I am confused. The Robert Francis inquiry is a the response to the Healthcare Commission’s investigation into the higher than expected mortality rate at the Mid Staffordshire NHS Foundation Trust.

The enquiry says “many staff” expressed concerns, but were “ignored”. Nurses complained there were not enough beds to cope with the demands placed on the service, and that they were expected to deal with a workload far above what could be safely managed.

Pressures to meet waiting time targets compromised care – for example patients were moved out of A&E regardless of their clinical state and how much monitoring they needed.

There were not enough senior and skilled nurses.

Wards were made more mixed to contain more different types of cases, despite objections from clinical staff that it would compromise care.

Trained staff numbers were reduced in ward reorganisations which went ahead despite opposition from clinical staff.

Why were the savings being made? The hospital was in debt, and this is what drove staff cuts.

Alan Johnson, then health secretary, has said there was a ”a complete failure of management to address serious problems and monitor performance”. But management had in fact been doing an awful lot of what they had been told to do: sort out the financial problems, meet the targets.

We are now coming round to thinking that it isn’t just individual mistakes that should be seen as problems, but the system, which allowed them to occur.

Blaming the managers is an easy option. Isn’t it the case that the system that managed this Trust – the political structure that told it what ‘good outcomes’ were – is the one to blame?