Recommendation F81: Accountability of providers' directors
From Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, published 6 February 2013.
Recommendation
Consideration should be given to including in the criteria for fitness a minimum level of experience and/or training, while giving appropriate latitude for recognition of equivalence.
In brief (written by this site)
The Inquiry recommended setting minimum experience or training standards within director fitness criteria. In commentary of September 2024, published in February 2026, the Department of Health and Social Care (DHSC) and NHS England stated that regulations and Care Quality Commission (CQC) guidance require directors to hold necessary qualifications, competence, skills, and experience (DHSC and NHS England, Feb 2026). They added that NHS England published a competency framework in February 2024 to support fitness assessments, though recognition of equivalence was not mentioned (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the government had accepted the recommendation and relied on governance codes regarding relevant director skills (The Thirlwall Inquiry legal team, May 2024).
AI-generated summary of the record on this page, checked by a second model and automatic checks, 1 Oct 2026. The record below is the sources' own words.
Government response
Accepted.
We agree that people in leading positions in NHS organisations should have the appropriate experience and training to take up those positions and that this should be one of the criteria for any assessment of whether someone is a fit and proper person. It is vital that they are assessed as a key element of the recruitment process and of ongoing appraisal. As set out in The Healthy NHS Board 2013, as well as experience and technical skill, values and behaviour are also critical to getting the right leaders in place. We also endorse the document’s advice that regular skills audits of current board members should be carried out.
Monitor’s Risk Assessment Framework sets out how it oversees NHS Foundation Trusts compliance with the provider licence. Where a breach has occurred in respect of governance, one of the areas Monitor may investigate is the Foundation Trust’s management and organisational capability in making an assessment about return to compliance. Monitor’s Code of Governance for Foundation Trusts sets a clear expectation that there should be a formal, rigorous and transparent procedure for the appointment of directors and that care should be taken to ensure that new appointees have relevant skills and experience.
Monitor is working with the Foundation Trust Network to offer a 2-day induction programme for new non-executive directors of NHS Foundation Trusts. The first of these programmes was run in September 2013. Monitor will be working together with the NHS Leadership Academy, NHS Trust Development Authority and Foundation Trust Network to increase external support for chief executives of NHS Trusts and Foundation Trusts. Monitor will also consider how best to support medical directors in the coming year.
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 completed (27 February 2026)
Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 includes requirements for a fit and proper person. This includes having the qualifications, competence, skills, and experience necessary for the role.
CQC guidance sets out that providers must have appropriate processes for assessing and checking that the candidate holds the required qualifications and has the competence, skills and experience required, (which may include appropriate communication and leadership skills and a caring and compassionate nature) to undertake the role. These must be followed in all cases and relevant records kept. The Fit and Proper Person Test Framework for board members sets out the FPPT core elements to be considered in evaluating whether a board member is fit and proper to perform a board role. This includes possessing the qualifications, competence, skills required and experience.
Furthermore, NHS England published the Board Leadership Competency Framework in February 2024. This has been designed around six competency domains to support the recently refreshed Fit and Proper Persons regime.
NHS England’s Code of governance for NHS provider trusts, published in April 2023, sets out that directors and governors should meet the ‘fit and proper’ persons test.
Since this recommendation, the Kark Review made further recommendations in relation to the Fit and Proper Persons test under Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as it applies to directors.
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 “Implemented – Closed”. Table row: section 18.2 No. 81, PDF page 464-465.
Department of Health and Social Care says in progress (11 February 2015)
Monitor has run a series of events with Chief Executive Officers to help identify their support needs and the follow-on action is now under consideration. The development of an induction event for Executive Directors including Medical and Nursing Directors is in hand. The need for further support will be reviewed in light of this work.
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.
Site note: The Inquiry addressed this recommendation to the Care Quality Commission, not to the Department of Health. The annex gives this update in the Department's publication and does not say who wrote it, so the row is the Department's report of the progress made on 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 accepted by the Government.
In the January 2014 Hard Truths report, the Government said that experience and training should be one of the criteria for any assessment of whether someone is a fit and proper person, and it was vital that these were assessed at the recruitment stage and during ongoing appraisal.
The Government also referred to Monitor’s Code of Governance as setting an expectation that care should be taken to ensure that new appointees have relevant skills and experience.
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. 81, PDF page 430.
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