Sweet and sour

Published: 19/06/2003, Volume II3, No. 5860 Page 20, 21

On a sunny, muggy afternoon in Whitehall, Sir Nigel Crisp is sitting on the back of a sofa in his Richmond House office. A senior press officer is holding a large reflector behind the NHS chief executive, as HSJ's photographer sits on the floor, experimenting with flash effects.

'Try to include some of my daughter's paintings, ' says Sir Nigel, mildly, pointing out the striking canvasses he has chosen to hang in preference to a pick of the government's art collection.

If Sir Nigel feels kindly towards photographers, he does not feel kindly towards reporters just at the moment.

Indeed, while never less than civil, he is irritated that journalists - all journalists, even those working for HSJ - insist on writing about targets and red tape when they could write about the solid achievements of the NHS.

The sort of achievements set out in his annual report, for example, which just did not get the coverage it deserved.

'What you have to fix on in this job is what is happening for patients and how that is happening, ' he says. 'And what you have is two years in which waiting lists have come down and targets have gone in the right direction.'

Three important things happened last year, according to Sir Nigel. First, the number of people waiting for outpatient and inpatient treatment fell. Second, 'and I do not think any reporter has referred to this', more work was done in primary care, keeping people out of hospital.

And third, modernisation is happening - 'not enough, but it is happening'. In this context, Sir Nigel points to the development of 'see and treat' in accident and emergency departments and the launch of Patient Choice.

Sir Nigel is so keen to hammer home these points that he enumerates them several times.

One: waiting reduced. Two:

more work in primary care.

Three: modernisation happening.

Got it?

Around this, Sir Nigel says, there is 'a lot of nonsense'. The nonsense, apparently, includes the two big stories running in the newspapers in the week before this interview.

These were the claims in two Rupert Murdoch-published newspapers that the NHS is wasting funds on 'meaningless' management jobs, and reports of the Audit Commission's claims that several highly starred trusts have weak management and financial systems.

'Why is the Audit Commission behaving as it is when we have the Commission for Health Improvement?' Sir Nigel muses.

'There are lots of things that are not helpful. You just have to get away from that.'

The endless discussion of targets and their impact on the NHS misses several points, Sir Nigel feels.

First, targets are only part of the change process. Investment and the dissemination of best practice are also crucial.

Second, targets aim to capture things that matter to people - such as timely access to treatment - and they can have unintended good consequences - such as a morale boost for staff when they are hit.

Third, that most of the 44 targets faced by the NHS - 'one for every£1.5bn spent' - are actually clinical targets.

And fourth, that most of what the NHS spends does not go on targets anyway.

'I think things like the Audit Commission report do the NHS a great disservice, ' says Sir Nigel.

'It implied that all we are doing is concentrating on waiting lists, which is not true, [and that] it is not important.' In fact, he says, 'if you have something wrong with you, the quicker you are treated the better'.

Next year, Sir Nigel claims, the NHS will have met its ninemonth waiting target and the debate will have moved on. 'The press will be saying: fiWhat about the patient experience? fl 'That is the bit we need to concentrate on in the future, ' he says.

'That is why Patient Choice is so important - we need to involve people more and give them more say. We need to make them feel this is their NHS, and not something that does things to them.'

The London Patient Choice project was 'spectacularly good', Sir Nigel says, because it 'showed patients want [choice] when the accepted view was that they did not want it.'

This suggests that the NHS still needs convincing. 'Well, ' Sir Nigel says, 'it is not where we come from. People in the NHS are very patient-focused, but it is not how the service has been organised.'

In the future, it will be - but 'that is a change in the system, not the people'.

The flip side of patient rights, some would argue, is patient responsibility.However, Sir Nigel, as a good civil servant, is unwilling to comment on the Labour Party discussion document that suggests overweight people and smokers might have to sign contracts to improve their lifestyles before getting NHS treatment.

Sir Nigel is a relatively new civil servant. Famously, he had a short career in industry, at a Trebor sweet factory, before joining the NHS in 1986.

He ran a learning disabilities unit before moving into acute hospital management and then regional management. He was London regional director when appointed NHS chief executive and Department of Health permanent secretary on 1 November 2000.

