Putting his ideas into action is Dalton's biggest challenge

The world of the NHS provider can appear a binary one. You are either an ‘independent’ foundation trust, the master of your own destiny, or an NHS trust, straining for FT authorisation or waiting to be swallowed or broken up.

It is this black and white world of winners and losers – which never really reflected the reality of the NHS – which Sir David Dalton is seeking to challenge in the review he is undertaking for the government.

• Exclusive: Dalton unveils plans for hospital reform
• Dalton downplays talk of ‘superheads’
• More on the Dalton review
• Also this week: Hunt dodges the tricky issues NHS finance

When the Dalton review was launched in February the focus was on the creation of “hospital chains”, which would see successful NHS providers heading up groups consisting of poorer performers – who would see improvements as a result. This mood music grew louder as the health secretary referenced the education “superheads” and specifically praised Sir David and University Hospital Birmingham Foundation Trust’s Dame Julie Moore.

The idea of “chains” is unmistakably part of the review, but as Sir David makes it clear in our in-depth and exclusive interview this incredibly important initiative is much more wide-ranging and significant.

He and the group of senior hospital bosses he has assembled are, in a nutshell, out to the challenge idea that it is “foundation trust or bust”.

Sir David explains that he wants to explore a wide range of organisational models – which would create a provider landscape of differentiated and networked providers whose aspirations to deliver high quality services are not constrained by a centrally imposed structure.

Looking to Europe

The review is in its early days but Sir David is already clearly attracted to the greater standardisation present in the provider sectors operating in other countries, notably continental Europe. This standardisation “at scale”, both of procurement and of care pathways, seems to offer highly attractive efficiencies without the straitjacket of any particular organisational model.

Quite how an attempt to get the NHS to adopt common approaches will play with “localism” encouraged by all political parties or the desire for control exercised by various interested groups – particularly medical – will be something the review will need to wrestle with.

Sir David is also very clear about the importance of rebalancing the risk/reward equation and is unashamed about the need to put money into encouraging the best hospital leadership teams to spread their expertise. His call to take cash spent on “management consultants” and regulator-imposed “turn-around directors” and place it into a pot to pay for the development of the new models is likely to be warmly received within the service.

Just as popular will be his view that cooperation should be an important characteristic of the new provider landscape and that competition regulations should not stand in the way of their development.

However, perhaps the sternest test the review will face is how to get the ideas it ends up endorsing into the NHS’s bloodstream quickly enough to do some good. NHS leaders will need the confidence and cover to try new models at scale. The scope and size of the problems facing the NHS provider sector will also require many of the new models to be adopted at pace.

Sir David speaks of piloting the ideas the review suggests. The evolutionary approach that he understandably prefers may need to be injected with a greater sense of urgency and just a touch more central direction than he would like if it is to have a significant impact on the NHS provider sector at this crucial point in its history.