Recommendation F286: Impact assessments before structural change
From Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, published 6 February 2013.
Recommendation
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?
In brief (written by this site)
In September 2024, in commentary published in February 2026, the Department of Health and Social Care and NHS England stated that an impact assessment was undertaken for the Health and Care Act and maintained that major changes of policy and system structure should be carefully considered (DHSC and NHS England, Feb 2026). Earlier, the Thirlwall Inquiry legal team noted in May 2024 that the government had accepted the recommendation (The Thirlwall Inquiry legal team, May 2024).
AI-generated summary of the record on this page, checked by a second model and automatic checks, 26 Sep 2026. The record below is the sources' own words.
About this summary
This recommendation applies across many organisations. The record reflects central policy activity; adoption in individual organisations may vary.
Government response
Accepted.
It is good practice for all major changes of policy and of system structure to be carefully considered and taken forward on the basis of a clearly defined purpose and with a clear and detailed implementation plan that takes account of the major risks to the safety or welfare of patients, and to the effective operation of the system. When the policy or change of system structure is completed, or has advanced to a predetermined degree, it should undergo a comprehensive evaluation.
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)
As the Government response sets out, it is good practice for all major changes of policy and system structure to be carefully considered. An impact assessment was undertaken for the Health and Care Act.
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 “Implemented – Ongoing”. Table row: section 18.2 No. 286, PDF page 577.
Department of Health and Social Care states no delivery position (11 February 2015)
No further update is required. Please see response to the recommendation in Hard Truths
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 legal team (15 May 2024)
This recommendation was accepted by the Government.
In the January 2014 Hard Truths report, the Government stated that it was good practice for all major changes of police and of system structure to be carefully considered.
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. 286, PDF page 529.
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 legal team
Finding