Spent three hours locked in with the press going through nearly 4000 pages, three volumes and 290 recommendations of the Francis Inquiry and then to the Press Conference. The Press are searching for heads but none are immediately visible as Francis is not leading a charge for scapegoats.

However, really challenging change is on the way. The good news is that he has not recommended yet another round of organisational change.

The very first recommendation is that patients must come first with care delivered by caring, committed and compassionate staff working within a common culture. The NHS constitution should have these values embedded in it Francis recommends. Even the Prime Minister put quality ahead of budgets. The Chancellor of the Exchequer must be seriously worried...he wants both and his cost improvement programme. The Nicholson challenge has not gone away.

It should be a criminal offense, Francis recommends, if a patient is harmed by a breach of regulatory requirements. It should also be an offense to make a wilful or false statement as to compliance with safety or fundamental standards. Fiddle the figures and go to jail! Zero tolerance should be the new standard. This is, I think, just short of corporate manslaughter but only just.

The CQC [whose role is expanded] should, he recommends, authorise Foundation Trusts and see all Serious Untoward Incident reports. It is the CQC who should inspect Trust Quality accounts. In an unusually opaque recommendation Francis appears to be saying Monitor should go, incrementally handing their responsibilities to the CQC. Who will regulate the market? Perhaps the Office of Fair Trading?

The idea of appointing an Independent Inspector of Quality in the NHS comes from the Prime Minister not Francis. How it all fits together is a mystery. Now doubt the Department are furiously trying to work it all out.

According to Francis the Mid-Staff's Trust Board was weak .....it did not listen to its patients and staff or ensure the correction of deficiencies brought to its attention. It did not tackle the tolerance of poor standards and the disengagement of senior clinical staff from managerial and leadership responsibilities. The Board were too focused on reaching targets, achieving financial balance and seeking Foundation Trust status at the expense of acceptable standards of care.

All Boards need to look at themselves in a Stafford mirror.

Stafford was, Francis argues, a case of none of the bedpans rattling in the corridors of Whitehall. Stafford was not on anybody's radar for a long time. He has a lot to say about the inadequacy of NHS information systems.

There was bullying but it was not systemic.

There should be a code of conduct for Trust Board Directors and a fit and proper person test installed to govern their continuance in office. The National Patients Safety function should go to a regulator not the NHS Commissioning Board as is currently planned.

Commissioners must have the final say in what services are to be provided not providers. There should be lay members of Commissioning Boards which should become recognisable public bodies... rather like PCTs!  

Commissioners should have the power to intervene if provider services are considered unsafe including a power to order a provider to stop providing a service.  LA Scrutiny committees should have the right to inspect providers. There should be a statutory duty of candour. No secrets any longer.

There should be an aptitude test for nurses entering training and three months compulsory experience in the direct care of patients. The RCN should tear down its Chinese walls and be either a royal college or a trade union. There should be a new registered status for the older person's nurse.

There should be a national code of conduct and a registration system for healthcare support workers. There should be an accreditation scheme for leaders of all disciplines and a national leadership staff College.

For the elderly; Boards should make sure one person is in charge of individual patient care. I think this goes way beyond the named nurse ... can the patient have a say ?

All providers should have a Board level person in charge of information. Quality accounts must be in a common format and made publically available. The NHS should move to real time information in the field of patient safety.

The Department of Health should be required to make public a risk assessment before there is any further reorganisation of the NHS. The constant reorganisation of the NHS made it difficult he argues for quality to be a constant focus... too true! These changes do not, Francis claims, require another major reorganisation.

Patient involvement must be increased.

It would not be safe to assume that Stafford was a one off. Every Trust has to publish its Stafford action plan so that it can be reviewed in Parliament and the recommendations don't just rot on a shelf after the initial media storm.

Much of what Francis says makes sense but one wishes he had stuck to the big issues rather than chase down every detail, with a lawyer's instinct.

It is I am afraid a full week's read for everybody. Expect dozens of Department of Health working parties and expert groups.  

My advice is the same as Francis; don't wait for the Department of Health. Get on with it!