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Interview: Sir David Nicholson

Interview: Sir David Nicholson

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Head of NHS England, Sir David Nicholson is stepping down in March 2014. He tells The Commissioning Review about how he plans to use the time he has left

There’s little more than six months to go before David Nicholson steps down from his post as chief executive of NHS England. Love him or loathe him, everyone accepts he’ll leave some pretty big shoes to fill. So who should be the person to do that?

“I do not think they have to come from the NHS,” he says. “They need to have some understanding of health but I think they also need to understand how to work with government, because… for the CCGs [clinical commissioning groups] to thrive and develop, they need to be protected from some of the political goings on, and you need someone who is able to do that.”

Moreover, with the intense scrutiny that accompanies the position, he names ‘resilience’ and an ‘exemplary private life’ the other key attributes his successor must possess. “Everybody has a view, social media has developed a situation where everything that you do is under the microscope and you need to be pretty resilient to do all that. It does impinge on every element of your life. Their private life will become common currency.”

The one piece of advice he’d give his replacement is to “trust your instincts”. Referencing the publication of the ‘Francis’ report on Mid Staffordshire NHS Foundation Trust in February this year which contributed to his decision to stand down, he says: “The example I would give – a Mid-Staffordshire example – is that my instinct was to go and meet the patient group [which represented the families and patients affected by the trust’s appalling quality of care]. I was persuaded not to, and I was wrong. 

“I remember taking the report home one weekend to read through before it was published and there was an appendix which had all the patients’ stories; that was pretty bad. If ever there was a time when I reflected on what I did and why I did it, I think that was it.”

Nicholson has no set plans following his departure but it likely he’ll still be involved in the NHS in a more liberated capacity. “I cannot imagine a time when I am not engaged or involved in the NHS; I am such a passionate supporter of it and I think it is such an important thing for us. So we will just see. “My guess is that when I have finished I will be freer to talk about all of those sorts of things, if it is helpful. There is nothing worse than having the ghost of the old machine sat around.”

Though many will define Nicholson’s eight years as head of the NHS by the Mid Staffs scandal, the man himself regards the health service’s wider increased “focus on quality and patients” as one of his main achievements.

“I pitched for the job in 2005/06 at a time when the NHS was in a billion pound deficit and was in real, real trouble. I did not think at that time that the leadership of the NHS was sufficiently focussed on quality and patients. Since then, I have worked literally all the time to create that.

“So, I think if you look today at the NHS it is significantly stronger than it was in that period, both financially and clinically; outcomes are better, waiting times are shorter, patient satisfaction is higher, staff satisfaction is higher. I understand that sometimes it did not feel like that, but I think people will say that I took the NHS from a period of high growth to one of low growth, or no growth at all, and managed it in an effective way which improved services for patients. That is what I think people will say when they get perspective.”

There’s still time to add to that legacy, of course. Before next March he plans to publish a strategy for the NHS and re-negotiate the GP contract so that it better supports the aims of CCGs.

The strategy will start landing in the New Year, not as one mighty tome but a series of ‘products’ on CCGs, primary care, specialised services and public health spending. The bedrock of the strategy will be three-to-five-year plans from all 211 CCGs which must be delivered by January. 

“[These plans will set] out what the CCG hopes to achieve for its local population, having been through a process of discussing that with its local population,” he says. “That, in a sense, is the building block for everything else. That is really important to do because, if you think about the spending review and what it says about the transfer of resources to local government, we need to be really clear on what that looks like for each CCG by the end of this year, the beginning of next year.” 

“We want to see what CCGs want to do around incentives and levers and then to say ‘how can we organise the incentives and levers to do what they need to do?’” 

Nicholson acknowledges the capacity issues for CCGs and will support them through the Commissioning Assembly, a group set up for CCGs for them to communicate with each other and NHS England, and by “buying in capacity” to help.

“If you look at what came out of the authorisation process, some of the weaker parts of CCGs was the ability to plan over a period. So we are going to have to help and support them but I do not think we are going to have a template: ‘you must do it in this particular way’.”

NHS England will play its part in setting out the nature and shape of primary care over the next three to five years and how it is going to use the contractual levers to make that a reality. 

This will need to be defined swiftly as negotiations with the General Practitioners Committee (GPC) will begin in Autumn.

Of course, producing a plan for the way ahead for the NHS is always a risky business, especially when there is an election on the horizon. 

Many CCGs believed they had two years to prove they are making a difference so can a strategy withstand a change in Government? 

“Even if a government came in on day one and said they wanted to change everything, you need primary legislation to do it and that will take them two years. We are all going to be faced with the same issues, irrespective of what kind of government there is. I do think that out of this we could challenge politicians to be circumspect about what they say and do about the NHS going forward.”

While CCGs grapple with the idea of performance managing their peers, the buck stops with NHS England as they have taken over from primary care trusts (PCTs) as the holder of the GP contact. Nicholson says this situation is unlikely to change as “there is a big of conflict of interest”. 

“I do think that CCGs have a duty to support the improvement of primary care/general practice and that we, as NHS England, need to work really closely with CCGs. It is a powerful lever for both of us to use and I think we should work much more collaboratively and much closer together, jointly, on how we take the contract forward in the future.”

The CCG strategies will inform changes that can be made with the contract as “CCGs have been able to do things in general practice, in primary care, in this country that nobody has ever been able to do before in terms of shifting standards and attitudes”.

Although they are not the contract holder Nicholson does see it as a CCG responsibility to guard against poor care in general practice.

“Generally speaking, I would say we would rely on the CCGs to raise that as an issue with us in terms of their duty for improving quality in primary care. If it is something really horrible happening which involves real harm to patients, clearly we would expect CCGs or CQC or whoever gets to know about it to raise it. The CCGs, however, are really the eyes and ears of all of that.” 

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