Putting the patient first
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.
- The statutory duty of candour was introduced to require health providers to be open and honest with patients when things go wrong (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, SI 2014/2936).
- The Department of Health and Social Care published a review of the statutory duty of candour in November 2024, noting that 52% of respondents felt the Care Quality Commission had not adequately enforced the duty (Duty of Candour Review, DHSC, November 2024).
- Freedom to Speak Up Guardians were established across NHS trusts to support staff in raising concerns (Freedom to Speak Up Guardians, National Guardian's Office, 2016).
How was this evidence gathered?
Response
Accepted
Response
AcceptedThe 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
Progress Timeline
DHSC and NHS England implementation update provided to the Thirlwall Inquiry (April 2025). This is the government's own account of progress, submitted to the inquiry. Reviewed extent of implementation: Implemented - Ongoing. The NHS Constitution provides that the NHS aspires to the highest standards of excellence and professionalism and to provide high quality care that is safe, effective and focused on patient experience. The Constitution sets out the six core NHS values. These include a commitment to quality of care and working together for patients. NHS values and standards are set at the highest level by the Department of Health and Social Care through the NHS Constitution and the Government's Mandate to NHS England. Leaders at all levels and across all organisations operating within the NHS are expected to model and embed these values. NHS England seeks to support and enable this nationally through training and development initiatives, as well as through its regional offices in the form of more localised support for providers. NHS England has a continuing focus on enhancing the offering for learning and development. Other recent developments include the publication of the Directory of Board level learning and development opportunities which sits as part of the NHS England Fit and Proper Person Test Framework for board members. In addition, the NHS England Culture and Leadership programme provides tools to enable individual Trusts to understand and improve their culture. The NHS staff survey and NHS People Pulse now provide a consistent and standardised framework to understand, measure and improve employee experience. Results are publicly available.
Published Evidence
Published assessments of progress from inspectorates, select committees, official progress reports, and other sources. Source type badge indicates whether each assessment is independent or government self-reported.
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.
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.
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.
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.
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.
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.