of electronic systems to enable effective information sharing across different organisations?
How do you enable new technology to be adopted and used across different organisations?
How do you consider relevant tools and guidance when developing work processes across different organisations?
How do you ensure shared governance forums are appropriately established and resourced, and are effective?
How do you ensure concerns about the care pathway are escalated and acted on by senior and executive leadership teams across different organisations and the integrated care board?
How do you ensure consistency in how data is collected and shared across different organisations, including with integrated care boards?
How do you ensure that risks to the care pathway are identified and mitigated to as low as reasonably practicable across different organisations?
How do you ensure messages about the care pathway are effectively shared and understood by staff across different organisations?
How do you identify and facilitate proactive communication with a point of contact at the integrated care board with oversight of the care pathway?
When those expectations were not fully met, this led to the concerns described and perceptions that risks to patient safety created by the implementation had not been mitigated. 2.2.3 Various tools are available to support the design and implementation of care pathways (see 1.2). These tools commonly refer to the need for a staged or phased approach, with continuous review and improvement. Throughout the phases, the tools describe the need to proactively engage staff to develop a shared understanding of future need and how the implementation of the care pathway will be achieved. This includes testing assumptions about a planned implementation and considering mitigations should those assumptions not be realised. Considering these tools and the findings of the investigation, the following learning is shared. Safety learning for integrated care boards ICB/2026/019: HSSIB suggests that integrated care boards proactively identify the impact of commissioning decisions on pathways prior to implementation and develop mitigations to reduce any potential impacts on patient safety and equitable access to care. Safety learning for integrated care boards ICB/2026/020: HSSIB suggests that integrated care boards support organisations to effectively evaluate the implementation of new care pathways. Local-level learning HSSIB investigations include local-level learning where this may help organisations and staff identify and think about how to respond to specific patient safety concerns at the local level. HSSIB has developed the following prompts to support local-level learning for NHS trusts when collaborating with other organisations across a regional care pathway. Safe implementation of the care pathway How do you identify and resource dedicated support to implement new care pathways?
When seeing data from other organisations that they had not seen before, some staff described it as “reassuring” as it alleviated some of their concerns about the numbers of patients being declined from the pathway. Risk management processes 4.1.7 The investigation was told by staff outside of the specialist service that the concerns they had about risks to patient safety had not been heard by senior leadership teams. Some staff described also being told not to challenge situations when patients were declined for the care pathway, and interpreted this as being asked to not raise concerns about patient safety. This further contributed to the negative sentiments towards the pathway and disengagement from its governance. 4.1.8 The investigation explored how risks to patients were identified and mitigated. This was heard to be part of the COG’s responsibilities and had been considered throughout planning, design and implementation. Following implementation, the investigation identified that the issues with disengagement and limited evaluation meant the risks across the pathway had not been fully considered. 4.1.9 Staff in some of the organisations had raised concerns that risks associated with patients not receiving timely access to specialised care could not be eliminated or effectively mitigated due to the design of the current pathway. Because of this, some patients did not receive timely care and there were perceptions that the ‘risk’ was being passed between organisations. It was unclear whether collaborative efforts across the organisations had aimed to understand the risks to patient care and mitigate them to ‘as low as reasonably practicable’ (ALARP). ALARP is a risk concept that involves weighing a risk against the effort, time and money needed to control it. 4.1.10 The investigation found that staff had significant concerns about caring for patients without specialist support. These included concerns about the resource-intensive nature of caring for some patients who staff felt should be on the specialist pathway, and which staff felt took resource away from other patients. 4.1.11 Similarly, staff and organisations involved in providing the pathway’s specialist care were concerned that some patients were escalated to them unnecessarily and that this could impact on patients who they felt were a higher priority for specialist support. This included staff feeling that demand and bed availability influenced decisions about whether to admit patients for specialist care because they “simply don’t have the space to take all [patients]”. 4.1.12 Staff across organisations described a lack of “assurance” – that is, confidence – those risks to patients introduced by implementation of the redesigned pathway had been recognised and mitigated. 