Editorial Thursday 21 June 2012: Comrade Sir David Nicholson speaks (The 'No Communist Imagery' edition)

Comrade Sir David Nicholson was described as the Anneka Rice of the Health Service by chair Cathy Newman.

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I’ve not got the bottom for Anneka Rice, and I’m not going to show it to you now or at any time in future, no matter how desperate I become.

It's great to see so many people at the Confederation conference, and I want to pay tribute to Mike and Keith, the Confed's leaders who have been working on trying to shape the legislation. A strong Confederation is really important for the NHS overall. Somewhere bring together, learn from and work with each other really important.

Reflecting on last 18 months in particular, extraordinary. I've worked in the NHS for over 35 years, been CE for 6, and I've never known a time like it.

In trying to think about the new system, the consequences for the system and for us as individuals, how to deliver today, plan for tomorrow, deal with anxieties and emotions about our personal futures, that gives rise to an extraordinary range of emotions with which to work.

Bereavement follows a series of phases: denial, anger, depression and acceptance. And I think we saw all emotions. When the Coalition came in, and even when we met Andrew Lansley pre-election, my immediate response was 'you can't possibly want to do that'. I felt angry when the government came in and started to denigrate pubic leaders, and I got depressed when I thought we couldn’t make changes needed. And then I thought 'OK, accept this and let’s make this work for patients'. Many of us have gone through a journey like that over the past 12-18 months. It's not sequential, you feel them all individually, and there is not a date you can turn them off and put them all behind you. This is the last Confed I will address as the NHS CE. For those of you who are Tweeting, I have not just resigned live on stage; hopefully, I will come back as CE of the NHS Commissioning Board.

We should acknowledge the personal consequences for people and the anxieties across system, and indeed that makes what you've been doing over the last 12 months even more extraordinary. Think about the ways we've managed to deliver performance in NHS: quality - phenomenal progress delivering, literally saving lives around people with VTE, taking forward HCVAI work, set of changes around LTCs across the country. It's remarkable. We delivered all the basic access targets, it's a remarkable set of results.

The NHS annual report has been published, and it's a really good read. not just for my well-crafted words: just look through its record of achievement of your teams. It is remarkable and you should be really proud of it. I spend lot of time looking at numbers and you should be really proud, thanks on DH behalf and community behalf

At same time, started to build new system, CCGs starting to work, clinicians starting to engage in the commissioning process in away never seen on the scale at this moment. Done by you. Not by Andrew Lansley, not politicians, not DH, not even the Kings Fund. You, as the people leading the NHS, deserve fantastic credit for that.

Why have you achieved this when you've been told that there's too many of you, that you're not valued or that you're going to be abolished? What makes people like us do things we do? The sense of purpose we have as people who work in and with NHS about what we want to do: developing great services for our patients not just come in as consumer but go and reach those people who fort various reasons find it difficult to engage with the NHS as an organisation.

Many other industries and orgs jealous of our sense of common mission to improve services for patients and communities. should recognise

But we need to redefine what success means. In recent years, tried to work out 1 definition of success: identify what really important things to patients, public and clinicians about what that definition of success is

And it’s changed. 10 years ago, definition of success at running a hospital it was, my surgeons told me, having a waiting list. A long waiting list, our surgeons told us, meant we were good. I remember Working For Patients. We became a First Wave NHS Trust, employed management consultants to make us more commercial and focused on customer. I remember one good session on customer focus, and it was only halfway through, that I realised medics thought they were customer and our job was delighting them

access to services: NHS Plan as people thought services was OK, but access not good., heavens above have we made access better. Then HCAIs defining success as attacking harm in that way, next phase of defining success: not giving up on access, but starting to think about outcomes in a much more organised way. We will talk about saving extending and improving quality of lives, ensure people with ongoing MH problems get into paid employment: these connect with staff but also public. Redefining success will be critical part of what w do going forwards

Forward not the same as the past. Challenges not new, but developed themselves and set themselves up in way very acute in this moment of time.

A positive of this Confed conference is the agreement about what challenge is and what need to happen to make it happen.

Challenge is international: issue of rise in LTCs, potential quality improvement around concentration and centralisation, use of technology

But face additional challenge universal and free at point of use; really central to the values and purpose talked of earlier.

