Consolidation of regulatory functions
The Secretary of State should consider transferring the functions of regulating governance of healthcare providers and the fitness of persons to be directors, governors or equivalent persons from Monitor to the Care Quality Commission.
- The Department of Health and Social Care stated in April 2025 that the Care Quality Commission has the power to take enforcement action against trusts for non-compliance with director fitness requirements (DHSC and NHS England implementation update to the Thirlwall Inquiry, April 2025).
- An independent review in 2019 found that the Fit and Proper Person Test did not effectively prevent unfit directors from moving through the system (Kark Review of the Fit and Proper Person Test, 2019).
- NHS England published an updated Fit and Proper Person Test Framework effective from 30 September 2023 (Fit and Proper Person Test Framework, NHS England, 2023).
How was this evidence gathered?
Response
Accepted in Part
Response
Accepted in PartThe 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 – Closed.. Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (2014 regulations) place a duty on trusts to ensure that their directors meet the fit and proper persons requirements set out in the 2014 regulation 5, as defined above, are compliant with the FPP. The regulations stipulate that trusts must not appoint or have in place an executive or a non-executive director unless they meet the fit and proper persons requirements in the 2014 regulations. While it is the trust's duty to ensure that they do not appoint or have in place directors unless they meet the fit and proper persons requirements, CQC has the power to take enforcement action against the trust if it considers that the trust has not complied with regulation 5. This may come about if concerns are raised to CQC about an individual or during the annual well-led review of the appropriate procedures. The above was implemented by the previous government. Though CQC was not given the power to disbar directors or to regulate individual directors, in light of this government's commitment to bring managers into regulation the nature and scope of further implementation may need to be considered.
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.
Tom Kark QC reviewed the Fit and Proper Person Test in 2019 and found it essentially "does not ensure directors are fit for the post they hold, and does not stop the unfit from moving around the system." NHS England published updated FPPT Framework effective 30 September 2023 requiring standardised board-level assessments.
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.
Francis recommended consolidation of regulatory functions. Monitor and the NHS Trust Development Authority merged into NHS Improvement (2016). NHS Improvement then merged into NHS England (formally completed July 2022). However, CQC remains separate, and the system is not the fully consolidated single regulator Francis envisioned.
View detailed findings
Significant consolidation achieved through the creation of NHS England as a merged body but CQC remains separate for quality regulation.
Monitor merged with the Trust Development Authority to form NHS Improvement from 1 April 2016. NHS Improvement then merged with NHS England from 1 July 2022 under Health and Care Act 2022. Francis recommended incremental merger of system regulatory functions between Monitor and CQC; this was partially achieved through structural reorganisation.
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 5: Fit and Proper Person Requirement came into force November 2014. Requires providers to ensure directors meet fitness requirements including good character, qualifications, competence. CQC can require removal of directors.
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.