Duty to require and monitor delivery of fundamental standards
The commissioner is entitled to and should, wherever it is possible to do so, apply a fundamental safety and quality standard in respect of each item of service it is commissioning. In relation to each such standard, it should agree a method of measuring compliance and redress for non-compliance. Commissioners should consider whether it would incentivise compliance by requiring redress for individual patients who have received sub-standard service to be offered by the provider. These must be consistent with fundamental standards enforceable by the Care Quality Commission.
- NHS England stated that the 'clawback' element of the Commissioning for Quality and Innovation (CQUIN) incentive scheme is paused for the 2024/25 period (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
- A review of incentives for quality in the NHS is currently being undertaken by the Department of Health and Social Care (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
- National service specifications for specialised services set out mandatory quality requirements for providers (DHSC and NHS England implementation update provided to the Thirlwall Inquiry, April 2025).
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: Implemented – Ongoing. The NHS Standard Contract 2024/25 includes a service condition (no. 37) on local quality requirements. This allows for the agreement of enhanced standards as part of the annual contractual agreement between commissioners and providers. For specialised services, national service specifications additionally set out key quality requirements. CQUIN The Commissioning for Quality and Innovation (CQUIN) incentive scheme is intended to support improvements in the quality of services and the creation of new, improved patterns of care. CQUIN centres on set of annually agreed evidence-based improvement indicators, supported by specifications and an element of provider income was conditional on demonstrating related improvements in quality. Providers and commissioners agree a fixed element that assumes full achievement of CQUIN criteria, with funding then paid back by providers if they achieve less than this. The clawback element of the scheme is currently paused for 2024/25. A wider review of incentives for quality is now being undertaken.
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.
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.
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.
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.