So, it’s goodbye to Simon Stevens after 7 years and hello to Amanda Pritchard, who took over on 1 August as the chief executive of NHS England and Improvement. Heading a £130bn per year organisation, the nation’s biggest employer which sees well over a million patients a day and is central to public and political concerns, is challenging at the best of times. Throw in COVID-19, the large backlog in care, staff shortages and pay tensions, the new Health and Care Bill, plus a new Secretary of State and the job looks daunting. How can it be done well?

First, you need the right postholder. Pritchard brings 25 years’ experience in the NHS – a huge asset. A graduate of the NHS management scheme, as was her predecessor, she successfully ran a large London teaching hospital, and for 2 years was Stevens’s deputy. She knows the ropes and has huge credibility from the shop floor to NHS England and a large support network of colleagues around the service. The NHS is large and complex: having insider knowledge and top management ‘form’ is vital to hit the ground running as a leader. Obvious, you might think, but the government’s regular flirtation with candidates from outside health proves otherwise.

Second, cultivate the right relationship with the health secretary. Conflict distracts and drags progress. One of Matt Hancock’s legacies is part of the current Health and Care Bill wending through parliament that proposes to give him more powers of direction over the NHS. Why is another story. But what trumps the statute book is the chemistry between the NHS chief and the Secretary of State. Jeremy Hunt, the longest-serving health secretary, remarked that there was no reasonable priority he felt he couldn’t get Stevens and the NHS to make progress on. And that was under Andrew Lansley’s Health and Care Act 2012, which reduced ministerial powers over the NHS. 

Third, manage relationships with government, specifically the Department of Health and Social Care, Number 10 and most importantly the Treasury. Budget pressures on the NHS are always intense. The current skirmishes on pay will soon be overtaken by a chorus of legitimate asks before the autumn spending review. In an outgoing interview at lunch with the Financial Times, Stevens was tart: ‘We’re not heading for a 13 million waiting list if we choose to do something about it…’. Bombproof clear analysis, with heavy duty data projections, and spelling out the hard opportunities and risks to funding options, not fantasy thinking, will be crucial to win the arm wrestles with the Treasury. 

Fourth, communicate well with the media. Unless there is an overwhelming public mandate for change, wise governments’ media strategy for the NHS centres on achieving an image of tranquillity, with a regular stream of good news stories linked to the PM and relevant ministers. This is a clear enough task for NHS England to help with, requiring a low media profile for the chief executive. Except, of course, when things aren’t so tranquil, or when the media can help build pressure for needed change – usually boosting investment or addressing staff shortages. In these cases, the NHS chief executive will need guile bordering on cunning to avoid unreasonable blame for problems, and to orchestrate willing helpers inside and outside the NHS to put the case for funding. No small feat, and one where a built-up insider’s store of credibility, respect, and sheer charisma with NHS membership bodies, Royal Colleges, think tanks and academics, to name a few, pays dividends. 

Fifth, make the weather. The in-tray of urgent tasks is vast, especially now. But the chief executive must make space to think about the medium term, and to decide the three or four significant steps the NHS must make to improve care for patients. These might be unrelated to government and ministerial priorities, which may be short-term, public-focused and bounded. And they might be highly technical, but critical, and never see the light of day in the media, government speeches or public protests. You don’t often see a demonstration banner saying, ‘What do we want?! A revised payment regime to speed the spread of technological innovation in the NHS! When do we want it? Now!’.

Finally, realise the key to progress isn’t in strategies from Number 10, the Treasury or the Department of Health, but in the everyday activities of the NHS – of clinicians, and patients. Enabling the shop floor to improve care faster will be key to progress in future, whether it is in the design and uptake of innovations or supporting patients to stay well. The challenge for the chief executive is to be alert to problems in local care, and weave remedies into national strategy. This requires cognitive range that is, to say the least, unusual.

As new postholder Amanda Pritchard disarmingly remarked, ‘I sort of couldn’t imagine why you wouldn’t want to work for the NHS.’ That level of commitment must be a given for one of the most difficult, and rewarding, jobs in Britain.

This article was originally published by Prospect magazine on 6 August 2021.

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