This week is expected to see the publication of the revised Health and Social Care Bill. Health secretary Andrew Lansley has written that it will contain more than 150 amendments. It would be only mildly surprising to find one of them enshrining in law Sir David Nicholson’s position as NHS chief executive.
On Monday the government set out the full scope of the proposed changes to its NHS reforms. It included specific mention that Sir David would remain as NHS chief executive until April 2013, before switching to perform the same role at the NHS Commissioning Board.
HSJ cannot remember a similar endorsement of a named individual in such an important Department of Health policy statement. When HSJ interviewed him on the same day, Sir David admitted that neither could he, quickly adding: “and I didn’t write it”.
The question now is what will he do with the power his position gives him?
HSJ asks this week if the NHS reforms can really change their spots. Sir David – the biggest beast in the NHS jungle – is clearly happier, telling HSJ there is now “a much stronger transition path than we had before”. He praises the performance of the NHS during the coalition’s first year, saying it has been “remarkable” given the context and revealing that the DH quarter four report will show that “on all the big measures, healthcare-acquired infections, access to services, cancer waiting times… [performance] has held all pretty well.”
He is keen to “draw a line” under reform controversy and get stuck into building the new system, agreeing with HSJ that risk grows as uncertainty continues.
He echoes the line used by the health secretary in claiming the “intent” of the reforms was misunderstood – although he lays much of the blame for that misunderstanding on “the way” government documents, including the December 2010 command paper, “were drafted”.
He is mindful of accusations of empire building as a result of the accretion of powers around the Commissioning Board and is keen to stress, for example, how commissioning support and back office services for commissioning groups should not be provided by the board.
However, the sheer power of Sir David’s position puts him in a quandary. Last week the NHS chief executive admitted he feared the impact of the original competition proposals. Asked by HSJ when he first raised these concerns with ministers, Sir David said simply: “My job is to give ministers advice and to identify the strengths and weaknesses [of proposals] – and that’s what I’ve been doing throughout all this process.”
A true civil servant’s answer. But people will know that his influence makes him much more than that. He is also chief executive designate of an organisation which was commonly described by Mr Lansley in opposition as an “independent” NHS board.
Sir David declares his “general approach” to NHS reform is “well known”, citing, for example, that he has consistently said that “competition is an important tool to improve quality for patients”.
It is an interesting example, given that he is probably best known by those who have worked closely with him for pointing out the limitations and dangers of competition.
It shows Sir David’s skill that he can avoid being pigeon-holed as either an NHS backwoodsman or rampant reformer intent on liberating the service from public sector monopolies. The fact that he has and is regularly accused of both is another sign of that skill.
But as transition to the new system begins to motor, Sir David’s leadership will need to take on an even higher profile. Everybody knows he is in charge and that will mean being absolutely clear about what is best for the service – and not only to ministers.