Editorial Thursday 21 February 2013 History repeating: David Nich-love, or how I learned to stop worrying & love the Daily Mail

Becoming the story, which Comrade Sir David Nicholson has rather comprehensively done over a poorly-hadled response to the Francis Public Inquiry on top of a regime of grip, is not usually associated with positive career outcomes.

New Labour's former chief spin-medic Alastair Campbell had a rule-of-thumb that if a minister were on the front cover of a newspaper for more than a week, that minister had to go.

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By this standard, Comrade Sir David - whom Number 10 and the Treasury appointed as de facto health secretary during the dramatic debacle of the Health Bill because they lacked the political courage to actually sack Andrew Lansley (saviour, liberator) - should already be toast, much as his predecessor Nigel Crisp flew too near the sun.

It's not so much The Sun as the good old Daily Mail, which today again splashes on its 'Nicholson Must GO!' trope.

Now, whenever you find yourself on the same side of an argument as the Mail, it is behovely to have a little think about your motivation - and of course theirs.

Polls find unpopular person is unpopular
The Mail story is based on two polls which concluded that NHS staff think Nicholson should go. The first poll is from Roy Lilley's NHS Managers email community, of whose 1, 723 respondents, 91.6% answered 'yes' to the question "is it time for Sir David Nicholson to step down from his role in the NHS?" (The full breakdown is here.)

The other poll was in GP, and asked 'Should Sir David Nicholson stay or go?'. Of the 255 respondents, 89% felt  he should go.

The findings are not surprising; the more so because the first of the two questions is very leading. What is actually surprising to me is that the response rate was so low. Roy's email list has something like 100,000 addresses (which is hugely impressive), and the poll was promoted and run over several days. GPclaims that 34,500 GPs receive the publication each fortnight", and the poll seems to be online-only: their website readership is unclear.

But given Sir David's media ubiquity in recent weeks, I'm amazed the response rate wasn't higher. For the Mail to reply on these as proof that "nine out of ten NHS employees want health chief Sir David to resign ... Polls say 92 per cent of health workers and 89 per cent of GPs want him out", on the basis of a less than two percent response rate for Roy's survey and not even a few hundred GPs, is mildly unscientific.

Reading the Daily Mail is like taking a trip inside the head of someone very conventional from Britain in the 1950s. Some years ago, I blogged about a particularly stupid and blatantly set-up Mail attack on one of the very best health journalists, Sally Gainsbury. Mail-monstering didn't exactly harm her career, as she went on from HSJ to the FT.

The Mail's credibility in and on the NHS is epically low. The service has noticed that its coverage is by and large not supportive. There is a particularly fabulous outing of typical Mail journalism on this thread on the vastly much more intelligent Mumsnet message board.

Worry about the Telegraph
Comrade Sir David's team should probably worry more about the Daily Telegraph, which is the paper the Prime Minister actually reads. And the Telegraph has done some stonking anti-Nicholson pieces in recent days.

Today, interestingly, there is this opinion piece in defence of the Comrade-In-Chief by Sue Cameron. It has one epically telling quote from health select committee chair (and former health secretary) Stephen Dorrell on Nicholson: “He played a blinder for the Government when it was trying to push through its health reform Bill. Now people should pay their debt for the support he gave”.

Mmmmmmm.

Overall, the piece is massively confused about accountability, which is a simple thing. The Ipsos MORI poll reported in Health Service Journal (probably a bit more methodologically rigorous than others mentioned above, since polling is what Ipsos MORI do) found that just over half of the public surveyed blamed NHS managers, 16% blamed politicians and 11% blamed health regulators.

The person who takes responsibility for the managers in the NHS is its chief executive. If the public believe NHS managers are accountable, there is a logical corrolary.

Avoiding the political syllogism
The non-stupid way to approach the question of who should lead the NHS in changing its culture (which is as I wrote previously, the key message from the Francis Public Inquiry) would be to first create a picture of the culture we need.

The stupid way to react to the Francis Public Inquiry is to use my much-quoted 'politician's syllogism from Yes, Minister:
Something must be done;
this is something;
therefore this must be done.

The Daily Mail does not want Sir David Nicholson to be sacked because it believes strongly in a more decentralised, open, patient-centred, clinician-led NHS which allows local variation (a "postcode lottery"!), the sharing of uncertainty and risk and intelligent flexibilities over access targets.

It wants him sacked because it has said he should be sacked - oh, and also because he earns a lot of money, travels first-class and has a younger second wife. (The first two of those things are for the Mail only acceptable in the private sector, so neo-Mail allies can be comforted that the NHS has not in fact been privatised.)

Robert Francis' Mid-Staffs public inquiry report was a clever piece of work. It did not 'name the guilty men and women' - and it was never going to.

Instead, it made it epically clear that the NHS needs what most of its system will experience as (to borrow one of the Comrade-In-Chief's Communist metaphors) a cultural revolution of openness, transparency and decentralisation.

I don't think there is any evidence at all that Comrade Sir David can credibly lead that culture. Neither do I think almost anyone around him (the 'Trent mafia') can.

The reason I haven't done my old British Journal of Healthcare Management'sack the NHS chief executive because I say so!' thing - such a one-trick pony, eh? - is that we are far from clear about the new NHS culture we need to create. Indeed, I suspect a lot of the new system leaders are frantically hoping this will all die down and go away.

Which it won't.

I'm not unduly famous as a fan of the "grip and grasp" approach for which the Prime Minister lauds Comrade Sir David in the Mail piece.

My view is that the Francis public inquiry report has given Comrade Sir David a sidewall puncture.

With tyres, you can repair puncture damage in the grooved road surface face pretty easily, but if you get that damage on the sidewall, you've intrinsically weakened the internal cords and done for the tyre - the next time it's hit or pressured in that place, it'll blow out.

The risk with Nicholson is that hasty removal leads to hasty replacement - probably with one of his 'grip' posse. 'Different Comrade, same grip' is not a headline that I particularly want to have to write.

I lift my concluding thought from Hilary Mantel's excellent lecture, published in the London Review of Books and vastly misunderstood by stupid people in the media: "History makes fools of us, makes puppets of us, often enough. But it doesn’t have to repeat itself". Amen.

Or the risk is that, as Comrade Sir David's idol Karl Marx wrote, channeling Hegel, "history repeats itself: the first time as tragedy, the second time as farce".