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Leaders in Healthcare - Sir David Nicholson

Posted on 2/08/2017 by

Suhail Mirza, H1 Healthcare’s Chairman, has spent the past ten years or so, getting close to the most prominent leaders in the Healthcare Sector and has become widely acknowledged for his insightful articles.

The following is his interview with Sir David Nicholson, former Chief Executive of the NHS. In this piece Sir David outlines the challenges facing not only the NHS, but health systems interationally.

Sir David Nicholson needs no introduction for anyone in the world of healthcare. Chief executive of the NHS from 2006 to 2013 and then NHS England until March 2014, he has seen the twists and turns of government policy on the NHS and overseen many of the resulting reforms. And, since leaving the NHS in 2014, he has worked on a number of international projects, giving him a global view of the challenges facing healthcare. ‘I have always been committed to the idea of healthcare for everyone and my main focus over the past two years has been projects which fall under the universal healthcare banner,’ he says. ‘This includes setting up a Centre for Universal healthcare at Imperial college. I am visiting professor in the Global Health and Innovation department and I chair the World Innovation for Health (WISH) forum on universal healthcare.

I also chair the impact committee of the Abraaj Global Health Fund – a billion dollar fund designed to create ten healthcare systems in ten cities in Africa and South Asia with early work in India, Nigeria, Ethiopia and Pakistan.’

In addition, Sir David has completed a variety of projects with the likes of the World Health Organisation, KPMG and international governments.

Internationally, health economies are tackling very similar issues such as how to support an ageing population with higher rates of co-morbidity and ever higher expectations. According to Sir David, the last two years has also seen a number of new trends for policy-makers to grapple with.

One of these has been what he describes as a massive rise in non-communicable diseases, particularly in South Asia where there is a genetic pre-disposition to diabetes which threatens to overwhelm services. Another is workforce challenges.

‘There are real workforce supply problems; not only world shortages of doctors and nurses but also massive shortages of trained people to lead health organisations and systems,’ he says. ‘For example, the WHO has estimated that China alone will need 500,000 people to lead and manage its developing health system.’

Policy responses across the world to these ‘system-wide’ issues have varied. The UK healthcare service, for example, is much more uniform and centralised across the four home nations compared to the greater regional autonomy in Spain or Sweden. And Sir David counsels against the search for a panacea.

There are no silver bullets I am afraid. There is no healthcare system with all the answers. But there are some common themes, including focusing on prevention, on people taking more control over their health and healthcare and ways of supporting them with technology and education,’ he says. He also points to policy initiatives, such as the Five Year Forward View, which place far greater emphasis on out-of-hospital care and integration.

‘The importance of enhancing and developing primary care is recognised globally as is breaking down boundaries between hospital and community/social care. Perhaps of particular pertinence is the imperative of using innovation and technology to drive cost reduction through volume and scale as witnessed through the pioneering work of Dr Dev Shetty in India,’ he says.

Turning to the lessons that these international insights might hold for the NHS against a backdrop of increasing deficits and rising waiting lists, Sir David is candid.

‘Perspective is called for rather than shrill headlines in the tabloid press demanding policy on the hoof,’ he says. ‘The NHS remains a fundamentally sound system that needs to open itself up to learning from other systems and industries. This includes cooperative working with the independent sector. International experience offers lessons; the NHS could learn a lot about integration of care delivery from Nordic countries and cost control and lean processes from India, for instance, and the value of sound planning from Denmark.’

With any discussion of the NHS and UK healthcare system comes the vexed issue of funding. Analysis from the King’s Fund shows that in 2000, the UK spent 6.3% of GDP on healthcare against a European average of 8.5%. This pulled back under the Labour governments and in 2009 stood at 8.8% versus an EU average of 10.1%. However, it is likely to drop back to 6.6% of GDP in 2020/21 based on current budget plans.

‘The comparative data is pretty clear and we have, in comparison with other advanced nations particularly in Europe, devoted far less funding to support the NHS when you measure this as a proportion of GDP,’ says Sir David.

He believes that this is a critical issue, with implications for the health system which will become ever more severe – particularly in the context of constrained real term funding increases.

Given this macro environment the importance of effective leadership within health systems has never been greater. A growing body of academic literature supports the link between effective healthcare delivery and quality leadership. Healthcare delivery is cultivated within the experience, history and culture of communities. This is one of the reasons it is so difficult to deliver change.

Leaders need to use a variety of tools and approaches to create an environment to encourage change to happen and it is very hard to force it, particularly at a system level. One thing that does help in a leader is longevity and the body of available research confirms that high performing healthcare systems tend to have long serving leaders. ‘This is very important and as I have stated often we found it challenging to recruit people who wanted to be chief executives in the NHS hospital system. The average time they spent in post, I recall, was 700 days and I doubt this has changed dramatically,’ says Sir David.

Finally I invite Sir David to look further into the future and share some of the initiatives he believes can help address these global issues.

‘It fundamentally rests on a partnership between the population and health professionals,’ he says. ‘So the future will be made by how we empower people to take more control over their health and healthcare. The use of technology is vital here. For example, given the increasingly global nature of the workforce, the idea of Dev Shetty’s global medical schools on line are potentially going to revolutionise the nature of medicine and also broaden the types of people with access to a medical education.’

On a final note, Sir David also highlights the important role governments must play.

‘Meeting the global healthcare needs of the 21st century is predicated on governments’ adopting policies that work in partnership with people and providers,’ he says. ‘This includes tax policy (such as the recent sugar tax in the UK) being used to nudge people to make healthier choices. It is also about leading debate such as recognising the importance of breaking down traditional barriers between physical and mental health and acute and community based care delivery. Ultimately, empowering people to make informed choices around prevention and the nature and location of the care they wish to receive rests on a partnership of all stakeholders – including government.


This article was first published in Healthcare market News in July 2016