I couldn’t be more serious in beginning to reflect on the Francis report with a joke. The joke is employed by Slovenian philosopher Slavoj Zizek in his illustration of ideology, quoting from the director Ernst Lubitsch’s film Ninotchka. In this film, the hero visits a cafeteria and orders coffee without cream; the waiter replies: “I’m sorry, sir, we have no cream. Can it be without milk?” For Zizek, the philosophical import of this joke expresses the Hegelian notion that “what you don’t get is part of the identity of what you do get.” The Francis report is a strong cup of coffee, but in the interests of our patients we should be more mindful of what was left out.

I am referring to the fact that the terms of reference narrowed the inquiry to a restricted interest in purported failures of scrutiny, regulation, and monitoring. There is no room for inquiry into whether a system of care modelled on competitive markets might be to blame. In this respect the report takes on an ideological function; its most essential attributes reside in what was actually left out. Francis himself articulates the dominant ideology when he says that “it is not the system itself which will ensure that the patient is put first…” and that quality care should be possible “whatever the system of provision.” This in spite of the fact that he repeatedly identifies the toxic effects of a corporate organisation in the midst of a healthcare market, that through market imperatives finds itself placing “a high priority on the achievement of targets…dominated by financial pressures…statistics and reports were preferred to patient experience…” There could be no better example of the domination of use-value (quality of care) by exchange-value (targets and financial performance).

Constrained in its remit as the inquiry was, the results are predictable. By my count over 80% of 290 recommendations allude to regulation, monitoring, and scrutiny. This restricted scope produces some comical results. Most absurd is the suggestion that there be “training” in compassionate care, as if this most social of human attributes were not a product of the very structure of social relations in which it manifests. When compassion fails, we must look primarily at the system that produces this lack, and not expect to train or regulate it into existence. In his analysis of corporations, Joel Bakan describes the tendency of such institutions to adopt rather psychopathic traits. It is primarily the market system, and not individuals, that becomes inhumane.

In the same way that the financial crash of 2008 should lead to reflection on the legitimacy of finance capitalism, the crisis at Mid Staffs should lead to reflection on the legitimacy of a healthcare market. As Marx remarked, “To be radical is to grasp things by the root.” I fear that Francis was merely pruning leaves. It seems inevitable that the future will bring further major inquiries. I live in hope that they might come served with milk or cream.

Sean Roche is a consultant psychiatrist in North London, and a visiting research fellow in philosophy at King’s College London. After completing his philosophy PhD in 2011 he has maintained a research interest in philosophical and political issues that are relevant to both psychiatry and medicine.

I declare that I have read and understood the BMJ Group policy on declaration of interests and I have no relevant interests to declare.