Nicholson seeks "legitimacy" amidst a storm of protest

From 1 April he will no longer, in his words, draw his “legitimacy from an elected politician”, but run an organisation which justifies its work though “its connection with patients and the public.”

Sir David dealt forthrightly with a wide range of subjects during his HSJ interview including an eyebrow-raising interventionist approach to service redesign, the board’s management style, care integration and the problems experienced by those whose jobs are being affected by NHS reform.

However, it was his comments on Robert Francis’ Mid Staffs inquiry which understandably drew the most attention when published online.

Like many healthcare leaders he was genuinely shocked by the findings of the first inquiry and, as he revealed to HSJ, he considered resigning after reading the patient stories in the report. But Sir David is proud of his record as NHS chief executive and believes he has “unfinished business” in “giving patients more clout” through the board’s actions.

The credibility for this aspiration is strengthened by his continued support for central “grip” where necessary. Few would take him seriously if he switched horses entirely in mid-stream. This is still a man who believes that leading from the centre works best in times of danger for the service, with some aspects of poor performance or when something needs to be fixed on a regional scale.

He would argue that the robustness of the service’s performance in tough times is evidence that his approach works. Indeed many leading figures who feared the reforms would fragment NHS services have privately expressed the belief that while Sir David is in charge the service is “safe”.

There will be a clamour for “heads to roll” following the publication of the Francis inquiry. But when considering Sir David’s position, Jeremy Hunt will have to think hard about the impact on a rapidly developing system of pushing for removal of the board chief. The answer to the question: “If not Nicholson, who?” is very far from obvious.

Much of the criticism directed at Sir David by HSJ readers is connected to a belief that he let a culture of management “bullying” develop. No doubt, Mr Francis will have something to say on that emotive subject, but HSJ suspects the NHS chief executive is often simply a convenient scapegoat for the, mostly successful, target culture of the last decade and for those who have had – justified and unjustified – bruising encounters as a result.

HSJ is more concerned with Sir David’s claim that the new commissioning structures are “undoubtedly” already better able to spot quality problems. His belief is based on the emerging system of quality summits and the idea that GPs involved in clinical commissioning groups have a feel for service quality through long experience of “referring and hearing feedback from patients”.

There is no reason why CCGs should not develop a more sensitive approach to quality monitoring. But to say that, during the turmoil of reorganisation, commissioners’ quality radar is better “now”, opens him up to accusations of naivety – something he was accused of during his cross-examination at the Mid Staffs inquiry. It also worth remembering that, as Andrew Lansley pointed out, local GPs should have blown the whistle on Mid Staffs but did not.

Sir David, of course, does not have a naïve bone in his body when it comes to how the NHS works – so his claim is likely to be an attempt to bolster the standing of his new CCG “partners”. However, he will do them little benefit by over claiming their capabilities at this early stage in their development.