Public Inquiry Recommendations

F129 Accepted

Mid Staffs Inquiry (2013)

Ensuring assessment and enforcement of fundamental standards through contracts

In selecting indicators and means of measuring compliance, the principal focus of commissioners should be on what is reasonably necessary to safeguard patients and to ensure that at least fundamental …

- The NHS Standard Contract 2024/25 includes a suite of quality indicators and performance measures that commissioners use to monitor provider compliance with safety and …

F130 Accepted

Mid Staffs Inquiry (2013)

Relative position of commissioner and provider

Commissioners – not providers – should decide what they want to be provided. They need to take into account what can be provided, and for that purpose will have to …

- The Health and Care Act 2022 establishes ICBs as the statutory commissioners responsible for planning and commissioning NHS services to meet the needs of …

F131 Accepted

Mid Staffs Inquiry (2013)

Development of alternative sources of provision

Commissioners need, wherever possible, to identify and make available alternative sources of provision. This may mean that commissioning has to be undertaken on behalf of consortia of commissioning groups to …

- The Provider Selection Regime (PSR), introduced in January 2024 under SI 2023/1348, provides commissioners with a structured framework for identifying and selecting alternative providers. …

F132 Accepted

Mid Staffs Inquiry (2013)

Monitoring tools

Commissioners must have the capacity to monitor the performance of every commissioning contract on a continuing basis during the contract period: Such monitoring may include requiring quality information generated by …

- The NHS Standard Contract 2024/25 includes comprehensive provisions for commissioner monitoring of provider performance. The contract requires providers to submit regular quality and performance …

F133 Accepted in Part

Mid Staffs Inquiry (2013)

Role of commissioners in complaints

Commissioners should be entitled to intervene in the management of an individual complaint on behalf of the patient where it appears to them it is not being dealt with satisfactorily, …

- The NHS Standard Contract 2024/25 includes provisions requiring providers to have effective complaint handling arrangements and to report complaints data to commissioners. Commissioners can …

F134 Accepted

Mid Staffs Inquiry (2013)

Role of commissioners in provision of support for complainants

Consideration should be given to whether commissioners should be given responsibility for commissioning patients' advocates and support services for complaints against providers.

- The Health and Social Care Act 2012 (section 185) placed a duty on local authorities (not NHS commissioners) to commission independent advocacy services for …

F135 Accepted in Part

Mid Staffs Inquiry (2013)

Public accountability of commissioners and public engagement

Commissioners should be accountable to their public for the scope and quality of services they commission. Acting on behalf of the public requires their full involvement and engagement: There should …

- The Health and Care Act 2022 requires ICBs to involve patients and the public in decisions about the commissioning of services. ICBs must make …

F136 Accepted

Mid Staffs Inquiry (2013)

Public accountability of commissioners and public engagement

Commissioners need to be recognisable public bodies, visibly acting on behalf of the public they serve and with a sufficient infrastructure of technical support. Effective local commissioning can only work …

- Integrated Care Boards (ICBs) are established as statutory NHS bodies under the Health and Care Act 2022, with their own legal identity, branding, websites, …

F137 Not Accepted

Mid Staffs Inquiry (2013)

Intervention and sanctions for substandard or unsafe services

Commissioners should have powers of intervention where substandard or unsafe services are being provided, including requiring the substitution of staff or other measures necessary to protect patients from the risk …

- The NHS Standard Contract 2024/25 includes provisions enabling commissioners to take action where providers fail to meet contractual quality standards. These include issuing contract …

F138 Accepted

Mid Staffs Inquiry (2013)

Local scrutiny

Commissioners should have contingency plans with regard to the protection of patients from harm, where it is found that they are at risk from substandard or unsafe services.

- NHS England's System Oversight Framework (SOF) includes requirements for ICBs and NHS England regional teams to have contingency plans for the continuity of services …

F139 Accepted

Mid Staffs Inquiry (2013)

The need to put patients first at all times

The first priority for any organisation charged with responsibility for performance management of a healthcare provider should be ensuring that fundamental patient safety and quality standards are being met. Such …

- NHS England's System Oversight Framework (SOF) establishes patient safety and quality as the primary considerations in oversight of NHS providers and ICBs. SOF assessment …

F140 Accepted

Mid Staffs Inquiry (2013)

