The nature of standards
Standards should be divided into: Fundamental standards of minimum safety and quality – in respect of which non-compliance should not be tolerated. Failures leading to death or serious harm should remain offences for which prosecutions can be brought against organisations. There should be a defined set of duties to maintain and operate an effective system to ensure compliance; Enhanced quality standards – such standards could set requirements higher than the fundamental standards but be discretionary matters for commissioning and subject to availability of resources; Developmental standards which set out longer term goals for providers – these would focus on improvements in effectiveness and are more likely to be the focus of commissioners and progressive provider leadership than the regulator. All such standards would require regular review and modification.
- The Health Act 2009 requires all organisations delivering services under an NHS Standard Contract to produce annual Quality Accounts (Health Act 2009).
- The NHS Oversight Framework (2024) sets out the approach for NHS England to monitor providers and ICBs using specific oversight metrics (NHS Oversight Framework, NHS England, 2024).
- The Penny Dash Review of the CQC in October 2024 found significant failings in the inspection regime, noting that one in five services had never been rated and that there was a lack of specialist inspector expertise (Review of the operational effectiveness of the Care Quality Commission, DHSC, October 2024).
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. CQC is the independent regulator of health and adult social care in England. They monitor, inspect and regulate services to ensure health and social care services are safe, effective, compassionate and providing high quality care. Where a registered provider of healthcare services is found to have breached the fundamental standards as set out in the Health and Social Care 2008 (Regulated Activities) Regulations 2014, CQC can bring civil enforcement action or a criminal prosecution. The highest level of civil enforcement action available is to cancel a providers registration. All organisations are required under the Health Act 2009 to produce Quality Accounts if they deliver services under an NHS Standard Contract. Guidance published by the Healthcare Quality Improvement Partnership sets out that the legislation governing Quality Accounts requires details of the trust's clinical audit participation for each of the national audits, enquiries and quality improvement programmes they participate in. They also require information related to improvements responding to clinical audit report recommendations. In addition to the CQC's fundamental standards, the NHS Oversight Framework (2024) set NHS England's approach to oversight of NHS providers and ICBs. This includes oversight metrics to indicate issues. The NHS provider licence included a condition covering provider governance (FT4) that required organisations to meet specific standards as set by DHSC, Monitor, CQC or NHS England. The Code of governance for NHS provider trusts (2023) sets out the expectation that the board of directors will establish procedures that manage risk.
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.
Penny Dash Review (commissioned May 2024) found significant failings at CQC. Health Secretary declared CQC "not fit for purpose". Key findings: one in five services never rated; inspection levels well below pre-pandemic levels; lack of specialist inspector expertise; 5,000 notification-of-concern backlog. CQC consulting on resetting its approach from October 2025.
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.
Clinical Commissioning Groups replaced by 42 Integrated Care Boards from 1 July 2022 under Health and Care Act 2022. ICBs have broader responsibilities for population health, bringing together NHS organisations, local authorities and partners. Implements some Francis recommendations on commissioning integration.
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.
Fundamental standards of minimum safety and quality enacted as Regulations 8-20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in force from 1 April 2015. Three tiers of standards (fundamental, enhanced, developmental) broadly implemented as Francis recommended. Regulation 22 creates criminal offences for breaches causing harm.
View detailed findings
Fundamental standards implemented through legislation with criminal liability for serious breaches, as recommended.
New "Fundamental Standards" replaced previous CQC registration requirements from 7 November 2014. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 introduced clearer minimum standards including: person-centred care (Reg 9), dignity (Reg 10), safe care (Reg 12), staffing (Reg 18), good governance (Reg 17), fit and proper persons (Reg 5), duty of candour (Reg 20).
CQC overhauled its inspection regime in response to Francis. Professor Sir Mike Richards appointed as first Chief Inspector of Hospitals (July 2013). New methodology based on five key questions (Safe, Effective, Caring, Responsive, Well-led) rolled out nationally October 2014. Four-tier ratings introduced (Outstanding/Good/Requires Improvement/Inadequate). Specialist expert-led inspection teams replaced generalist compliance model.
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.