When the Francis Inquiry report1 was published in February 2013, one of the main criticisms made was that there were too many recommendations and a lack of clarity about what needed to be done. When, as someone who had been an assessor to the Inquiry I put the question back to people ‘so what would you suggest needs to be done?’, I nearly always got the reply ‘ah, that's very difficult...’

With hindsight, it is all too easy to forget that the initial response from the National Health Service (NHS) policy and management community was often one of ambivalence. The report's diagnosis, (which most people seemed to agree with) was apparently harder to bear if there was no clear scapegoat at whom the finger of blame could be pointed. They acknowledged that doctors, nurses and other staff failed to uphold basic professional duties; the leadership team at Stafford was distracted by centrally imposed targets and the need to achieve financial balance and foundation trust status; and the regulatory and supervisory system was seemingly incapable of reacting to many warning signs. The apparently amorphous ‘culture’ was to blame, but where did this leave the clinician, ward manager, hospital board, clinical commissioner or Department of Health official trying to work out what to do …