A national survey of board members and board secretaries of all specialist and non-specialist acute hospitals has revealed the true impact of the Francis Report. By Naomi Chambers

It has been three years – some would argue three very long years – since the Francis Inquiry report was published.

naomi chambers


Currently, a research study funded by the Department of Health’s policy research programme is examining how boards of acute hospitals have responded to the recommendations of Francis, and what the impact has been on leadership culture in the NHS.

The study includes a national survey of board members and board secretaries of all specialist and non-specialist acute hospitals in England in early 2016.

‘Only 37% of board members who responded were female’

The survey asked respondents about the top five challenges facing their organisation today, how they perceived the main purpose of the board, what new policies and procedures have been put in place since, or as a result, of the Francis Inquiry report, and what changes in leadership culture and behaviours were believed to have occurred. In total, 444 responses were received.

A dearth of diversity

The demographics of the respondents indicates a continuing problem with representativeness and lack of diversity on boards: only 37% of board members who responded were female, while 77% of the NHS workforce is female.

Some 94% of respondents are white, compared with 78% of the NHS workforce.

These statistics disappointingly mirror the influential “snowy white peaks” of the NHS report by Roger Kline in 2014.

‘There are no weekends or Christmas breaks in our world’

That report found that NHS board members in London were 60% men and 92% white. While our survey relates to respondents only and is across the whole of England, as opposed to publicly available data about boards in London, the data suggests that little has changed, or indeed the NHS may even have taken a backward step here.

Top challenges

Figure 1 shows what boards judged to be their top challenge. Patient safety was most frequently reported as the first, with finances and patient experience rated second and third. There were some differences of emphasis – non executive directors are more likely to view patient experience as key, while more chairs and executive directors consider A&E performance as the top challenge.


Figure 2 shows that finances, patient safety, service reorganisation, workforce shortages, patient experience and A&E performance are in the top five challenges for more than 40% of respondents.


This echoes findings from a set of stakeholder interviews carried out in the initial phase of this study, and also the Nuffield Trust’s research into the early responses by hospitals to Francis, that boards are really struggling to manage what health economists have described as the iron triangle trade-offs of quality, cost, and access.

As one respondent put it: “There are no weekends or Christmas breaks in our world and the pressure to perform miracles with less funding are unabated.”

‘The pressure to perform miracles with less funding are unabated’

Barriers to progress

Asked about the most significant barriers to improving leadership in hospitals, shown in Figure 3, 73% of board members cited financial pressures, 68% the demands of regulators and 41% poor relationships in the local health and social care economy.


As a counterpoint to this, and notwithstanding the potential for hubris, 86% of board members reported that they felt that they had been able to make a positive impact on patient safety.

So it remains a challenge to keep a strong focus on patient safety, but this is perceived to be within the control, as well as remit of boards.

Benefits of candour

More than two thirds of respondents also reported, as shown in Figure 4, that implementing their duty of candour had resulted in an increase in learning and improvement within the trust and a stronger culture of openness.


Comments by survey respondents suggested that changes in leadership style and behaviours since the publication of the Francis report were more likely the result of new appointments to executive and non-executive roles rather than the emergence of new attitudes on the part of existing incumbents.

Many board members also reported an increase in board enggement, visibility, openness and transparency, and a greater level of both support and challenge within the board.

Contradictory views

There were contradictory views expressed about how far Francis had had a significant impact. Some repsondents felt that the report’s impact has been exaggerated and that board level changes had been instigated independently of Francis, while others considered the report to have been a wake-up call for hospitals.

A third view was that Francis reaffirmed, validated and legitimised the direction of travel that many boards were taking anyway.

‘Part of the solution may lie with boards themselves’

Although the survey indicated that board members thought they generally knew what was important to patients, staff and regulators, they rated their knowledge as highest for regulators and lowest in relation to patients.

And therein lies another real problem. To what extent has the regulatory system and culture that was strengthened as a consequence of Francis become part of the problem rather than part of the solution?

Part of the solution may lie with boards themselves. Some have argued that despite the appearance of an extensive trust board governance architecture, the NHS has in fact for a very long time been centrally run and regulated by an oligarchy.

Underestimating boards

But trust boards may have been underestimated, if they really can keep at bay unhelpful aspects of regulation and micro management.

National NHS staff survey results indicate that confidence in local senior managers rose around the time of the publication of Francis report, and that higher level of confidence has been maintained since.

‘Our survey shows that many boards now claim to be very engaged’

Our survey shows that many boards now claim to be very engaged and focused on taking charge of what should always have been their central mission – supporting their staff to deliver the best possible standards of patient safety, patient experience and clinical effectiveness of care and working collaboratively with others across the health economy.

Responses to our survey detailing plans to improve board leadership over the next 12 months demonstrate serious intent and therefore perhaps, after all, some grounds for optimism.

The case study element of the research study over the next nine months will explore the extent to which this optimism can be justified.

Naomi Chambers, Alan Boyd, Hannah Kendrick, Nathan Proudlove, Ruth Thorlby, Judith Smith and Russell Mannion. 

This article is an output from independent research commissioned and funded by the Department of Health Policy Research Programme (PR-R11-0914-12003 Learning from leadership changes made by boards of hospital NHS trusts and foundation trusts following the Francis Inquiry report). The views expressed in this publication are those of the authors and not necessarily those of the Department of Health.