Interview: Sir David Nicholson

First, do no harm. It’s a guiding principle of medical ethics, but it doesn’t always seem to hold true in the NHS today – at least not if you base your picture of the NHS on media coverage that, in recent months, has seemed full of stories about patients suffering and dying under NHS care. Nor if you read the three official reports published since February on the topics of patient safety, high mortality rates, and the scandal of substandard care that led to at least 400 deaths in the Mid Staffordshire NHS Foundation Trust between 2005 and 2009. Between them, these reports contain “something like 1,000 recommendations” says NHS England’s chief executive Sir David Nicholson, but one can “boil virtually all of them down into one simple thing: the NHS needs to listen to patients, and do something about what they say to us”.

It may sound clichéd – listening to service users or patients is a common mantra among public service reformers – but in the NHS it is literally, he continues, a matter of life or death: since when things go wrong in the service, it is often because this basic principle has not been followed. “Mid Staffordshire is a good example of that,” he says. “Even in the best organised healthcare systems sometimes we do harm to patients, but the difference at Mid Staffordshire was the patients said we were doing harm, the relatives said we were doing harm, and people ignored them, walked away.”

Many people believe that Nicholson is one of those who walked away: he was chief executive of the strategic health authority which oversaw the Mid Staffordshire NHS Foundation Trust in 2005, when the period of poor care was beginning and early warnings were sounded. Earlier this year he told the Commons’ Health Committee that he had “no idea” about the developing crisis, but admitted that he was part of a leadership culture which was too focused on targets and organisational change, and helped to contribute to the scandal.

Speaking to CSW about how he coped with the personal attacks from media and patients as the Mid Staffordshire crisis unfolded, it’s clear that Nicholson takes his obligations to patients seriously, though one can also see the dogged self-belief which led him to be called “the man with no shame” by campaigners and the Daily Mail. He recalls reading the patients’ stories set out in the first Francis report into the crisis, published in 2010. “They are pretty harrowing stories,” says Nicholson, “it was the lowest point for me in all of this. I had to think about whether my personal actions had affected those individuals but, more importantly, were the things that I was committed to doing, and my general approach, going to improve things or not? And I made the judgement then that I was improving things. I could see how I could make it better.” That “basic set of inner ideas” enabled him to keep going “even though I was criticised and all those things were said about me,” he says.

Change and continuity
Given Nicholson’s strong belief in the ideas he was pursuing in 2010, it’s perhaps not surprising that when we move on to discuss the most recent set of reforms – which have seen massive organisational change and a new legislative footing for the NHS – Nicholson starts by emphasising continuities with the past. He picks out three key themes that have continued from when he became chief executive of the NHS in 2006: a focus on the outcomes of saving and improving the quality of lives, rather than targets such as reducing waiting lists; “giving patients more power”; and increasing clinical leadership of the service.

The new system addresses the first two themes by publishing information on clinical outcomes such as mortality rates, and through the introduction of a ‘Friends and Family Test’ as a basic measure of patient experience in all hospitals, he says. The final theme is fulfilled by clinical commissioning groups (CCGs): consortia of GPs who are charged with organising and buying healthcare in their area under the supervision of NHS England. With power over the vast majority of NHS budgets, these groups can be seen as the ultimate form of clinical leadership.

These local changes are the most important part of the significant organisational “churn and change” of the last few years, says Nicholson. Not only are CCGs “close to their local communities” with patients “involved and engaged with the governance,” giving patients a greater say into the local service design and improvement; but he also hopes that giving money and power to these local organisations will help to achieve the next big changes that the NHS needs to effect.

There is still “an enormous amount to do” in terms of reforming the NHS, Nicholson told an audience of NHS managers at the NHS Confederation annual conference in June. He even suggested then that the last few years of organisational change have been an impediment to the service reforms that are desperately needed – for example, developing specialised paediatric cardiology services. Yet in one important way, he argues, the current organisational and legal changes will help to ensure these reforms can now happen.

“Before the reforms,” he tells CSW, “the NHS was essentially what the secretary of state wanted it to be.” The new legislation has created a “whole set of organisations” with their own powers and responsibilities which are independent of – or, rather, “they run concurrently with” – those of the secretary of state. “That is a big change, and an important change if you’re thinking strategically,” he says. “The average secretary of state spends just over a year in their job.” He suggests it’s quite hard for managers to take a more strategic view in that environment but insists the reforms make it easier.

