Recommendation F64: Authorisation of foundation trusts
From Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, published 6 February 2013.
Recommendation
The authorisation process should be conducted by one regulator, which should be equipped with the relevant powers and expertise to undertake this effectively. With due regard to protecting the public from the adverse consequences inherent to any reorganisation, the regulation of the authorisation process and compliance with foundation trust standards should be transferred to the Care Quality Commission, which should incorporate the relevant departments of Monitor.
In brief (written by this site)
In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that the government did not accept the recommendation, noting that the latter is responsible for provider licensing, finance, governance, and performance oversight, while the Care Quality Commission handles registration and inspection (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team found that the government had not accepted the recommendation and did not merge regulatory functions into a single regulator (The Thirlwall Inquiry legal team, May 2024).
AI-generated summary of the record on this page, checked by a second model and automatic checks, 26 Sep 2026. The record below is the sources' own words.
Government response
Not accepted, although we agree with the principle of better regulation of the authorisation process.
As outlined in relation to recommendation 19, we agree with the principle of better regulation of the authorisation process, but we do not intend to merge regulatory functions. What is needed is radically better coordination between the regulators, and a far stronger focus on the quality and safety of services within the authorisation process, than was the case at Mid Staffordshire NHS Trust.
The Department of Health, with the Care Quality Commission’s chief inspectors, is currently developing fundamental standards and will consult on setting these out in regulations, which make clear the standards below which care should never fall. A provider who is in breach of fundamental standards should not be authorised as a Foundation Trust.
As set out in recommendation 20, the Care Quality Commission’s new approach to inspection will look more broadly than just compliance with regulations. It will reach judgements about the overall quality of services, taking into account how safe, effective, caring, responsive and well-led they are. No provider will be authorised as a Foundation Trust unless the Care Quality Commission, through its Chief Inspector of Hospitals, judges that the quality of their services is ‘good’ or ‘outstanding’.
The NHS Trust Development Authority, Monitor and the Care Quality Commission have undertaken an end-to-end review of the Foundation Trust assessment and authorisation process. The review aligns Monitor’s Quality Governance Framework with the Care Quality Commission’s approach to assessing leadership, culture and governance as part of the new inspection methodology. Monitor, the NHS Trust Development Authority and the Care Quality Commission will also develop a common set of quality indicators. This should ensure that there is a seemless process at every stage of assessment.
How this response relates to the recommendation
Site note: This is volume two of "Hard Truths: The Journey to Putting Patients First" (Cm 8777-II), the government's response to the Inquiry's 290 recommendations, published by the Department of Health on GOV.UK on 19 November 2013 and dated to that day here. The PDF the row links to is the accessible edition, whose title page reads "January 2014". The Department of Health has been the Department of Health and Social Care since January 2018. The volume says it includes accounts from each of the national organisations the recommendations name, but it does not mark which passage each organisation wrote, so every row is filed under the Department that published it.
Blanket government agreement does not establish acceptance or delivery by each addressee. Some response passages cover groups of recommendations.
Scope of the government response
Government responded via "Hard Truths: The Journey to Putting Patients First" (2014), a single document covering all 290 recommendations with a blanket acceptance. Individual recommendation responses were not broken out.
Delivery
DHSC and NHS England say not accepted (27 February 2026)
The Government did not accept this recommendation. NHS England is now responsible for licensing and financial, governance, and performance oversight of NHS providers as well as the commissioning of services, whereas the CQC is responsible for registration and inspection of all health and care providers, whether or not within the public sector.
Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Not accepted”. Table row: section 18.2 No. 64, PDF page 457.
Department of Health and Social Care says in progress (11 February 2015)
The NHS Trust Development Authority, Monitor and the Care Quality Commission published How Monitor, the Care Quality Commission and the NHS Trust Development Authority will work together to assess how well led organisations are in May 2014.
The metrics by which the NHS Trust Development Authority will assess the quality of services delivered by any given Trusts, which are set out in the NHS Trust Development Authority Accountability Framework for NHS Trusts, are consistent with those used by the Care Quality Commission in its Intelligent Monitoring system.
Site note: This is the supporting annex published on 11 February 2015 with "Culture change in the NHS: applying the lessons of the Francis Inquiries" (Cm 9009), attached to the GOV.UK page as "Culture change in the NHS supporting annex". The annex has no title page; that title is GOV.UK's and the PDF's own. Its table has four columns (No., Recommendation, Hard Truths Government response, Progress update), and the row carries the Progress update cell. No column says which organisation wrote an update, so the row is filed under the Department of Health (now the Department of Health and Social Care), which published it.
What other bodies have found
In their own words. These do not change the delivery statement above.
Thirlwall Inquiry legal team (15 May 2024)
This recommendation was not accepted by the Government in the January 2014 Hard Truths report.
The Government did not merge regulatory functions through the development of a single regulator.
However, the Government said that no provider would be authorised as a Foundation Trust unless the Care Quality Commission judged the quality of their services as good or outstanding.
Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review does not colour its Extent of Implementation cell for this recommendation green; it leaves the cell uncoloured where a recommendation was rejected, where evidence of implementation was insufficient, or where steps had been taken but implementation was not yet complete. Table row: section 16.2 No. 64, PDF page 422.
Source
Responsible bodies
Themes and tags
Who has spoken
- Department of Health and Social Care
Response, delivery statement - DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding