Leadership framework
The leadership framework should be improved by increasing the emphasis given to patient safety in the thinking of all in the health service. This could be done by, for example, creating a separate domain for managing safety, or by defining the service to be delivered as a safe and effective service.
- The Health Services Safety Investigations Body (HSSIB) was established as an independent statutory body on 1 October 2023 to conduct system-focused patient safety investigations (Health and Care Act 2022, July 2022).
- The Patient Safety Incident Response Framework (PSIRF) became mandatory for all NHS-funded secondary care providers in Autumn 2023, shifting focus from individual blame to system-based learning (Patient Safety Incident Response Framework, NHS England, 2023).
- The Learn from Patient Safety Events (LFPSE) service replaced the National Reporting and Learning System on 30 June 2024, utilizing machine learning for improved trend identification (Learn from Patient Safety Events, NHS England, June 2024).
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 215 above for detail on the Leadership Competency Framework and associate resources. Competency 1 of this framework focuses on high quality and sustainable outcomes with a strong focus on safe and effective services. The NHS Patient Safety Strategy, published in July 2019 and updated in 2021, and 2023 sets out the co-ordinated, long term and whole system vision to continuously improve patient safety. The Strategy is in its fifth year of operation and has demonstrated success in implementing initiatives, hitting milestones and improving outcomes. The Patient Safety Incident Response Framework, which forms part of the strategy, is a contractual requirement under the NHS Standard Contract and puts a strong focus on compassionate engagement and involvement of those affected by patient safety incidents, including patients, families and staff. Guidance is available.
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.
Learn from Patient Safety Events (LFPSE) service replaced the National Reporting and Learning System (NRLS). NRLS fully decommissioned 30 June 2024. LFPSE has broader coverage including primary care, uses machine learning for analysis and improved trend identification.
HSSIB formally launched 1 October 2023 as independent statutory body under Health and Care Act 2022. Replaced HSIB (non-statutory, established 2016). Has statutory "safe space" protections, powers of entry, inspection and seizure. Conducts system-focused patient safety investigations.
Patient Safety Incident Response Framework (PSIRF) replaced the Serious Incident Framework from Autumn 2023. Shifts from individual blame to system-based learning approaches. Mandatory for all NHS-funded secondary care providers. Part of NHS Patient Safety Strategy (July 2019).
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.
First Patient Safety Commissioner Dr Henrietta Hughes OBE appointed 12 September 2022 under Medicines and Medical Devices Act 2021. Independent champion for patient safety regarding medicines and medical devices.
Care Certificate launched 1 April 2015 as standardised induction training for all new healthcare assistants and social care support workers. Covers 15 standards (updated to 16). Implements recommendations from Cavendish Review (July 2013) and Francis Report on healthcare support worker training.
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.