The man appointed to lead the NHS was the only public sector candidate on the shortlist. But as Laura Donnelly reports, he believes the market is the route to equity equity

'I'm absolutely over the moon.'

After an international talent search, and a field that included candidates from the US and domestic private health sectors, a man who has worked in the NHS for 25 years has got the top job.

David Nicholson is thrilled. For now, that is all he will say about it, since he does not take up post as NHS chief executive until September, but he was interviewed by HSJjust before the deadline for applications closed, when he described himself as an 'extraordinarily competitive person'.

He also spoke about his management style ('I can be direct. I drive things hard, I expect people to do what they say they are going to do. People who don't like me would say I was a bit harsh'), his passion for Nottingham Forest, on whose grounds his father's ashes are scattered, and perhaps most relevantly his view of how the NHS should operate.

His opinions are likely to have pleased the interview panel, not to mention the prime minister, on whose approval the appointment rested.

A need for speed

Asked in June what he wanted to see from the government over the next six months, Mr Nicholson said he wanted to drive the reforms faster, and was keen to see plenty of new entrants to the market 'right through to the private sector running district general hospitals'.

Now he is in the right place to make it happen.

'I want to drive the reforms faster if anything. I'm very keen on new entrants to the market from social enterprise organisations right through to the private sector running DGHs. I think that's all part of what we need to start developing and I think government's job is to make that happen.'

Like several recent health secretaries, Mr Nicholson is a former Communist who appears to have taken an interesting ideological journey. Colleagues describe him as a pragmatist, but say he keeps his values central.

Mike Farrar, chief executive of North West strategic health authority, and one of the applicants for the top job, speaks warmly of Mr Nicholson, having worked alongside him for years.

'For David, it's not party political, but it's value-based,' says Mr Farrar.

'David is not dogmatic; if it will improve services, David is on the side of it. I would say his subconscious test is &Quot;would this be right for my mum?&Quot; not &Quot;which policy area does this come under?&Quot;.'

Mr Farrar believes his background strengthens those values: 'He's a working class lad from a working class family. He believes in the NHS and he believes in equity.'

Taxpayers before organisations

It is a point that Mr Nicholson repeatedly made in his interview with HSJ, stressing that 'the interests and needs of taxpayers are above those of individual organisations' and describing strategic health authorities as 'on the side of the angels'.

Asked what the priorities for the service should be, Mr Nicholson was clear: 'The biggest challenge for us in terms of transformation is hospital utilisation. That's the big issue we've got to get a handle on; otherwise we spend two-thirds of GDP on tertiary services.'

Mr Nicholson's career began with a decade in mental health and learning disabilities, the area he chose after completing the national management training scheme. It was an unusual choice at the time, he says: 'People said you shouldn't do that, it's not good for your career - you have to work in acute hospitals, but I decided that I would do mental health.'

As unit manager for learning disabilities in Doncaster, in 1985 he met Neil McKay, then unit manager of Doncaster Royal Infirmary, now chief executive of Leeds Teaching Hospitals trust and formerly deputy chief executive of the NHS.

The pair are now close friends, and Mr McKay describes Mr Nicholson has having the 'ability to deliver no matter what the odds'. He sees the appointment as an endorsement for the NHS, and the quality of its management. 'Given the fanfare coming out of Whitehall about this international search, I think this is a ringing endorsement. He's an NHS man through and through. I think we should all celebrate this - it's a success for all of us.'

Decades of experience

After 10 years in community services, Mr Nicholson spent a decade in acute hospitals. And then, since 1997, he has been in performance management and a series of roles in the intermediate tier. These include stints as Trent regional director, Midlands director of health and social care, and for the last three years chief executive of Birmingham and the Black Country SHA, and an expanding range of SHAs.

He also has a lot of experience of national policy formulation: he was responsible for the human resources strategy behind the last NHS reorganisation, Shifting the Balance of Power, and for the early stages of the HR strategy for the current set of changes. Last month he took up post leading London, a job which will now last less than three months in total.

West Midlands SHA director of strategy and regulation Peter Spilsbury has worked closely with Mr Nicholson, who he describes as 'one of the most impressive people I have ever worked with in any sphere'.

'He's utterly dedicated to achieving results for patients and the public. He's also passionate about tackling inequalities in health - that's what drives him, that's why he came into the service.'

He reels of a list of qualities he sees in his former boss, who he describes as 'a true leader'. 'He's very astute: he does nothing by accident. He genuinely believes that NHS management and staff are capable of leading the service forward. That they can push a lot of the change, and don't necessarily need to be pulled... He's extremely analytical and extremely numeric; I have seen the cleverest people with numbers be unpicked by David.'

NHS Confederation chief executive Dr Gill Morgan agrees, describing Mr Nicholson as someone who 'tries to hide his intellect under a bushel'.

Earning respect

She adds: 'He's worked at every level of the service and he knows it from top to bottom. It's just so good to have someone with that sort of respect who comes from the service, and has beaten international competition from all sectors to get the job.'

The phrase that sums him up, she thinks, is one that many others use about him: 'tough but fair'.

She continues: 'He gets people to pull together. He doesn't take hostages. That's much easier than dealing with ambiguity.'

Mr Spilsbury concurs: 'When he started in Birmingham, the reputation that came before him was that he was this tough, hard man. In fact I don't think David would be too worried about that, but in his actual behaviour he's pretty compassionate.'

'If he is dealing with a performance issue with a colleague then he is absolutely direct, but he works with them to find a solution. Some people do find honesty very difficult, and he has high expectations of people. He doesn't duck issues at all. He's direct but he's compassionate. He's not a thug.'

He adds: 'David never needed to breathe fire down our necks. I think because we admired him it wasn't his wrath we feared, but his disappointment.'

Mike Farrar became chief executive of South Yorkshire SHA after Mr Nicholson had been regional director of Trent. He said: 'What I inherited was something that was sustainable. He creates things that last when he moves. That's actually really rare and in the past that's something I personally have found quite difficult. That tells you volumes about his style: he is really good at developing people.'

A clear view ahead

Peter Spilsbury is optimistic that Mr Nicholson's school of leadership will bring 'clarity of strategy'. 'I would imagine far less flurries of policy documents and a much more collegiate and trusting approach, letting organisations manage but setting out high aspirations,' he suggests.

Few people can talk about Mr Nicholson without discussing his sense of humour. Dr Morgan checks herself before almost suggesting he is wasted in NHS management. But she does say: 'He's really fun. He's got a fantastic sense of humour and he can tell a story better than anyone. I look forward to a lot more laughter in NHS management.'

Now, she believes, Mr Nicholson has 'four big challenges ahead'.

'Firstly, to deliver on the financial side, secondly, to rebuild a collegiate and collective spirit that makes people deliver - and I think that feels very dented. I think the appointment in itself will help towards that. Thirdly, it's about improving clinical engagement in shaping the direction and politics. Finally we need to get a strategic vision, in some context: not just looking a couple of years ahead, but to the next four or five years.'

NHS Confederation policy director Nigel Edwards adds: 'There is some &Quot;unfinished business&Quot; for him to deal with in terms of the way the Department of Health works. I think he needs to work with the new permanent secretary to work with the more dysfunctional elements and create a culture which is less toxic. The culture can overwhelm people, but he's a tough cookie.'

He also suggests that the DoH's greatest mistake would be to try to mould Mr Nicholson into something he isn't, in particular with regard to his media role: 'If he's allowed to be himself, he'll be fine.'

Neil McKay offers some reassurance: 'Oh, he's his own man, he's very straight and he's very true to his roots. He won't be seduced by the razzmatazz.'