The NHS will be chewing over the 1,919 pages of Robert Francis’ report on the care failings at Mid Staffordshire Foundation Trust and its implications for the regulation of the service for months. The full government response to his 290 recommendations, due in March, will have to be equally extensive and need just as much consideration.

So huge in fact is the Francis report that the reaction to it brings to mind the tale of the elephant and the blind men. It is easy to get the feel for a “trunk” or “leg” but almost impossible to see how the full set of recommendations would impact the NHS.

At this stage it is only possible to say that Mr Francis has written a verbose report − which makes some sensible recommendations and a few impractical ones.

‘Francis lacks ambition in limiting his recommendation to incidents which caused “death or serious injury”’

Mr Francis is to be praised for not playing to the gallery and indulging in a litany of blame. You can hardly call for an end to the blame culture while laying into people left and right. For some there will be a feeling of unfinished business, of having not drawn a line under an inappropriate management culture. The truth is that the inquiry took too long to have any real impact on those closely involved in the failure at Mid Staffs − the caravan has moved on.

The inquiry chair is also to be applauded for identifying the tendency of healthcare leaders and organisations to highlight the positive messages contained in data about service performance, while ignoring the more difficult findings. A greater honesty about the challenges facing the service would be welcome, though it will require a more mature approach from politicians and the media.

No clear route

A stronger duty of candour requiring staff to report mistakes as soon as possible could also have a very positive effect on the NHS’s patient safety culture. But Mr Francis lacks ambition in limiting his recommendation to incidents which caused “death or serious injury”, this will only cover a small minority of healthcare “mistakes”. His idea of making it a criminal offence to obstruct the duty of candour is also likely to be self-defeating in that it will encourage a culture of fear and defensiveness.

‘If Berwick’s work is wide ranging and well resourced it could have a greater impact than Francis’ report’

Many had expected Mr Francis to propose a merging of Care Quality Commission and Monitor and initially it looked like he had done exactly that. But it soon became clear that Monitor would have a continued, perhaps even extended role, while CQC chair David Prior was resistant to a formal transferring of powers.

The idea of a quality regulator which can judge a healthcare provider’s financial and clinical performance in the round is a desirable one, but the Francis report and the reaction to date does not give us a clear route to achieving that, possibly unreachable, goal.

Timing is all

A similar conclusion can be reached on Mr Francis’ proposals to ensure the quality of NHS management. He was right to reject professional regulation, but his proposal relies on a robust code of conduct and a workable mechanism to hold managers to account. Many HSJ readers will know this is much easier said than done.

The proposal to have the National Institute for Health and Clinical Excellence develop guidance on staffing levels which has broad public and professional support is a neat idea. But it could also spell trouble for trusts that cannot make the grade and accelerate their demise or acquisition. Timing is all.

Of course, Mr Francis can only recommend and it is how the government chooses to respond which really counts. Here the news is mostly good. The decision to ask Don Berwick, co-founder of the Institute of Healthcare Improvement, to help the NHS achieve a “zero harm” culture is a master stroke. It is to be hoped Professor Berwick’s work will be wide ranging and well resourced − if so it could potentially have a greater impact than Mr Francis’ report.

However, the declaration that trusts boards will now face removal for overseeing unacceptable standards of care as well as poor financial management smacks of announcement in search of policy mechanism to make it happen. Monitor already has the power to sack boards for failing on quality and if this is to signal trusts being held to a higher standard, it is unclear how this will happen.