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| NHS chief Sir David Nicholson faces judgment day over Mid Staffs scandal | NHS chief Sir David Nicholson faces judgment day over Mid Staffs scandal |
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| When the long-awaited Francis report on why health service managers and regulators failed to spot the terrible failures of care at Mid Staffordshire hospital trust is published on Wednesday, the media and political spotlight will home in on what it says about the actions of one individual in particular: Sir David Nicholson. | When the long-awaited Francis report on why health service managers and regulators failed to spot the terrible failures of care at Mid Staffordshire hospital trust is published on Wednesday, the media and political spotlight will home in on what it says about the actions of one individual in particular: Sir David Nicholson. |
| He was the inquiry's star witness. As a regional NHS official he had oversight of the performance of Mid Staffs in 2005, at the time the clinical failures were happening. In his subsequent role as chief executive of the NHS he was accountable for the way in which the service responded to the emerging scandal. He is arguably the most powerful person in the NHS. | He was the inquiry's star witness. As a regional NHS official he had oversight of the performance of Mid Staffs in 2005, at the time the clinical failures were happening. In his subsequent role as chief executive of the NHS he was accountable for the way in which the service responded to the emerging scandal. He is arguably the most powerful person in the NHS. |
| The significance of the inquiry's judgment on Nicholson lies partly in its assessment of how culpable he was for the handling of one of the worst NHS care scandals. The report will also be seen as a more general verdict on the way the NHS has been run in recent years, and the centralised, top-down, target-driven management style and culture that Nicholson has come to personify. | The significance of the inquiry's judgment on Nicholson lies partly in its assessment of how culpable he was for the handling of one of the worst NHS care scandals. The report will also be seen as a more general verdict on the way the NHS has been run in recent years, and the centralised, top-down, target-driven management style and culture that Nicholson has come to personify. |
| Despite his apology to the people of Staffordshire last week, Nicholson will face calls to resign. Whether the health secretary, Jeremy Hunt, agrees that he should go will be instructive. Nicholson's departure would enable ministers to send a symbolic message that they have called time on an NHS era they claim their changes will leave behind. But Hunt also knows this is not a straightforward call. | Despite his apology to the people of Staffordshire last week, Nicholson will face calls to resign. Whether the health secretary, Jeremy Hunt, agrees that he should go will be instructive. Nicholson's departure would enable ministers to send a symbolic message that they have called time on an NHS era they claim their changes will leave behind. But Hunt also knows this is not a straightforward call. |
| Nicholson is a great survivor, and part of the reason is that whatever politicians of all hues say about "light touch" leadership and the "post-bureaucratic era", the volatile world of NHS politics means they ultimately find the robust, centralist Nicholsonian style indispensable. | Nicholson is a great survivor, and part of the reason is that whatever politicians of all hues say about "light touch" leadership and the "post-bureaucratic era", the volatile world of NHS politics means they ultimately find the robust, centralist Nicholsonian style indispensable. |
| Nicholson is, everyone agrees, a big character. In an era of grey-suited managerialism, few top public servants have come to embody so vividly the culture and practice of the service they run. In leadership terms he is a colossus: after nearly seven years, he is one of the longest-serving NHS chief executives, and arguably its most successful. He has served five health secretaries across two governments. | Nicholson is, everyone agrees, a big character. In an era of grey-suited managerialism, few top public servants have come to embody so vividly the culture and practice of the service they run. In leadership terms he is a colossus: after nearly seven years, he is one of the longest-serving NHS chief executives, and arguably its most successful. He has served five health secretaries across two governments. |
| No one (including him) expected Nicholson to get the NHS top job in 2006, because at that time Labour wanted a high-flying private healthcare executive, preferably from the US. No one (including him) expected Nicholson to survive the transition to coalition government, but he outlasted its first health secretary, Andrew Lansley, who almost everyone supposed would be his nemesis. | No one (including him) expected Nicholson to get the NHS top job in 2006, because at that time Labour wanted a high-flying private healthcare executive, preferably from the US. No one (including him) expected Nicholson to survive the transition to coalition government, but he outlasted its first health secretary, Andrew Lansley, who almost everyone supposed would be his nemesis. |
