Mackey must be Streeting’s ‘chief adviser’, says ex-NHSE chief exec

Sir David Nicholson was appointed NHS chief executive in 2006, when the post existed within the DH. In 2011, he became the first CEO of the NHS Commissioning Board, which became known as NHSE.

Amanda Pritchardstepped down as NHSE chief executive last week, with health and social care secretary Wes Streeting declaring the need for “a new relationship between the Department for Health and Social Care and NHS England”. He had already questioned whether the formation of NHSE has been a wise move.

HSJ understands the government favours a return to the so-called “three at the top” structure which existed between 2006 and 2011. This saw the department led by a permanent secretary, an NHS CEO and a chief medical officer, who shared equal status under the direction of the health secretary. Creating this set up could largely be achieved without legislation.

Sir Jim has been given the task of“transitioning” NHSE into its new relationship with the DHSC over the next two years.

Speaking to HSJ, Sir David stressed he had no inside track on the government’s plans and was speaking only from experience. He is married to NHSE deputy chief operating officer Sarah-Jane Marsh, but joked that “he never saw her”.

Sir David said he found it very valuable to be the health secretary’s most senior policy adviser and regretted the loss of that role when he moved to NHSE.

“Any policy papers that went to the secretary of state used to – literally – have my stamp on them, which said this has been supported, or not, by the chief executive of the NHS.”

This “counted for something” within government, where there were always many competing voices for the health secretary’s ear, he said.

Closeness between the NHS CEO and health secretary had other advantages, he claimed.

“Having a divided camp does not do you any good at all with the Treasury,” said Sir David, as any “sliver of a difference” would be exploited to weaken the NHS’s negotiating stance. After the creation of NHSE, the DHSC insisted on leading on negotiations with Treasury, but were now “one step away from the delivery side”. This frustrated NHSE which could not – officially – make its case directly.

Sir David, who now chairs four trusts in the West Midlands, added that if there were “multiple voices [from the centre] talking to the system, then it’s a big problem”.

Suggesting this had become a greater problem over recent years, he said: “Everyone needs to be on the same page. The NHS watches for nuance [and will notice] any kind of differences. The discipline involved between the secretary of state, Jim [Mackey] and whoever the permanent secretary is going to be is going to be enormously important.”

Interviews for the vacant DHSC permanent secretary role take place this month.

Sir David noted the NHSE communications team had grown “massively” since he left the organisation in 2014. He said merging it with the DHSC comms team “sooner rather than later” was “a really important part” of ensuring a consistent message.

‘Nonsense’ that NHSE was ever independent

Sir David said the idea that NHSE had “independence” from government was “all nonsense” – and that it was “unreasonable” to expect ministers to stay out of the most important clinical and operational decisions.

In this context he said he was “absolutely amazed” when NHSE was given the responsibility “of allocating resources, which in lots of ways is essentially a political, not a management, decision”.

However, Sir David warned that in his experience “the department was essentially a governance-free zone” where too many decisions were made on ministerial whim, and the influence of the strongest professional and public interest groups held too much sway.

The creation of NHSE had “created a proper systematic way of governing this huge amount of resource”. It was important this was not lost, he added. Independence also enabled investment in areas politicians would not prioritise, like “the need to enhance and develop leadership across the system”, he said.

More positively, Sir David said the creation of a new structure could potentially end the significant tension created by DHSC and NHSE using different data when debating policy decisions.

This trend accelerated during the tenure Sir David’s successor, Lord Simon Stevens, as NHSE CEO. But even before this, Sir David said it was common to find a “counter narrative” to NHSE proposals was held by ministers and civil servants, based on analysis of their own information.

Sir David warned against “slashing and burning” the NHSE workforce any more than already planned until there was “a clear plan and resource envelope” for how the service would be run.

“If you turn everything upside down, all that will happen… is that you lose all your best people”, he added.

Pritchard’s departure ‘not a surprise’

The former NHSE CEO said he was not surprised at Ms Pritchard’s departure, since the leader of the service was often changed after a general election.

Sir David said that as the government prepared to launch its 10-year plan, “they want someone they completely, utterly trust”. This, he stressed, was “not a comment about Amanda, [but] because I think anyone who’d worked for the Tories for so long… would not have been the right person”.

Trust was vital, remarked Sir David, as it would “trump” any structure which was adopted to run the service. “If you’ve got the right people who are on the right page, the [exact] arrangements are less important,” he added.

The former NHSE CEO noted that when he created the organisation it had just 5,000 staff. He said NHSE’s rapid growth – to, at peak, a workforce of more than 20,000 – had distracted it from its core role.

This, he said, was twofold: to provide the “management capacity” needed to drive change, as well as delivering investment in digital technology and capital projects.

He noted that – at regional level at least – NHSE was not able to provide the “leverage” to “enable us to do the big changes and improve productivity”.

Sir David said he hoped the changes led by the new NHSE CEO would change this.