Principles of openness transparency and candour
Every healthcare organisation and everyone working for them must be honest, open and truthful in all their dealings with patients and the public, and organisational and personal interests must never be allowed to outweigh the duty to be honest, open and truthful.
- A review of the statutory duty of candour in November 2024 found that 52% of respondents believed the Care Quality Commission had not adequately enforced the duty (DHSC - Duty of Candour Review, November 2024).
- A review of the statutory duty of candour in November 2024 found that 40% of respondents thought the purpose of the duty was clear and well understood (DHSC - Duty of Candour Review, November 2024).
- An academic review in February 2023 stated that while structural changes like the duty of candour were delivered, cultural change was not fully embedded (Academic Review - Ten Years After Francis, February 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
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. Please see response to recommendation 2 for detail on the values set out in the NHS Constitution. These values are embodied in the NHS Patient Safety Strategy. A statutory Duty of Candour was introduced in 2014, as set out in our response to recommendation 21.
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.
DHSC published findings of call for evidence on statutory duty of candour. 261 responses received. Key finding: 52% of respondents said CQC had not adequately enforced the duty. Many reported it had become a "tick-box exercise". Only 40% thought the purpose was clear and well understood. Final government response still pending.
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.
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 20: statutory duty of candour came into force for NHS trusts November 2014, extended to all CQC-registered providers April 2015. Requires providers to notify patients/families of notifiable safety incidents and apologise.
Francis recommended principles of openness, transparency and candour. The statutory duty of candour was enacted as Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. In force for NHS bodies from 27 November 2014 and all CQC-registered providers from 1 April 2015. Requires providers to notify patients of notifiable safety incidents, provide truthful accounts, offer apologies, and follow up in writing. Professional duty of candour also established through GMC/NMC codes.
View detailed findings
Statutory duty of candour fully implemented. This is arguably the most successfully implemented Francis recommendation.
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.