The strategic challenge that the NHS needs to address is one that Nicholson has been discussing since he was first appointed its chief executive after a large budget crisis in 2006: improving productivity in order to maintain services at a time when budgets were frozen and demand increasing. That challenge remains – in fact it’s grown, he suggests, as the world financial crisis means that resources are now likely to be frozen not just for a few years but for the forseeable future – but he believes that improving outcomes and patient experience, while living within constrained resources, is “perfectly possible if we take some really tough decisions over the next two years”.

Closing hospitals
Those decisions are likely to be around the closure or reduction of services based in general hospitals. The biggest risk facing the NHS as it plans for the medium term, he says, is that “for a whole variety of reasons, public, political and clinical, we’re unable to release resources [by] reducing the size of hospitals” to invest in improving out-of-hospital care. He emphasises the need to improve community-based care for people with long-term conditions such as dementia or heart disease. “If we don’t invest properly in that,” he says, “we will spend more and more money building bigger and bigger hospitals which provide, for those groups of patients, care which is sub-optimal.” (See our feature on health and social care.)

At the NHS Confederation conference, Nicholson acknowledged the political difficulty of this position, noting that “politicians will never run around saying: ‘Close hospitals’,” so he laid the responsibility for driving this change at the feet of NHS leaders, working closely with patient groups. Asked how the new system will enable the NHS to make tough decisions and redirect resources away from hospitals, he returns to the opportunities created by localised CCGs. “GPs having the control over the resources to make sure they’re put in the right place, so the services are redesigned at a local level, will make the big difference that we’ve failed to deliver.”

He goes on to describe a recent meeting with a group of GPs who have changed diabetes services in their area. “My response to them was: ‘Where have you been all my life?’ One answered: ‘Probably trying to stop you doing everything that you wanted to do’.” The GP was “exaggerating to make the point,” says Nicholson, but the fact that GPs now have more control and are in theory free from central diktats will mean they are “much more likely to make the right decisions for a local level.”

Changing cultures
The GP’s response also reveals the difficulty behind this localist ambition: the NHS, and Nicholson himself, are known for taking a centralist, directive approach to service reform. A blog published by the British Medical Journal shortly after Nicholson’s NHS Confederation speech notes that some local managers are already complaining that NHS England’s local area teams are “behaving with the abrupt, directional style of strategic health authorities at their worst”.

Asked what he is doing to change this culture, Nicholson first clarifies that “I don’t believe that the way you make change is to give everything away and let everybody do what they like. In any change programme there is always local and national action. There are some things that you can only do nationally.” Nevertheless, he says that NHS England is “absolutely committed” to “creating an environment where people have more flexibility to innovate and change.” It has established a Commissioning Assembly made up of representatives from CCGs and NHS England staff, to judge and monitor how successfully the organisation is giving commissioners freedom to innovate.

He adds that “everyone in the system has a responsibility” to effect this change. Politicians must refrain from passing down too many objectives to the head of the NHS who will then be forced to pass those down to local groups: “It’s no good the Department of Health (DH) saying to me ‘We’ve got 1,000 things we want you to do’ because that creates the environment where I then have to do [those things],” he says. Every government directive means “a little bit of freedom and flexibility going away from the local level”.

Nicholson acknowledges that there will always be political interest in the NHS but under the new system, he argues, the greater level of transparency about who is responsible for delivery and how money is allocated will help to ensure that political considerations do not obstruct public and clinical priorities. “The important thing is to be really transparent about what the government requires of the NHS and then how we’re going to deliver it,” he says. Within the opacity of the old system, he suggests, money might be moved about the system to deal with political problems. “You can’t do that now,” he says, and both civil servants and politicians will need to get used to working in this more transparent world.

Nicholson returns to the distinct roles of politicians and officials when asked to elaborate on why Alan Johnson was his favourite secretary of state (as he told the Guardian earlier this year). Johnson “was really good at identifying what he as a politician needed to do, and how he needed to intervene, and what he could leave officials and managers to get on and do.” Nicholson points to Johnson’s intervention in the campaign to reduce healthcare-acquired infections, noting that “he forced the whole system to confront that issue in the way that only a politician can”. However, he is less positive about another of Johnson’s interventions: the creation of the Care Quality Commission (CQC), which he believes is an example of political considerations overriding issues of good governance and patient safety.

