5 min read

Editorial Tuesday 25 June 2013: Welcome to the blogosphere and The Age Of Noise, Comrade Sir David Nicholson

Don't worry: I have already alerted the Office of Fair Trading to the news that Comrade Sir David Nicholson, NHS England supremo, has decided to pitch his tanks on my lawn with his first blog, on negative media perceptions of the NHS.

This competition on NHS policy and politics - hitherto pretty much my monopsony - is in the spirit of the age: 'o tempora, o mores'.

Still, I'm sure it's all in the best interest of patients, and so I extend a laurel and hearty handshake of new media friendship to the Comrade-In-Chief. As the Prime Minister said, "we're all in this together'. Or was it Aleksandr Solzhenitsyn?

The timing is interesting, given the recent flak under which his protege Cynthia Bower and colleagues from the CQC have come.

The media are shit
Comrade Sir David and I agree on something (delightfully), which is that much of the media's output on health is, to put it mildly, shit.

However, I think we might disagree about why it's shit.

As Comrade Sir David puts it, "The thing that characterises the views and comments for me is the lack of balance". Mmmmm. Balance is a fascinating thing when writing about any political subject, such as the NHS.

Not only is it intrinsically subjective, efforts to present balance can be actively unhelpful. The most obvious medical example is the gross irresponsibility of the mainstream national media in continuing to report as serious the claims of anti-MMR buffoon Andrew Wakefield, long after it was clear that his 'findings' could not be replicated, and even beyond the point where Brian Deer had irrevocably proved him deceitful in the BMJ.

Balance is also not evident in the debate over whistleblowing. We need not go back very far to find that unless whistleblowers had strikingly strong evidence for their claims, Private Eye (which funnily, also supported Wakefield's nonsense long after it should have rumbled him) was their only likely venue for a fair media hearing.

That 'balanced' view, strongly encouraged by the NHS hierarchy, was previously that most whistleblowers were troublemakers seeking to deflect from their own misconduct (and in fairness, this is sometimes the case).

It is now fairly widely recognised, due to Kim Holt, Gary Walker, James Titcombe, Kay Sheldon and others that whistleblowers have been treated very, very badly indeed by people at the top of the NHS.

The NHS can be very hard to understand
The media are also often shit on the NHS because many journalists frankly don't understand it terribly well. In fairness, it's complex: genuinely understanding the NHS requires understanding history, politics (big and small 'p'), economics, sociology, anthropology, statistics and medicine. That is quite a lot.

Much of the media are also often shit on the NHS because they have decided that their readers are stupid, and dumb down their output accordingly. Healthcare and the NHS can involve such complexity that writing about it in a way that assumes your audience aren't clever and can't understand complexity is almost certain to produce ... well, shit.

This tends not to be a problem for the quality trade press like my colleagues at Health Service Journal, or for a niche blogger like me: we know perfectly well that our readers are cleverer than we are, and write accordingly.

We are also well held to account by our use of Twitter, where dialogue and feedback can be prompt and robust.

This is also before we get to the point that many national media organisations are profoundly proprietorially biased that the world needs to be made a better place for elderly super-rich caucasians. This tends to make them appoint editors on the political right, with a certain complaisance to this view (honourable exception mention for James Harding - now of the BBC - as editor of The Times for overseeing robust reporting of News Corp's role in the phone hacking scandal).

All generalisations are dangerous (even this one)
Comrade Sir David's blog reminds me of a very good point made by a conference speaker (it may indeed have been him) that the NHS is so vast an organisation that anything you say about it - that it's wonderful, or terrible - is, somewhere, probably true. This is no more than Alexandre Dumas' point that 'all generalisations are dangerous, even this one'.

He continues, "We need to find a better way of having a conversation about what is happening in the NHS that recognises both. At the heart of this debate must be openness and transparency and how it can improve services for individual patients, as well as the overall performance of the NHS.  Although some pioneers can predate their commitment to it, in practice, the NHS began its difficult transition to openness and transparency during the development of ‘High Quality Care for All’ in 2008.

"The explosion of data available through NHS Choices, the definition of quality, the focus on outcomes, evidence based standards, ‘giving patients more clout’, together with Freedom of Information legislation, started to transform the environment we all worked in.  Add to that the increasing availability of data, and the use of social media, there is an enormous opportunity, but also an enormous challenge to public sector leaders.  The question is are we up to it?"

Bravo. I agree with pretty much every word, but there is an obvious and unstated challenge - a big challenge, that really matters.

The Age Of Noise
This challenge is that if you embrace post-perestroika glasnost, then you embrace The Age Of Noise.

And the job of a chief executive in the NHS has traditionally been 1. to avoid generating noise that embarrasses the minister; 2. not to blow up the money; and 3. not to kill your patients in publicly-visible numbers. Prioritised in that order.

This noise will be hard to respond to on occasions, and it will be uncomfortable. It will include people telling some falsehoods, some half-truths and some home truths.

The only way around The Age Of Noise is to go round and round and round it in circles, getting nowhere. We have got to go through it. That means a commonly-agreed and clearly-articulated sense of direction, in which most people share a clear and consensual aim.


The Comrade-In-Chief also asked if NHS leaders are 'up to it' (it being the data, openness and social media challenge); some are already doing it. You'll know their names on Twitter: among providers, Mark Newbold, Lisa Rodrigues, Rob Webster, Samantha Jones.

Longer-serving managers are there too: Robert Naylor, Andrew Foster and others. Commissioners are there too, like Steve Kell and Jon Fagge.

There are data, knowledge and policy experts, from Rob Findlay of Gooroo to Brian Jarman and Muir Gray and Nigel Edwards and Chris Ham, and on to health economists like iridescent John Appleby, Alan Maynard and Karen Bloor. There are clinicians galore: Fielden, Gerada, Tomlinson, Kar.

And there are journalists, and troublemakers. And surprisingly, we usually get along with some courtesy a lot of the time, even when we disagree.

Twitter is not a panacea (indeed it can be quite a thief of time, if you let it). But it is a convenient, free and open way to discuss and express views, listen, question, transmit, receive and talk to people.

Sounds like a good thing as we enter The Age Of Noise. Time to conscript the Comrade-In-Chief.

Updated: The sharp-witted David Williams of HSJ spotted that the two extant David Nicholson impersonators on Twitter have been joined by an authentic-looking 'David Nicholson'. Williams reasons that the numbers represent his date of birth (1955) and the Comrade-In-Chief's beloved Nottingham Forest FC's four trophy years: 59, 78, 79 and 80.