Measuring cultural health
Mid Staffs Inquiry · Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · Issued 6 February 2013 · Addressed to: Healthcare providers
Source — verbatim from the inquiry
●Inquiry recommendation
Healthcare providers should be encouraged by incentives to develop and deploy reliable and transparent measures of the cultural health of front-line nursing workplaces and teams, which build on the experience and feedback of nursing staff using a robust methodology, such as the "cultural barometer".
Mid Staffs Inquiry, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · 6 Feb 2013 Source PDF →
Published evidence summary
Publicly available evidence relating to this recommendation:
- The NHS Staff Survey, conducted annually, includes questions on staff engagement, morale, safety culture, and willingness to recommend the organisation as a place to work or receive treatment. Results are published at organisation level and provide a partial measure of cultural health, though not at the ward-level granularity Francis recommended (NHS Staff Survey, NHS England, annual).
- CQC's inspection framework includes the "well-led" key question, which assesses organisational culture, leadership, and governance. Inspectors consider staff survey results and staff feedback as part of this assessment (CQC Inspection Framework, CQC).
- A specific national "cultural barometer" tool for front-line nursing workplaces, as Francis recommended, has not been mandated or deployed across the NHS. Some trusts have developed local cultural assessment tools, but there is no standardised national instrument measuring cultural health at ward or team level (NHS Staff Survey; CQC Well-Led Framework).
- No further published evidence has been identified of a national programme to develop the specific ward-level cultural measurement tool that Francis envisaged.
Response — verbatim from government
●Department of Health and Social Care
The 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
Department of Health and Social Care · 19 Nov 2013 Written response →
Evidence trail — what's actually happened since
- 6 Feb 2026 · NHS England Francis recommended measuring the cultural health of organisations. The NHS Staff Survey provides some cultural metrics and the CQC's 'well-led' domain assesses leadership culture. However, Francis himself said in 2023 that culture has 'not changed very much' and the continuing pattern of healthcare scandals suggests that cultural measurement tools have not been effective at driving change. View source → Insufficient Progress
- 6 Feb 2023 · Academic Review - Ten Years After Francis 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. View source → Reasonable Progress
- 1 Apr 2016 · NMC - Nursing Revalidation NMC Revalidation launched 1 April 2016 in direct response to Francis Report. All nurses and midwives must revalidate every three years. Replaced the Post-Registration Education and Practice system. Updated NMC Code published March 2015 strengthened requirements around candour and raising concerns. View source → Confirmed Completed
- 31 Mar 2015 · NMC - Updated Professional Code (2015) NMC published updated Code of Professional Standards for nurses and midwives (March 2015). Standard 14 specifically requires nurses and midwives to be open and candid with all service users about all aspects of care, including when mistakes or harm have occurred. View source → Confirmed Completed
- 11 Feb 2015 · UK Government - Culture Change in 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. View source → Good Progress
- 15 Jul 2014 · NICE - Safe Staffing Guidance SG1 NICE published "Safe staffing for nursing in adult inpatient wards in acute hospitals" (SG1) on 15 July 2014. Evidence showed increased risk when registered nurse cares for >8 patients. Red flag: fewer than 2 RNs on any ward during any shift. However, NICE's broader safe staffing programme was controversially halted in June 2015 by NHS England. No mandatory nurse-to-patient ratios introduced in England (unlike Wales). View source → Reasonable Progress
- 19 Nov 2013 · UK Government - Hard Truths Vol 1 & 2 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. View source → Good Progress
Each entry above links to a primary source — gov.uk written statement, consultation response document, or inspection report. The Index does not characterise government intent; it tracks what has been published.
How this page is built
Source and Response are verbatim from primary documents. The Evidence trail records published activity since — written statements, consultation outcomes, inspection findings, parliamentary references. The Index does not paraphrase or characterise intent; it tracks what has been published. Where the evidence is the absence of action (a missed deadline, a slipped timetable), that absence is documented from primary sources rather than inferred.
This recommendation's data is verified periodically against primary sources. The Index is monitored for staleness weekly.