2 min read

Editorial Thursday 6 June 2013: The liberation of Comrade Sir David and the bonfire of the policies

Nothing so pleases the God of Health Policy as a sinner come to repentance, but it remains a matter of gobsmacking chutzpah that NHS England CE Comrade Sir David Nicholson uses his first of what might be many 'exit' interviews with Health Service Journal to call for a more decentralised NHS.

Delegates at the NHS Confederation conference might be excused for snorting cornflakes out of their nostrils as they read this over breakfast.

The Comrade-In-Chief told HSJ's Dave West that NHS England’s strategy will seek to “liberate” the service to “experiment” with a range of solutions to challenges faced by the NHS: “the idea you could have one model in a sort of Stalinist way driven from the centre seems out of kilter really with the kind of NHS we want to create”.

Mmmm. If not mmmmmmmmmmm.

Comrade Sir David is a genuinely clever man, and will not be unaware of the piquant irony that only now he is going does he feel liberated to call for a cultural revolution in this way.

The bonfire of the policies
He also made a variety of remarks about, in essence, saying cheerio to the Health and Social Care Act's legal emphasis on the purchaser-provider split: “we’re very interested in thinking about integration of commissioning and provision and we can work with Monitor and others on how that could work, in particular circumstances and against particular sets of challenges ...  (NHS England is already) thinking about the possibility of mutual [organisations and] social enterprises, and also about whether the straightforward commissioner-provider split is the right thing for all communities.

Sir David called on the service to look closely at US organisations Geisinger and Kaiser Permanente, which serve as insurer and provider for a defined membership: “we need to be much more creative about those sorts of models of integration, which go beyond simple provider integration”.

An all-FT provider sector also goes up in the bonfire of the policies, with his condemnation of a “cookie-cutter foundation trust pipeline ... (strategy will examine whether the foundation trust is the right model for all [provider] organisations in the NHS. We should liberate people… if they think [alternative models] are the right thing to do, they should do it”.

The cynic in me notes that Comrade Sir David says we "should" liberate people, which is no guarantee that we will.

He claims policy justification for this volte-face thus: "the mandate doesn’t say you [have to] build a great commissioning system; it says you have to improve outcomes. So of course we’re interested in the nature of the NHS that’s being created. We’re not a regulator of commissioners”.

NHS England is, of course, absolutely a regulator of commissioners. This is a curiously disingenuous statement.

The revolutionary liberation of Comrade Sir David
Most of what Comrade Sir David says in his HSJ interview is genuinely revolutionary for the man in charge to admit.

The ideas are not new: it has been clear for some time, as Professor Alan Maynard succinctly summarised in his recent Health Policy Insight piece, that in a prolonged period of no more money, the market is no longer the solution (if it ever were).

Is this Damscene-looking about-face from a man mainly famous as a centraliser and gripper genuine? We have no evidence of it in Nicholsonism hitherto, but must hope that it is.

Cautious optimism is probably wise. It would be very interesting to see whether a liberating Comrade-In-Chief keeps his words on this - and whether the service will respond with alacrity, wariness or Stockholm Syndrome.

Time will tell, in her clear, true voice.