| Political bosses as ideologically diverse as Patricia Hewitt, Andy Burnham and David Cameron have relied on him, not least because he has almost invariably delivered their priorities. After the NHS ran up a billion-pound deficit in 2006 (a crisis that led to the sacking of his predecessor) he swiftly pulled it back into the black. When the service was rocked by hospital-acquired infections scandals in 2007, he delivered the clean-up. Waiting times have remained relatively stable three years into the biggest efficiency drive mounted in the NHS, even as Nicholson presented a £3bn surplus to the Treasury. | Political bosses as ideologically diverse as Patricia Hewitt, Andy Burnham and David Cameron have relied on him, not least because he has almost invariably delivered their priorities. After the NHS ran up a billion-pound deficit in 2006 (a crisis that led to the sacking of his predecessor) he swiftly pulled it back into the black. When the service was rocked by hospital-acquired infections scandals in 2007, he delivered the clean-up. Waiting times have remained relatively stable three years into the biggest efficiency drive mounted in the NHS, even as Nicholson presented a £3bn surplus to the Treasury. |
| Perhaps the most dramatic illustration of his indispensability was during the political crisis over the coalition's health and social care bill in 2010-11. Nicholas Timmins, in his book Never Again?, relates how Nicholson was at the NHS exit door, about to start negotiating his severance deal, when public opposition over the proposals blew up. As the furore grew, so panic spread in the Treasury and No 10 that their proposals were unravelling. | Perhaps the most dramatic illustration of his indispensability was during the political crisis over the coalition's health and social care bill in 2010-11. Nicholas Timmins, in his book Never Again?, relates how Nicholson was at the NHS exit door, about to start negotiating his severance deal, when public opposition over the proposals blew up. As the furore grew, so panic spread in the Treasury and No 10 that their proposals were unravelling. |
| Cameron and the chancellor, George Osborne, turned to Nicholson to fix the problem, effectively sidelining Lansley. As Timmins writes: "A born and bred manager, he knew how the system worked … Above all he knew better than anyone else in the department how to hold the service together amid this whirlwind of controversy and change." | Cameron and the chancellor, George Osborne, turned to Nicholson to fix the problem, effectively sidelining Lansley. As Timmins writes: "A born and bred manager, he knew how the system worked … Above all he knew better than anyone else in the department how to hold the service together amid this whirlwind of controversy and change." |
| Nicholson, in theory, was not a natural defender of the coalition's proposals and previously had spoken openly about the limits of using markets to change the health service. But nor was he a refusenik and, as Timmins notes, his sceptical appreciation of what was needed to drive through the changes persuaded a nervous cabinet he was precisely the kind of manager they needed. | Nicholson, in theory, was not a natural defender of the coalition's proposals and previously had spoken openly about the limits of using markets to change the health service. But nor was he a refusenik and, as Timmins notes, his sceptical appreciation of what was needed to drive through the changes persuaded a nervous cabinet he was precisely the kind of manager they needed. |
| Timmins quotes a Whitehall official as saying: "David emerged the saviour of the day. [He] basically convinced a tremulous Treasury and No 10 that he could hold the budget and deliver it. And they liked him, I think, and he gave them a lot of confidence … They realised that what the system needed wasn't a reforming zealot but somebody to hang on to the bloody thing." | Timmins quotes a Whitehall official as saying: "David emerged the saviour of the day. [He] basically convinced a tremulous Treasury and No 10 that he could hold the budget and deliver it. And they liked him, I think, and he gave them a lot of confidence … They realised that what the system needed wasn't a reforming zealot but somebody to hang on to the bloody thing." |
| Nicholson's reward was to be given the powerful role of chief executive of the NHS commissioning board, the body that will supervise the spending of tens of billions of funds by devolved GP-led commissioning groups. It was not supposed to be this way. Timmins cites a government official as saying: "Anybody who told Andrew Lansley … before the election that David would end up being appointed to the national commissioning board … would have absolutely been laughed out of court." | Nicholson's reward was to be given the powerful role of chief executive of the NHS commissioning board, the body that will supervise the spending of tens of billions of funds by devolved GP-led commissioning groups. It was not supposed to be this way. Timmins cites a government official as saying: "Anybody who told Andrew Lansley … before the election that David would end up being appointed to the national commissioning board … would have absolutely been laughed out of court." |
| Ask people to assess Nicholson's virtues, and his plain-speaking (especially for a top civil servant) crops up time and again. Back in December 2010, months after ministers had signed a coalition agreement promising no more major top-down reorganisations of the NHS, Nicholson memorably described the planned NHS bill as unprecedented in the scale of change it proposed. "Someone said to me: 'It is the only change management system you can see from space – it is that large,'" he said. | Ask people to assess Nicholson's virtues, and his plain-speaking (especially for a top civil servant) crops up time and again. Back in December 2010, months after ministers had signed a coalition agreement promising no more major top-down reorganisations of the NHS, Nicholson memorably described the planned NHS bill as unprecedented in the scale of change it proposed. "Someone said to me: 'It is the only change management system you can see from space – it is that large,'" he said. |
