Experience on the front line
The Department of Health should promote a shared positive culture by setting an example in its statements by being open about deficiencies, ensuring those harmed have a remedy, and making information publicly available about performance at the most detailed level possible.
- DHSC has taken steps towards greater transparency and openness since the Francis Report. The NHS Constitution (most recently updated 2024) sets out values including accountability, openness, and honesty. The statutory duty of candour (CQC Regulation 20, from November 2014) embeds the principle of openness about deficiencies at provider level.
- The government's responses to subsequent inquiries — including Grenfell Tower, Infected Blood, and the Post Office Horizon IT Inquiry — have been subject to public scrutiny and parliamentary debate, demonstrating a degree of openness about systemic failings.
- However, the cultural change Francis recommended at departmental level — being open about deficiencies, ensuring those harmed have a remedy, and publishing detailed performance information — is inherently difficult to assess from outside. The duty of candour review (2024) found that only 23% of respondents thought the duty is correctly complied with when a notifiable safety incident occurs, suggesting the culture of openness remains a work in progress across the system.
- The publication of detailed performance data has improved significantly through NHS England Digital, CQC, and the Model Health System, addressing the information transparency element of this recommendation. Whether DHSC itself models a positive culture of openness about deficiencies in its own policy-making is a judgement that falls outside the scope of published evidence.
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.