Sir David Nicholson, Former Chief Executive, National Health Service, UK: Exclusive Interview
Sir David Nicholson left the UK’s National Health Service last year, after spending his whole career in this vast organisation. He talks to Global Government Forum about the lessons he learnt and his next big project
How do you gain people’s trust? How do you tell ministers things they don’t want to hear? How do you effectively connect policy and implementation? And how do you deal with a crisis? After eight years running the UK’s universal National Health Service (NHS), whose 1.6m staff make it one of the world’s biggest employers, Sir David Nicholson has some answers to these questions.
He left the post of NHS chief executive after implementing the organisation’s biggest reforms since its foundation in 1948: a set of changes, masterminded by Tory health secretary Andrew Lansley, of such scale that Nicholson told a Commons select committee they could be “seen from space”. And he’s proud that, alongside these reforms, he delivered an £18bn efficiency programme and the highest patient satisfaction rates in NHS history. But this last job represented only the culmination of a 36-year career in NHS management, and Nicholson is full of experiences and ideas that will be of interest to anyone involved in managing a large and dispersed organisation.
Gaining people’s confidence
Early in his career in NHS management, Nicholson realised that one of his biggest challenges would be to overcome the divide between managerial and clinical staff. When he took over his first hospital in the northern English town of Doncaster in 1988, he recalls, his two predecessors had been there for three years each. Yet most medical staff would spend their whole professional careers in one institution: as Nicholson says: “Why would they trust you? Why would they want to be led by you?”
So Nicholson spent his first three years gaining the trust and confidence of his team, “particularly the consultant medical staff… The first thing you have to do is to build a common mission. You’ve got to get everyone on the same page. You’ve got to get to a place where all the people buy into what you want to try and do – and you have to buy into what they want to try and do as well, because some of them were very ambitious about the future of the hospital and they wanted to see a chief executive who was also ambitious about their hospital.”
Nicholson’s mission for the hospital’s future included three ambitions. He wanted to integrate primary, community and hospital care so that patients were better looked after before they entered and once they left hospital – something that he hoped to achieve by creating ‘integrated pathways of care’. The second objective was to “attract patients from a broader population to use our services”, because at the time he took over the hospital, it became clear that it wasn’t drawing people who needed its specialist services from a broad enough footprint, so the numbers weren’t sufficient to make its specialist services financially viable and it needed to broaden that footprint. The third pillar of his vision was a promise to all hospital staff that, “if you work flexibly, if you keep yourself up to date, if you keep your professional standards high, we will guarantee you a job for life.” These ambitions combined, he says, “worked relatively well” and meant that, once his staff trusted in him as a CEO, “there was nothing we couldn’t do. It was a fantastic place to work; we had a great time.”
After nine years in Doncaster, he moved on to run a number of other hospitals and strategic health authorities (SHAs) – since abolished NHS organisations responsible for enacting and implementing government policy at a regional level – in the North of England, where he used the same management style. He led the Birmingham and the Black Country SHA, for around four years, before it was abolished along with 17 other SHAs as part of a government reorganisation of the NHS. Employees of the abolished health authorities had to apply for similar jobs in other SHAs around the country. “We all had to put in order which place we wanted to work in. I put London third, and they made me go to London,” he says jokingly.
Following this unexpected move to London, he saw the job of NHS chief executive advertised. “I’d never had that [role] as an ambition,” he says. “But these jobs don’t come up very often, and so I applied for it.” In his application, he leaned both on his track record of successfully managing hospitals and health authorities, and the front-line experience he gained during the 1970s as a trainee on the 27-month NHS graduate scheme: it proved a persuasive combination, and he was appointed chief executive of the NHS in September 2006.
Policy and implementation
This graduate training scheme, he says, was “what’s described as a ‘Cook’s tour’ of the NHS, which gives you a fantastic grounding and understanding of it.” He did everything from looking after patients as a nursing auxiliary to working as a porter; covering shifts in the administrative office to washing uniforms in the laundry. This gave him an understanding of what working life is like for these various hospital professions, he says – and that vastly helped him as chief executive. Even though he took up the post almost 30 years later, he believes the training scheme gave him the ability to “always be thinking about how a policy would work out in practice – for the ward sister or the person in outpatients.”
Another benefit of the graduate scheme was that it gave him an insight into how public servants voice their concerns about policies imposed by the Department of Health (DH) – enabling him to tap into information he could then feed back to policymakers. Because he had worked alongside hospital staff for more than two years, when he became chief executive he knew what kind of questions to ask people on site visits. “I would probably do one day a week where I’d be visiting organisations, talking to the staff and patients, and one of the questions I would ask members of staff was: ‘When you’re together with your colleagues and it’s a cold, miserable day, what are the things that you all grumble about?’ So I did it in a slightly humorous way, but it’s amazing what you can get out of people when they start talking about things from the perspective of their own experiences; you can learn things about their organisation and the way they operate in a way that I found really helpful.”
When working with policymakers, he also drew on his experience in mental health, where he worked for ten years before running his first hospital: “I was always interested in checking how a policy would work for people with learning disabilities.” Nicholson says that ‘learning disabilities’ was a “watchword”, giving an indication of the overall quality of services: “If you get primary care right for people with learning disabilities, chances are you’ll get it right for everybody, because you have to think about the individual and the person in a particular way.”
