The Nicholson Challenge Part 2

The Health and Social Care Bill may just about stagger through the Lords but its ability to improve the NHS is crucially dependent on the support of NHS staff, and it just isn’t there. The vast majority of managers, consultants, GPs, nurses and other clinical staff are either against much of it, don’t think it’s doable with the current level of resources or are just ignoring it because another health secretary with a different set of reforms will be along soon. 

Supporting the Bill are ten percent of GPs, who have already made impressive improvements in the care of the elderly, mentally ill and patients with chronic diseases by treating them closer to home.  Clearly what Lansley needs is an NHS chief executive who believes in the reforms and can win over the hearts and minds of the rightly sceptical and ‘reformed-out’ staff. Unfortunately for Lansley, that chief executive is David Nicholson.

Nicholson is a civil servant and supposedly limited by what he can say in public. He is also the most astute ‘politician’ in the Department of Health. As Lansley was trying to reassure the public and staff that the reforms were evolutionary and not the big top down reorganisation the Tories had promised not to inflict, Nicholson was merrily touring conferences telling everyone the reforms were ‘so big you could see them from space’ and only evolutionary in the sense that GPs will be going ‘from fish to bloke in two years.’ And Nicholson is right. The statutory, legal and bureaucratic implications of forcing GPs to take over commissioning responsibility as well as providing services are huge. And 40% of clinical commissioning groups have said they’re not ready to put their head in that particular noose.

Nicholson was angered by Lansley’s downplaying of the achievements of NHS managers under Labour and his crass decision to announce mass redundancies at Strategic Health Authorities (SHAs) and Primary Care Trusts just as Nicholson was trying to get the same managers on board to make £20 billion efficiency savings – the so-called Nicholson challenge. Senior Tories Stephen Dorrell and Oliver Letwin believe Nicholson is the only person who can deliver the savings and he strolled into the job of chief executive of the new NHS National Commissioning Board (NCB) with no apparent competition and well before the legislation has gone through.

Nicholson’s ability to bring a service in ‘on budget’ is admirable but he has overseen a top down enforcement culture in the NHS that failed to spot the horrors of Mid Staffs and is very unsupportive of NHS whistleblowers (Eyes passim). The over-controlling former communist party member just doesn’t trust GPs to do commissioning properly. And the NHS reforms are dead in the water without the belief of its chief executive that they will work.

In desperation, Lansley asked Blair’s favourite health secretary Alan Milburn – about the only politician who could match Nicholson in a cage fight – to be chair of the NCB. Milburn declined – ‘why the bloody hell would I want to do that?’ – and the NCB seems destined to comprise of cronies from the DH and SHAs. Nicholson even appears to have the ear of Clare Gerada, reform sceptic and chair of the Royal College of GPs. Gerada told the Health Service Journal: ‘Once we go to EU competition law and have any qualified provider, once we lift the cap on Foundation Trusts earning private income and lift GP practice boundaries, there is only one way forward: American-style health management organizations restricting access and an insurance model.’

When Gerada was asked if Nicholson supported her anti-Health Bill campaign she said: ‘I have a lot of people ringing me up in confidence, very senior people in high places who are anxious about the Health and Social Care Bill but can’t say it in public because they are frightened for their own jobs.’ Nicholson has no reason to be frightened – his job is far more secure than Lansley’s – and most NHS staff agree with his scepticism about the likely success of the reform programme. He could resign, but he sees himself as the not-so-secret saviour of the NHS. Whatever happens in the Lords, Nicholson will survive. But he needs to stop being so controlling and allow the one bit of the reforms that make sense – treating patients closer to home – to flourish.