Patients First and Foremost was published just before Easter. It is described as the Initial Government Response to the report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Fortunately it is slightly shorter than the Francis Report itself, coming in at just over 80 pages!


The foreword has been written by the Secretary of State for Health. It is a rallying cry, a call to action. It is described as being for every part of the system, every individual, every team and every organisation.

He states that the whole health and care system needs to listen, reflect and act to tackle the key challenges of culture and behaviour. Importantly he emphasises that whilst the initial response focuses on hospitals everyone across the health and care system must challenge ourselves to embrace the lessons of such failure, including in primary and community care and in social care.

In light of Winterbourne View the response highlights that the call for action is as applicable to staff working in an independent hospital or treatment unit for patients with mental health problems or learning disability as it is for staff in an acute hospital.

Jeremy Hunt notes that, at every level, individuals and organisations let down patients and families that they were there to care for and protect and that we must never allow this to happen again.

He wants reflection, with openness and humility, about how lessons learnt can make a meaningful difference for people who use services.

Quality of care is to be as important as quality of treatment.

Common purpose

12 commitments have been signed off by the Local Government Association, Monitor, NHS England, NHS Confederation and Employers, NHS Leadership Academy, NICE, NHS TDA, NMC, Health and Social Care Information Centre and Public Health England.

Those commitments are:

  1. We renew and reaffirm our personal commitment and our organisations’ commitment to the values of the NHS set out in its Constitution
  2. We apologise to every individual affected by this deeply disturbing and tragic failing in a service that means so much to us all
  3. We will put patients first…we will listen to patients
  4. We will listen most carefully to those whose voices are weakest and find it hardest to speak for themselves
  5. We will work together
  6. We will ensure that the fundamental standards of care that people have a right to expect are met consistently, whatever the settings.
  7. Everyone of us commits to ensuring a direct connection to patients and to the staff who care for them
  8. We will work together to minimise bureaucracy enabling time to care and time to lead, freeing up the expertise of NHS staff and the value and professionalism that called them to serve
  9. We will build a single set of nationally agreed and locally owned measures of success , focussed on what matters most to patients
  10. We will seek out and act on feedback both positive and negative
  11. Changing ourselves, our behaviour, individually and institutionally is difficult but we pledge to do so
  12. We invite all organisations in the health and care system to signing up to this statement 

Five point plan

This five point plan is to revolutionise the care that people receive, putting an end to failure and issuing a call for excellence. The five points are:

  1. Preventing problems
  2. Detecting problems quickly
  3. Taking action promptly
  4. Ensuring robust accountability
  5. Ensuring staff are trained and motivated  

The Government note that both the Inquiry and their response focus on acute hospitals but they highlight that many of the messages are equally relevant to other health and care settings.  

Separate chapters are devoted to each of these points but they are summarised in the Executive Summary at pages 15 -20. The key recommendations are as follows:  

Preventing problems:

Clearly the first focus has to be on preventing poor care in the first place

  • A Chief Inspector of Hospitals
  • At a local level commissioners to work with hospitals to identify and tackle poor care
  • Health and Social Care Information Centre to collect information / reduce the information burden on the service
  • Don Berwick to work with NHS England to ensure a robust safety culture and zero tolerance of avoidable harm

Detecting problems quickly

  • Assessments based on judgment and data
  • Expert led investigations
  • Comply or explain approach
  • Single version of the truth
  • Chief Inspector of Social Care
  • Publication of individual specialty outcomes
  • Penalties for misinformation
  • Statutory Duty of Candour
  • Ban on clauses intended to prevent public interest disclosures
  • Review of best practice on complaints

Taking action promptly

  • New set of fundamental standards (making explicit the basic standards beneath which care should never fall
  • Time limited 3 stage failure regime
  • CQC, Monitor and NHS TDA to agree the data and methodology for assessing hospitals to ensure a single set of expectations.
  • Quality Accounts to demonstrate how those are being met  

