Nursing and Midwifery Council Investigation of systemic concerns
The Nursing and Midwifery Council needs to have its own internal capacity to assess systems and launch its own proactive investigations where it becomes aware of concerns which may give rise to nursing fitness to practise issues. It may decide to seek the cooperation of the Care Quality Commission, but as an independent regulator it must be empowered to act on its own if it considers it necessary in the public interest. This will require resources in terms of appropriately expert staff, data systems and finance. Given the power of the registrar to refer cases without a formal third party complaint, it would not appear that a change of regulation is necessary, but this should be reviewed.
- The NMC stated it uses the Regulatory Intelligence Unit, established in 2020, to identify and manage wider systems issues in collaboration with partners (DHSC and NHS England implementation update to the Thirlwall Inquiry, April 2025).
- The Nursing and Midwifery Council (Fitness to Practise) Rules 2004 were amended in 2015 to allow the NMC to make enquiries when in possession of information indicating a concern (The Nursing and Midwifery Council (Fitness to Practise) (Education, Registrations and Registrations Appeals) (Amendment) Rules Order of Council 2015, SI 2015/52).
- An independent review in 2019 found that the Fit and Proper Person Test did not ensure directors were fit for their posts or prevent unfit individuals from moving within the system (Kark Review of FPPT, September 2023 update).
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: Partially implemented – Ongoing. Whilst the NMC did not support this recommendation, it introduced a range of new measures and processes aimed at enhancing its ability to identify, manage and respond to wider systems issues in collaboration with partners. This includes the introduction of a Regulatory Intelligence Unit in 2020 and strengthened working relationships and formal agreements with key stakeholders such as the Care Quality Commission, Healthcare Improvement Scotland, Healthcare Inspectorate Wales, and agreed further memoranda of understanding such as the framework for sharing intelligence with health and care regulators in Scotland and Northern Ireland Pursuant to Article 22(6) of the Nursing and Midwifery Order 2001 and Rule 2A of The Nursing and Midwifery Council (Fitness to Practise) Rules 2004 (as amended by the Nursing and Midwifery Council (Fitness to Practise) (Education, Registrations and Registrations Appeals) (Amendment) Rules order of Council 2015 , if the NMC come into possession of information or intelligence outside of its usual referral process that could indicate a concern, it can make further enquiries to understand whether it's something that requires action, including whether it should be referred to the screening team to open a case. This could include information that might indicate a potential fitness to practise or education concern. It could also include information that might indicate a potential concern about the wider system. In January 2024 the NMC introduced a new internal Pre-case enquiries and referrals policy which confirms its ability to make enquiries and referrals outside of a formal complaint. It sets out the process to take, including when to share intelligence externally for action, helping ensure concerns are effectively responded to and acted upon across the system.
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.
Penny Dash Review (commissioned May 2024) found significant failings at CQC. Health Secretary declared CQC "not fit for purpose". Key findings: one in five services never rated; inspection levels well below pre-pandemic levels; lack of specialist inspector expertise; 5,000 notification-of-concern backlog. CQC consulting on resetting its approach from October 2025.
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.
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.
PHSO developed NHS Complaint Standards framework providing consistent approach to complaint handling across NHS. Piloted 2021-2022, introduced across NHS from 2022. Applies to all NHS organisations and independent healthcare providers delivering NHS-funded care.
NMC Revalidation launched 1 April 2016 in direct response to Francis Report. All nurses and midwives must revalidate every three years. Replaced the Post-Registration Education and Practice system. Updated NMC Code published March 2015 strengthened requirements around candour and raising concerns.
NMC published updated Code of Professional Standards for nurses and midwives (March 2015). Standard 14 specifically requires nurses and midwives to be open and candid with all service users about all aspects of care, including when mistakes or harm have occurred.
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.
New "Fundamental Standards" replaced previous CQC registration requirements from 7 November 2014. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 introduced clearer minimum standards including: person-centred care (Reg 9), dignity (Reg 10), safe care (Reg 12), staffing (Reg 18), good governance (Reg 17), fit and proper persons (Reg 5), duty of candour (Reg 20).
CQC overhauled its inspection regime in response to Francis. Professor Sir Mike Richards appointed as first Chief Inspector of Hospitals (July 2013). New methodology based on five key questions (Safe, Effective, Caring, Responsive, Well-led) rolled out nationally October 2014. Four-tier ratings introduced (Outstanding/Good/Requires Improvement/Inadequate). Specialist expert-led inspection teams replaced generalist compliance model.
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.
Ann Clwyd MP and Professor Tricia Hart published review of NHS hospital complaints handling on 28 October 2013. Key recommendations: Chief Executives must sign off complaint responses; Trust Boards must scrutinise complaints; trusts must publish annual complaints reports in plain English.