Nicholson urges NHS to begin creative phase
6 June, 2013 | By Alastair McLellan
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.
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.
Sir David Nicholson announces major review of NHS strategy
7 June, 2013 | By Dave West
NHS England chief executive Sir David Nicholson has told LGC’s sister title Health Service Journal it is time to question whether “the straightforward commissioner-provider split” is the best way to organise care for some communities.
He also called for the “cookie cutter” policy of all NHS providers becoming foundations trusts to be abandoned.
The NHS England chief executive announced a major review of NHS strategy in an exclusive interview with HSJ in the run up to this week’s NHS Confederation conference.
Sir David, who has announced he will retire by March next year, insisted he would not be “reaching for my pipe and slippers” in his remaining months in the post. He said NHS England’s strategy would seek to “liberate” the service to “experiment” with a range of solutions to challenges faced by the NHS.
“The idea you could have one model in a sort of Stalinist way driven from the centre seems out of kilter really with the kind of NHS we want to create,” he said.
NHS England will publish a “case for change” in the coming weeks then lead a national discussion with the public on a three-to-five year NHS service strategy. There will also be a “call for evidence” and review of the best “provider landscape”. Findings are expected to be published early next year.
Sir David highlighted the uniting of commissioners and providers as one of the main ideas to be explored in the strategy review.
“We’re very interested in thinking about integration of commissioning and provision and we can work with Monitor and others on how that could work, in particular circumstances and against particular sets of challenges.”
He said NHS England was already “thinking about the possibility of mutual [organisations and] social enterprises, and also about whether the straightforward commissioner-provider split is the right thing for all communities”.
Sir David called on the service to look closely at US organisations Geisinger and Kaiser Permanente, which serve as insurer and provider for a defined membership. He said: “We need to be much more creative about those sorts of models of integration, which go beyond simple provider integration.”
The review will consider “the different ways of organising ourselves from, on the one hand, chains of hospitals, through to integration,” he said.
Sir David also condemned the idea of a “cookie cutter foundation trust pipeline”. The strategy will examine “whether the foundation trust is the right model for all [provider] organisations in the NHS”, he said. “We should liberate people… if they think [alternative models] are the right thing to do, they should do it.”
Sir David said the strategy work, which will also include discussions in each locality, should lead to service transformation. Progress on this had been “variable across the country” since 2008, he claimed.
He said the strategy work was based on a strength of the NHS reforms − the creation of a “vehicle” in NHS England which is “separate from the government [and can] look strategically… see outside of the electoral cycle”. It can also look beyond the current design of the commissioning system, he said.
“The [government’s] mandate doesn’t say you [have to] build a great commissioning system; it says you have to improve outcomes. So of course we’re interested in the nature of the NHS that’s being created. We’re not a regulator of commissioners.”
He added: “The NHS needs and wants a sense of direction, which I think NHS England can provide.”
Sir David has said he may retire before March if his replacement is appointed. Asked whether his successor would necessarily follow his strategy work, he said: “If we do it properly.” The successor is likely to be involved in the final stages of the work.
Sir David said NHS England had a strong set of non-executive directors. “They want to create something which is long-lasting and not something which will shift every time you have either a new executive director or even a new government.”
“What is really important to the chair in appointing my successor is to get someone who buys into the values and principles of NHS England.”
Part of the NHS England’s strategy will specifically cover specialised services, which it commissions directly. Sir David said NHS England could potentially identify “a smaller group of organisations which are equipped and organised” to provide these, with which it could “essentially concentrate and centralise” services. It could “give them much more flexibility in the way those things are operated”.
Sir David, who has said he will retire by March 2014, has highlighted that uniting commissioners and providers is one of the main ideas to be explored in the strategy review. A “case for change” in the coming weeks will be published by NHS England which will guide a national discussion with the public on a three to five year NHS service strategy. Sir David said: “The NHS needs and wants a sense of direction, which I think NHS England can provide.”