The current leadership of the NHS should take “complete” responsibility for the culture of fear that led to the care failings at Mid Staffordshire Foundation Trust, the outgoing chief executive of the Health Foundation has told HSJ.

Stephen Thornton is retiring at the end of the month after 12 years at the quality improvement charity and a career which has also included more than 20 years in health service leadership.

In an exclusive interview he criticised the “Stalinist mindset” of NHS management over the past decade and called for NHS England’s next chief executive to be prepared to lead major reform.

Mr Thornton said during his time at the foundation he had observed a gradual shift “towards a much more centrally driven, target focused, hit them harder, work them faster mentality” in management.

“In the hands of very sophisticated people that’s OK … but in the wrong hands – in the hands of rather naive people, people not very good, people overwhelmed, people out of their depth – it turns nasty, it turns into the deeply negative cultural traits that we saw at Mid Staffs,” he said.

Mr Thornton said the personality of the new NHS England chief executive would be critical to moving forward and he insisted the holder of the post must not be “one of the old guard”.

In his report into Mid Staffordshire, Robert Francis pointedly chose not to criticise NHS England chief executive Sir David Nicholson and other senior officials, arguing to do so would be “futile” amid such a widespread system failure.

Asked how much responsibility the “old guard” should bear for the development of such a culture, Mr Thornton said “complete”.

“They are the leaders. They have been the leaders of the last decade. I’m not pointing fingers at individuals… this is collective. Those who contributed and benefited from and led the culture of fear are the people who are responsible for what’s happened, including what’s happened at Mid Staffs,” he said.

Mr Thornton said Sir David’s replacement should be someone who understood quality improvement science and their priority should be reforming “out of hospital care”, particularly general practice.

Describing the division between community services and general practice as a “nonsense”, Mr Thornton said the separate flows of funding and the GP contract had made it “incredibly difficult” to think about doing things differently.

Asked whether the reformed NHS would be better or worse at driving reconfiguration of services, Mr Thornton said his “hunch” was it would be worse, due to confusion about where responsibility lies in the system and how much reliance should be placed on competition.

Mr Thornton, whose seven years as a non-executive director at Monitor is coming to an end in January, told HSJ he was proud of the foundation’s work supporting people to drive change “despite the system”. The foundation has recently signed a deal with the Scottish government to set up an academy of improvement science.

Asked why the foundation trust pipeline had all but dried up, with only three organisations authorised since the start of the year, Mr Thornton said the impact of the funding squeeze should not be underestimated.  

“I think trusts that five years’ ago would have jumped all the hurdles are now finding it extremely difficult in terms of cost improvement assumptions that are being made,” he said.

“A small number have got management difficulties; most of the rest are in stressed and unsustainable health economies.”

He said the NHS Trust Development Authority, responsible for referring trusts to Monitor’s authorisation process, was “more and more” looking at the need for whole system reform. Rather than “squeeze” trusts through the process, “greenfield” systems - based on out-of-hospital care and unencumbered by existing structures - should be considered.

Nuffield Trust chief executive Jennifer Dixon will succeed Mr Thornton in the role. He will continue in a number of non-executive roles with the Nursing and Midwifery Council and as vice chair of the East Anglia Academic Health Science Network.

Mr Thornton served as chief executive of Cambridge and Huntingdon Health Authority for five years until 1997 before becoming chief executive of the NHS Confederation.