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.
- NICE published safe staffing guideline SG1 in July 2014, covering nurse staffing in adult inpatient wards. However, NICE's safe staffing programme was subsequently discontinued, and no further safe staffing guidelines were published (NICE SG1, July 2014; programme discontinued 2015).
- NHS England published the Developing Workforce Safeguards framework in October 2018, requiring providers to use evidence-based tools for workforce planning including safe staffing assessments, but this is an NHS England framework rather than a NICE standard (Developing Workforce Safeguards, NHS Improvement/NHS England, October 2018).
- The NHS Staff Survey measures aspects of staff experience and organisational culture. CQC uses staff survey results as part of its intelligence model (NHS Staff Survey, annual publication; CQC Insight model).
- No single comprehensive NICE framework covering staff competence, organisational culture, and evidence-based staffing tools across all specialties has been published as described in this recommendation.
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
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 being watered down for financial reasons.
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.