Learning and information from complaints
Commissioners should require access to all complaints information as and when complaints are made, and should receive complaints and their outcomes on as near a real-time basis as possible. This means commissioners should be required by the NHS Commissioning Board to undertake the support and oversight role of GPs in this area, and be given the resources to do so.
- NHS England stated in April 2025 that it was finalising an oversight and assurance process for Integrated Care Board (ICB) complaint handling (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
- GP practices are required to complete a KO41b data return on complaints for publication (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
- The Health and Care Act 2022 established 42 Integrated Care Boards to replace Clinical Commissioning Groups with broader responsibilities for population health (Health and Care Act 2022, July 2022).
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: Partially implemented - Ongoing. This recommendation was accepted in part by the Government. GP practices produce an annual report on complaints, which they must provide to their commissioning body on request. They must also provide a summary of complaints to NHS England local teams. NHS England expects practices to complete a KO41b data return on complaints. This is published via data collection referenced in response to recommendation 119. ICBs do not have a specific oversight role with GP complaint handling. However, NHS England is currently finalising an oversight and assurance process of ICB complaints handling (delegated from July 2023). In addition, the LFPSE service is a national NHS system for the recording and analysis of patient safety events that occur in healthcare. All healthcare staff in England , including those working in primary care, are encouraged to use the system to record any events where: • a patient was harmed, or could have been harmed • there has been a poor outcome but it is not yet clear whether an incident contributed or not • risks to patient safety in the future have been identified • good care has been delivered that could be learned from to improve patient safety
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.
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.
PHSO developed NHS Complaint Standards framework providing consistent approach to complaint handling across NHS. Piloted 2021-2022, introduced across NHS from 2022. Applies to all NHS organisations and independent healthcare providers delivering NHS-funded care.
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.
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.
Ann Clwyd MP and Professor Tricia Hart published review of NHS hospital complaints handling on 28 October 2013. Key recommendations: Chief Executives must sign off complaint responses; Trust Boards must scrutinise complaints; trusts must publish annual complaints reports in plain English.