NHS chief executive David Nicholson is in no doubt of the strength of staff's opposition to more change, or to their distaste for the idea of organisations competing against each other. Rebecca Evans quizzed him on what those staff can expect next

Ask NHS chief executive David Nicholson what has been his greatest achievement over the past year and he does not cite just one, but four. After 12 months in the top job, Mr Nicholson sees progress in four areas: using reforms to improve services to patients; sorting out the financial position of the NHS; developing a vision for the NHS and improving the relationship between clinicians and managers as the means to bring about change.

His description of the necessary changes as a 'journey' indicates that although he thinks the NHS has come a long way, there is still some distance to travel.

The chief executive's first anniversary coincides with a visible reawakening in and around Whitehall. Although Parliament is still in recess, MPs are beginning to re-emerge and are gearing up for the party conference season and the next session.

Mr Nicholson agrees that the timing of Gordon Brown becoming prime minister and appointing his new ministerial team just before the summer lull means managers have not yet been able to get a strong sense of what they can expect from the new health ministers.

Knock-on pressures

But he is keen to provide reassurances: 'The general thrust of change and reform has been continued. I don't see any big shift or change in the general direction which the NHS, and the reform of the NHS, is going.'

Other than this, though, he is not giving a great deal away about the ministers. There will be greater clarity after the comprehensive spending review in October, he says, 'when we've got a clearer idea about how much resource we are going to get'.

He does, however, address fears that a low settlement for social care would inevitably create knock-on financial pressures for health.

'[In] the evidence that we've given to the CSR and discussions with the Treasury on the CSR, we've taken the NHS and social care together because a poor settlement for social care and a good one for the NHS does not help the overall position.

'So we've consistently been looking at how we can make those cases together and provide an integrated front with the Treasury about what the system as a whole requires.'

In the meantime, Mr Nicholson has been, as the Department of Health press office put it recently, 'touring the country' with junior health minister Lord Darzi, whose interim report of his review of the NHS, now renamed Our NHS, Our Future, is due to feed into the spending review. He describes the regional visits he has made with the surgeon as 'a fantastic experience'.

'We've met literally hundreds of frontline staff; people have been very open with us,' he enthuses.

Nevertheless, what they have told him and Lord Darzi has not been particularly surprising.

'They say things to me like: no more organisational change. The second thing they said was: don't try and come up with a national blueprint.'

On both these counts, again, he wants to reassure. Although health secretary Alan Johnson has already said the review is not about organisational change, Mr Nicholson is happy to repeat the message. 'We have to keep reiterating it because history has not always proved that.'

And although the review's themes will be national, 'the way in which they are delivered is local'. Lord Darzi will draw up the national framework and each region will set out how it will be translated locally.

'There will be a review that's published nationally in the spring but there will also be 10 regional ones which set out circumstances. Each region will be in a place where they will set out what their vision for their part of the NHS is in the future.

'Until then, trusts and strategic health authorities should not feel that they must put their plans on hold, he says. If trusts are planning reconfigurations, for example, they should continue.

'If they are using the evidence and their proposals for change are clinically driven and they give benefits to patients, they should move ahead with them.

'What it [the review] will give the NHS locally is a much better picture of what the totality of service might look like, rather than the individual bits people are dealing with.'

Reporting burdens

And Mr Nicholson pledges to continue the push for devolution, which he says he is 'really quite passionate about'.

'Hopefully as I develop the relationship between the centre of the department, of the headquarters of the NHS, and the rest of the NHS, we will see a change in that relationship, fewer national targets, that kind of thing.'

Particularly welcomed by managers will be his intention to look at reducing the bureaucratic and reporting burdens they face.

Asked what is being done to tackle some of the damning conclusions of the Cabinet Office's capability review of the department, he says now that he has finished completing his top team at the centre, 'we will see some big changes in the way the department operates'.

'My next phase of this change is to start to be much clearer about what the relationship between the centre is and the rest of the NHS. So we will be looking at all the ways in which we interact as a department with the NHS, all the information that we ask for, what we do with it, whether we can significantly reduce the amount of information we get,' Mr Nicholson says.