Most senior DH officials lacked the ability to make those connections and imagine what policies would look like in practice, Nicholson says: “There was not an obvious route for them to have got that kind of experience.” To address this short-coming, DH is running the ‘Connect’ programme for its senior civil service – as part of which officials have to complete a number of days every year on hospital wards. This work, Nicholson argues, “is really important and makes a big difference.”
One major skillset senior DH civil servants had, but Nicholson says he initially lacked, was the art of “delighting ministers”. Departmental senior officials, he says, tended to advance well in their careers “if they were really good with ministers: that’s a different – and really important – skillset.”
To an extent, he says, acquiring that particular skill was “trial and error: there’s no book, and I made some mistakes early on.” Because healthcare is such an important part of people’s lives, ministers and prime ministers generally show a lot of interest in the NHS, which often turns into a political battleground. “So as chief executive of the NHS, you’re quite exposed,” Nicholson comments.
When Nicholson, who in his regional jobs had gained little experience of dealing with the national press, told the Guardian newspaper in an early interview as chief executive that the government might shut down 60 hospitals, his secretary of state – then Patricia Hewitt – was not impressed. “She went absolutely spare, and asked me why I did it,” he recalls, “and I said: ‘I was just trying to be helpful’, to which she replied: ‘The only person you are ever helpful to in the future is me!’ So that was quite a big lesson for me at the beginning.”
Another difficult aspect of the job Nicholson was getting ministers to take in information they would rather not know. “This thing about ‘speaking truth unto power’ is very tricky,” he says, “because sometimes you have to tell them things they just don’t want to hear, and what ministers often do in those circumstances is they ignore civil servants.” Nicholson says he often saw officials being excluded from meetings after raising awkward questions that challenged ministers’ ideas. “It’s not that ministers say: ‘I’m not going to speak to you anymore’, but you just won’t be sat around the table in the future.” He says that this tactic was never used on him, but then adds jokingly: “It might have happened to me and I didn’t know! But I don’t think so.”
Nicholson says he learnt quickly what he needed to do in order to retain a seat at the policymaking table. Instead of just highlighting problems with ministers’ plans, he says, you have to offer solutions: “For example, if a minister wants to boost the number of nurses in the NHS, there is a financial and training consequence. You can’t do it overnight; it may take several years to build that up – you have to train and then employ them. But sometimes, they really don’t want to know that detail; they just want to make a big announcement. If you just say to them: ‘It won’t work, and here’s why not’, they will exclude you; they won’t involve you in the conversation. But if you say: ‘This is the consequence – and this is how I think you can best achieve what you want, either that or another way’, you’re much more likely to get invited.”
Dealing with a crisis
Nicholson loved his job and had taken it up with a mission to improve patient care. But a major scandal unfolded under his watch, until he and his family, friends and neighbours were being hounded by the press and calls for his resignation became louder and louder.
Hundreds of patients experienced poor care between January 2005 and March 2009 at Stafford Hospital in the West Midlands of England, run by the Mid Staffordshire NHS hospital trust. There were also concerns about higher-than-average mortality rates at the hospital. Much of the media blamed Nicholson, stating that he was “in charge of the regional health authority responsible for Stafford Hospital at the height of the failings between 2005 and 2006,” as reported by Sky News and the Independent newspaper. But, Nicholson says: “This is part of the problem: much of that’s not true. However, you can’t say that, because it sounds as if you’re being defensive.” In 2005, Nicholson explains, he was chief executive of the Birmingham and the Black Country SHA. As part of a government-driven restructure, his, as well as the neighbouring West Midlands South SHA and Shropshire and Staffordshire SHA, which was responsible for Stafford Hospital, were going to be merged into one. “But they couldn’t do that until eight months later, so they asked me to take on the extra responsibilities.” He took on the role of acting chief executive for Shropshire and Staffordshire SHA as well as West Midlands South SHA one day a week for eight months “while the reorganisation was going on.”
So for a period of eight months, Nicholson was effectively CEO for three SHAs. He says he did it as a favour to his boss, but now concludes that “it was untenable to expect one individual to be the chief executive of three separate statutory organisations at the same time.” Though he was only there one day a week for less than a quarter of the whole crisis, he says: “Of course, I take some responsibility for what happened there. The organisations weren’t doing what they were supposed to be doing.” Yet when the scandal first emerged in 2009, Nicholson’s prominent position in the NHS made him a lightning rod for every piece of bad news about Mid Staffs: journalists tried to gain access to every possible aspect of his life, pursuing his children, ex-wife and neighbours, and regularly turning up at his home. “You really are under the microscope,” he recalls. “But you just have to be resilient.”
