Enforcement of standards and accountability
Serious non-compliance with the code, and in particular, non-compliance leading to actual or potential harm to patients, should render board-level leaders and managers liable to be found not to be fit and proper persons to hold such positions by a fair and proportionate procedure, with the effect of disqualifying them from holding such positions in future.
- Regulation 5 requires that directors of CQC-registered providers are of good character, have the necessary qualifications and experience, and are not unfit by reason of misconduct or incompetence. However, the Kark Review (February 2019) found that "the promises made by the government in its 'Hard Truths' response to Sir Robert Francis QC's report on Mid Staffs that a new FPPT would enable the CQC to bar directors who are unfit from individual posts has not actually happened" — the CQC has no power over individual directors and is not structured to regulate individuals (Kark Review of the Fit and Proper Persons Test, Tom Kark KC, February 2019).
- The Kark Review recommended a disbarring power for directors guilty of serious misconduct, but this recommendation was initially rejected by the government.
- In July 2025, following a consultation launched 26 November 2024, the government announced it will bring forward legislation to provide the Health and Care Professions Council with powers to run a statutory barring system for NHS board-level leaders and their direct reports. Draft legislation is subject to further statutory consultation, with parliamentary laying anticipated H2 2026 (Leading the NHS: Consultation Response, DHSC, July 2025).
- The disqualification mechanism Francis envisaged in this recommendation has not yet been legislated, though it is now actively being developed 13 years after the Francis Report.
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
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.
Tom Kark QC reviewed the Fit and Proper Person Test in 2019 and found it essentially "does not ensure directors are fit for the post they hold, and does not stop the unfit from moving around the system." NHS England published updated FPPT Framework effective 30 September 2023 requiring standardised board-level assessments.
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.
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.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 5: Fit and Proper Person Requirement came into force November 2014. Requires providers to ensure directors meet fitness requirements including good character, qualifications, competence. CQC can require removal of directors.
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.