Sir David Nicholson was appointed chief executive of the NHS in 2006. He retained his position after the coalition came to power and pursued a set of reforms so big, he said, that you could probably see them from space.
The first barrier to reform, he says, was the sheer scale of the NHS: “You have to work really hard to make things happen.” Labour imposed top-down targets to force change; and whilst Nicholson admits they had adverse consequences, he argues that they were necessary to force important changes.
Reaching consensus on the detail of service changes was another awkward task. “Politicians are very happy to talk about improvements in care, but often less keen to talk about the consequences of living within budgetary limits,” he comments. “It can be toxic for them.”
Nicholson identified the top 1,000 leaders in the NHS, and worked with them to identify a common purpose for the organisation. “They went out among their own staff and had the arguments,” he says. Staff engagement and improved pay and conditions helped the implementation of reforms, he says.
Increasing media scrutiny of the reforms meant Nicholson had to develop his communication skills quickly. “I went from dealing with local newspapers to doing press conferences with Tony Blair and being interviewed by Jeremy Paxman,” he says. “I was completely unequipped at first.”
Things got really tough when Nicholson was linked to the Mid Staffs hospital scandal – he had run the West Midlands strategic health authority at the time. “Nothing prepares you for being at the centre of a media storm, though I completely understand how angry and upset the relatives of patients who had been harmed at Mid Staffs were,” he says. “Their complaints about me I accepted, but I did not agree that I should resign.”
There were very difficult moments when “journalists pursued my sons and ex-wife: you feel particularly powerless when this happens. Also the death threats.” But he retained the support of ministers, which “gave me the strength and determination to carry on. Plus, as many colleagues will tell you, I am a very resilient character.”
The most important voices, he adds, were those of patients: “They can give you a more realistic view of the world. Staff have a tendency to tell you what you want to hear.”
"Whatever doesn't kill you..." is a new regular mini feature in Civil Service World.
Next month: former information commissioner Richard Thomas