False assurances
The CQC, which inspects health and social care providers in the UK, was created from the merger of two previous inspection bodies in 2009. It is now facing at least 30 civil negligence claims after it failed to identify poor care in a number of organisations, and apparently it then tried to cover up its own weaknesses. The first lesson Nicholson takes from this is that that structural change should always be rigorously questioned. “A politician,” he says, neglecting to mention Johnson by name, “decided that they were going to merge these organisations together. I don’t think that was rigorously dealt with at the time.” Structural change is not an easy option, he continues, and in the future “we need to be really careful and circumspect about whether we see that as a solution to a problem.”

Secondly, one should be really clear about what is expected of new organisations, and ensure “that they’re properly resourced to do the job.” And finally he returns to the focus on patients, not targets. A lot of the CQC’s early work, he says, “was responding to standards and things that were set out by the government, as opposed to being set out by what patients actually required.”

Though he says he is confident that the CQC now has both the resources it needs and a team of “highly regarded, very credible individuals” leading it, he is still wary about placing too much emphasis on regulation and inspection alone as a guarantee of quality. He notes that “false assurance is the biggest problem with regulation” and says: “Regulation will not guarantee safety and quality of services for patients. What guarantees that is the quality of people who are running the services and the people who are delivering them. So just because you’ve got a good regulator or an improving regulator, we [shouldn’t be any less] vigilant about the services that we operate and the quality of the people who run our hospitals.”

One problem highlighted by the CQC crisis is that those who were vigilant about safety, and tried to speak up about failures or problems, do not appear to have been listened to. CQC board member Kay Sheldon has said she was subjected to “appalling treatment” after she made whistleblowing disclosures about failures in the organisation; and Nicholson himself has faced allegations that he ignored whistleblowers concerned about safety in various hospital trusts. The NHS has also been criticised for its use of ‘gagging orders’ when staff leave the service: these often appear to stop whistleblowers from going public with their concerns.

Nicholson has denied that any NHS staff were ever gagged, and he gives CSW strong assurances of support for whistleblowers. He notes that the NHS staff survey indicates that increasing numbers of employees feel supported to raise concerns, but acknowledges that some organisations “undoubtedly” have a problem, and supporting whistleblowers, he adds, is “particularly important when you’re going through big change [and] there’s big pressure on the system.” Nicholson’s responsibility, he says, is to “say that it’s absolutely right to speak out if you feel that patient safety is at risk; you absolutely have the legal protection to do that no matter what the contractual arrangements might have been”.

Balance, not blame
As we return to the question of harm in the NHS, and the recent focus on poor quality care, his answers suggest that the media and politicians need to be more balanced in their discussions of the NHS if staff are to feel comfortable raising concerns about safety. When asked if he recognises the picture of the NHS in crisis, he acknowledges that the service does “really bad things to patients”, but says it’s also true that hospital mortality rates have fallen by about 30 per cent in the last decade.

“If you spend all of your time trumpeting the success of the NHS you kind of get yourself into a place where you’re more interested in what the line to take is than what’s really happening to patients,” he says. “If you go to the other side of it you miss out all the great things and you significantly, I think, affect the morale of people working in the service – so that balance is really critical. Over the last few months that balance has completely gone. I understand why, but we need to get back to that balanced position.”

He suggests that the balance has tipped because the NHS is publishing more data and becoming increasingly transparent about the quality of its care. This transparency is a “vitally important part of the NHS’s journey, and [the NHS] will come out of it stronger; transparency has to be absolutely at the heart of what we do,” he says. “It’s important that the NHS, public and politicians confront the uncomfortable truths which are being published.”

Organisations with excellent services, he suggests, learn from mistakes and become better because of them. If, however, “every time a mistake is made the world falls in, you can see exactly how you would get the opposite culture in the NHS.” He concludes in what could be seen as a personal appeal from a man who has been the subject of a Parliamentary motion: “If we use every mistake as a learning opportunity, I think the public will get a better service than they will if every time something goes wrong they want people suspended.”