A new study has found that national patient safety recommendations often fail to translate into real change because the people who write them and the people who must act on them are, in effect, speaking different languages and influenced by different pressures and priorities.

Researchers from the University of Leicester, University of Birmingham, University of Manchester and City St George’s, University of London examined how recommendations from the Health Services Safety Investigations Body (HSSIB) and its predecessor, the Healthcare Safety Investigation Branch (HSIB), are produced by investigators and received by the national organisations responsible for acting on them.

Funded by the NIHR Patient Safety Research Collaboration: Greater Manchester, the team analysed 22 published investigation reports, ran two focus groups with 12 HSSIB investigators, and carried out interviews with 11 senior representatives from national bodies including NHS England, the Care Quality Commission, the General Medical Council, and several medical royal colleges.

The study found that HSSIB investigators approach their work through a safety science mindset, focused on understanding how work actually happens on the ground, learning without blame, and thinking about problems as system-wide risks. Recipient organisations, meanwhile, approach the same recommendations through a managerial mindset, weighing up cost, feasibility, competing priorities, and what can realistically be resourced and delivered.

When these two ways of thinking collide, the researchers found four consequences:

1. Recommendations get softened during negotiation to make them more palatable;
2. Organisations struggle to prioritise them among a crowded field of competing demands from multiple bodies;
3. It becomes unclear who within a large organisation is actually responsible for acting on the recommendations;
4. and HSSIB’s main way of holding organisations to account, which involves publishing its findings and their responses, carries little real force against the regulatory and financial pressures that actually drive organisational behaviour.

Dr Mohammad Farhad Peerally, Associate Professor at the University of Leicester and Consultant Gastroenterologist at Kettering General Hospital NHS Foundation Trust, who led the study, said:

“HSSIB represents an important development for patient safety in the UK. It is an independent, non-punitive body dedicated to system-level learning. But our findings show that the very independence that gives HSSIB its legitimacy as a learning body can also distance it from the operational realities that determine whether its recommendations are ever acted on. If HSSIB is to fulfil its potential, it needs sustained support: clearer mechanisms for shared accountability with recipient organisations, better coordination across the growing number of bodies issuing safety recommendations, and investment in safety science capability within the organisations expected to respond.”

The findings come as the government reviews the future shape of patient safety investigation in England, including proposals to bring HSSIB within the Care Quality Commission’s structure — a move the researchers caution could reproduce the same tension in a different form, unless HSSIB’s investigative independence and distinct safety science identity are preserved.

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