| In some environments, such candour would be regarded as subversive. But politicians, it seems, appreciate it. Burnham, the former health secretary and now shadow health secretary, recalled of Nicholson: "Unlike many people who inhabit the upper echelons [of Whitehall] he had a down-to-earth ability to engage with people and speak to their heart as well as their head. His plain-speaking stood out in a world where people mince their words. He's clear about what he wants. But that's part of being a good leader." | In some environments, such candour would be regarded as subversive. But politicians, it seems, appreciate it. Burnham, the former health secretary and now shadow health secretary, recalled of Nicholson: "Unlike many people who inhabit the upper echelons [of Whitehall] he had a down-to-earth ability to engage with people and speak to their heart as well as their head. His plain-speaking stood out in a world where people mince their words. He's clear about what he wants. But that's part of being a good leader." |
| A mythology has grown up around Nicholson the iron-fisted centralist, one that at times he seems playfully to encourage. He was a member of the Communist party in the 1970s, a political sympathy that outlasted youthful idealism (he did not leave until 1983). His signature words "grip" and "purpose" spatter his public pronouncements ("grip" is also the quality people most often attribute to him). He told MPs in 2010 he was putting in place Stalinist controls of NHS finances to enable the coalition's market reforms to bed down. | A mythology has grown up around Nicholson the iron-fisted centralist, one that at times he seems playfully to encourage. He was a member of the Communist party in the 1970s, a political sympathy that outlasted youthful idealism (he did not leave until 1983). His signature words "grip" and "purpose" spatter his public pronouncements ("grip" is also the quality people most often attribute to him). He told MPs in 2010 he was putting in place Stalinist controls of NHS finances to enable the coalition's market reforms to bed down. |
| It was hard not to think he was having a private joke when he told Health Service Journal this year that a central role of the NHS commissioning board was to reshape England's supposedly autonomous teaching hospitals. The hospitals were, he said, "the commanding heights of the economy". The phrase was Lenin's, who coined it to describe the necessity of nationalising key private industries. | It was hard not to think he was having a private joke when he told Health Service Journal this year that a central role of the NHS commissioning board was to reshape England's supposedly autonomous teaching hospitals. The hospitals were, he said, "the commanding heights of the economy". The phrase was Lenin's, who coined it to describe the necessity of nationalising key private industries. |
| Nicholson was born in Nottingham in 1955, the son of a plasterer. He played rugby, supported Nottingham Forest football club, and went to a grammar school. As a boy he was thrust into close contact with the NHS after his father contracted emphysema. | Nicholson was born in Nottingham in 1955, the son of a plasterer. He played rugby, supported Nottingham Forest football club, and went to a grammar school. As a boy he was thrust into close contact with the NHS after his father contracted emphysema. |
| He tells the story of how his father's experience gave him an early lesson in the value of health service reform. One year, Nicholson recalled, his father was admitted to hospital 14 times. "Then they decided to provide him with an oxygen cylinder and the phone number of a nurse who could come round if there was a problem. In his last two years he was hardly admitted to hospital at all." | He tells the story of how his father's experience gave him an early lesson in the value of health service reform. One year, Nicholson recalled, his father was admitted to hospital 14 times. "Then they decided to provide him with an oxygen cylinder and the phone number of a nurse who could come round if there was a problem. In his last two years he was hardly admitted to hospital at all." |
| Nicholson graduated from Bristol Polytechnic before joining the NHS as a management trainee in 1977. Convention holds that the fast track to the top of NHS management goes via prestigious metropolitan teaching hospitals, a visit to Harvard business school and in recent years a spell in the private sector. Nicholson's rise was gradual and unshowy: he spent the first 10 years of his career managing unfashionable mental health services in Yorkshire before heading a small acute trust in Doncaster. His entire 35-year career has been in the NHS. | |
| Those formative experiences help explain his fanatical devotion to NHS values and define the way he operates, some say. One senior manager said: "He's been at the coalface of the NHS, and that comes through in his approach. Most of his career he's been within touching distance of patients, and trying to get better care for them." A Whitehall insider who worked closely with Nicholson said it was clear ministers found it refreshing to work with an official who understood the frontline: "People think he's a structures man but he's not, he understands your average punter." | Those formative experiences help explain his fanatical devotion to NHS values and define the way he operates, some say. One senior manager said: "He's been at the coalface of the NHS, and that comes through in his approach. Most of his career he's been within touching distance of patients, and trying to get better care for them." A Whitehall insider who worked closely with Nicholson said it was clear ministers found it refreshing to work with an official who understood the frontline: "People think he's a structures man but he's not, he understands your average punter." |