Performance managers working constructively with regulators

Where concerns are raised that such standards are not being complied with, a performance management organisation should share, wherever possible, all relevant information with the relevant regulator, including information about …

- NHS England and CQC operate a memorandum of understanding governing the sharing of information about provider quality and safety. The agreement provides for the …

F141 Accepted in Part

Mid Staffs Inquiry (2013)

Taking responsibility for quality

Any differences of judgement as to immediate safety concerns between a performance manager and a regulator should be discussed between them and resolved where possible, but each should recognise its …

- The System Oversight Framework (SOF) provides a structured mechanism for resolving differences between NHS England (as performance manager) and CQC (as regulator) regarding provider …

F142 Accepted

Mid Staffs Inquiry (2013)

Clear lines of responsibility supported by good information flows

For an organisation to be effective in performance management, there must exist unambiguous lines of referral and information flows, so that the performance manager is not in ignorance of the …

- The Health and Care Act 2022 established a statutory framework for information flows within the NHS. ICBs have duties to obtain information about the …

F143 Accepted

Mid Staffs Inquiry (2013)

Clear metrics on quality

Metrics need to be established which are relevant to the quality of care and patient safety across the service, to allow norms to be established so that outliers or progression …

- The NHS Outcomes Framework (NHS OF) provides a national set of outcome indicators across five domains: preventing people from dying prematurely, enhancing quality of …

F144 Accepted

Mid Staffs Inquiry (2013)

Need for ownership of quality metrics at a strategic level

The NHS Commissioning Board should ensure the development of metrics on quality and outcomes of care for use by commissioners in managing the performance of providers, and retain oversight of …

- NHS England (originally the NHS Commissioning Board) developed and maintains the NHS Outcomes Framework, a suite of outcome indicators used to assess the overall …

F145 Not Accepted

Mid Staffs Inquiry (2013)

Structure of Local Healthwatch

There should be a consistent basic structure for Local Healthwatch throughout the country, in accordance with the principles set out in Chapter 6: Patient and public local involvement and scrutiny.

- The Health and Social Care Act 2012 (sections 221-227) established the statutory framework for Local Healthwatch organisations. Every upper-tier local authority in England is …

F146 Accepted in Part

Mid Staffs Inquiry (2013)

Finance and oversight of Local Healthwatch

Local authorities should be required to pass over the centrally provided funds allocated to its Local Healthwatch, while requiring the latter to account to it for its stewardship of the …

- The Health and Social Care Act 2012 placed a duty on local authorities to commission Local Healthwatch for their area, with funding provided through …

F147 Accepted

Mid Staffs Inquiry (2013)

Coordination of local public scrutiny bodies

Guidance should be given to promote the coordination and cooperation between Local Healthwatch, Health and Wellbeing Boards, and local government scrutiny committees.

- The Department of Health and Social Care published updated guidance on Health and Wellbeing Boards in November 2022, following the Health and Care Act …

F148 Accepted

Mid Staffs Inquiry (2013)

Training

The complexities of the health service are such that proper training must be available to the leadership of Local Healthwatch as well as, when the occasion arises, expert advice.

- Healthwatch England provides a programme of support and development resources for Local Healthwatch organisations, including guidance documents, webinars, and network events. Healthwatch England's Quality …

F149 Accepted

Mid Staffs Inquiry (2013)

Expert assistance

Scrutiny committees should be provided with appropriate support to enable them to carry out their scrutiny role, including easily accessible guidance and benchmarks.

- The Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013 (SI 2013/218) set out the powers and duties of local …

F150 Accepted in Part

Mid Staffs Inquiry (2013)

Inspection powers

Scrutiny committees should have powers to inspect providers, rather than relying on local patient involvement structures to carry out this role, or should actively work with those structures to trigger …

- The Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013 (SI 2013/218) provide local authority health scrutiny committees with powers …

F151 Accepted in Part

Mid Staffs Inquiry (2013)

Complaints to MPs

MPs are advised to consider adopting some simple system for identifying trends in the complaints and information they received from constituents. They should also consider whether individual complaints imply concerns …

- The government's response to the Francis Report in "Hard Truths" (Cm 8777, November 2013) noted that MPs have a significant role in representing the …

F152 Accepted

Mid Staffs Inquiry (2013)

Medical training

Any organisation which in the course of a review, inspection or other performance of its duties, identifies concerns potentially relevant to the acceptability of training provided by a healthcare provider, …

