Impact assessments before structural change
Impact and risk assessments should be made public, and debated publicly, before a proposal for any major structural change to the healthcare system is accepted. Such assessments should cover at least the following issues: What is the precise issue or concern in respect of which change is necessary? Can the policy objective identified be achieved by modifications within the existing structure? How are the successful aspects of the existing system to be incorporated and continued in the new system? How are the existing skills which are relevant to the new system to be transferred to it? How is the existing corporate and individual knowledge base to be preserved, transferred and exploited? How is flexibility to meet new circumstances and to respond to experience built into the new system to avoid the need for further structural change? How are necessary functions to be performed effectively during any transitional period? What are the respective risks and benefits to service users and the public and, in particular, are there any risks to safety or welfare?
- The Health and Care Act 2022 was accompanied by seven published impact assessments, rated as fit for purpose by the Regulatory Policy Committee. These assessed the legislative provisions (ICS establishment, HSSIB creation, etc.) and were published on 4 November 2022. The Act followed a white paper ("Integration and Innovation") published in February 2021 (Health and Care Act 2022: Combined Impact Assessments, DHSC, November 2022).
- However, subsequent major structural changes to the NHS — including the abolition of approximately 18,000 administrative posts across NHS England and ICBs, announced in 2024-2025 — have not been accompanied by formal public impact assessments evaluating the effect on frontline clinical services. A parliamentary petition called for an impact assessment before proceeding with these redundancies.
- Francis's recommendation specified that impact assessments for structural changes should cover preservation of existing skills and knowledge, continuity during transition, and risks to safety and welfare. While the 2022 Act's impact assessments covered the legislative measures themselves, the operational restructuring decisions — which arguably have a greater direct impact on services — have not been subject to equivalent published analysis.
- The pattern of NHS structural reorganisation without comprehensive published impact assessment persists, suggesting this recommendation has been applied selectively rather than as a consistent principle for all major changes.
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.
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.
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.