How get into place to respond. Mike Farrar and panel session made clear that if try to deal with challenges in financial environment by constantly trying to deliver efficiency, won’t deliver changes we need and get into really dangerous place of cost-cutting across organisations we have.

I can genuinely say that never a day goes by that I don't think about the lessons from Mid-Staffs. It was a very traumatic experience for the NHS overall. And it showed how sometimes, when management work together and talk about esoteric management issues, those issues can have damaging effect on individual patients on wards. It shows how important what we do it, but on the other side how can that have really deleterious effect on patient care. efficiency savings could do great harm and we have to be really vigilant about that

Service transformation and change - Ruth Carnall's experience in London significant issue for us all. Today, the board papers going out for SHA meeting in London for one of the biggest ever NHS changes, led by local CCG who have got hold of issue, understand issue, from patient perspective, but determined to make happen. This is really important set of changes, have to put these into action. North West London is a good example of getting hold and really trying to get hold of quality and value while keeping the money under control. I was particularly taken by Stephen Dorrell's quotes from the famous Enoch Powell 1962 'water towers' speech. Made case for radical change in mental health services to close asylums.1962 water tower speech. Made case for radical change in mental health services to close asylums.

It was ground-breaking, and sort of speech need national politicians to make at moment, being honest with public about nature and scale of change to make great care universally available within resources.

As good as Powell's speech was, very little happened after he made it good 10 yrs till real action started to be taken, driven by series of scandals and famous inquiries. Our response as NHS leadership to that criticism was not to heap criticism on individual clinicians (although some lost their liberty), nature of institutions creating those behaviours. Shifting model of care for MH was way responded to that set of scandals. I can see great similarities. No matter how compassionate and brilliant our nurses, it's really had to give frail elderly people the care and support the need on acute medical wards. We need to shift model of care how people supported, prevented and supported in community. We need to move from default position of getting into a hospital bed. We've known this for a long time, but argue financial position given us burning deck to put this right. How take this forward, see new system work to make this more likely and get clinical and public buy-in?
Start with the clinical commissioning system: we need to build one. Build it on basis of individual practices, can’t get more local than group of clinicians responsible for health of population. GPs do 80-90% of contacts, see and understand and navigate people through system, relatively small changes can alter referral patterns as in recent years, firm base, which patients and public really understand. In hundreds of NHS reorganisations since 1948, the basis of GP practices has been a constant. Some CCGs v large, some very small, but we know there is no right size. CCGs will have to bring in AHPs, other clinicians, if conversations going to take place in CCGs, need to invite everyone to that discussion, other primary and secondary care clinicians. Building CCGs critical


But CCGs can't deliver change alone, some service cover 1, 2 & 3ary care. Help in changes and implementation. Some need much more significant geography, 6-7 million, so need clinical senates to support and help clinicians make decisions about service change with clinicians in leadership to tackle issues. NCB job to turn £100 bn into great outcomes, by making clinical commissioning the best it can possibly be

We need to build a system to make that happen, but commissioners alone can’t make it happen. Need providers to make that change. Provision in a sense was moved to one side in the conversations about the HSC Act, but it has to be central to service change. Provision can never be the consequence of commissioning, we all know ... providers need to lead that service change, need to be put in position to lead. But our provider system needs to be able to make that change, why we set up NHSTDA. You will remember some years ago we set up World-Class Commissioning. Now I don’t know if Mark Britnell is in the audience (you’ll hear him if he is): I told him to make it sexy. Now you can have you own opinion how successfully he did that, but CCGs have a better chance.

David Flory's job is to make the FT pipeline sexy; good luck, David.

Bits of the NHS have lacked focus of management and politicians, some parts very poor indeed. Wheelchair services, assisted home living tools, important we can use AQP and innovators to help improve and support those, important for providers to do that.

