Francis recommends fitness test for senior managers but stops short of regulation

BMJ 2013; 346 doi: (Published 07 February 2013) Cite this as: BMJ 2013;346:f856
  1. Gareth Iacobucci
  1. 1BMJ

Only people who pass a new “fit and proper person” test should be allowed to become board level executives of trusts and other providers of NHS services, the public inquiry into the Mid Staffordshire scandal has recommended.

But the long awaited report by Robert Francis QC into the failings at Mid Staffordshire NHS Foundation Trust—which identified a catalogue of managerial failings that led to the deaths of hundreds of patients—stops short of calling for professional regulation of NHS managers.1

Instead it proposes a new common code of ethics and conduct for NHS leaders and senior managers, which would afford regulators the power to remove or suspend senior managers from their post if they showed “serious non-compliance.”

Francis acknowledged the need to create a “level playing field,” given that the current system allowed regulators to discipline doctors and nurses, but not managers, for failing to protect patients.

But he said that it should be possible to create this within existing regulatory frameworks, although the report does state that “the need for a separate entity for this purpose should be kept under review.”

The report advises that anyone who was judged not to be a fit and proper person by the new test should be disqualified from being a director of any healthcare organisation.

In cases where a healthcare regulator was no longer satisfied that a director was a fit and proper person, the regulator should be given the power to “remove or suspend that person from office after due process.”

The report advises the regulators Monitor and the Care Quality Commission to formulate guidance for NHS and foundation trusts on procedures they should follow if executive or non-executive directors were found to have been guilty of “serious failure” in their performance.

It also recommends that foundation trusts implement new programmes for the training and continuing professional development of directors.

In a statement published with the report, Francis concluded that managers on the Mid Staffs board were “weak” and “too focussed on reaching targets, achieving financial balance and seeking foundation trust status at the cost of delivering acceptable standards of care.”

It criticises managers at the local and regional level for failing to respond to complaints and for being “uncritical” in their support of the trust’s bid for foundation trust status.

Mike Farrar, chief executive of the NHS Confederation, said that the report was a “hard hitting but fair analysis” and urged NHS managers to respond to the recommendations swiftly and positively.

Farrar said, “Everyone in the NHS must now consider these recommendations and find ways of acting on them.

“We owe it to every patient, family member, and carer to commit to making sure these sorts of tragedies do not happen again. It is up to all of us in the NHS to take responsibility for putting things right. We cannot externalise responsibility for standards of care to government, politicians or regulators, or anybody else.

Dean Royles, director of NHS Employers, part of the NHS Confederation, said, “Away from the headlines, the NHS will need to examine approaches to recruitment, induction, training, development, appraisal, supervision, and management to drive the cultural change needed.

“If we get it right, Francis can become a byword for improvement rather than failure.”


Cite this as: BMJ 2013;346:f856



  • News: Organisations not individual people are to blame, says Francis (BMJ 2013;346:f849, doi:10.1136/bmj.f849)

  • News: Recommendations of the Francis report (BMJ 2013;346:f854, doi:10.1136/bmj.f854)

  • News: Doctors accused of keeping their heads down at Mid Staffs trust (BMJ 2013;346:f840, doi:10.1136/bmj.f840)

  • News: Doctors must accept some portion of responsibility for events at Mid Staffordshire hospital, BMA says (BMJ 2013;346:f848, doi:10.1136/bmj.f848)

  • News: NHS must adopt a culture of “zero tolerance” for patient harm, Francis report says (BMJ 2013;346:f847, doi:10.1136/bmj.f847)

  • News: Inability to detect failures at Mid Staffs means it could happen again, Francis concludes (BMJ 2013;346:f853, doi:10.1136/bmj.f853)

  • Feature: Did the government ignore criticisms of the NHS in the run up to the Mid Staffs scandal? (BMJ 2013;346:f652, doi:10.1136/bmj.f652)