The elephant in the room: Patient safety and Integrated Care Systems

  • 11th July 2023

In a new report, Patient Safety Learning considers the roles and responsibilities of Integrated Care Systems (ICSs) in relation to patient safety, and how this fits in with the wider patient safety landscape in England. This article contains a summary of the report.

Action is needed to ensure that ICSs are not ‘patient safety free zones’, says Patient Safety Learning.

A year on from ICSs being placed on a statutory footing, a new report, The elephant in the room: Patient Safety and Integrated Care Systems, argues that there needs to be a greater focus on the role that they play in patient safety.

The report sets out what we mean by avoidable harm in healthcare, outlining the scale of this problem and the need for a transformation in approach to improving patient safety. It also looks at the landscape of different coordinating groups and organisations in England that have roles and responsibilities to improve patient safety and reduce avoidable harm. What is revealed is a complex and fragmented environment, lacking strong measures for cross-organisational thinking and coordination to address complex systemic threats to patient safety.

Considering the creation and initial development of ICSs, the report highlights how there has been little mention of their role in, or impact on, patient safety. It illustrates that although patient safety has not been set as explicit priority for ICSs, the delivery of safe care runs implicitly through each of their main aims. It goes on to consider the potential role that ICSs can potentially play in helping to embed and improve patient safety.


Considering the steps that could be taken to address the current gap that exists between patient safety and ICSs, and the wider fragmentation of the patient safety landscape in which they operate within, the report makes the following recommendations:

  1. The Department of Health and Social Care and NHS England should consider introducing a fifth aim for ICSs making explicit their role in helping to improve patient safety and reduce avoidable harm.
  2. NHS England should update the NHS Patient Safety Strategy to account for ICSs being placed on a statutory footing in July 2022 and set out their roles and responsibilities in relation to this.
  3. The Department of Health and Social Care and NHS England should consider revising the remit of the National Patient Safety Committee to take on a greater role in coordinating and joining-up the existing patient safety landscape in England.
  4. The National Patient Safety Committee should regularly publish agendas, papers and the minutes of its meetings to help inform all bodies that may be impacted by this, such as ICSs and individual healthcare providers, and also patients and the wider public.

Patient Safety Learning comment

Patient Safety Learning Chief Executive Helen Hughes said:

“ICSs present a significant opportunity to drive improvements in patient safety in local health systems across the NHS. However, we think patient safety remains the ‘elephant in the room’ in the development of ICS roles and responsibilities. Currently there is not clear guidance or support to ensure that ICSs treat patient safety as a core purpose of healthcare. We believe they need to have specific aims for reducing avoidable harm and improving patient safety.

There also needs to be clarity on where the patient safety role of ICSs fits into the wider healthcare system. The landscape of organisations with patient safety roles and responsibilities in England is fragmented and lacks coordination, often ill-suited to tackling complex systemic challenges to patient safety. We believe that the Department of Health and Social Care and NHS England need to consider how to better join-up this system, to promote cross-organisational working, coordination and ultimately reduce avoidable harm.”

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