Sir David Nicholson - Chief Executive of NHS England HARDtalk

handed her over. Time now for HARDtalk.

Welcome to HARDtalk. In Britain, healthcare is state`funded, free at

the point of delivery to all citizens. The National Health

Service is routinely described by politicians of all stripes as one of

the country's greatest treasures. But the NHS's reputation has been

damaged by recent shocking revelations of failings in patient

care. HARDTalk speaks to the chief executive of NHS England, Sir David

Nicholson. Is his health service capable of meeting the shifting

demands and daunting financial challenges of 21st`century

healthcare? Sir David Nicholson, welcome to

HARDtalk. It is fair say that the NHS in the UK and England is facing

unprecedented financial pressures right now. Although it has been

adjusted for inflation purposes, the cost is rising and demand is rising.

Can it cope? It is not just in the UK, all healthcare systems across

the world are dealing with these major issues. It is not just

financial, it is to do with demographics, it is to do with

technology, it is to do with the expectations of patients. All of

those challenges are happening to healthcare systems across the world.

We think that we are responding well. It is very difficult,

undoubtedly, to satisfy all of those things. We think it is possible to

not only deal with those challenges, but improve healthcare of the next

few years. Would you accept that in certain significant ways the quality

of the service provided, the healthcare provided, has been

compromised? There are parts of the country where we have had troubles.

We provide great care for the vast majority of patients. Sometimes and

in some cases, we fail them. We have to put up our hand and accept that.

As the boss of the NHS in England, is it not your responsibility to

tell the government that their spending plans for the NHS are not

working? That you are failing significant members of your

population? It is, if you take the view that it is the lack of

resources driving the problems we have. If you look at some of the

high profile cases we have had, in terms of poor care, it has not been

resources that have been the problem, it has been poor

leadership. We will go through a few instances of great concern raised by

professionals in your service. The College of Emergency Medicine says

there are pressures in A departments. 62% of doctors said

they did not believe their current job was sustainable. It is

absolutely concerning. There is no doubt that emergency care has come

under great pressure. All credit to the great people of the frontline

who have continued to service. It is poorer than it was. We are taking

action in the short term to solve those problems. They are only

short`term fixes. You said you are the leader. You said often these are

issues of leadership. Are we to put the blame at your door? What we need

to do is identify the problems and take the appropriate action. That is

exactly what we are doing at the moment. There was a long`term

problem. This has been the issue for some time. We have gone for

short`term fixes when we need fundamental reform and changes. It

is absolutely necessary. When you hear other significant institutions

such as the Royal College of GPs talking about a dangerous tipping

point in services, they point out that spending is down 7% in the past

year, the Royal College of Nursing talking about a huge rise in stress

and work`related sickness among nurses. It is unprecedented levels

threatening the quality of patient care. These are all inputs from your

crucial members of staff, your team members, saying that the system is

dysfunctional. But for the vast majority of our patients, the

feedback we get from them is that we get excellent care. Most of the ways

that you would measure the quality of care, we are improving.

Nevertheless, the report needs to be dealt with. You are the boss of NHS

England, you work with funds provided by central government, but

you are not a part of government yourself, you are one step removed.

It comes back to your responsibility to squeal long and loud if you do

not believe the government is giving you the tools to do the job

properly. Is it time to do that? The government has just indicated that

it wants to see a pay freeze for NHS staff in 2014. Do you believe that

is right or do you believe it will be a terrible mistake? What is clear

to the NHS in this country is that there is unlikely to be large

amounts of extra resources coming into healthcare of the next few

years. That is the case for most healthcare systems across the world.

In those circumstances, how do you best use the resources you have? Pay

is a massive issue for us. 75% of the money we spend goes on pay.

Controlling the pay element is an important thing. What the government

have raised is that the consequences of that is the need to do something

about the way we manage the payment, I think that is absolutely right. So

when the unions of different descriptions all say that this is

entirely unacceptable and unfair, given that George Osborne, the

Chancellor, appeared to promise that there could be a pay rise for public

sector workers, including NHS workers, you are saying, actually,

the freeze is right and they are wrong. No, there is no doubt that

pay restraint can only work for a temporary period. For lots of staff

there is a global market for them, not just an internal market. We need

to keep up with people. However, the circumstances we find ourselves in,

the higher the pay award we give staff, the fewer staff would can

afford to have. That trade`off is an obvious critical trade`off for me.

Constraining pay but keeping jobs seems to be a much better option.

How do you feel as leader NHS England about this, more than 10,000

NHS managers have seen their pay rise by 13% in the past four years?

