We must redefine the role of NHS England chief executive

Sir David Nicholson’s retirement plans have prompted inevitable discussion about who might be chief executive next. This is a difficult task for pundits (not that it stops us trying), partly because, as I have written before, there is a lack of obvious candidates.

Yet who should do the job is probably the wrong question. The real issue is: what should the job description be?

NHS England is a new organisation and, to be effective, it will need to be more than the old NHS Executive offshored. If it ends up being this it will meet the same fate as the NHS Executive. I think NHS England knows this, but unfortunately I am not sure that it has determined what it wants to be instead.

Getting a grip of the new job

Sir David got the job because he was the obvious choice and, at a time of great instability, offered some continuity and grip. These were good reasons at the time. For the many in NHS England who have yet to be given a desk or a phone, or for those who were not paid in April, it will remain a good reason now.

For health ministers (who must approve of any appointment) who are buffeted by the accident and emergency crisis, it will also feel pretty compelling − as it will to the Treasury, which is always worried about a loss of financial control.

But “grip” wasn’t a good enough reason then and it should not be now. To succeed, NHS England has to be about more than simply managing trouble effectively and its new leader must be able to offer more than this virtue.

Independence − much trumpeted and described as “a prize worth fighting for” in Sir David’s retirement letter − only matters if you use it. Whoever is appointed will need to demonstrate they are prepared to stand up to ministers and to do so in the interests of patients.

‘Failures on specialised commissioning will undermine the credibility of NHS England more than anything’

The early months of NHS England have seen it disagree with ministers (for example on the A&E “rescue fund”), but not in a way that is identifiably in the interests of patients. The impression arising is that it is on the side of the service, not the people who use it.  A key part of the job will be to change this perception.

Dictation of the NHS from Whitehall should not be replaced by dictation from a new centre. The point of the reforms (and therefore of NHS England) was not to simply create a more independent (and arguably less directly accountable) form of centralised system management − yet this is what many in clinical commissioning groups feel. 

The process of establishment and authorisation has not felt the most liberating. Whoever takes over will find that maintaining leadership without crushing the enthusiasm or autonomy of clinical commissioners is a major task.

Control of commissioning

NHS England is the biggest commissioner in the country. The changes to specialised commissioning centralised responsibility for a good deal of services, and fundamentally changed the nature of specialised commissioning (for example, is the delivery of chemotherapy − something performed in most trusts and in the community − really a specialised service?). This being so, NHS England needs to demonstrate that it is effective − and more effective than CCGs would be − in commissioning these services. 

‘The political temptation will be to make a “banner” hire, which provides a clear political statement that things are changing’

Commissioning always involves difficult decisions, and the ability to explain these will be critical. Transferring such decisions to a national level makes sense in terms of consistency, but it raises the stakes considerably. Failures on specialised commissioning will undermine the credibility of NHS England more than anything. Whoever leads it will need to genuinely understand commissioning (many senior NHS leaders actually have little experience in this area) and have the ability to communicate effectively on the most difficult of issues.

The other area of direct commissioning responsibility for NHS England is the primary care professional contracts. With the ongoing row between the government and GPs, together with the Office of Fair Trading’s renewed interest in dentistry, this promises to be no easier. 

Negotiating professional contracts is a notoriously bruising experience even when there is additional money to ease the process. This time there will not be.

The political temptation will be to make a “banner” hire, which provides a clear political statement that things are changing. Appointing a clinician/NHS outsider/someone from a different health system (delete as appropriate) will only work if the candidate has the substance to back up the spin around the appointment.

The short-term benefit of a political gesture will be far outweighed by the long-term consequences of appointing someone without the diverse range of attributes required to make NHS England a success.

Mike Birtwistle is managing director at MHP Health Mandate