Editorial Tuesday 20 October 2015: NHS Improvement - how the NHS can avoid getting Netflix-and-chilled

The appointment of Northumbria Healthcare FT/ACO leader Jim Mackey as the debut chief executive of NHS Improvement has been pretty much universally welcomed.

At the risk of going with the consensus, he does indeed seem to be an excellent appointment. The double-act with chair Ed Smith, a formidable NED of NHS England, is a good start.

That does't reduce the sheer daunting scale of their task. It's not at all obvious that the DH ministerial team, Chancellor and Prime Minister realise or are engaged in the sheer scale of the challenge facing the NHS.

There has to be a fast, system-wide and real change of service provision. It makes "a reorganisation so big you can see it from space" (to borrow the former Comrade-In-Chief's fine phrase) look like a minor rebranding exercise.

Simon Stevens has taken to referring to the various challenges as 'the exam question'. It is by no means clear that system leaders, alongside politicians, have yet grasped what the real exam question is.

The real exam question is the basic level of Maslow's hierarchy of needs. It's survival.

Slightly more specifically, it's 'how does the NHS go on providing a comprehensive, universal, safe, high-quality and timely service at a time when ideology trumps macroeconomics in a desire to roll public spending back to 35% of GDP?'

This is not so much an opportunity cost; more an ideology cost.

If the NHS doesn't change effectively and fast, then it will be Netflix-and-chilled. And not in a good way.

'We haven't got the money, so we've got to think' - Ernest Rutherford
Nothing could be quite as useful to Jim Mackey, Ed Smith and other system leaders as the views of a mouthy journalist (chosen specialised subject: 'childish abuse').

Here, therefore, are some things I think that they, and other system leaders, should do.

Get a Bruce: an under-50, female non-caucasian Bruce
Nothing so became Margaret Thatcher as her line on the indispensability of Lord Whitelaw: "everyone needs a Willie".

The NHS equivalent is 'everybody needs a Bruce'. Not only is he a hero of publishing cardiac surgeons' data, but Professor Sir Bruce Keogh has probably stopped more stupid nonsense in its tracks than I've tweeted about Simon Burns. Which is a lot.

So NHS Improvement needs someone Bruce-like but slightly younger. Ideally, under 50. And ideally not a male caucasian.

The broader point here is less about the identity politics (although that matters). It is that NHS Improvement will fail unless it has clinicians who have respect and can connect at its senior levels, and indeed throughout the organisation.

The changes the NHS has to make because 'there isn't the money' are not in administration: they are in clinical services and clinical practice. Traditionally, clinicians will do this if they trust those in charge: consider the London stroke reconfiguration. Or Manchester maternity. Both got there in the end, but took years.

And we don't have years.

NHS Self-Improvement: co-producers of change must hold hands, while discouraging dependency
NHS Improvement is going to have to find a cohort of people with NHS understanding and experience who can strike the right balance with those needing improvement.

The organisations and health economies where it must focus are not the innovators, early adopters or outstanding performers. It's the early majority: the ones who are keen, but  lacking in self-ignition. If NHS Improvement starts to get traction with its work in this cohort, change could happen at the scale and pace needed.

The right people to do this will have the soft skills to hold people's hands as they make the first steps out of existing, familiar comfort zones of traditional practice. At the same time, they will have the experience and judgement neither to 'go native' to the organisations they're trying to help self-improve; not to become a focus of dependency.

NHS Improvement will need to recruit or second based as much on these individuals' soft skills and personal manners as on their track records (which also matter).

Did I mention that the NHS needs a chief anthropologist much more than it needs any chief inspector? I did? Frequently? Oh good.

Telling stories
Here, it would be ideal to see some common work between NHS Improvement in its field and NHS England's New Models Of Care and Success Regiment. They need to gather and tell stories.

Change is hard at a time where there is no lubricant-cash, and it's even harder when people don't understand why or see experiences of progress and success (and also failure and setback) to which they can relate and aspire.

OK, not so much aspiring to the failure.

But the point is this: we tend to understand the world through stories. While it would be interesting to see some research matching a selection of the Vanguards with non-Vanguard rough equivalents as a  control group and to track progress in various aspects, there won't be time to evaluate all of this change. The cash crunch is too big.

So this requires a means of transferring learning. It will also need some uncomfortable honesty (rarely a strong tradition of the NHS system) about setbacks, blind alleys and failures. Because these things will happen. If they don't, there is a lack of radicalism and innovation.

These stories need to be timely, concise and candid. Their potential for motivation, development and setting a process and timescale for change could be great.

Sort out retention of senior figures' skills
It remains astonishing that the NHS is as poor as it is at retaining the talent and experience of its senior leaders.

The unfortunate fetishisation of management consultancies that started under New Labour and continues with Monitor's gung-ho application of management consultancies to deepen the financial woes of FTs in financial breach have helped the system to ignore the nice idea but patchy reality of IMAS.

A generation of senior leaders are moving towards the final few years of their careers. They have given the NHS a great deal more than they've taken. Failing to grasp the opportunity this offers of finding a transitional, remote-working, well-supported means of keeping their expertise available at reasonable cost would be a disastrous move.

Sort out estates
NHS PropCo is more or less a sideshow, with mainly ex-PCT estate. There is some value there, but much more in the possession of FTs and trusts. NHS Improvement and NHS England will have their beady eyes on this.

Considering the above point, there can be few people who have the experience, savvy and love of making property deals of Sir Robert 'The Builder' Naylor. That would surely be a no-brainer.