National Health Service History
David Nicholson, the new chief executive of the NHS in England, took up the reins of office last week and set about dispelling the notion that he might provide the service with a period of consolidation and calm.
When his appointment was announced seven weeks ago, there was a huge sense of relief among managers and clinicians that the job had gone to a person steeped in NHS values. People seemed to think that he was somehow less threatening than the two American managers on the final shortlist, who might have been expected to further commercialise healthcare delivery.
But, in his first interview as chief executive, he has told Society Guardian that it is his NHS pedigree that has made him determined to push through reforms even faster than before. He thinks that up to 60 hospital trusts may need help to survive the pressures of change, as they lose work to primary care services operating in the community - and to specialist tertiary hospitals where the harder cases will be treated. In some cases they may have to be taken over by stronger neighbours with the management muscle to carry through the necessary changes.
And NHS trusts in England, both weak and strong, will have to come to terms with a reconfiguration of key services that will reduce the number of hospitals offering a full A&E department, paediatrics and maternity services.
These are three of the hospital services that are most cherished by their local communities. Up and down the land, the NHS will have to handle the job of reorganising them with extreme sensitivity if it is not to spark local revolts that could have huge political implications in the runup to the next general election.
Nicholson has been with the NHS for 29 years. He joined as a graduate trainee in the same year he joined the Communist party, which he then saw as the best vehicle to take forward his passionate support for the anti-apartheid struggle. He says he was not a Eurocommunist: he was among the Tankies who did not see an ideological need to distance themselves from Moscow. During the interview, the working-class lad who has reached the top pokes fun at himself by asking how much of this early baggage needs to appear on the civil service security vetting form that is sitting on his desk awaiting his attention. Perhaps former Communist John Reid, Patricia Hewitt's predecessor as health secretary, might be in the best position to advise?
Nicholson drifted away from the Communist party and abandoned his membership in 1983. But he has stuck with the NHS in a career that has spanned three phases. For the first 10 years he worked in mental health, mainly in Yorkshire, where he was involved in implementing the policy of closing the old asylums and developing services in the community. He says the lesson he learned then was how it became possible for the NHS to deliver big changes if managers could harness the support of patients and relatives.
For the next nine years, Nicholson moved into the acute hospital sector. He was chief executive of Doncaster Royal Infirmary, one of the first wave of NHS trusts to break free from Whitehall control under Margaret Thatcher's policy of NHS reform. That "liberating" experience taught him the benefits of independence and the need to mobilise support for reform among clinical staff. "Once you engage them and gain their trust, there is nothing stopping you," he says.
The third stage of his career, which has led him to the top of the NHS tree, was in regional and strategic health authority management. It was there, he says, that he learned how to deliver change on a grand scale by getting all the bits of the system pointing in the same direction.
Nicholson says the NHS is in much better shape than five years ago, thanks to increased resources and reforms to link hospitals' income to performance. But this is not enough.
"People don't feel the reforms are relevant to them. We haven't made sure we connect the reforms to benefits for patients. There is a strong argument for driving reforms forward faster, not slower. That is what we need to do. But we need to make them relevant to clinical staff and help them do the jobs they need to do."
He says it is already clear that not all acute hospital trusts will be ready to apply for foundation status by 2008, the original target date. Many will not be strong enough to achieve independence without significant reconfiguration. In some areas, the answer might be for the weak trusts to be taken over by the strong.
"I am reluctant to get into [a wave of] mergers across the system," he says. "Very few mergers I have seen in my career have delivered the benefits that people said they would. The problems remain in the organisation. Often these problems are more deep-seated than [can be solved by] having a new set of managers come in. I think we will see some of the better hospitals acquiring others that are in difficulty."
The government's proposals for treating more patients closer to home by expanding primary care would put a big strain on the district general hospitals. "I have not seen any that have to close, but they are going to have to work in a networked way," he says. "And you are going to have to use the ambulance service in a more creative way."
Nicholson does not spell out the implications, but his remarks suggest the closure of some departments, allowing hospitals to specialise in what they do best. Patients may get a better service, but would have to travel further to access it. "Undoubtedly there will be tough decisions to make over the next 12 months to reflect changing services," he adds.
The toughest would involve reorganisation of emergency care, paediatrics and maternity services. A key decision has had to be taken about the number of major trauma centres across England for dealing with the most serious emergencies. That has had implications for the number of hospitals running a full A&E department. Many patients with minor ailments could be looked after better in local walk-in centres rather than A&E.
Similarly, the NHS has had to decide the number of births needed to sustain a 24-hour consultant-led maternity service and the most appropriate size for paediatric departments. Were these not the three most bothersome areas of NHS care in terms of likely revolts against closure of local facilities?
Yes, says Nicholson. But he is determinedly optimistic about winning public support for change if consultation is managed properly. Trusts have to ask: are the clinicians on board; will they stand up and argue the case; can the trust demonstrate the health benefits of a reconfiguration of services; and can it say how many lives will be saved, to set against the claims that will undoubtedly be made by protesters that lives will be lost?
"We will be going out to consultation later this year or early next on a whole series of reconfigurations. I understand the politics of it. But this is about the way we deliver care that is predominantly closer to home."