| His personal manner divides people. To some he is brusque, slightly bullying, "in your face", and regarded "with fear and loathing". But while some find him intimidating, others appreciate his clarity and directness: "He's very down to earth. You do not come away from a meeting with him unsure of what he requires from you. I always found it very easy to support David because I knew he was doing the right thing for the NHS." | His personal manner divides people. To some he is brusque, slightly bullying, "in your face", and regarded "with fear and loathing". But while some find him intimidating, others appreciate his clarity and directness: "He's very down to earth. You do not come away from a meeting with him unsure of what he requires from you. I always found it very easy to support David because I knew he was doing the right thing for the NHS." |
| Like him or loathe him, there is almost universal acknowledgement that even if his methods are unfashionable he gets results. "The thing not to forget about David is that if you take, for example, waiting lists and delivering on hospital-acquired infections, his performance has been world class," said one senior manager. | Like him or loathe him, there is almost universal acknowledgement that even if his methods are unfashionable he gets results. "The thing not to forget about David is that if you take, for example, waiting lists and delivering on hospital-acquired infections, his performance has been world class," said one senior manager. |
| Nicholson epitomises a management style that leadership experts define as "pace-setting", according to Chris Ham, chief executive of the Kings Fund health thinktank. "He leads from the front. He sets a fast pace. He's demanding and ambitious in achieving improvements in care, on budget." | Nicholson epitomises a management style that leadership experts define as "pace-setting", according to Chris Ham, chief executive of the Kings Fund health thinktank. "He leads from the front. He sets a fast pace. He's demanding and ambitious in achieving improvements in care, on budget." |
| According to Hay Group, which has developed an inventory of leadership styles, the "pace-setter" sets high standards of excellence (which employees are expected to emulate), and puts great store in meeting organisational objectives fast. It works when clear, immediate targets are set; it is less effective when the objectives are less task-orientated and require delegation and collaboration. | According to Hay Group, which has developed an inventory of leadership styles, the "pace-setter" sets high standards of excellence (which employees are expected to emulate), and puts great store in meeting organisational objectives fast. It works when clear, immediate targets are set; it is less effective when the objectives are less task-orientated and require delegation and collaboration. |
| Some argue that in the NHS context, this relentless focus on meeting performance targets – whether balancing the hospital books, or meeting A&E waiting times – can be dangerous because it persuades managers and frontline staff to think that accomplishing those tasks are all that matters, while day-to-day issues around care, safety and quality are overlooked. | Some argue that in the NHS context, this relentless focus on meeting performance targets – whether balancing the hospital books, or meeting A&E waiting times – can be dangerous because it persuades managers and frontline staff to think that accomplishing those tasks are all that matters, while day-to-day issues around care, safety and quality are overlooked. |
| During the Francis inquiry, Nicholson was repeatedly questioned about this. During one exchange he was asked by the inquiry counsel, Tom Kark QC, about his robust approach to ensuring overspends in the Staffordshire region's hospitals in 2005 were tackled. Did Nicholson agree that during the period when he was the regional boss, "balancing the deficit was really the headline that all NHS managers were interested in"? | During the Francis inquiry, Nicholson was repeatedly questioned about this. During one exchange he was asked by the inquiry counsel, Tom Kark QC, about his robust approach to ensuring overspends in the Staffordshire region's hospitals in 2005 were tackled. Did Nicholson agree that during the period when he was the regional boss, "balancing the deficit was really the headline that all NHS managers were interested in"? |
| Nicholson said he did not. "I don't know of many managers during that period who would have said: 'Hang quality, we're just going to go for the money.'" | Nicholson said he did not. "I don't know of many managers during that period who would have said: 'Hang quality, we're just going to go for the money.'" |
| The new world envisaged for the NHS under the coalition's changes demands a more devolved style of leadership, goes the argument. It requires a style that is more collaborative and supportive, seeking out alliances across organisations, and recognising the shift in the balance of NHS power to doctors and nurses. In this environment, the theory goes, command and control simply won't work. As one NHS observer said: "A lot of people have legitimate questions about whether David Nicholson can change his style to fit." | The new world envisaged for the NHS under the coalition's changes demands a more devolved style of leadership, goes the argument. It requires a style that is more collaborative and supportive, seeking out alliances across organisations, and recognising the shift in the balance of NHS power to doctors and nurses. In this environment, the theory goes, command and control simply won't work. As one NHS observer said: "A lot of people have legitimate questions about whether David Nicholson can change his style to fit." |
