Sir David Nicholson secured an unprecedented standing ovation at the end of his final speech to the NHS Confederation’s annual conference, which took place in Liverpool last week. The sight of the audience rising to its feet was a personal tribute to Sir David, who he has undoubtedly bruised some NHS managers in his pursuit of financial stability and politically sensitive targets, but who has also done a good job of rallying the troops and standing up for the health service’s core values over seven increasingly difficult years.
However, the ovation also marked what felt like the ending of an era in other ways. The future of the NHS is now very much up for grabs. Andrew Lansley’s ‘Liberating the NHS’ reforms may, finally, have been implemented, but it is far clear who will wield power and influence within them. While Sir David headed NHS England, it looked as though the commissioning board might emerge as a powerful executive body, along the lines of the old NHS Executive (whose acronym and offices in Leeds it not coincidentally occupies). With Sir David gone, however, other bodies will be jockying for the ear of ministers and the fear of trusts, starting with the rump of the Department of Health, and the regulator Monitor (whose staff are always the sleekest and most confident speakers at any health service get-together).
Which organisation comes out on top matters because the different bodies jockeying for position have different answers to the key question at this year’s Confed – will competition or co-operation shape a health service that everybody agrees needs to change. Sir David is clearly hoping to impose an answer in the ten months before he departs as chief executive of NHS England, by having the commissioning board lead a strategic review that will, in his words, “make the case for change” and “decide what the NHS should look like in the future.”
The “big conversation” is a bold idea. However, the last time the NHS tried something similar was when New Labour launched the NHS Plan in 2000. This was intended to reach a consensus on how the NHS should spend the huge sums that prime minister Tony Blair was persauded to pour into a health service that had been run down under the Tory government of John Major. But the plan only succeeded because the health minister of the time, Frank Dobson, was fundamentally in agreement with the NHS employees who wrote in to demand more staff, better facilities, and new services (such as the digital outpost, NHS Direct). His replacement, Alan Milburn, soon looked for more market-led solutions to the health service’s chronic productivity and quality problems, and it was only the money that papered over the gaps.
This time, there is no money. After ten years of fluctating policy on the NHS, it is far from clear that there is a consensus on its future shape and direction. If there is, it may not be strong enough to achieve Sir David’s stated aim of giving the NHS space to change by protecting it from political buffetting and contradictory press attacks. And even if it is strong enough, it is not clear that Sir David still has enough power to harness it. Even as most of his audience was rising to his feet, some of its was leaving the Liverpool arena, having heard the last of “yesterday’s man.” As such, the ‘big conversation’ is a bold idea, but probably one that will end in failure.