Recommendation F219: A regulator as an alternative
From Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, published 6 February 2013.
Recommendation
An alternative option to enforcing compliance with a management code of conduct, with the risk of disqualification, would be to set up an independent professional regulator. The need for this would be greater if it were thought appropriate to extend a regulatory requirement to a wider range of managers and leaders. The proportionality of such a step could be better assessed after reviewing the experience of a licensing provision for directors.
In brief (written by this site)
The Inquiry proposed considering an independent professional regulator for healthcare managers. In commentary of September 2024, published in February 2026, the Department of Health and Social Care and NHS England stated that the department was exploring options to introduce professional standards for National Health Service (NHS) managers and bring them into regulation (DHSC and NHS England, Feb 2026). In September 2026, the Thirlwall Inquiry found it unclear how regulating senior managers would professionalise leadership generally, except as a first step toward wider regulation (The Rt Hon. Lady Justice Thirlwall DBE, Sep 2026).
AI-generated summary of the record on this page, checked by a second model and automatic checks, 5 Oct 2026. The record below is the sources' own words.
Government response
Accepted in part.
The Government agrees that a focus on standards and their enforcement through normal employment processes and a fit and proper person test is the right place to start. Further action may be justified following a review of how this approach works in practice; but the Government agrees that the proportionate approach is to test how well the combination of a standards-based approach and the use of a ‘fit and proper persons’ test by the regulators would work.
How this response relates to the recommendation
Site note: This is volume two of "Hard Truths: The Journey to Putting Patients First" (Cm 8777-II), the government's response to the Inquiry's 290 recommendations, published by the Department of Health on GOV.UK on 19 November 2013 and dated to that day here. The PDF the row links to is the accessible edition, whose title page reads "January 2014". The Department of Health has been the Department of Health and Social Care since January 2018. The volume says it includes accounts from each of the national organisations the recommendations name, but it does not mark which passage each organisation wrote, so every row is filed under the Department that published it.
Blanket government agreement does not establish acceptance or delivery by each addressee. Some response passages cover groups of recommendations.
Scope of the government response
Government responded via "Hard Truths: The Journey to Putting Patients First" (2014), a single document covering all 290 recommendations with a blanket acceptance. Individual recommendation responses were not broken out.
Delivery
DHSC and NHS England say in progress (27 February 2026)
Please see response to recommendation 60 and 79 for detail on the Fit and Proper Person requirement and supporting framework.
The new government manifesto includes a commitment to introduce professional standards for NHS managers and bring them into regulation. The department is currently exploring options for taking this work forwards.
Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Not yet actioned (no independent regulator in place)”. Table row: section 18.2 No. 219, PDF page 537-538.
Department of Health and Social Care says in progress (11 February 2015)
Fit and Proper Persons Test Regulations have been passed by Parliament and are in place in November 2014 for NHS organisations and from April 2015 for other organisations. The Care Quality Commission held a consultation between July and October 2014 setting out proposals on how organisations can meet the fit and proper person test. It will be the responsibility of the provider and, in the case of NHS bodies, the chair, to ensure that all directors meet the fitness test and do not meet any of the ‘unfit’ criteria. The Care Quality Commission will work with providers, other regulators and government departments to define the processes that its inspectors will use to make these assessments and judgments. The Department of Health will keep in view how the implementation of this test is progressing as part of ongoing monitoring of the reforms.
Site note: This is the supporting annex published on 11 February 2015 with "Culture change in the NHS: applying the lessons of the Francis Inquiries" (Cm 9009), attached to the GOV.UK page as "Culture change in the NHS supporting annex". The annex has no title page; that title is GOV.UK's and the PDF's own. Its table has four columns (No., Recommendation, Hard Truths Government response, Progress update), and the row carries the Progress update cell. No column says which organisation wrote an update, so the row is filed under the Department of Health (now the Department of Health and Social Care), which published it.
What other bodies have found
In their own words. These do not change the delivery statement above.
Thirlwall Inquiry (15 September 2026)
It is not clear how regulating only the most senior managers – that is, board-level directors and their direct reports – within NHS bodies will help professionalise NHS leaders generally, save as a first step to wider regulation.
From: Report of the Thirlwall Inquiry: Countess of Chester Hospital, 2015 to 2018, Volume III (accessible)
Thirlwall Inquiry legal team (15 May 2024)
This recommendation was accepted in part by the Government.
In the January 2014 Hard Truths report, the Government said that a focus on standards and their enforcement through normal employment processes and a fit and proper person test was the right place to start. It accepted that further action might be justified following a review of how the approached worked in practice.
In the February 2015 Culture Change report, the Government said that it would be the responsibility of the provider, and in the case of NHS bodies, the chair, to ensure that all directors met the fitness test and did not meet any of the ‘unfit’ criteria. The Government said it monitor the reforms.
Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review does not colour its Extent of Implementation cell for this recommendation green; it leaves the cell uncoloured where a recommendation was rejected, where evidence of implementation was insufficient, or where steps had been taken but implementation was not yet complete. Table row: section 16.2 No. 219, PDF page 498.
Source
Responsible bodies
Themes and tags
Who has spoken
- Department of Health and Social Care
Response, delivery statement - DHSC and NHS England
Delivery statement - Thirlwall Inquiry
Finding - Thirlwall Inquiry legal team
Finding