F2 Response Accepted AI-assessed

Putting the patient first

Recommendation

The NHS and all who work for it must adopt and demonstrate a shared culture in which the patient is the priority in everything done. This requires: A common set of core values and standards shared throughout the system; Leadership at all levels from ward to the top of the Department of Health, committed to and capable of involving all staff with those values and standards; A system which recognises and applies the values of transparency, honesty and candour; Freely available, useful, reliable and full information on attainment of the values and standards; A tool or methodology such as a cultural barometer to measure the cultural health of all parts of the system.

Published Evidence Summary
The following publicly available evidence relates to this recommendation:
According to the available evidence, the statutory Duty of Candour came into force for NHS trusts in November 2014 and was extended to all CQC-registered providers in April 2015. According to the available evidence, the NHS Constitution was updated to embed values of transparency, honesty, and candour, and Freedom to Speak Up Guardians were created. According to Robert Francis QC in 2023, NHS culture 'has not changed very much,' and according to a DHSC review in November 2024, the duty of candour often became a 'tick-box exercise,' indicating inconsistent cultural change.
How was this assessed?
Assessed by gemini-2.5-flash on 19 Mar 2026
Checked data held on this site (government responses, progress updates, independent evidence)
External sources searched: www.gov.uk, www.legislation.gov.uk, hansard.parliament.uk
This recommendation asks for cultural or behavioural change, which is difficult to verify objectively. The assessment is based on policy commitments, not measured outcomes.
Jurisdiction
England
Response
Accepted
Accepted Department of Health and Social Care
19 Nov 2013

The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" in March 2013. Key reforms included a new Chief Inspector of Hospitals, strengthened Care Quality Commission inspection regime, a statutory duty of candour, and the fit and proper person test for NHS directors. Volume 2 (Cm 8754) contains the government's detailed responses to each of the 290 recommendations. See: https://assets.publishing.service.gov.uk/media/5a7cd486ed915d63cc65d167/34658_Cm_8777_Vol_1_accessible.pdf

Read Full Response
Note: Government responded via "Hard Truths: The Journey to Putting Patients First" (2014), a single document covering all 290 recommendations with a blanket acceptance. Individual recommendation responses were not broken out.
Published Evidence

Published assessments of implementation progress from inspectorates, select committees, official progress reports, and other sources. Check the source type badge to see whether each assessment is independent or government self-reported.

Reasonable Progress
06 Feb 2026
NHS England / Department of Health Other

The NHS Constitution was updated and values of transparency, honesty and candour were formally embedded. Duty of candour became law. Freedom to Speak Up Guardians were created. However, Francis himself said in February 2023 (10th anniversary) that NHS culture 'has not changed very much' and described the current NHS crisis as 'the Mid Staffordshire scandal playing out on a national level.' Subsequent scandals at Shrewsbury and Telford, East Kent, Nottingham, and the Countess of Chester (Lucy Letby) demonstrated persistent culture failures.

View detailed findings

Structural reforms in place but the deep cultural change Francis called for remains inconsistent. Francis himself assessed in 2023 that insufficient progress had been made on the fundamental culture shift.

Nuffield Trust - 10 years on: interview with Sir … View Source
Reasonable Progress
26 Nov 2024
DHSC - Duty of Candour Review

DHSC published findings of call for evidence on statutory duty of candour. 261 responses received. Key finding: 52% of respondents said CQC had not adequately enforced the duty. Many reported it had become a "tick-box exercise". Only 40% thought the purpose was clear and well understood. Final government response still pending.

Findings of the Call for Evidence on the Statutor… View Source
Reasonable Progress
06 Feb 2023
Academic Review - Ten Years After Francis

Research published 2023 marking ten years since the Francis Report found mixed results. Structural and legislative changes largely delivered (duty of candour, FPPR, CQC overhaul, revalidation, Freedom to Speak Up Guardians). However, cultural change not fully embedded; understaffing, fear of speaking up, and poor complaint handling persist in parts of the NHS.

University of Birmingham: Ten years after Francis View Source
Good Progress
11 Feb 2015
UK Government - Culture Change in the NHS

Government published "Culture Change in the NHS" (Cm 9009) reporting progress on all 290 recommendations. Key achievements: 19 hospitals placed in special measures; those trusts recruited 109 additional doctors and 1,805 additional nurses; 129 board-level changes made; excess avoidable deaths fell by 450 in less than a year.

Confirmed Completed
27 Nov 2014
Legislation - Duty of Candour (Regulation 20)

Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20: statutory duty of candour came into force for NHS trusts November 2014, extended to all CQC-registered providers April 2015. Requires providers to notify patients/families of notifiable safety incidents and apologise.

Health and Social Care Act 2008 (Regulated Activi… View Source
Good Progress
19 Nov 2013
UK Government - Hard Truths Vol 1 & 2

Government published "Hard Truths: The Journey to Putting Patients First" (Cm 8777) in two volumes. Vol 1 set out new actions; Vol 2 provided detailed response to each of the 290 recommendations. Approximately 204 of 290 recommendations were fully accepted.

Source
Report Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry 06 Feb 2013
Responsible Bodies
NHS Primary
Recommendation age 13.1 yrs
Last formal update 4508 days ago