| Nicholson's genius, however, may be his ability to work successfully within the eternal contradictions of NHS management: overseeing radical upheaval in a huge, sprawling organisation while limiting political risk; devolving power to foundation trusts and GPs while keeping a tight central grip on finances and standards; and providing administrative stability while embracing the notion of permanent reform. | Nicholson's genius, however, may be his ability to work successfully within the eternal contradictions of NHS management: overseeing radical upheaval in a huge, sprawling organisation while limiting political risk; devolving power to foundation trusts and GPs while keeping a tight central grip on finances and standards; and providing administrative stability while embracing the notion of permanent reform. |
| Legitimate questions equally might be asked of ministers as to whether they have the appetite to push Nicholson out. He won the support of the prime minister not because he fitted an executive headhunter's profile but because he delivered stability. Mid Staffs patient activists will demand that Nicholson is sacked. But two years before an election, with budgets tight and hospital closures causing public disquiet, can Hunt afford to do this? | Legitimate questions equally might be asked of ministers as to whether they have the appetite to push Nicholson out. He won the support of the prime minister not because he fitted an executive headhunter's profile but because he delivered stability. Mid Staffs patient activists will demand that Nicholson is sacked. But two years before an election, with budgets tight and hospital closures causing public disquiet, can Hunt afford to do this? |
| Another problem for Hunt is that the coalition's NHS changes intentionally devolve accountability and governance to a smattering of diverse national and local bodies. As Ham has written: "At a national level, it is difficult to see who, if anyone, will be in charge of the NHS." The Francis inquiry may well wonder at the wisdom of this. If not Nicholson, to whom could Hunt turn with the experience to hold things together? | Another problem for Hunt is that the coalition's NHS changes intentionally devolve accountability and governance to a smattering of diverse national and local bodies. As Ham has written: "At a national level, it is difficult to see who, if anyone, will be in charge of the NHS." The Francis inquiry may well wonder at the wisdom of this. If not Nicholson, to whom could Hunt turn with the experience to hold things together? |
| "They have not got anyone … with Nicholson's sense of grip on the money, and they daren't let go," said the NHS commentator and former trust chair Roy Lilley. "Nicholson is from a different era and it's a different service now … But he gets his head down and forces stuff through. And who is to say that is not what the NHS needs?" | "They have not got anyone … with Nicholson's sense of grip on the money, and they daren't let go," said the NHS commentator and former trust chair Roy Lilley. "Nicholson is from a different era and it's a different service now … But he gets his head down and forces stuff through. And who is to say that is not what the NHS needs?" |
| CV | CV |
| Age: 57 | Age: 57 |
| Career: NHS manager, joining the service as a trainee in the late 70s. Appointed NHS chief executive in 2006 after holding a series of several senior manager posts, including supervision of the Shropshire and Staffordshire region at the time of the Mid Staffs hospital scandal. Is also the chief executive of the NHS commissioning board. | Career: NHS manager, joining the service as a trainee in the late 70s. Appointed NHS chief executive in 2006 after holding a series of several senior manager posts, including supervision of the Shropshire and Staffordshire region at the time of the Mid Staffs hospital scandal. Is also the chief executive of the NHS commissioning board. |
| Low point: the first Francis report, which in February 2010 detailed the horrific experiences of Mid Staffs patients: "I read at length all the accounts of patients' families and experiences. Anyone who read these harrowing accounts could not fail to be moved and it was a watershed moment for me." | Low point: the first Francis report, which in February 2010 detailed the horrific experiences of Mid Staffs patients: "I read at length all the accounts of patients' families and experiences. Anyone who read these harrowing accounts could not fail to be moved and it was a watershed moment for me." |
| What he says: "The NHS is not just an organisation, it's a set of cultures, a set of principles. It's loved broadly by the general public. So you feel that you're really privileged to be kind of part of that as you take it forward." (At the second Francis inquiry, September 2011) | What he says: "The NHS is not just an organisation, it's a set of cultures, a set of principles. It's loved broadly by the general public. So you feel that you're really privileged to be kind of part of that as you take it forward." (At the second Francis inquiry, September 2011) |
| What they say: He should "step down immediately if he has got any conscience – he stood by and watched as hundreds of people died." (Julie Bailey, Cure the NHS campaigner, whose mother Bella died in Stafford hospital, speaking in January.) | What they say: He should "step down immediately if he has got any conscience – he stood by and watched as hundreds of people died." (Julie Bailey, Cure the NHS campaigner, whose mother Bella died in Stafford hospital, speaking in January.) |
| • This article was amended on 8 February 2013. The original said incorrectly that Sir David Nicholson graduated from Bristol University. |