Fundamentally, issue about mindsets. It reminds me of some work on the USA's railways, and why so many were failing. You could see why unsuccessful ones failing, had strategies about running railways, great engines and kit, luxurious ways of connecting system, great etch but failed because thought were running railways. Successful thought we take people and freight form A TO B and invested time and thought on making that happen

If your organisation believes that your job is to run a hospital, in the environment of future, the likelihood is that you will fail. The future is about pathways and following the patient: quality is systemic. We don’t have to manage everything, can do it in partnership, as Rotherham have working very closely with CCG. Revolutionising provision, getting a clinically and financially sustainable system, developing levers like AHSN to connect hospitals and health orgs together: all critical to make that service change. But even great commissioning and revolutionised provision not make service change happen: have to connect with people, empowered patients, understanding and getting involved in own care, have better outcomes than those don’t connection with local communities, politicians, HWBs, know acne prevent change, but engaging around role of HWB. If we get great commissioning, support in provision and HWB working, we can see how new system will make change happen

Finally, I want to take stock of where we are. It's a thin line between realism and defeatism. I am under no illusion about how difficult and complex this is success is not guaranteed. We absolutely will all make mistakes as take this forward. It is not guaranteed, but we should heave optimism about future, think about changes of last 6-7 years, and see where your services and organisations are now. You should have confidence that you as leadership community can do this

NHSCB set up around outcomes, trying to build new way of operating in NHS. Building of new CCGs really important assets. Could never have done some things, as managers without clinical support, should have optimism, but measured optimism about the future. Need to think forward to 2020. I know some people will see out transition and move on - thank you, you have done NHS proud, but many-most in room will still be around in 2020. I don’t want to sound like Margaret Thatcher, and say I’ll go on and on. When I sit in little chair, with my small child in my knee, says 'Daddy what did you do in the great transition', do I want to say 'I sat there, folded my arms and said it'll never happen' or "I worked with clinicians; we worked together and worked on outcomes as never before'. A whole generation of NHS managers took NHS form 2-year-long waits for access to among best access sin developed world, taken quality to creditable and some world-class outcomes, of care, that is where position is for future, recognise with you anxiety people have; think about purpose of NHS and values, redefine success in patient outcomes. Make sure clinical commissioning genuinely built from bottom up, providers equipped and supported to make change over the next few years; connect to make changes happen. Connects all by our shared sense of purpose. NHS Constitution "belongs to the people"


Chair Cathy Newman: You said that success is not guaranteed, but what's the £ and p on the £20 bn savings?

CSD: WE delivered 4.3 ban savings Audit Commission in last year before QIPP. This year 5.8 bn, again biggest ever done, various ways, sometimes fantastically well, plans this year for another 5.8 bn of productivity gains pay restraint, management t targets, national work.  Then efficiency of reducing tariff. If do that alone, won’t make savings, not delivering on the service change, that is what will save the money, if don’t do it, have to go to the efficiency gains as that is where danger lies. All round difficult, including the politics. 2 bits to changes, general shift from hospital to community services, consequences for acute sector, difficult to make shift happen, also concentration and centralisation very hard, but if look London stroke and major trauma, possible but needs to be resourced and organised. After slow start, politicians starting to respond, but politicians at all levels need to be straightforward about radical change, without honesty, hard to talk to public about what free at point of use, available within financial constraint for as long as most of us will be in NHS

Q: Need to spend more on patient education?

CSD: absolutely.

Q: Govt will have to find additional money: if the gap is £50 bn where is it coming from?

In 2009, asked is it possible, asked PwC is it possible, they said yes, these kinds of things so QIPP, 4 year programme. If another 4 years what consequences. Need to have argument in open to have proper conversations.

CN: a friend of your said you have a Stalinist view of how things work, which I think was just vindicated.

CSD: I haven’t got any friends.

CN: after the election did you feel a bereavement? How are you rubbing along with the Tories?

CSD: They're all very nice, they treat you very well, I won’t answer that - stop yourself, David. I have worked with 4 SOS and 3 PMs, saw from AL yesterday. All were deeply committed to a universal NHS free at point of use: that value connection means it's not difficult to work with them. I have value connection with them.

Q: How much is the NHS in surplus and why is that money not used for patient care, as Parliament voted?

CSD: Let me try to explain: in 2006, we were trying to manage the NHS to get 0 in the bottom left hand corner of the accounts, and it's simply impossible, and we got into all sorts of problems in spending money on non-value or shifting around system. We judged would create surplus to help us do that but also to enable us to build up a resource we could use when things got really, really difficult. Of total, c. 1%

NED David Peat: as well as clinical engagement, need political engagement and resource incentives

CSD: Change is always difficult to make. Most levers, tariff, contract, allocation process, capital budget all national and think dissonance between those national levers and what people’s ambitions are locally. To maximise the capital asset of a hospital, you have to fill it. We know we'll have to shift the financial incentives in future.