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Editorial Monday 31 March 2014: Some thoughts for NHS England CE Simon Stevens

NHS England has been run by a former Communist, and from today it is run by a former Labour councillor. Perhaps in our children’s children’s time, NHS England will be run by a former Lib Dem?

Anyway, Simon Stevens is a great hire. He runs the risk of inflated expectations leading to disappointment when miracles do not immediately ensue, which is a nice problem to have.

Here, to speed Simon on his way, are a few observations about the job.

1. Be a benevolent con-man. Con is the abbreviation of confidence trick. Confidence tricks work because people want to believe what they are hearing, and suspend their disbelief.

Confidence in a new leadership is desperately needed: there is almost a hunger to be led. A lot of the empirical evidence about the current state of the NHS (in particular, on finance and demand) would not suggest confidence.

It may have to start out as a trick, based on people's desire to believe, but the aim must be for confidence to become a habit.

2. The job is dative, not accusative. I always knew Latin grammar would be handy one day: the powers of the NHS England job are essentially dative ones, rather than accusative. It is indirect, rather than direct.

This poem gives you Latin verbs that take the dative:
A dative put with show and give,
Tell, envy, spare, permit, believe,
Persuade, obey, command. To these
Add threaten, succour, pardon, please
With vacare and displicere,
Heal, favour, hurt, resist and indulgere.

3. Don’t ’put on the poor mouth’ (too early). When it comes to funding, the Oliver Twist - "please, sir, may I have some more?" - is not a dance move to pull often or early. As Ernest Rutherford said, ”we haven't the money, so we've got to think".

3a. On the subject of politics (i.e. the funding), political capital is your non-recurrent revenue funding: you can only spend it once.

4. The network beats the hierarchy. This is going to be about a form of leadership that creates its own authority and legitimacy. The 2012 Act and subsequent chaos made the NHS into a multipolar system.

Unfortunately, it is an unstable one, which has led to much energy being wasted on jockeying for position and suchlike aimless dicking-about. Time for a primus inter pares to deliver a Pax Americana and well-defined spheres of influence.

Key skills of this brave new multipolar world include diplomacy, negotiation and communication. If NHS England has a Clinton campaign-type war-room, put up the slogan 'it's the relationships, stupid'. Running NHS England is going to be pretty much a permanent campaign.

5. Communication has to be a top priority now money is tight. This probably involves a postmodern approach, such as in the Pompidou Centre, putting the workings on the outside so that all can see them. Surprises are probably best avoided.

6. Stakhanov is not our role model. People got the NHS to this point without the quality blowing up and money running out to no small extent by working harder. That is not sustainable, clearly.

The next bit has to be about working much smarter.

7. Care.Data is a mess and has forfeited much public confidence. The case will have to be re-made (sigh), and the data protection implications of commercial access reconsidered.

Data on patient and provider outcomes will be a key part of the future of the NHS. Getting this right is much more important than getting it done fast. Purveyors of apocalyptic warnings that not going full speed ahead will spell the end of the NHS should be avoided, here as in other areas.

8. Plan carefully and openly, based on good evidence and where possible, consensually and collaboratively. (It won't always be possible to be consensual, but hear opponents of change: you will need to know their arguments to beat them).

But this is a balance to be struck. 'Consciously uncoupling' may work for Gwynneth Paltrow and the singer from Coldplay: there's also a time to be ruthless judiciously. As Mike Tyson said, "everyone has a plan till they get punched in the mouth".

So ignore General Patton‘s line that “a good plan, violently executed now, is better than a perfect plan next week”. Favour Einstein’s approach: “If I had an hour to solve a problem I'd spend 55 minutes thinking about the problem and five minutes thinking about solutions”.

9. Impose any change of structures only if all else fails first. It might be good to allow evolution and diversity of solution to problems that may seem structural.

Form should follow function. Instead of this, the NHS has too often sought to make form uniform (a polyclinic in every PCT, need it or not!), and it hasn't worked.

10. It's all about the relationships (AKA the soft stuff is the hard stuff). If culture really does eat strategy for breakfast, then relationships provide the ingredients, utensils, crockery, recipe and stove.

11. Welcome intelligent dissent. Feeding the mouth that bites your hand may seem deeply counter-intuitive, but it may be biting you for a reason, and that reason may be worth knowing.

Likewise, do not define a successful CE as one who can manage down the 'noise'. The NHS has also tried this, and it likewise doesn't work.

12. Start your succession planning on day one. Sounds a bit premature. Isn't. When the Comrade-In-Chief finally saw the light at the end of the tunnel, the NHS had no obviously likely pool of successors from a different generation.

One of the problems with a 'big beast' is that nothing can grow in its shadow. Hire or steal ambitious, bright people.

From the HPI archives
Simon Stevens talk at the Kings Fund, 2009
Simon Stevens interview, 2009
Simon Stevens interview, 2011