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Feature: Exit Interview

15 May 2014

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In his final interview before stepping down as NHS England chief executive, Sir David Nicholson reflects on his time at the top

Sir David Nicholson appeared relaxed, sitting in the speakers lounge after his final talk as chief executive of NHS England at Commissioning Live, London.

But it’s been tough at the top. 

He’s been branded ‘The Man With No Shame’ by the tabloid press for his role as head of the strategic health authority overseeing Mid Staffordshire Foundation Trust at the time of high death rates and poor care documented in the Francis report. 

He is also the man who brought in stringent cost-cutting targets for the NHS (the ‘Nicholson challenge’ to save £20bn) which were heavily criticised by the Healthcare Commission for causing managers to be too focused on finances, and hitting targets rather than good care. 

Fears that this would be his legacy may be well founded.

Speaking with Management in Practice just one day before retirement on 31 March 2014, Sir David acknowledged that as a chief executive, criticism is par for the course – particularly when he is freely available on social media websites. 

He joined Twitter at the end of January 2014, and instantly created a furore over sharing an ill-advised link to a video with the NHS England director of patients and information’s head pasted onto Hitler’s body. 

Like a chastised child, Sir David mumbles: “One of my problems is, I think I’m really funny. When I saw the video of Tim Kelsey I laughed so much, I wanted to share it with everyone! But when I pressed the button everything exploded. 

“People were offended by it and I know I shouldn’t have sent it.” 

He casually leans forward over his cup of tea, revealing his real reasons for exposing his quirky sense of humour and making himself freely accessible to scrutiny online. 

“I always thought that I should go on social media, because it’s a really powerful way of connecting with people. A major part of any chief executive’s job is connecting. But my organisation was slightly worried about me doing it for two or three reasons.

“There is a group of people out there who I would describe as a lynch-mob,” he says.

 “Wherever I operate they come and are very critical. There is a group of people who constantly abuse me on there – but I wasn’t worried about that. It’s part of the job. I’m never going to be popular with everybody and people have a right to express their views.”

This apparent willingness to do what needs to be done, regardless of ‘lynch mobs’ and criticisms, could be why Sir David has proposed joining the new press regulator – when it’s set up.

When asked whether this was a promise or a threat, Sir David appeared taken aback. His aim, on retirement, is to help the NHS in any way possible.

“I strongly believe that public service gets a raw deal and there’s no one to defend them. I think I could play a role in helping newspapers to better understand public service – it’s vitally important to millions of people,” he says. 

Sir David Nicholson joined the NHS 36 years ago after joining as a graduate trainee. He worked in mental health, community care and hospitals before working his way up to the NHS England chief executive role in 2011. This is a health service devotee, a self-described “NHS lifer”. Judging by his attempts to remain in the game until the very last moment, it’s possible he isn’t ready for retirement.

 Still, with every goodbye there are lingering regrets. For Sir David, his biggest was being unable to straighten out the way that competition is used in the NHS.

During his speech at Commissioning Live he revealed that NHS England and Monitor, the healthcare sector regulator, had been “struggling” to create a set of rules that everyone could understand. According to Sir David, the idea of competition in the NHS is not new.

‘Competition confusion’

The Health and Social Care Act – which created clinical commissioning groups (CCGs), health and wellbeing boards, and NHS England itself – was an attempt to create a locally based competition regulator. The highly criticised section 75 of the Act compels CCGs to put services out to tender unless there is only a single possible provider.

“I think I was more hopeful that I could get out a clear exposition of what competition means in the NHS, that people could use and understand,” says Sir David.

“The confusion around competition, and the current way it’s being dealt with is holding back the NHS from making the changes that are needed. It’s becoming a disincentive to making ambitious change. I wish I’d got that sorted earlier – I just haven’t had a chance to do it.”

But the issue of competition wasn’t his only regret. He also revealed concerns over the way that primary care and other services are commissioned – what he called the “split”. 

Sir David believes in aligning incentives. He believes in joint commissioning. That hasn’t come naturally to the health service following the implementation of the Act, but Sir David said it will be vital if the NHS is to improve outcomes. 

“You can see how at the seams there are some significant challenges to tackle. Increasingly, I think we will see joint commissioning between CCGs and NHS England in terms of primary care. It’s important that we move onto that quickly.

“We know that given our ambition to get better outcomes for our patients, and the pressures on a day-to-day basis that we can all see – the population is shifting, the demands on the service are increasing, the ambition of our people – all of this is moving demand in very different ways.” 

Some politicians – Sir David didn’t care to name names – are of the opinion that since the NHS has been given more money, in the guise of real-terms growth, and is “better off” than local government, that the health service should just be getting on with it. 

But he had a short, sharp answer. 

“No, we can’t. We have to think carefully about the way we deliver services for our patients to ensure that we can improve outcomes.” 

The Call to Action – first unveiled in July 2013 and followed up by a General Practice Call to Action in August 2013 – was NHS England’s first attempt to plan how the NHS will tackle the challenges of people living longer, the burden of long-term conditions and dementia and the forecast of a £30 billion funding gap between 2013/14 and 2020/21. Over a quarter of the population – just over 15 million people – has a long-term condition such as diabetes, depression, dementia or high blood pressure. They account for half of all GP appointments and 70% of hospital bed days. 

“At NHS England we set out six things we think every healthcare system will have to do to become sustainable in the future,” he says (see box one). 

“The first one I think many would sign up to, but for some it becomes a slogan or statement rather than a reality. ‘How can we create an environment where citizens, patients, carers, service users have power over their own health and their own healthcare, and exercise that power? How can we make that a reality?’ 

“We all know that given the right information, technology and education you can make remarkable changes to your own health and your own healthcare. 

“If you think about the challenges going forward, that’s going to be a vital part.” 

Nicholson has challenged the NHS to save a total of £20 billion through efficiency savings by next year. Many clinicians maintain that frontline services will have to be cut in order to meet the savings. 

But if this no-nonsense measure works, despite the job losses and service cuts, if it actually manages to improve the quality of healthcare in the long run, saving the health service from consuming itself… Wouldn’t that be a legacy to be proud of?