The next chief executive of NHS EnglandBMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f4464 (Published 10 July 2013) Cite this as: BMJ 2013;347:f4464
NHS England’s role as the body responsible for overseeing the commissioning of health services has been brought to a head by concern about the failure to achieve the target of 95% of patients attending emergency departments being seen within four hours. In response, Jeremy Hunt, the health secretary, has asked NHS England to take the lead in coordinating the production of local plans to bring emergency department performance back into line with the four hour target. NHS England will work closely with the regulator of foundation trusts, Monitor, and the NHS Trust Development Authority, but it is now undoubtedly seen by ministers as first among equals in this process.
The health secretary’s decision that NHS England should act on his behalf in responding to performance challenges is a matter of more than academic interest. His predecessor, Andrew Lansley, legislated to distance himself from detailed involvement in operational matters by restricting the health secretary’s powers in the Health and Social Care Act 2012. The theory was that ministers would set the broad direction for the NHS in the mandate issued to NHS England, thereby avoiding the risk of micromanagement of the NHS in the manner perfected by former health secretaries.
Hunt’s intervention reflects the view he expressed in a recent interview that he remains “accountable for the entire health budget” and that “the buck stops with me.”1 Faced with a choice between NHS England, Monitor, the NHS Trust Development Authority, and the other national bodies established under the 2012 act, it was hardly surprising that Hunt chose NHS England to take on this role. Its capacity and capability at a regional and local level to bring together local recovery and improvement plans, together with the experience of its chief executive, David Nicholson, made it the most credible candidate for the job
This means that Nicholson is essentially the leader of the national health system, even if no longer chief executive of the NHS. His successor will therefore be much more than head of the body responsible for leading the commissioning of health services in England. He or she will be the person the health secretary calls in when performance problems need to be resolved. The chief executive of NHS England will therefore need to have a close relationship with the leaders of other national bodies like Monitor, the NHS Trust Development Authority, the Care Quality Commission, and Public Health England.
Precisely how this works out will depend on the style both of future health secretaries and of the chief executive of NHS England. The message for those involved in appointing the chief executive is clear. This is now the most senior leadership role in the NHS, and the successful candidate will need the experience and skills to match the job. It would therefore not be surprising if those leading the selection process were tempted to seek a leader with a track record in a large complex system outside healthcare and possibly outside the public sector.
There is a precedent here in the appointment of businessman Victor Paige as the first chief executive of the NHS management board in 1985. Expecting to lead the NHS at arm’s length from ministers, Paige became frustrated and disenchanted at what he saw as undue political interference in his role. This led to his resignation halfway through his three year contract and belated recognition that, in a huge publicly funded healthcare system, ministers would always find it difficult to exercise a self denying ordinance.
The recent turn of events is pointing in a similar direction. Although the leaders of NHS England expressed a clear intention to be based in Leeds rather than London and to resist being at the beck and call of ministers, this already seems like a distant dream. With the health secretary expecting frequent contact with these leaders and relying on them to tackle operational issues, NHS England is taking on the appearance of a directorate of the Department of Health, acting as the principal performance manager and fixer on behalf of ministers.
Whoever is appointed as the next chief executive of NHS England will therefore have a demanding set of responsibilities, having to meet the needs of ministers on the one hand and provide leadership of the NHS on the other. He or she will have to work as much through influence and persuasion as through direction and instruction, particularly when the centre of the NHS has been fractured between several national bodies whose responsibilities overlap. The scope for conflict was illustrated recently when NHS England’s plans to develop a strategy for the future of the NHS were questioned by the head of Monitor as going beyond its remit.2
The next chief executive will also have to reconcile the espoused commitment to devolve responsibility to clinical commissioning groups and foundation trusts with the reality that performance management is still the intervention of choice when things go wrong. A further complexity is the emphasis placed on market regulation to bring about improvements in performance through the role of Monitor and the Office of Fair Trading alongside continuing reliance on hierarchical controls. NHS England is also expected to play a major part in the response to the report of the Francis Inquiry into Mid Staffordshire NHS Foundation Trust, with its next chief executive responsible for leading the cultural changes proposed in the report.
An important lesson from this experience is that the gap between legislation and implementation should never be underestimated. The preoccupation with the precise wording of the Health and Social Care Bill 2012 during parliamentary debates overlooked the tendency of leaders in Whitehall and the health system to interpret the meaning of legislation in ways that differ, sometimes greatly, from the intentions of those who framed it. In the words of TS Eliot “Between the idea and the reality . . . falls the shadow.”
The question now is will other key aspects of the legislation be diluted and distorted in similar ways, with the consequence that reforms designed to transform the health and social care system have a much more limited impact in practice?
Cite this as: BMJ 2013;347:f4464
Competing interests: I have read and understood the BMJ policy on declaration of interests and declare the following interests: None.
Provenance and peer review: Commissioned; not externally peer reviewed.