- The Health and Social Care Act 2012 (section 96) placed a statutory duty on specified bodies — including CQC, NHS England (then the NHS …

F153 Accepted in Part

Mid Staffs Inquiry (2013)

Medical training

The Secretary of State should by statutory instrument specify all medical education and training regulators as relevant bodies for the purpose of their statutory duty to cooperate. Information sharing between …

- The Health and Social Care Act 2012 (section 96) placed a statutory duty to cooperate on CQC, NHS England, Monitor, and HEE. The Secretary …

F154 Accepted

Mid Staffs Inquiry (2013)

Medical training

The Care Quality Commission and Monitor should develop practices and procedures with training regulators and bodies responsible for the commissioning and oversight of medical training to coordinate their oversight of …

- CQC and the GMC operate a memorandum of understanding governing information sharing and coordination of oversight of healthcare organisations that provide medical education and …

F155 Accepted

Mid Staffs Inquiry (2013)

Medical training

The General Medical Council should set out a standard requirement for routine visits to each local education provider, and programme in accordance with the following principles: The Postgraduate Dean should …

- The GMC published "Promoting Excellence: Standards for Medical Education and Training" in 2015, replacing "Tomorrow's Doctors" (2009) and "The Trainee Doctor" (2011). The standards …

F156 Accepted

Mid Staffs Inquiry (2013)

Medical training

The system for approving and accrediting training placement providers and programmes should be configured to apply the principles set out above.

- The GMC's "Promoting Excellence: Standards for Medical Education and Training" (2015) sets out the standards for the approval and accreditation of medical education and …

F157 Accepted

Mid Staffs Inquiry (2013)

Matters to be reported to the General Medical Council

The General Medical Council should set out a clear statement of what matters; deaneries are required to report to the General Medical Council either routinely or as they arise. Reports …

- The GMC's "Promoting Excellence: Standards for Medical Education and Training" (2015) includes requirements for designated bodies (employers of doctors) and postgraduate deans to report …

F158 Accepted

Mid Staffs Inquiry (2013)

Training and training establishments as a source of safety information

The General Medical Council should amend its standards for undergraduate medical education to include a requirement that providers actively seek feedback from students and tutors on compliance by placement providers …

- The GMC published "Promoting Excellence: Standards for Medical Education and Training" in 2015, which includes specific requirements for medical schools to actively seek and …

F159 Accepted

Mid Staffs Inquiry (2013)

Training and training establishments as a source of safety information

Surveys of medical students and trainees should be developed to optimise them as a source of feedback of perceptions of the standards of care provided to patients. The General Medical …

- The GMC's National Training Survey (NTS) is conducted annually and collects data from all doctors in training in the UK. The NTS includes questions …

F160 Accepted

Mid Staffs Inquiry (2013)

Training and training establishments as a source of safety information

Proactive steps need to be taken to encourage openness on the part of trainees and to protect them from any adverse consequences in relation to raising concerns.

- The Freedom to Speak Up Review (Sir Robert Francis QC, February 2015) made 20 recommendations for creating a culture of openness in the NHS, …

F161 Accepted

Mid Staffs Inquiry (2013)

Training and training establishments as a source of safety information

Training visits should make an important contribution to the protection of patients: Obtaining information directly from trainees should remain a valuable source of information – but it should not be …

- The GMC's "Promoting Excellence: Standards for Medical Education and Training" (2015) sets out requirements for quality assurance visits to training environments, including direct observation …

F162 Accepted

Mid Staffs Inquiry (2013)

Training and training establishments as a source of safety information

The General Medical Council should in the course of its review of its standards and regulatory process ensure that the system of medical training and education maintains as its first …

- The GMC published "Promoting Excellence: Standards for Medical Education and Training" in 2015, following a comprehensive review of its education and training standards. The …

F163 Accepted

Mid Staffs Inquiry (2013)

Safe staff numbers and skills

The General Medical Council's system of reviewing the acceptability of the provision of training by healthcare providers must include a review of the sufficiency of the numbers and skills of …

- The GMC's "Promoting Excellence: Standards for Medical Education and Training" (2015) includes requirements that education and training providers must have sufficient numbers of appropriately …

F164 Accepted in Part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The Department of Health and the General Medical Council should review whether the resources available for regulating Approved Practice Setting are adequate and, if not, make arrangements for the provision …

- The GMC's approved practice settings scheme enables doctors working outside NHS trusts (for example, in locum agencies, private practice, or non-NHS organisations) to satisfy …

F165 Accepted in Part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The General Medical Council should immediately review its approved practice settings criteria with a view to recognition of the priority to be given to protecting patients and the public.

