Public accountability of commissioners and public engagement
Commissioners should be accountable to their public for the scope and quality of services they commission. Acting on behalf of the public requires their full involvement and engagement: There should be a membership system whereby eligible members of the public can be involved in and contribute to the work of the commissioners. There should be lay members of the commissioner's board. Commissioners should create and consult with patient forums and local representative groups. Individual members of the public (whether or not members) must have access to a consultative process so their views can be taken into account. There should be regular surveys of patients and the public more generally. Decision-making processes should be transparent: decision-making bodies should hold public meetings. Commissioners need to create and maintain a recognisable identity which becomes a familiar point of reference for the community.
- DHSC and NHS England stated in April 2025 that statutory guidance exists for ICBs on working in partnership with people and communities to meet public involvement legal duties (DHSC/NHS England implementation update to Thirlwall Inquiry, April 2025).
- DHSC and NHS England stated in April 2025 that NHS England performs annual assessments of how ICBs promote patient and public involvement, which are published on individual ICB websites (DHSC/NHS England implementation update to Thirlwall Inquiry, April 2025).
- An academic review in February 2023 found that while structural and legislative changes were largely delivered, cultural change was not fully embedded across the NHS (Ten Years After Francis, Academic Review, February 2023).
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 (named infrastructure is partly superseded). Health and wellbeing boards (HWBs) have been a key mechanism for driving joined up working at a local level since they were established in 2013 and provide a forum where political, clinical, professional and community leaders from across the care and health system come together to improve the health and wellbeing of their local population, and look to reduce health inequalities. In developing Joint Strategic Needs Assessments, HWBs should look to involve the local community and representative organisations. The Health and Care Act 2022 introduced new architecture to the health and care system, specifically the establishment of integrated care boards (ICBs) and integrated care partnerships (ICPs). These replaced Clinical Commissioning Groups. HWBs play a vital role in integrated care systems, as part of the closer working arrangements between health and local authority partners. Statutory guidance exists for Integrated Care Boards on how they should work in partnership with people and communities including supporting them to meet their public involvement legal duties. This work needs to be described in the Integrated Care Board (ICB) annual report. NHS England is required to carry out an annual assessment setting out how well the ICB has performed on its statutory duties, including how the ICB has promoted patient and public involvement and choice. Assessments can be viewed via individual ICB websites.
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.
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.