In his two and a half years in post, the NHS has undergone significant structural change and come under more scrutiny. At the same time, managers have arguably come under more pressure.

They have certainly been the subject of a renewed bout of 'management bashing' in the right-wing press. The Sunday Times and The Sun have both run articles this month claiming that money is being wasted on an army of managers.

Sir Nigel has taken a robust view of NHS management. 'We need to improve as managers, ' he says, though he adds quickly: 'That is not to say there are not excellent managers in the system.' Over the past year or so, he says, managers have learned more about how to make changes and buy from the private sector.'

Sir Nigel has also instituted the Managing for Excellence programme, with its code of conduct, and wants to turn his attention to middle managers who, he says, can feel squeezed between the demands of frontline staff and top-line management.

He says 'there is evidence that good management improves things'.

'It annoys me that papers like The Sunday Times and The Sun lump lots of people together and call them all pencil pushers.'

An obvious way to stop this happening would be to disaggregate the figures that allow these papers to incorrectly compare the numbers of administrative or support staff with doctors and nurses.

Sir Nigel admits that the way the figures are presented at the moment amount to something of an 'own goal'.

DoH statisticians have been asked to come up with some 'clearer definitions'.Unfortunately, this will only happen 'in due course'.

Further change is, of course, on the way. The DoH itself is being slimmed down radically, a process that Sir Nigel admits will involve compulsory redundancies.

About 700 posts will go, though he hopes most of the people in them will be redeployed or lost through natural wastage.

Foundation trusts will be created - 'subject to the passage of legislation' - and there will be further changes in the inspection regime.

CHI will become the Commission for Healthcare Audit and Inspection next year, while a new, independent regulator will be created for foundation trusts.

Put these two bodies alongside the National Audit Office and the Audit Commission, and the NHS is facing a lot of inspection.

Sir Nigel sets out one model of who will be doing what: 'CHAI will do regulation of the service, ' he says. 'The foundation trust regulator will be a business regulator. The Modernisation Agency will be there to help with modernisation.'

Which leaves the NAO and the Audit Commission. NAO, the investigatory arm of the Commons public accounts committee, is not going anywhere. Where does the Audit Commission fit in?

'I think it needs to work out what its role is going to be, ' says Sir Nigel.

But he clearly feels that some rationalisation is necessary.At the moment, he points out, CHI, NAO and the Audit Commission can all publish reports on the same day - and demand that senior figures account for them. 'We do not want confusion and duplication, ' he says.

So will one or more of the regulators be disbanded? 'I do not know, ' says Sir Nigel. 'We have made it clear that CHAI is the health service regulator, but where it will end up I do not know.'

Could CHAI end up taking over the role of the foundation trust regulator? 'No, ' says Sir Nigel. 'It would not be a good thing for CHAI to be inspecting the thing it is also regulating. There would be a conflict of interests.'

So if anything was going to go, it would be the Audit Commission, wouldn't it? 'If I were a good civil servant, ' says Sir Nigel, 'I would know the answer to that question, but I have not got there yet.' Then he says, again, that there is currently 'too much politicking' going on and this is 'not helpful'.

The photographer decides to try a new effect, moving Sir Nigel to the fireplace and shooting through a mirror. 'You could get my mother's picture in from there, ' he says, pointing out a colourful figurative scene.

Then he talks about the next few years in the NHS, picking up on his earlier three points. 'First, people will hit their targets. I am sure they will, ' he says.

'Second, there will be a further shift into primary care. Third, there will be a continuation of the modernisation programme, ' with, for example, diagnostic and treatment centres coming on line, some of which will be run by the private sector.

This suggests that the NHS will be moving towards a more mixed market in healthcare provision, though Sir Nigel is not sure how far this will have gone in three years.

'The NHS will be starting to feel different, ' he says.

'Waiting lists will be lower, there will be more choice around. The health service will be provided by more of a mix of providers, including foundation trusts and the private sector.

'We are doing a lot every day.We want to see the NHS improve. I think the record of the past two years shows it has started [to] but there is a long way to go.'

With more, irritating, nonsense to get in the way, no doubt. l