After Sir David, who next?

So, Sir David Nicholson is leaving the top job in the NHS after the best part of a decade. This prompts the question of who is likely to be appointed to replace him as chief executive of NHS England. At the NHS Confederation’s annual conference in Liverpool, there was much naming of names.

Top of many lists was the name of Mike Farrar, the chief executive of the NHS Confederation itself. When Farrar left the huge fiefdom that was NHS North West to lead the managers’ body a couple of years back, it was widely assumed that he was keeping his powder dry for a shot at the top job when the present reforms bedded down.

New health secretary Jeremy Hunt has got him to lead a bureaucracy review. And his speech in Liverpool bore some uncanny similarities to the speech that Sir David gave, with its call for a new IT strategy and a focus on transparency to “sunshine” the kind of data that might have stopped the Mid Staffs scandal earlier.

On the other hand, two years is a long time to be out of frontline management. There’s a danger that Farrar will be too closely associated with the previous regime. And he may, or may not want to return to the kind of pressure that leading NHS England would bring.

Next up was the name of Mark Britnell. Britnell was widely regarded as “the next chief executive of the NHS” when he headed Birmingham’s main trust. But then the man who was supposedly “NHS to his finger tips” left for consultancy KPMG in 2009.

My old employer, HSJ, has reported that Britnell was sounded out as commissioning board deputy chief executive, when Ian Dalton left that post for a job at BT this spring. But he hasn’t turned up at NHS England yet. And he wasn’t very visible at Confed.

Britnell may also be too closely associated with New Labour and too far steeped in the world of consultancy to return. He would be an interesting appointment, given his often repeated comments from a conference in 2010, about the opportunities for private firms in the NHS.

One of the key questions at Confed was whether the NHS will be shaped by competition or co-operation. And fairly or not, appointing Britnell to lead it would be seen as a clear answer in favour of the former.

Still, most of the hot gossip at the annual managers’ shindig focused on Sir Bruce Keogh, the medical director of the NHS since 2007. Sir Bruce seems to be leading just about every review of the NHS going at the moment – including the review of A&E and out-of-hours services that formed the centrepiece of health secretary Jeremy Hunt’s speech.

He also has an obvious appeal for politicians. He would be the first clinician to manage the NHS. And, as a former heart surgeon, he has more experience than most of publishing data (even if he had just taken up his medical director post when Mid Staffs erupted). Wise heads at Confed, however, muttered that Sir Bruce will need a good chief operating officer to work with him.

Interesting as it is, there is something odd about this speculation. It shows that Sir David has not managed to manage his succession. There is no obvious deputy to step into his job and continue his work. Indeed, the departure of Dalton and others suggest some senior figures believe the future lies elsewhere.

At the same time, it assumes that no new blood will be found, from either inside or outside the health service. And that might be worrying. With Sir David at the helm, the assumption was that NHS England would become a powerful executive body, reinstituting the ‘command and control’ that the Department of Health was told to give up by the reforms.

With him gone, and with a new and possibly less substantial figure in his place, it could yet become the weaker, advisory body legislation suggests that it should be. In which case, the interesting speculation will be who will be taking up top jobs elsewhere – back at the DH, over at Monitor.

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