Responsibility for regulating and monitoring compliance
The measures formulated by the National Institute for Health and Clinical Excellence should include measures not only of clinical outcomes, but of the suitability and competence of staff, and the culture of organisations. The standard procedures and practice should include evidence-based tools for establishing what each service is likely to require as a minimum in terms of staff numbers and skill mix. This should include nursing staff on wards, as well as clinical staff. These tools should be created after appropriate input from specialties, professional organisations, and patient and public representatives, and consideration of the benefits and value for money of possible staff: patient ratios.
- NHS England launched the Medical Devices Outcomes Registry (MDOR) in April 2024 to collect data on responsible consultants and surgeons linked to patient outcomes (DHSC and NHS England implementation update to the Thirlwall Inquiry, April 2025).
- Independent evidence states that while NICE published safe staffing guidance for adult inpatient wards in July 2014, NHS England cancelled NICE's safe staffing work programme in June 2015 (NICE / NHS England evidence review, February 2026).
- There are no mandatory nurse-to-patient ratios in England (NICE / NHS England evidence review, February 2026).
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 Thirlwall Inquiry has noted action taken following the conclusion of the Mid-Staffordshire Inquiry 2013. As the Thirlwall Inquiry has noted, NICE issued guidance on safe staffing in 2014-2015. NICE continues to issue guidance on the topics raised and recent examples include guides on creating a safeguarding culture, and positive working culture for support children and young people with complex needs. See response to Recommendation 93 (Safe staffing). NHS England has also published safe staffing improvement resources across a number of specific service settings. They were designed by service users and health professionals to support Trusts to make safe and sustainable staffing decisions Medical Devices Outcomes Registry NHS England launched the Medical Devices Outcomes Registry (MODR) in April 2024, which resides on NHS England's Outcome Registries Platform as a single repository to collect the responsible consultant (GMC number), supervising surgeon (GMC number) and lead surgeon (GMC number) . The MDOR will support improved patient safety by enabling analysis to facilitate surveillance of High-Risk Medical Devices through linkage of component data modules, including associated patient outcomes, to support patient focussed activities such as review or recall of specific patients and devices. The NCIP portal is a free data platform that allows consultants to review their own data: improving clinical quality, patient safety and supporting career development. It provides consultants with data covering their NHS practice wherever it is performed with high-quality, specialty-specific dashboards at patient level. Nearly all Trusts in England have been enrolled in NCIP (99%) and over 9,000 consultants now have access to the portal following universal access given across 7 surgical specialties. NCIP is on track to give access to every consultant in 14 surgical specialties by 1 April 2025 with the intention of expanding into non-surgical specialties subsequently. Access to the portal has also been given to Medical Directors, Responsible Officers (who have governance responsibilities) and Trust Specialty Clinical Leads. NCIP is now established as the visualisation platform for individual consultant outcome data but for very cogent reasons is not in the public domain. However, once a single repository is established and there is confidence in the accuracy of the data, discussions will take place with the profession as to what information is appropriate for publication.
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.
Francis recommended evidence-based staffing tools including nurse-to-patient ratios. NICE was commissioned and published guidance for adult inpatient wards (July 2014) establishing a 1:8 nurse-patient red flag. However, in June 2015 NHS England chief Simon Stevens cancelled NICE's safe staffing work for remaining settings. A senior NICE figure said the programme was scrapped because leaders 'didn't like the answer.' England still has no legally mandated minimum staffing ratios (unlike Wales, which enacted the Nurse Staffing Levels Act 2016). A University of Southampton study (2019) found 25% of trusts routinely exceeded the 1:8 ratio.
View detailed findings
Safe staffing work was accepted then actively cancelled. England has no mandatory nurse-to-patient ratios. This is one of the clearest examples of a Francis recommendation not being fully pursued.
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.
NMC Revalidation launched 1 April 2016 in direct response to Francis Report. All nurses and midwives must revalidate every three years. Replaced the Post-Registration Education and Practice system. Updated NMC Code published March 2015 strengthened requirements around candour and raising concerns.
NMC published updated Code of Professional Standards for nurses and midwives (March 2015). Standard 14 specifically requires nurses and midwives to be open and candid with all service users about all aspects of care, including when mistakes or harm have occurred.
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.
NICE published "Safe staffing for nursing in adult inpatient wards in acute hospitals" (SG1) on 15 July 2014. Evidence showed increased risk when registered nurse cares for >8 patients. Red flag: fewer than 2 RNs on any ward during any shift. However, NICE's broader safe staffing programme was controversially halted in June 2015 by NHS England. No mandatory nurse-to-patient ratios introduced in England (unlike Wales).
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.