40 years' change in the NHS

40 years’ change in the NHS

Sir David Nicholson, Chief Executive NHS in England

“Working in the NHS, the last 40 years have seen many challenges for managers like me. They’ve spanned a range of issues, but what they all have in common is the interplay between clinicians, managers and patients and the broader economic circumstances of the time.

In the early 1970s, there was a radical Conservative government committed to reforming the NHS. The financial context was also very challenging, with interventions by the International Monetary Fund and the introduction of ‘cash limiting.’ Up until this point, clinicians could effectively seek funding for whatever they wanted to do, and it was from this moment on that greater financial awareness was needed in order for us to meet rising need within more constrained budgets.

In the 1980s, the first Griffiths review placed general managers rather than clinicians at the heart of the system – although the role of patients remained limited. In one sense it wasn’t until The NHS Plan in 2000 that the views of patients – about access and waiting times, for example – became more influential (often through politicians examining the polling data and using this to construct the ‘must do’ targets of the day). Ironically, this led to even greater power for managers as the implementers of government targets – and patients were still only really represented indirectly via the targets set by national government.

Following the Health and Social Care Act, the financial and political context has parallels with the early 1970s – although arguably the scale of challenge is even greater. After many years of additional investment, the international economic outlook has changed, and we are going to have to get used to doing much more with little or no growth in budgets. This is going to have to involve patients, clinicians and managers working together in new ways.

For me, there are three main pillars that we need to build on:

1. Clinical commissioning: GPs are at the heart of the health service, and play a crucial role in people’s lives and in local communities. The decisions they make also impact on almost all other parts of the system, and it is vital that GPs are at the forefront of the current changes. However, GP by themselves aren’t enough – and we need nurses, allied health professionals and all the primary health care team involved in greater clinical commissioning and leadership.

2. The financial challenges we face are such that we cannot focus only on our own profession or our own organisation. We will have to find ways of working together more effectively across primary, community and acute care. Clinical senates will therefore be an important forum to break down traditional barriers and to develop more joined-up responses to need.

3. The role of the public is crucial – and local government (via Health and Well-being Boards) has an essential role in terms of providing local leadership, joining up care and prioritising local needs.

Of course, 2012 also sees the 40th anniversary of the Health Services Management Centre (HSMC) at the University of Birmingham. Throughout the last 40 years, HSMC has been actively involved in working with policy makers, managers, clinicians and patients to help develop new ideas, implement new approaches and evaluate the impact of the changes made. This includes the work of people like John Yates on waiting times, Peter Spurgeon’s work on general management, John Clark’s work around clinical leadership and the contribution of people like Chris Ham, Edward Peck, Helen Parker and Jon Glasby around putting patients at the centre and developing more integrated care.

As we move forwards with implementing the current changes, patients, clinicians and managers will all have a role to play. But we will also need places like HSMC to help implement, reflect upon and evaluate policy, as well as contributing to generating new ideas for the future. If we do all this, then I believe we have a genuine opportunity to rise to the challenges we face and to protect and improve the health service for future generations."

> Sir David Nicholson is Chief Executive of the NHS in England. Sir David recently delivered the Health Services Management Centre annual Health Policy Lecture on “40 years of change in the NHS” as part of the Centre’s 40th anniversary celebrations.

Watch a clip of Sir David Nicholson being interviewed ahead of the Health Policy Lecture by Professor Jon Glasby here:

David has also received an honorary degree from the University of Birmingham. His longstanding relationship with the City and the Region – as Chief Executive of the former Birmingham and The Black Country Strategic Health Authority and as Regional Director for the Eastern and West Midlands Regions whilst shadowing as Director of Health and Social Care – meant that Sir David was an obvious choice to deliver the annual Health Policy Lecture in the year that HSMC celebrates its 40th anniversary.