The first independent inquiry into the failings, requested by Nicholson, produced in 2009 by British barrister Sir Robert Francis QC, found that the hospital’s poorly-led board, an obsession with hitting government targets, poor clinical management and weak supervision had led to a breakdown in service. Nicholson believes that there was another important factor that had led to the poor care: an endless succession of structural reorganisations. Throughout his time at the NHS, he says, it was “constantly being reorganised. Governments often feel that administrative reorganisations will make them look as if they’re doing something while being cost-free, but they are potentially really dangerous.” If NHS managers constantly have to fear for their jobs and “speculate about where they will be in 12 months’ time, people start looking out for themselves, instead of focusing their attention on improving services for patients.” And Nicholson knows what he’s talking about: he did, after all, implement a massive and radical set of NHS-wide reforms for crusading health secretary Andrew Lansley.
Although Nicholson refused to resign over the scandal, because he “knew what we needed to do to make the problems right,” the continuous media focus on the Mid Staffordshire Scandal “deflected away from what I wanted to achieve moving forward and it got to the point where it was affecting my ability to do the job.” Anyway, it was probably time to go: after eight years in the role, he’d become the NHS’s longest-serving chief executive, and didn’t want to hold on until after the May 2015 election. So Nicholson handed in his resignation in May 2013, and – to give his new chairman ample time to find a successor – left the service a year later.
Healthcare for all
Since then, Nicholson has found a new “mission to keep me going: universal healthcare.” He is passionate about the idea of giving “the whole world access to healthcare, not just the people who can pay for it and demand it.” For, he adds, healthcare is a fundamental stepping stone to creating an equal society. People’s frustration over their inability to access healthcare has contributed to major uprisings, he argues, including the Arab Spring.
To further his goal, he got involved in a number of projects. He joined the Institute of Global Health Innovation at Imperial College London as adjunct professor, and is now working with the college on creating a centre for universal healthcare. He chairs the impact committee of the Abraj Global Health Fund, a US$1bn investment fund of predominantly private money which is “trying to create ten healthcare systems in ten cities in Africa and Asia.” And he chairs the World Innovation Summit for Health (WISH): a group of policymakers, healthcare providers, researchers, academics, and industry leaders from around the world who strive to produce ideas for overcoming the world’s most urgent healthcare challenges.
A report by the World Health Organisation (WHO) and the World Bank Group published last month found that 400m people do not have access to basic health services. The report looked at global access to essential health services—including family planning, antenatal care, skilled birth attendance, child immunisation, antiretroviral therapy, tuberculosis treatment, and access to clean water and sanitation—in 2013, and found that at least 400m people lacked access to at least one of these services.
So what needs to be done to give these people access? Nicholson argues that any government wanting to create a universal healthcare system needs three things: “First of all, you need political leadership. Politicians can do fantastic things.” Britain’s system – the NHS, which is entirely publicly-funded and free at the point of use – was founded in July 1948, after “hundreds of thousands of our own people were killed in a world war, all of our major cities were in rubble, and we had basic foods like bread on rationing,” Nicholson says. “But the politicians decided that was the time to launch universal healthcare. So even if you’re a poor country, the right kind of political leadership can make it happen.”
Secondly, Nicholson says, “you need to create the ability to pool resources – a mechanism by which people pay into it, and then take out of it when they become ill.” Often, he adds, “the rich say: ‘We don’t want to be in this pool’.” The whole population must pay into the pool for the healthcare system to work and to get sufficient money for economies of scale, he says: “It doesn’t have to be tax-funded like our system in the UK, but it needs to be mandatory, even if it’s mandatory private health insurance. So getting that mandation right is absolutely critical.”
Thirdly, Nicholson says, a government should focus on “the missing middle.” Often, when governments create these systems, they don’t know where to start and initially focus on the very poor, or the very rich. “If you start to persuade the rich to come off their private healthcare you’ll be waiting forever,” he says, and providing care solely for the poor would be financially difficult as taxing them would not bring in enough money, and also mean that the high earners would not see a benefit. If governments start with the middle class, they would receive enough tax revenue to create a good service, and the people being taxed would exert pressure on authorities to ensure high quality, see the benefits of that service and be likely to back an expansion of the offer. “So you first need to get the commitment and involvement around the middle, and take it from there,” Nicholson adds.
In his travels since leaving the NHS – particularly in his role at the Abraj fund – Nicholson has met clinicians, health managers, politicians and policy-makers from many countries, including South Africa, China, Indonesia, the USA, Canada and India. And looking back, he argues now that this international experience would have been a huge help during his time leading the NHS: not only would it have provided many ideas and contacts who could have helped improve NHS services, but it would also have provided a reality check on how the NHS compares to its peers overseas – giving him the data and confidence to champion high-quality NHS services in the face of unrealistic public or ministerial expectations.
As Nicholson has explained, his experience of frontline services – gained as a young graduate on wards and in offices and laundries and staff rooms – gave him an understanding of very local health provision which proved a huge advantage much later in his high-flying career. But it was only after leaving the UK’s top health management job that he realised that experience at the far, international end of the scale can be just as helpful: if he had done all this travelling before 2005, he says now, he “would have been a better chief executive.” The perfect NHS chief would, perhaps, marry the micro with the macro; and whilst this is quite a lot to ask, cultural and technological changes are making it easier all the time. Nicholson’s successors will have a job just as tough; but perhaps they’ll find it a little easier to find the tools to do it with.