Accountability of providers' directors
Monitor and the Care Quality Commission should produce guidance to NHS and foundation trusts on procedures to be followed in the event of an executive or non-executive director being found to have been guilty of serious failure in the performance of his or her office, and in particular with regard to the need to have regard to the public interest in protection of patients and maintenance of confidence in the NHS and the healthcare system.
- The National Audit Office published a report on confidentiality clauses and special severance payments in June 2013, finding that 88% of compromise agreements sampled contained a confidentiality clause. The Public Accounts Committee subsequently found "shocking examples of using taxpayers' money to pay-off individuals who have flagged up concerns about patient safety and care" (NAO, Confidentiality clauses and special severance payments, June 2013; Public Accounts Committee 36th Report, 2013-14).
- NHS Employers published guidance on the use of settlement agreements and confidentiality clauses (most recently updated May 2024), requiring that all NHS providers include an express carve-out clause making clear a worker cannot waive their rights to make protected disclosures. The Public Interest Disclosure Act 1998 (as amended) renders unenforceable any contractual provision that purports to prevent a protected disclosure, but there is no outright statutory prohibition on confidentiality clauses in settlement agreements (NHS Employers, The use of settlement agreements and confidentiality clauses, May 2024).
- NHS England published guidance on processes for making severance payments (originally 2014, updated 2021), and the Cabinet Office published guidance on settlement agreements and confidentiality clauses applicable to the civil service. The NHS England FPPT Framework (September 2023) introduced mandatory Board Member References on departure, which must include information about investigations relevant to serious misconduct (NHSE severance payments guidance, 2021; FPPT Framework, NHS England, August 2023).
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.
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.
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.