Laura Donnelly interviews the then new chief executive of London SHA

Listening back to the tape of this interview with David Nicholson, the first noise is the sudden babble of a large school party arriving in the foyer of Birmingham's International Conference Centre. The second is an almost as loud, lengthy cackle steeped in schadenfreude as Mr Nicholson detects my horror at the challenge facing the Dictaphone.

In fact, technology makes an effort, recording several equally significant moments, including the one when NHS acting chief executive Sir Ian Carruthers whisks him off to the gents to talk shop. (The DoH minders didn't actually follow them in there ? it just looked that way, witnesses later reassure.)

Anyway, back to Mr Nicholson. What is he like? What does he think colleagues would say?

'Well, I don't think I'm deluded - people would say I'm very direct. I can separate the job from the person. Very often people can't and they fall out with people over the job: I don't. I can be quite direct -

I drive things hard, I expect people to do what they say they are going to do.'

A pause. 'People who don't like me would say I was bit harsh, but generally people like working with me.'

He continues the introspection: 'I am by nature an extraordinarily competitive person,' citing as an example his determination to prove to Sir Ian that West Midlands had beaten Dorset and Somerset strategic health authority in getting its waits down. ('He denies it of course, with some complex statistical calculation').

Anyway, if we really want to understand Nicholson the man, he suggests, we can take a closer look at his preferred reading matter, since it was previously revealed in the very pages of HSJ: Philip Roth's Portnoy's Complaint, a funny if unarguably filthy take on adolescence, and a history of Nottingham Forest football club ('Nottingham Forest,' he insists. 'We don't calls it Notts').

Mr Nicholson joined the service in 1978 as a general manager on the national training scheme in Yorkshire, and spent a decade working in mental health, learning disabilities and community services at the time the old asylums were being dismantled.

The roles appealed because 'I thought it was where the action was' it was about the management of change, not about keeping the system running'.

In Doncaster he used the 'enormously powerful lever' of a residents committee to transform an 'old-fashioned 500-bed institution ? the kind where all the staff come from two or three families' - into a community-based service.

Acting in the interests of the patients is a theme he returns to: 'It sounds a bit pious, but I'm on the side of the angels ? the patients and the taxpayers ? not the organisations.'

In a similar vein, he tells a story - warning, 'this is going to sound terribly soppy' - of the treatment of his father, who had emphysema and asthma in the last years of his life. 'One year he was admitted to hospital 14 times; it was terrible.'

It left Nicholson junior with several lessons about the role of the expert patient ('he used to hide his steroids to wean himself off them when they discharged him because they wouldn't let him take them out of the hospital') and the impact of 'low-tech, simple solutions' ? in this case, a leaflet from a community nurse on quality of his life.

At the end of the story there is a moment's pause, which he quickly fills: 'Of course, he was a miserable old bugger.'

As the Thatcher reforms took off, Mr Nicholson saw an opening for change in acute hospitals. He spent almost a decade at Doncaster Royal Infirmary and Montagu Hospital, taking it to trust status.

Such stability contrasts with the average two-and-a-half-year lifespan of a chief executive these days, I note.

He agrees: 'One of things in the intermediate tier is you do have quite a lot of influence and power over people's careers and you do have to use that very wisely.'

'In any job there are times when it goes bad.' He describes as 'wholly destructive' the tendency of the service to 'get people out the door' at the first sign of trouble.

'The people I really admire are the ones that have got the organisation out of trouble. I'm very cautious about getting people out. Sometimes you have to do it. I

have done it a few times, but I don't think it's the first course of action to take.'

In 1997, he became Trent director of performance, and later regional director. When Shifting the Balance created four temporary health and social care regions, he was given the Midlands. Since 2003 he has been at Birmingham and the Black Country, in charge of an expanding portfolio of SHAs.

What is the difference between running an old SHA and a new one? 'We are here to change things, not to protect the status quo. We've got much more of a leadership role in terms of reform rather than being behind it or in the middle of it. We are trying to change things to drive it further and faster.'

The kernel of all this, he says, is getting organisations fit for purpose. After that, then, will SHAs be able to take a backseat role? He looks unconvinced.

First, there's the SHA's role managing the system: 'The idea that it is self sustaining is not the case ? we will have to intervene in the market; there's exit and entry.'

Second, there's realism: 'If you have organisations that are fit for purpose, boards who know which way is up, financial balance and all that in place, then you don't need a whole load of people going around ticking boxes... but I don't think we will ever quite get there.

Organisations will change, and there will always be an organisation falling over somewhere,' he says, grimly cheerful.