Leadership and boards

Set a national standard for labour-ward coordinators, including feedback on how their behaviour affects the team.

Trusts

Make boards monitor every child and baby death, with a fixed route to escalate a worrying trend.

Hospital trusts

Rebuild the National Quality Board so that it owns a quality strategy and a way to collect, prioritise and track recommendations.

DHSC and NHS England

Keep rebuilding CQC as the principal quality regulator, with sector-specific assessment and a harder look at boards.

CQC

Put accountability for the quality of care back onto commissioners and providers.

ICBs and providers

The interim report's 11 recommendations addressed ventilation failures and NHS Lothian governance. The Scottish Government accepted all 11.

Scottish Government and NHS boards

Restore a clear view of provider quality that boards, ICBs and the public can use.

CQC

Rebuild leadership and culture so that abuse is not explained away as a difficult ward.

The trust and NHS England

Give ICSs real freedom where they can show capability, and intervene where they cannot.

NHS England

Introduce one set of behaviour-based standards and appraisal for managers.

NHS England

Make collaborative leadership across organisational boundaries a requirement, not a preference.

ICBs and providers

Give boards a clearer duty to act on outlier clinical practice and to recall patients promptly.

Department of Health, Northern Ireland

Give screening a single senior owner and replace obsolete IT.

NHS England

Fund and phase hospital digitisation, with chief clinical information officers in post.

NHS England

Ask the Secretary of State to report regularly on whether speaking up is getting safer.

Government

Report those investigations to the board.

Trust boards

Build an NHS leadership academy offer that reaches operational managers, not only the board.

NHS

Simplify the instructions the centre sends to trusts so leaders can lead.

Department of Health and NHS England

Give successful organisations a practical route to support or take on weaker ones.

NHS England and government

Judge any new form by whether it improves care, not by the transaction itself.

Boards

Make boards own complaint themes, and publish what they changed.

Hospital trusts

Apply a fit and proper person test to NHS directors.

Government

Give clinicians a leading role in designing local services.

NHS

Create a single local line of accountability for children's safeguarding.

Government and local services