Editorial Monday 28 November 2011: Comrade Sir David - glasnost, perestroika and being a lovably evil bastard

Perhaps it is inevitable in an NHS whose once and future king is Comrade Sir David Nicholson that we should come to glasnost (openness) and perestroika (restructuring).

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Last week, Comrade Sir David told the NHS chief executive's conference a couple of interesting things.

The first was the one-line 360-degree appraisal of his peers. It was, simply, "we love you, you evil bastard".

The second (which he has told conferences before) was that 'make-your-numbers' managers such as he has himself been are not the managers of the future.

There is a fascinating duality in this. Comrade Sir David speaks the words of a man who understands the logic of the new world of the NHS.

This is not the first time: he told the NHS Confederation conference in 2010 that "good leadership has always been about looking across boundaries, it has always been about that sort of thing, it has never been about standing behind your walls and defending yourself ... change ... is going to unfold in a different way to what it has done in the past ... This is going to be a slightly different way of change happening, much more of a kind of chemical reaction of changes than a sort of set of levers and structures happening".

He also told the NHS Confederation conference earlier this year that the strategy was to 'grip to let go'. When I asked his what this meant, he cited GP practice-based commissioning (which largely failed) and FTs, which researchers from York Centre for Health Economics have shown don't outperform non-FTs once data are properly adjusted.

Comrade Sir David holds what is pretty close to absolute power over the running of both the current and new systems. The NHS Commissioning Board will have not only its four geographical regions, but according to HSJ, 50 local branches, each with a medical director.

It doesn't sound all that different to what we have now.

Health Policy Insight has long pointed out that the strictures of grip seem an unlikely precursor to liberation. The promise of liberation - glasnost - has always been overshadowed by the threat of chaos induced by the system-wide top-down perestroika - restructuring.

And we know where glasnost and perestrokia led the USSR.