A new era: Why power must go to local leaders | Niall Dickson

Niall Dickson

There will be mixed views about Simon Stevens taking over at NHS Improvement – but, writes Niall Dickson, chief executive at NHS Confederation, aligning the national leadership is the right thing to do. 


For too long we have had mixed signals and dual messages from the centre – we should not mourn the passing of that era.

What we don’t know is how the new integrated centre and its regional outposts will behave, and while structures and powers are important, the soft cultural bit probably matters more.

Make no mistake, there are fears in the service that we could be entering an era of rigid top-down control, in spite of the rhetoric about local self-determination.

A key question then is the culture this new leadership team wishes to foster?

At our Independent Healthcare Providers Network conference late last year, NHS Improvement chair Baroness Dido Harding called for a fundamental change to the culture and behaviours of NHS England and NHS Improvement and said that the new regional tier would be fiefdoms ‘over her dead body’.

The good intentions are not in doubt and indeed this afternoon at our International Women’s Day reception in Parliament she went further, arguing that the current NHS culture was rotten.

But as Dido would be the first to acknowledge, changing culture is not straightforward and the way in which this will develop is not entirely clear. There is too a genuine tension between a desire for greater local autonomy and the legitimate demands for accountability, and frustration at unexplained variation.

The view from parts of the centre – not always expressed in its raw form – is that the NHS suffers from not enough high-quality leaders and too many organisations. Variations in clinical and financial performance are attributed to leadership capability more than local circumstances.

But if we are going to change to a culture which is genuinely inclusive and supportive, change will have to come from the top.

Niall Dickson is chief executive at NHS Confederation. Follow him on Twitter @NHSC_Niall and the Confederation @nhsconfed

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