HSSIB warns of safety risks across regional NHS care pathways
- Jun 18
- 2 min read
Patients may face delays in accessing specialist care when NHS services are not properly joined up across regional care pathways, the Health Services Safety Investigations Body has warned.
The findings come from a new HSSIB report examining a redesigned regional care pathway in England. The pathway involved multiple NHS organisations and the centralisation of specialist services at one site.
The pathway was intended to reduce health inequalities, improve outcomes and make better use of healthcare resources. However, the investigation found a gap between how the pathway was expected to work and how it operated in practice.
What the investigation found
HSSIB found that the integrated care board and the NHS trusts involved did not have a shared understanding of the pathway’s purpose, how it should be delivered, or the risks linked to it.
This affected how organisations viewed patient safety concerns and made it harder to coordinate decisions across services.
The investigation also found that responsibilities were not always clearly defined. A cross-organisational board had supported the redesign, but ICB support ended before the pathway had been fully embedded.
There was also no single guidance document being used across organisations when deciding whether patients should receive specialist care. This contributed to disagreement between clinical teams and variation in decision-making.
Why data sharing matters
HSSIB found that organisations collected different performance and safety information and did not routinely share it with one another.
This meant no single organisation had a complete view of how the pathway was working, or where patient safety risks were emerging.
Once the pathway was running, the ICB had limited access to information about quality and safety. This reduced its ability to identify risks early and support improvement across the pathway.
What this means for patients
Care pathways are the planned routes patients follow through services. This can include referral, assessment, tests, specialist review, treatment and follow-up.
When a pathway crosses several organisations, patients rely on those services working from the same understanding. If roles are unclear or information is not shared properly, patients may experience delays, inconsistent decisions or difficulty reaching the right specialist care.
HSSIB said patient safety should be monitored proactively when care is delivered across multiple organisations.
The report issued safety learning for integrated care boards, including the need to identify and reduce the impact of commissioning decisions when services are not implemented as planned, and to support proper evaluation of new care pathways.