Leader: Nicholson urges NHS to begin creative phase

Less than three months after NHS England formally came into being it already faces significant questions over its ability to lead the service. Its chief executive will be gone by March next year, his deputy is an interim and five of its most senior figures have moved on to apparently more attractive jobs.

‘Sir David seems to have loosened up. He did not quite say “let a thousand flowers bloom”, but that appears to be the message’

It will surprise no one that Sir David Nicholson has responded to this challenge by coming out fighting, claiming the NHS needs a “sense of direction” and that his organisation is the one to lead that work. What may surprise many is his proposed solution for determining that direction.

Sir David has given HSJ a wide-ranging exclusive interview, the first since he announced his impending retirement.

Who knows how thoughts of freedom from high office have affected Sir David’s thinking, but he seems determined to play against type. He says: “A Stalinist way driven from the centre just seems out of kilter really with the kind of NHS we want to create.” He encourages “experimentation” and urges the service to be “much more creative”. He even questions the relevance of the commissioner-provider split in some circumstances.

Maybe it is the knowledge that he will not have to manage the outcome of the strategy work that NHS England has officially launched this week, but Sir David seems to have loosened up. He did not quite say “let a thousand flowers bloom”, but that appears to be the message.

Planner in chief

It is also clear that he sees NHS England as much more than a wrangler of recalcitrant clinical commissioning groups. “We’re not a regulator of commissioners,” he declares − no doubt to the raised eyebrows of many CCG leads.

He adds that the government’s mandate does not require NHS England to “build a great commissioning system” − but to focus on improved patient care. Outcomes are what matters he says, so (almost) everything that affects those is fair game for NHS England.

‘Sir David intends to bequeath to his successor an NHS which will be travelling in a significantly different direction’

One could also imagine that Sir David is positioning NHS England as the “planner in chief” of a world in which there is much more service integration and much less direct purchasing of care by commissioners.

The latest polling shows the public attaches little importance to GP-led commissioning when it comes to redesigning hospital care. This is partly the product of ignorance, but the tide of health policy may be about turn to against the need for an internal market as previously conceived and if that did happen, there is little sign the electorate would worry or mourn. Many CCGs would also favour more emphasis on planning and less on purchasing.

Pipe and slippers

While acknowledging that Jeremy Hunt has correctly identified the fundamental issues facing the service, such as the care of the elderly, Sir David nevertheless stresses that NHS England can and should take a longer-term view than politicians who are ensnared within the electoral cycle.

The NHS England chief executive states he will not be “reaching for his pipe and slippers” any time soon and gently chides the service for its failure to understand the merits of the kind of extended handover between leaders common in other sectors. He is gearing up to lead the development of a strategy that will put momentum behind the “sort of conversations have been going on around the NHS for quite a long time now”.

He wants NHS England to “create the discussion and the debate, help people come to conclusions and then send signals out into the system to make it happen”.

Sir David knows the new leaders of NHS England are likely to have firm views and plans of their own. He intends to bequeath to his successor an NHS which will be travelling in a significantly different direction to the one that he has been managing for the last seven years.