Essential insight into England’s biggest health economy, by Ben Clover

At an as-yet-undetermined point between now and the end of March, NHS Improvement London regional director Steve Russell will step down and be replaced by Royal Free London Foundation Trust boss Sir David Sloman, in the new role of joint NHS Improvement and NHS England RD.

A badly-kept secret for quite some time before its official announcement last week, Sir David is the most eminent figure among the seven new regional directors.

These are roles the centre had difficulty filling and arguably Sir David is the only one of the seven who fits the description they had hoped for – people who had already run large, successful providers and for whom this might be seen as a prestigious final phase of a long career.

But before he starts, it’s worth reflecting on the two-and-a-half-year tenure of Mr Russell, formerly of Barking, Havering and Redbridge University Hospitals Trust, and Northumbria Healthcare FT.

There is a broad consensus that he and NHS Improvement London were hampered by the weird set-up that the bringing together of NHS Improvement and NHS England is intended to solve – so did a good job in impossible circumstances.

Who was in charge in the capital? NHS Improvement, NHS England – and at which level? - or the somewhat unaccountable big teaching trusts?

In truth it seemed to vary, depending largely on how an organisation was faring. Some of the bigger trusts would go straight to NHSI deputy chief executive Stephen Hay, bypassing the regional office. This is in part because the national team wanted to get involved in these issues, but also because the regional team could feel like a one-man band, some chief execs said.

For smaller trusts stricken with performance issues, there were complaints that there was too much “classic” performance management from NHSI London, at the expense of “improvement” work.

Given some of the performance issues in the capital over the past two years, it’s hard to imagine that people seriously expected otherwise.

Overall, the sense has been that Mr Russell and his team played a difficult hand as well as could be expected, and he is afforded a respect from many chief execs that is not given for someone who has never led a provider organisation himself.

How has it gone?

Well, there are no Care Quality Commission “inadequate” rated trusts in London at the moment. If you arranged all London providers’ CQC domain scores in a chart (and NHSI does), most of the red has been wiped off it.

The London Ambulance Service Trust is in a considerably better place than it was.

Barts Health Trust is no longer a basket case. These are important national institutions and their failure would make national headlines.

Zooming out for a moment, the financial picture is bad, but is not worsening at the rate of some other regions. That it has been contained as effectively as it has is a tribute to everyone concerned.

What has gone badly can be said in one word: King’s.

Responsible for a good chunk of the national waiting list problem, missing the accident and emergency target by some way and having a deficit closing in on £150m is problem enough – and that King’s is still heading the wrong way is a big worry.

Only limited blame can be laid at the door of NHSI London for this, though, with the special measures regime run out of the national office.

Of course, there are other problems in London. While North Middlesex has stabilised somewhat, Hillingdon Hospitals FT continues to be an issue. Both trusts came close have been in the zone of 50 per cent performance for type one A&E. Hillingdon dipped beneath that in March and although performance is now in the 70 per cents, worries remain.

There were concerns in the provider community about how problems at Barking, Havering and Redbridge University Hospitals were handled, with a feeling that the chief executive and medical director were not given the backing they should have had in dealing with a difficult medical culture.

But on the whole NHS leaders in London feel the regional office has been more humane than in the past.

One chief executive was happy to go on the record. Epsom and St Helier University Hospitals Trust boss Daniel Elkeles said: “The regional tier works best when leadership helps individual organisations navigate through complex and wicked problems they can’t sort themselves.

“I think Steve really got this and put a huge amount of his personal and his team’s energy to do this.”

What now?

The indications are the new regime might be more focussed on strategic change. It’s fair to say these didn’t get wholly resolved and London Eye understands this is now a priority.

There was some progress.

The shared chair for North East London FT (a mental health and community provider) and Barking is likely to be consequential in the medium term. Guy’s and St Thomas’ FT is, quietly, increasingly influential.

But these are small steps compared to what NHSI national boss Ian Dalton and Sir David are looking for.

(Some years back, Mr Dalton ran the national NHS “provider pipeline”, through which NHS trusts were meant to flow to becoming FTs by April 2014 – “unsustainable” trusts being swallowed up or dissolved in the process. Sir David took over Barnet and Chase Farm Hospitals Trust outright but his group model has received a fairly public rebuff from North Middlesex University Hospital and a quieter one from West Hertfordshire Hospitals).

The system, FTs and non-FTs alike, should expect more intervention on senior appointments but perhaps less day-to-day scrutiny of performance.

The appointment of a new chair – due soon – for Imperial College Healthcare Trust is likely to be consequential for the trust’s relationship with Chelsea and Westminster Hospital FT and, perhaps, the Royal Brompton’s planned relocation to St Thomas’.

What Sir David, a career manager, makes of a recent trend of appointing senior medics to chief exec roles (Imperial, Great Ormond Street) would be interesting to know.

Big chief exec appointments due include King’s College Hospital (rumoured to be going to a senior medic from outside the capital) and Sir David’s own Royal Free (whose elective performance has become a bit of a problem).

Most leaders in the NHS - and perhaps beyond - start off wanting to deal with strategy and find themselves firefighting performance issues, so good luck to Sir David.