Guest editorial Monday 4 March 2013: What should Sir David Nicholson do?

This guest editorial by Professor Kieran Walshe, Professor of Health Policy and Management at Manchester Business School, looks at the future of Sir David Nicholson.

After repeated maulings from the Daily Mail and Telegraph were joined by The Times' calling for his exit last Friday, and Charlotte Leslie MP's a Commons early day motion calling for him to go, Sir David Nicholson may have spent the weekend thinking about his future - and preparing for what could be a very rough ride at the Health Select Committee tomorrow morning.

So what should he do?

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I have a great respect for David Nicholson. I think he more than anyone else has kept the NHS running on an even keel over the last three years, through the chaos of the Lansley reforms and the growing financial pressures.

I have no doubt about his total commitment to the NHS, and to the values and ideals of a public healthcare system, which he has consistently and bravely defended.

Point of inflection
But I think the Francis report is a turning point not just for the NHS as whole, but for him.

It holds up a mirror to the system he has created and led, and the picture it presents of secrecy, defensiveness, complacency, and controlling and directive management and their consequences is unarguable.

Equally, the Francis report demands a sea-change in the way the NHS is led, and that poses the very difficult question of whether the NHS' current senior leaders are capable of making that change.

How to leave gracefully
I think he will probably, in the end, be forced from office if he does not resign.

But perhaps what matters most is not whether he goes, but how he goes - and what messages that sends to the whole NHS, and to all the many people affected directly or indirectly by the events at Mid-Staffs.

Perhaps this weekend he should be drafting a letter something like this:

Dear Malcolm,

It is with great sadness that I am writing to tender my resignation as Chief Executive of the NHS Commissioning Board. I have come to the conclusion, since the publication of the Francis report in early February, that the best way I can serve the NHS that I love, and in which I have worked for my whole career, is to step down. In doing so, I hope to achieve two things.

First, I want to take some personal responsibility for the tragedy at Mid-Staffordshire Hospitals NHS Trust. Many people played some part in the awful events which led to so many patient deaths, but I was the chief executive of the West Midlands SHA and then of the NHS in England at crucial junctures.

With hindsight, I wish we had acted differently - more quickly, and more effectively - to respond to the concerns raised by patients and to deal with poor care at Stafford.

Importantly, I recognise that the culture and climate in that hospital - and more broadly across the NHS - made many people unable or unwilling to voice their concerns or to act upon them.

I, like many other NHS senior leaders, have reflected over the last few weeks on how our honest and well-intentioned efforts to drive NHS performance and to improve services for patients contributed to creating that culture and climate.

Second, the NHS now needs to change, very fundamentally, the way things are done. We need, throughout the NHS, a renewed spirit of professionalism, much greater openness and transparency, a commitment to candour and integrity, and most of all a consistent, compassionate and patient-centred approach to care.

I would have liked to try to lead the NHS into this new era, but I recognise that I am very much identified in many people's minds with the old ways of doing things, and with the old ways of thinking and behaving that contributed to the tragedy at mid-Staffordshire Hospitals NHS Trust.

Fundamentally, new leadership is needed for this new era. I hope to be able to continue to play some part in the future development of the NHS, and to contribute to making a reality of the ambitious agenda for the NHS set out in the Francis report, but not as the chief executive of the NHS Commissioning Board.

The last few weeks have been humbling. I have been touched by the support and encouragement I've received from many people, and the kind things they have said about my contribution to leading the NHS through difficult and challenging times in recent years.

But now is a time for change - fundamental change - if we are to ensure as we must that a tragedy like that at Mid-Staffordshire Hospitals NHS Trust never happens again.

I wish you, the board, and my successor all the best with that endeavour.

Yours sincerely,

David Nicholson