Increases three times the rate of increase for nurses. The first thing

I would say about NHS managers, generally, is that we have reduced

the number considerably over the last 12 months also. We have reduced

the number by just over 20,000. We have significantly decreased the

number of people we have. Local organisations have to make

judgements. I want your judgement. Over 7,000 of your senior management

team on 6`figure salaries. More than 2,000 of them earn more than the

Prime Minister. The NHS is the largest integrated health`care

system in the world. 2,000 executives earn more money, in the

public sector, than the Prime Minister himself. And they manage

very complicated organisations. So does the Prime Minister, he manages

the country. We need to get the right talent. One of the things

we're doing quite a lot about is getting more and nurses and doctors

involved in the management of the NHS. We had to provide salaries that

are competitive. So no apologies from you at all about the scale of

pay that we now see in the upper echelons of your bureaucracy? The

point I would make is that we need great leaders to run the NHS. We

have significantly reduced the number, we have reduced the

resources. The amount of money we spend in total is tiny, one of the

lowest numbers of any health`care system in the world. It is going

down. You talked radicalism earlier, we will look at that in different

phases. One of the more radical things you want to see happen in the

NHS is a fundamental rearrangement of the provision of healthcare, so

that patients get used to the notion that much more of the sophisticated

healthcare takes place in hub centres, much less of it takes place

in the local hospital that has traditionally had its own A

department and paediatrics department. It seems that most

people do not want to see their local hospital closed, or operations

severely curtailed. Clearly we have a lot of work to do. Part of the

issue, and the reason we are raising it, is that we think there should be

that discussion across the country about what this means. Let me give

the best example I have, in London we had 32 hospitals providing stroke

services. We moved to eight hospitals providing stroke services

over a period. We went from some of the worst outcomes, to the best. By

using those examples and talking to our public and talking to

populations, do we have any chance of persuading members? I do not

underestimate how difficult that is. I can see it is difficult. There is

a contradiction here, you are very big, you said, patient power must

drive the future of the NHS. Surely that is an indication that above all

else, the NHS should reflect the will of the people. In almost the

same breath, you said that the NHS must escape from the tyranny of the

electoral cycle. Which is it, is it to reflect local democracy or not?

They were two separate points. The first is that there is no short form

of this. Local people who lead NHS organisations need to talk their

population and explain to them what the reality of the service that they

have is, and the reality of the potential service they could have if

they changed. The other point you make of the tyranny of the

electorate, many of these changes we need to make long`term. They are not

short`term fixes. Some of the changes would need to make to the

way the healthcare is delivered, we need to organise and talk about now,

and implement in three or four years' time. That sometimes does not

fit in with the electoral cycle. We need to get away from that,

otherwise we will not be able to make the changes and make them

happen. I have worked now in this job for eight years, and for the

NHS, 30. We got to the point we could not make changes the year

before a general election. When it got the general election,

politicians would promise all of these things, no change after the

election. It meant another year or two where nothing could happen. You

had a year where you could make change and then two years we

couldn't. That is no way to run a health`care system. You are running

a health`care system being used as a political football by politicians

for their short`term interests. Is there any indication that is

changing, or is that the case right now? This is the dilemma of a

state`funded system. Politics will always be part of that system. It is

inevitable. Politicians do the difficult thing, they take ?100

billion out of taxpayers' pockets to deliver the NHS. They will always

have an interest in it. There will never be a time when they are not.

You are saying they should look at the big picture, rather than looking

at the small self`interested picture. I am asking you whether

today's politicians are capable of doing that. Yes, they are utterly

capable of doing that. It is tough for them, they have elections to

fight, I do not underestimate that. Actually, my experience is, working

with both the opposition and the government, that there is a broad

consensus about what actually needs to happen to healthcare. They want

to come back to a big vision before the end. Now I wanted to do a

different vision. We have talked about money, the intersection of

money, healthcare and politics. We'll talk about something a bit

different. Accountability and transparency. You, as chief of NHS

England, and before that, one of the bigger regional chiefs looking after

strategic healthcare authority, which covered most of the West

Midlands, you have been intimately involved with the biggest scandal to

hit the NHS since its inception, it is called the Mid Staffordshire

scandal. The foundation was guilty, over a four`year period, of the most

terrible abuse and neglect of thousands of patients. It is

believed more than 1,000 died in avoidable circumstances. In all

honesty, there hasn't been accountability for that, has there?

I don't want to underestimate the scale and nature of that tragedy at

Staffordshire, and indeed, nor would I ever want to. The issue for us, as

we think about that, not underestimating that... And do you

take responsibility? At the beginning of the abuse, the

mistreatment, and the scandalous behaviour, you were the regional

boss. Of course, I have worked for 35 years for the NHS. I come to work

in the morning wanting to improve services for patients. But to take

on responsibility in the corporate for a screwup, if I can put it that

way, as bad as this, would have been quite clear. Of course, I have

worked for 35 years for the NHS. I come to work in the morning wanting

to improve services for patients. But to take on responsibility in the

corporate for a screwup, if I can put it that way, as bad as this,

would have been quite clear. You would not be talking to me as the

boss of the NHS, you would be out on your ear. We had an enquiry, what

they said, the people who ran the hospital were responsible for it.