4.2 Involvement of the integrated care board 4.2.1 The investigation also explored how the ICB supported organisations involved in the care pathway and oversaw the pathway. The investigation was unable to identify a specific function, role or person at the ICB that was responsible for overseeing the evaluation and ongoing improvement of the care pathway once it had been implemented; this was not included in the business case. This limited the ability for “good relationships” to develop between the organisations and the ICB to encourage effective information sharing, the benefit of which was identified in a previous HSSIB investigation ( 2025a ). 4.2.2 The investigation met with representatives from the ICB operational delivery group. This group’s role was to monitor performance of care pathways and receive escalation of issues from organisations. The group was aware of some of the challenges that had impacted on the implementation of the care pathway, such as the commissioning decisions around the modelled bed numbers. The investigation was unable to determine what engagement or mitigations had been put in place to help limit the impact of these challenges on patient care. 4.2.3 The ICB was not aware of some of the patient safety concerns that were raised to the investigation about the pathway. The operational delivery group described that it would react to safety and quality concerns raised about a care pathway but only sought certain information on a regular basis to monitor performance. This meant the ICB did not have full sight of the concerns about patient safety as these had not been shared with them. These findings echo those of HSSIB’s ( 2025a ) investigation, where HSSIB heard from ICBs that they did not understand the types of patient safety risks that were arising in care pathways because of limited information sharing by organisations. 4.2.4 The organisations involved in the care pathway also shared their perceptions that the ICB had limited ability to support the governance and ongoing improvement of the care pathway. The ICB said it was open to supporting collaboration if it was aware of issues, but also that it was facing challenges itself considering national changes across ICBs. ICBs are being impacted by staffing changes and requests to cut costs, and The King’s Fund (2025) has highlighted that ‘previous experience shows that a focus on cutting costs makes collaboration – key to strategic commissioning – harder’. 4.2.5 The ICB agreed to an HSSIB request for it to convene the organisations at a roundtable meeting, to re-establish relationships and expectations for the safe and effective operation of the care pathway. There was a delay in this meeting being convened due to significant ongoing operational pressures across the providers and changes in the ICB’s structure. 4.2.6 The roundtable was chaired by the ICB and attended by all the organisations involved in the care pathway. HSSIB also attended to provide additional context to the meeting about the investigation’s findings. An action plan to address the learning points was discussed collaboratively, and further actions were allocated to the appropriate organisations to continue the learning and improvement process. 4.2.7 The roundtable highlighted some early improvements, including a notable reduction in incivility, an increase in cross-organisational understanding of care pathway specifics and nuances, and the beginning of work considering digital systems. Other learning had not yet been addressed to the same degree, including digital system solutions and, in relation to governance, where the delivery of oversight mechanisms by the ICB was yet to be defined and resourced due to ongoing restructure challenges. 4.2.8 This reflects the challenges HSSIB has observed at local, regional and national level in relation to effective oversight and governance across boundaries of care, which will be explored further in a future HSSIB report. 4.3 Learning from the investigation 4.3.1 Gaps in the oversight of the pathway, and limited clarity across organisations around the risks to patients from implementation of the redesigned pathway, impacted on the ability to take an effective approach to implementation. Without defining the accountabilities of all stakeholders within the wider health and care system it was challenging for ICBs and providers to understand their role in the management of patient safety. This meant that there was limited opportunity to take a proactive approach to safety risk management or safety assurance, as potential hazards, risks and possible controls to mitigate any risks were not shared across organisations. 4.3.2 The investigation recognises the challenge of engaging and working collaboratively across multiple organisations involved in a care pathway. These challenges were highlighted through the lens of patient safety investigation in HSSIB’s ( 2025c ) report ‘Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development’. That report described how co-ordinating collaboration across multiple organisations was difficult and ICBs were not always able to provide the support and co-ordination needed. 4.3.3 These challenges are likely to continue at a national level given the current reorganisation of NHS England with the Department of Health and Social Care. While reorganisation is intended to reduce running costs and avoid duplication of functions (NHS England, 2025a), there is an impact on ensuring appropriate staff and services are available and able to take action to help drive improvements in patient safety. Local-level learning HSSIB investigations include local-level learning where this may help organisations and staff identify and think about how to respond to specific patient safety concerns at the local level. HSSIB has developed the following prompts to support local-level learning for NHS trusts when collaborating with other organisations across a regional care pathway. Oversight of the care pathway How do you ensure shared governance forums are appropriately established and resourced, and are effective?