This is a day for the NHS to reflect fully on the harrowing experiences of those personally affected by the failures at Mid Staffordshire NHS Foundation Trust.  The NHS Commissioning Board (NHS CB) takes on a key leadership role in the NHS in England from April and is absolutely committed, together with all other organisations in the health system, to addressing the failings that allowed these events to develop unchecked.

The only acceptable legacy of the Francis Report is that the NHS changes.  We strongly welcome the Government’s initial steps on improving safety, listening to patients’ complaints, and improving regulation and training.  Now we must develop our own detailed response to the Francis Report recommendations to bring about lasting improvements.

As an immediate first step, the NHS CB Medical Director, Sir Bruce Keogh, is to conduct an investigation into the five hospitals who have been outliers on Summary Hospital-level Mortality Indicator (SHMI) data for two successive years to 2012. These five hospitals are:

• Colchester Hospital University NHS Foundation Trust
• Tameside Hospital NHS Foundation Trust
• Blackpool Teaching Hospitals NHS Foundation Trust
• Basildon and Thurrock University Hospitals NHS Foundation Trust
• East Lancashire Hospitals NHS Trust

Sir Bruce will make further announcements shortly about the terms of reference for this work and any further hospitals to be looked at.

Action on the concerns previously identified is already underway or planned (see below).  There is much more to do but we hope people can see that the journey has begun. We are determined to repair the damage to public confidence.

• Standards & methods of compliance: there was not sufficient clarity around standards on safety and patient care. First step:Don Berwick, an internationally healthcare expert, will examine zero tolerance of harm. A national quality dashboard will be developed to identify safety failures in providers.
• Openness, transparency and candour: In Mid Staffs, early warning systems were immature and ineffective. The NHS CB plans far greater transparency, honesty and openness. First step: We have introduced a duty of candour into the NHS contract.
• Improved support for compassionate nursing: In Mid Staffs, the staff behaved in ways that were a total betrayal of what the NHS stands for. The NHS CB values kindness, thoughtfulness and compassion in NHS staff as much as their technical skills.  We will work with the whole NHS, especially Health Education England, to refocus training and recruitment on these values. First step:Implementation of “compassion in practice” our nursing strategy
• Strong, patient-centred leadership: In Mid Staffs, the NHS failed to listen to patients. The NHS CB will give patients much more clout so they are at the centre of decision-making and are always listened to. First step:Thefriends-and-family test will gather the views of all patients on whether they recommend a hospital to someone close to them. The NHS Leadership Academy will bring together clinical and management leadership.
• Accurate, useful and relevant information: Everything we know, we will share – so the public have better information about what is going on. First step:We will begin publishing consultant level outcomes data in ten surgical specialties, including mortality rates.