The whole of the board. But you came to me talking about the importance

of leadership. As far as I was concerned, I accounted for what I

did. I spent 11 hours in a public enquiry, my employees... It was not

how you responded to the enquiry, it is what you did at the time in key

management positions. Overall responsibility for that trust and

many others as well. Were you not aware? Did you never visit, did you

never look into the mortality figures? Were you not aware of the

terrible things that happened? That is exactly the point. Nobody was

aware of what was happening in that hospital in the system as a whole,

for all the problems of the system. There were fragments of information

held by various people, but nobody put the whole thing together. That

was the tragedy of it. Of course I feel responsible for it. But the

accountability was laid at the organisation itself. That my

employers, politicians, they backed me, they gave confidence, but I had

to think of myself, and as anyone who runs a healthcare system, part

of the original report that came out in 2008, there were two sections.

The first was about what had happened in the hospital, and the

second was the patient stories. What I did, I took the patient stories

away and read them over a weekend. You could not read them without

being moved, as an individual. Does it hang over you today? I hear the

pain in your voice, but does it hang over you today, and even today, do

you honestly wonder whether it was the right thing to stay, to stay and

be the figurehead, the absolute figurehead of the NHS, when this is

a stain on your record. That was the point I was going on to make. Of

course at the time it happened, which was 2005, 2006, one of the

reasons I applied for the job as chief executive of the NHS was that

I thought the national leader of the NHS... It was one of the reasons I

applied for the job, to make quality at the heart of it. What came out of

Mid`Staffordshire reinforced my view of how important that was. I do not

want to harp on this, but it turns out that you had lost the plot,

because you were the regional leader. We were focusing our

attention on the wrong things. The point that I am trying to make, is

that that experience, it seemed to me, focused my attention like

nothing else could, to put it right. In a sense, right from that time

afterwards, I have been trying to put it right. In those

circumstances, that is what I should do, and what I have been doing over

the last 5`6 years. Let's look forward. You have been very blunt

about the future. You are leaving in six months. You have said that given

the current... The growing demands on the system, from demographics,

raised expectations, the flipside of the real financial squeeze, you have

said that by 2020, there is likely to be a ?30 billion black hole

inside the National Health Service. Is there anything that you can do

about it? Unless we do something about it. We know broadly what we

need to do. It is not rocket science in that sense. We need to do

something about the way the service is organised. We need more early

intervention, more community services, more upstream activity in

the NHS. We need more concentration and centralisation of specialised

services to get better outcomes, we need patients to take more control

over their own healthcare, change the nature of the service. We need

to do all of those things. But maybe none of that is radical enough.

Maybe you should be using words such as rationing, saying to people, in

the end, given the financial constraints, we cannot offer you all

of the services that you have been expecting. For example. Certain key

drugs or key procedures will in future be rationed. The point that I

will make, one of the things about the NHS, it is not just a group of

organisations operating together, it is a set of ideals and principles.

Part of those principles is a more effective and more efficient

healthcare system, one which is free at the point of use and universally

available. But that itself is outdated. On the contrary, I think

it is very viable. I suppose your immediate colleague and in some

senses boss, Malcolm Grant, said that future governments will have to

reflect on the possibility of introducing user charges to the NHS.

That is in the future. I do not think that is the case in the

moment. We are talking about the future. We are talking about changes

that will safeguard healthcare in the country. Other countries are

looking at the UK as a model. My time horizon is 4`5 years. That is

something... Taking the service forward. If it comes to the point

where those things I have described do not deliver the improvements and

the way of working, then it is a possibility. But I do not think the

British people expect us to be there, the taxpayers expect us to

get the absolute value out of what we have already got. In America, we

see a huge wave of political opposition, stirred up by the

Opposition to Barack Obama, against what they refer to as Obamacare,

some people call a socialised medicine. A lot of Americans do not

seem to like it. But countries such as Mexico and India, where very

competitive healthcare is being offered in a much more affordable

way than ever before, I wonder whether you look at the US, the

developing world, do you do some big picture thinking, thinking that the

state provisional model is not the best for the future? You say state

provision, but in a sense, what we have been doing over the last few

years, we have been giving individual providers more freedom to

get on and innovate and do the things they need to do, and we need

to do more than that. But in terms of the idea of universally available

free at the point of care, if you think of the alternative, if you

look at alternative systems, they cost more. If you look across Europe

or the United States, you end up spending more on healthcare than we

do. They are inevitably less fair. That is what the British public have

said all along, that we want a fair system. The major changes in things

like genomics means it will be very difficult in future, if you can

imagine a time, when you as an individual, when somebody reads your

genome, they can predict the diseases that you will have in the

future, and you have potential for multiple sclerosis and things like

that, who is going to insure you? Getting social solidarity across the

whole of the population is a much more viable way of delivering

healthcare than breaking it up into the private sector. I wish we could

go on but we are out of time. Sir David Nicholson, thanks very much.

I have to say if you are getting a bit fed up of wet weather I cannot

offer you anything much more promising this week.

I have to say if you are getting a bit fed up of Certainly remaining

very unsettled which means there will be more rain around for all of

us this week. Also very windy, thanks to some big areas of low

pressure coming our way. It does remain very mild. The reason for the

mild weather is the southerly wind coming from the far south. Also

funneling in this rain around this area of low pressure. That is the

picture for today. On the recent satellite pictures, all the cloud

which was piling