Ensuring robust accountability

  • HSE to use criminal sanctions
  • Faster and more proactive professional regulation (with legislation to overhaul 150 years of complex legislation into a single act)
  • National barring list for unfit managers (based on barring scheme for teachers)
  • Clear responsibilities for tackling failure  

Ensuring staff are trained and motivated

  • HCA training before nursing degree
  • Revalidation for nurses
  • Standards of conduct and training for all care assistants
  • Barring system for HCAs
  • NHS Leadership Academy to initiate a major programme to encourage new talent from clinical professionals and from outside the NHS into top leadership positions
  • Frontline experience for DH staff  

The Government also set out at pages 22 – 24 what they have already done either during the Inquiry or since it finished hearing evidence.

Chief Inspector of Hospitals

The Chief Inspector features heavily in the five point plan described above. They are to be appointed by CQC and will have an all encompassing role.

They are described as shining a powerful light on the culture of hospitals, driving change through fundamental standards and national ratings.

We are told that the Chief inspector will be armed with a sophisticated battery of information about hospitals from across the system but, crucially, informed by expert judgments of inspectors who have walked the wards, spoken to patients and staff and looked the board in the eye.

The Chief Inspector is described as the nation’s whistleblower, naming poor care without fear or favour from politicians, institutional vested interests or through loyalty to the system.

This is to be supported by Quality Surveillance Groups (more on these in our March Health Legal Update) The Chief Inspector will ensure that there is a “single version of the truth” about how hospitals are performing. The OFSTED like rating could be “outstanding”, “good”, “requiring improvement” or “poor”.

Should a hospital be given a rating of “poor” then the Chief Inspector will firstly require the board to work with its commissioners to improve, within a fixed time period. This is not something the CQC will be responsible for making happen. If the hospital and their commissioners are unable to resolve the problems then CQC will call in Monitor or the NHS TDA. Finally, if problems are still not resolved, the Chief Inspector will initiate a failure regime.

The Chief Inspector will also be able to refer matters to the HSE where they identify criminally negligent practice so that the HSE can consider whether criminal prosecution of provider or individuals is necessary.

Another part of their role will be to assure that all hospitals are meeting their legal obligations to ensure that unsuitable HCAs are barred from future patient care.

Commentary from others

Nigel Edwards wrote for HSJ on 2 April and noted that the response highlights the paradox created by setting up a major public inquiry to report just before the largest piece of NHS legislation comes into force. He observed that Monitor, the NHS TDA , NHS England and the CQC have to collaborate very closely but is concerned that how this will work and who will be responsible for what is not very clear. He also commented that local commissioners who were supposed to be driving the system do not really feature in the way that might be expected.  

He concludes that the real answer lies in strong commissioners setting high quality aspirations, clear minimum standards, peer review and inspection where necessary and, above all, high quality governance, great frontline leadership and a willingness to learn and improve. Reassuringly he highlights that there are already great examples of this.

In NHS Confed’s response to Patients First and Foremost, Mike Farrar said “the response finds the right balance between external assurance measures and internal changes focussed on transforming the NHS culture. The NHS now has a real opportunity to do things differently and it is the responsibility of all of us to make a real difference to the care provided to patients.”


All organisations have to set out how they intend to respond to the Inquiry’s conclusions before December 2013.

There is much still to come from the government bearing in mind that this is only their initial response – more is expected in September. We know they intend to consult on further amendments to the Constitution later this year and that they intend to consult on whether a barring scheme should extend beyond board level to other managers.

In addition:

  • A common purpose framework relating to the caring for older people will be published in May
  • Don Berwick’s National Patient Safety Advisory Group will be reporting by the end of July.
  • The complaints review being conducted by Rt Hon Ann Clwyd MP and Professor Tricia Hart will also be reporting in the summer

In the meantime, we have prepared several briefing notes to assist you with your consideration, deliberation and cogitation as follows:  

  • New criminal sanctions
  • Staffing issues
  • Monitor
  • Constitution

The Government’s response repeats the point made by Robert Francis that the NHS and its staff do not need to wait for the Government to legislate or for guidance from national bodies.