For various different motives, the campaign to force out the NHS chief Sir David Nicholson seems to be gathering pace. The NHS blogger Roy Lilley added his advice to the smouldering fire this morning. But personally, I would be worried about replacing one NHS chief with another in exactly the same mould – unless there was some consensus about what we need instead.
And therein lies the difficulty. Nicholson is a symbol of the command-and-control NHS system which has been found so wanting, the creation of the Blair Brown years. But the coalition has not yet grasped the problems with that system, and has not yet fully articulated a different approach.
The NHS itself yearns to be set free from the straightjacket, but nobody has yet articulated the central philosophy around an alternative.
When it comes to the future of public services, the coalition are still half-in half-out of the old world – understanding some of the difficulties, but still clinging manfully to some of its most destructive tenets (see what I wroteabout some of these).
So let’s imagine for a moment if Sir David Nicholson was to go – and I expect he will retire eventually (most people do) – what kind of person should take over? This is my answer:
- Someone who recognises the central importance of the human element. In the end, it isn’t regulations or targets or IT systems which make the difference to healthcare. It is the ability of frontline staff to make effective relationships with patients and with each other, and to use their skills to make a difference. Managers forget that at their peril – and the old dispensation forgot it disastrously. Without those formal levers, the new NHS boss will need to exercise leadership on a whole new scale – but not to claw all the charisma to themselves, but to foster leadership at every level.
- Someone who understands the importance of flexibility. Not just because flexible services are more able to meet the needs of patients, but because inflexible services are staggeringly wasteful – those long-term patients who are expected to travel to see their consultant every six months, when they don’t need to, but can’t get an appointment when they do need to. Re-think some of those systems, use new kinds of communication – I believe there is this new invention called the telephone – and you might just release the resources that the new NHS needs.
- Someone who understands the importance of human scale. We need another NHS boss who believes in economies of scale like a hole in the head, when it must be quite obvious that – where economies of scale do exist – they are very rapidly overtaken by the diseconomies of scale. The evidence is that, the bigger the hospital, the more they cost to run – the era of hospital mergers and bigger and ever bigger systems needs to come to an end.
The old dispensation, shaped by Blair and Brown, led to sclerosis and ever higher costs. No, that wasn’t their intention, but that is what happened. It also led to divisions between the frontline and the centre, and continued divisions over disputed words like ‘choice’ – which remain major stumbling blocks even now.
So if we are going to recruit a new chief, we need someone who fully understands the failures of the past and the possibilities of the future. Somebody ought to write a job description – let’s debate it in public. If we do, I'm on the side of these three things: human relationships, flexibility and human scale.