Focus on compliance with fundamental standards
No NHS trust should be given support to make an application to Monitor unless, in addition to other criteria, the performance manager (the Strategic Health Authority cluster, the Department of Health team, or the NHS Trust Development Authority) is satisfied that the organisation currently meets Monitor's criteria for authorisation and that it is delivering a sustainable service which is, and will remain, safe for patients, and is compliant with at least fundamental standards.
- The foundation trust application pipeline was effectively closed by 2014, with most applications paused or deferred. The requirement that applicants demonstrate current compliance with fundamental standards before receiving support for an application became moot.
- The Fit and Proper Person Requirement (Regulation 5, SI 2014/2936) and the Fundamental Standards (Regulations 2014) established minimum quality and safety standards that all registered providers must meet, regardless of foundation trust status. CQC ratings — including whether a trust is rated "Inadequate" — are publicly available (SI 2014/2936; CQC ratings).
- The NHS Oversight Framework segments trusts 1-4 based on quality, finance, and leadership concerns. Trusts in segments 3 or 4 receive mandated support or intensive intervention. This provides a mechanism for identifying trusts that are not meeting fundamental standards, though it is not specific to foundation trust applications (NHS Oversight Framework 2025/26, NHS England).
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.
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.
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.
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.