The NHS- a lesson learned.

On the 22nd of March 2009, not long before he was unceremoniously dumped by The Observer, a paper for which he wrote a compelling management column for some 16 years, Simon Caulkin, with a considerable prescience wrote the following:

MRSA, Baby P, now Stafford  hospital. The Health Commission’s finding last week that pursuing targets to the detriment of patient care may have caused the deaths of 400 people at Stafford between 2005 and 2008 simply confirms what we already know. Put abstractly, targets distort judgment, disenfranchise professionals and wreck morale. Put concretely, in services where lives are at stake – as in the NHS or child protection – targets kill.

There is no need for an inquiry into the conduct of managers of Mid Staffordshire NHS Foundation Trust, as promised by Alan Johnson, the health secretary, because contrary to official pronouncements, it is exceptional only in the degree and gravity of its consequences. How much more evidence do we need?


Target-driven organisations are institutionally witless because they face the wrong way: towards ministers and target-setters, not customers or citizens. Accusing them of neglecting customers to focus on targets… is like berating cats for eating small birds. ……………

And why, in Calukin’s opinion, was this all wrong?

If people experience services run on these lines as fragmented, bureaucratic and impersonal, that’s not surprising, since that’s what they are set up to be. Paul Hodgkin, the Sheffield GP who created NHS feedback website Patient Opinion ( notes that the health service has been engineered to deliver abstract meta-goals such as four-hour waiting times in A&E and halving MRSA – which it does, sort of – but not individual care, which is what people actually experience. Consequently, even when targets are met, citizens detect no improvement. Hence the desperate and depressing ministerial calls for, in effect, new targets to make NHS staff show compassion and teachers teach interesting lessons.

The evidence that Caulkin thought we did not need came with the release of Robert Francis QC’s final report last week. It contained so much of what Caulkin had indicated it might that in today’s edition of  The Guardian we have Labour’s shadow health secretary, Andy Burnham more or less parroting what Caulkin was saying four years ago.

I draw three central lessons from Francis, starting with NHS culture. Over the past 20 years, there has been a drive to import a commercial mentality into the NHS, which has given rise to a new managerialism and a focus on finance and targets. This approach may be well suited to retail, but there are limits to how far it can be applied to healthcare. On the plus side, it has helped to reduce waiting times and make hospitals more efficient. But in places the response was a tendency to focus on numbers, not people.

Francis is right to say targets, properly constructed and implemented, have a place. But he is also right to warn of an over-reliance on targets. This is a lesson Labour is learning. If we don’t, the NHS won’t be able to rise to the complex challenge of caring for older people – the second lesson from Francis.

He is right to ask us to rethink from first principles the way older people are treated. Stories of older people lost in acute hospitals – disorientated and dehydrated – have become commonplace. I have thought carefully about why this is happening.

The World Health Organisation defines health as “a complete state of physical, mental and social wellbeing, not the absence of disease or infirmity”. But for 65 years England has tried to meet one person’s needs through three separate systems: physical, through the mainstream NHS; mental, through separate buildings on the fringes of the NHS; and social, through a council-run, means-tested system…..

 Burnham’s party may have been slow on the uptake, but it looks as it may have someone within its ranks someone who realises the full implications of what’s happening.