- The GMC reviewed and updated its approved practice settings criteria following the Francis Report. The Medical Act 1983 (section 29A, inserted by the Health …

F166 Accepted in Part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The General Medical Council should in consultation with patient interest groups and the public immediately review its procedures for assuring compliance with its approved practice settings criteria with a view …

- The GMC's quality assurance framework for approved practice settings includes active information sharing with CQC and other healthcare regulators. The statutory duty to cooperate …

F167 Accepted in Part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The Department of Health and the General Medical Council should review the powers available to the General Medical Council in support of assessment and monitoring of approved practice settings establishments …

- The GMC has powers under the Medical Act 1983 to set standards for medical education and training and to conduct quality assurance visits to …

F168 Accepted in Part

Mid Staffs Inquiry (2013)

Approved Practice Settings

The Department of Health and the General Medical Council should consider making the necessary statutory (and regulatory changes) to incorporate the approved practice settings scheme into the regulatory framework for …

- The Medical Act 1983 provides the statutory framework for the regulation of medical education and training by the GMC, including the approval of training …

F169 Accepted in Part

Mid Staffs Inquiry (2013)

Role of the Department of Health and the National Quality Board

The Department of Health, through the National Quality Board, should ensure that procedures are put in place for facilitating the identification of patient safety issues by training regulators and cooperation …

- The National Quality Board (NQB), established as a multi-stakeholder body bringing together NHS England, CQC, NICE, GMC, HSSIB, and other system leaders, provides a …

F170 Accepted

Mid Staffs Inquiry (2013)

Health Education England

Health Education England should have a medically qualified director of medical education and a lay patient representative on its board.

- Health Education England (HEE) was established as a non-departmental public body in June 2012 (as a special health authority) and given statutory footing under …

F171 Accepted

Mid Staffs Inquiry (2013)

Deans

All Local Education and Training Boards should have a post of medically qualified postgraduate dean responsible for all aspects of postgraduate medical education.

- Health Education England established Local Education and Training Boards (LETBs) across England, each with a medically qualified postgraduate dean responsible for all aspects of …

F172 Accepted

Mid Staffs Inquiry (2013)

Proficiency in the English language

The Government should consider urgently the introduction of a common requirement of proficiency in communication in the English language with patients and other persons providing healthcare to the standard required …

- The Medical Act 1983 was amended by the Health Care and Associated Professions (Knowledge of English) Order 2014 (SI 2014/1887) and by the Health …

F173 Accepted

Mid Staffs Inquiry (2013)

Principles of openness transparency and candour

Every healthcare organisation and everyone working for them must be honest, open and truthful in all their dealings with patients and the public, and organisational and personal interests must never …

- The statutory duty of candour was enacted as Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. It came …

F174 Accepted

Mid Staffs Inquiry (2013)

Candour about harm

Where death or serious harm has been or may have been caused to a patient by an act or omission of the organisation or its staff, the patient (or any …

- Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 imposes a specific obligation on registered providers to notify patients …

F175 Accepted

Mid Staffs Inquiry (2013)

Candour about harm

Full and truthful answers must be given to any question reasonably asked about his or her past or intended treatment by a patient (or, if deceased, to any lawfully entitled …

- Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires registered providers to be open and transparent with patients …

F176 Accepted

Mid Staffs Inquiry (2013)

Openness with regulators

Any statement made to a regulator or a commissioner in the course of its statutory duties must be completely truthful and not misleading by omission.

- Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 applies the duty of candour to registered providers in their …

F177 Accepted

Mid Staffs Inquiry (2013)

Openness in public statements

Any public statement made by a healthcare organisation about its performance must be truthful and not misleading by omission.

- Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires registered providers to act in an open and transparent …

F178 Accepted in Part

Mid Staffs Inquiry (2013)

Implementation of the duty Ensuring consistency of obligations under the duty of openness transparency and candour

The NHS Constitution should be revised to reflect the changes recommended with regard to a duty of openness, transparency and candour, and all organisations should review their contracts of employment, …

- The NHS Constitution was updated in July 2015 to incorporate the principles of openness, transparency, and candour recommended by Francis. The Constitution includes a …