This article was published in the Health Service Journal on 29 September 2025.
In my book Zero, I tell the story of Deb Hazeldine, whose mother Ellen died in appalling circumstances at Mid Staffordshire hospital. Ellen’s experience, and her daughter’s brave battle for truth and learning, became part of one of the biggest scandals in healthcare history. I now find myself worried that history may be about to repeat itself.
Ellen was 67 and in remission from cancer when she was admitted to hospital for physiotherapy after a fall. She should have been on the road to recovery but instead experienced a catalogue of neglect. Ellen was left for hours without food or fluids, never properly washed, sometimes covered in faeces. Nurses frequently failed to respond to her family’s calls for help and tragically, Ellen contracted both C.diff and MRSA hospital-acquired infections. When Deb complained, she was stonewalled.
When Ellen died, her family were told she had to be buried in a sealed body bag. Her daughter Deb described the hospital as “chaotic and uncaring” and she was right. But what happened to Ellen was not random, it was a consequence of a system that had become obsessed with meeting targets. Managers at Mid Staffs were under intense pressure to hit waiting-time and financial targets to secure coveted “foundation trust” status. That meant other priorities, including the basic hygiene and patient dignity that would have saved Ellen’s life, were pushed aside.
As Robert Francis QC wrote in his landmark inquiry, the appalling events at Mid Staffordshire were “in part the consequence of allowing a focus on reaching national access targets, achieving financial balance and seeking foundation trust status to be at the cost of delivering acceptable standards of care.”
Targets mattered more than patients, and people became numbers.
Not that targets are always wrong. I introduced a few of my own - for example on maternity safety, dementia diagnosis, and tackling E. coli infections. Long waits are distressing for patients and clinically dangerous so it was perfectly sensible for the Blair government to introduce targets to reduce them.
A few clear targets can galvanise the system. But multiple targets stop any local initiative and replace innovation on the front line with learned helplessness. At one point, hospital managers were expected to deliver on more than 100 different national objectives: emergency department waits, elective care wait times, multiple cancer treatment standards, mental health access, infection control, vaccine coverage, HIV transmission, sepsis, stroke, diabetes, obesity - the list went on. It was not until I became Chancellor, long after my time as Health Secretary, that I was able to work with Amanda Pritchard at NHS England to reduce this. But even now hospitals still have 18 monthly operational targets.GPs have 44 annual targets (through QOF.) We still have a top-down system that crushes innovation on the front line.
The effect of this overload is predictable. Managers on the ground ask which ones matter most. The answer they often get from the centre was the ones that make the headlines - mainly A&E waits, elective care, and financial balance. Right now A & E has been taken off the list so it is just two that really count. Other areas, in Ellen’s case, the basic hygiene that could have saved her life – are deprioritised. At the same time political pressure to ‘deliver’ creates a command and control culture, where managers feel they are accountable upwards to NHS England and the Department of Health, not downwards to patients. Targets became blunt instruments, where the focus becomes “hitting the number” even if that means “missing the point.”
Economists have a phrase for this: Goodhart’s Law - “when a measure becomes a target, it ceases to be a good measure.” We saw this during the pandemic where to ramp up Covid testing, the government set a target of 100,000 tests a day. It appeared to work - numbers surged - but behaviour was distorted. Postal test kits counted towards the target when they were dispatched, not when results were returned. Turnaround times, critical for isolating infectious people, were ignored. The headline numbers were delivered, but not the real outcome patients needed.
The same dynamic was at play at Mid-staffs. Nurses spent time filling out paperwork to meet bureaucratic requirements rather than answering patients’ call bells. Targets that were supposed to improve care ended up doing the opposite. Ellen’s story is nearly twenty years old, yet I worry the NHS risks repeating the same mistakes with the government recently reintroducing new NHS performance league tables. As NHS Providers has warned, trusts may focus only on the measures that immediately boost their ranking, regardless of whether they’re the right priorities for patient care. The King’s Fund also cautioned against oversimplifying hospital performance. To which I would add two further risks. First, the risk of confusion: should a trust focus on its league table position or getting a good Care Quality Commission rating (the latter does, of course, give a lot of weight to patient safety). And second, will the new league tables mean more top-down micromanagement in the NHS as hospital chief executives spend more time “managing up” than focusing on the patients in their care.
So what is the alternative? In short transparency not targets. Wes Streeting, Alan Milburn and I are all strong supporters of transparency. Both Alan and Wes will be seen as consequential health secretaries and I have great respect for them. But where we appear to be differing is how transparency is translated into signals in the system. For me the lesson of Mid Staffs is to take great care about giving overriding importance to a small number of targets. Much better to rate performance through an assessment that balances safety, quality, patient experience and waiting times - what the CQC ratings do. Then get the energy and dynamism into the system by dismantling micro-management and giving managers full autonomy to innovate. That way we have a chance of lower waiting times alongside quality of care not instead of it.
We can learn from how schools are now held to account. We do not set national targets for how many pupils should get good GCSEs each year. We do not have the Education Secretary calling headteachers to demand higher numbers. Instead, we use Ofsted inspections. These are professional, independent judgments about the quality of schools, published so that parents can see how their local school is doing.
That approach has led to real improvement in education, without the bureaucracy and manipulation that often come with national targets. We need the same approach in the NHS. That means fewer instructions from the centre, more focus on independent inspection by the Care Quality Commission, and greater openness about which hospitals are rated good or outstanding.
This does not mean lowering standards. Minimum levels of safety, timeliness, and quality must always be guaranteed. But it does mean recognising that not everything important can be measured, and that the best way to improve a complex and adaptive system like the NHS is to empower professionals, not micromanage them. The NHS does not need to return to a world where hospitals are judged by league tables or national performance scores. It should be judged by something simpler, and far more important: are patients receiving safe, kind, high quality care?
That was the lesson of Mid Staffs. It was the lesson of the pandemic. It must not be forgotten now.