'There's a whole series of things that you will start to see over the next few months happening to redefine the relationship between the department and the NHS in line with my absolute driving passion, which is to give the NHS, particularly the front line of the NHS, much more control and power over what happens.'

When it comes to autonomy, he cites foundation trusts as an example of greater freedom leading to 'better decision-making and better services'.

As the sector develops, he expects to see further changes. 'What we need to do now is start to drive some of the patient benefits of foundation trusts. Some of them have created surpluses - we need to start seeing how they are going to use those surpluses to improve services for patients.'

Mr Nicholson believes we will see further mergers, along the lines of the Good Hope Hospital takeover by Heart of England foundation trust in the West Midlands, and possibly even greater expansion as the entrepreneurship that foundation trust status offers is taken further.

'My guess is that over time we will see specialist chains being set up [by foundation trusts].'

Firm line

The NHS chief executive is waiting to see what the SHAs propose for those 'very difficult, very challenged' acute trusts that are still struggling financially, but mergers or foundation trusts taking responsibility for them are certainly a possibility, he says.

'What I want to get to by the end of this year is a position that we go into the next comprehensive review period - 2008-09 - as far as we possibly can without a whole set of historic debts around our neck for individual organisations.'

Looking ahead, there are some areas where the emphasis has shifted. Following Mr Johnson's announcement that there would be no third wave of independent sector treatment centres, the NHS chief executive confirms that the days of centrally driven private sector contracts are over.

'We are going to get away from the national and increasingly what we are going to be trying to do is to work out how we can be creating much more of a level playing field between the NHS and the private sector.'

The example he gives is of the extended choice network, which trusts can join if they meet tariff and quality standards.

He takes a firm line on the justification of using the private sector to improve poor primary care in urban centres.

'For 30 or 40 years we've been trying to solve this problem and we haven't managed to solve it yet. And I think that if it needs the use of the private sector to raise the standard and quality in those areas, then we should use it.'

But we can also expect a renewed emphasis on the NHS as a whole system. As part of the work the department has been doing on what the health service means to staff and patients, Mr Nicholson says some common themes have begun to emerge.

'People are connected to this idea of the NHS. The idea that the NHS is a group of autonomous organisations all competing, using contracts and cash, is completely running counter to what the people who work within the system think. I think that's a big part of the tension in the system - we need to go much more with the grain.'

Nicholson's greatest hits: The NHS boss on his achievements to date

What does the NHS chief executive believe are his major achievements after a year in the job?

Using reforms to improve services to patients

'What we've tried to do over the last year is explain to people that things like payment by results and practice-based commissioning enable you to [improve services].

'They are enormously powerful mechanisms to engage clinicians in change.'

Sorting out the financial position of the NHS

'Although it was a relatively small amount - half a billion on£90bn is not a massive amount - it was poisoning the environment around a whole series of changes that we wanted to make. Also it was questioning the competence of the NHS to manage its own affairs, and we had to sort that out.

'We have turned the corner. We've not solved every problem [but] it's been an incredible effort on the part of the NHS.

'When you think about last year where not only were we trying to improve services for patients, we were completely reorganising strategic health authorities and primary care trusts and putting people through all of that pain and difficulty, and we were trying to solve the financial [problems], I think they've done just the most fantastic job.'

Developing a 'compelling vision' for the NHS

Having built capacity via national targets and implemented the technical aspects of reform, the third stage in what Mr Nicholson describes as a 'journey' is how to take the system forward.

'It is a system and it's how that system works that I don't think we've quite articulated yet. We've started that work. And what I've been trying to do is define that in terms of what does the NHS mean for patients, what does it mean for staff and what does it mean for the public?'

Making change happen, with a focus on improving the relationship between clinical staff and managers

'What you find through the work that's been done is that often clinicians and managers can be quite suspicious about what motivations each have.

'But when you go underneath it they are all driven by the same kind of values.'