Who will get the top job at the NHS?

Who will get the top job at the NHS? Tories say the health service is 'safe in their hands', but finding the right person to run it is fraught with difficulty.

The job spec is probably the most daunting in the public sector for years. Wanted: "an inspirational and transformational leader" who is "an incredibly skilled communicator, [and] can operate across a wide and complex set of stakeholders and draw others into our vision".
The winning candidate must also be able to deliver ever-shifting government priorities, even though they are supposedly independent of Whitehall; prosper despite ultra-tight budgets for years to come; drive through radical change in a very conservative organisation; and "deliver more and better quality with less". That, in essence, is what NHS England is looking for in its search for the successor to chief executive Sir David Nicholson. No wonder NHS experts and some of those close to the process call it "an impossible job".

As Chris Ham, chief executive of the King's Fund, observes: "The attraction of the job is that it's leading an organisation that is first among equals among national bodies responsible for the NHS in England. It's arguably the most senior leadership role outside of the Department of Health [DH]. But the biggest issue for any candidate will be: is this the right time to be taking on this role? The funding pressures are huge and will get greater. The service pressures, things like busy A&E departments and GPs' surgeries, are growing by the day and won't get any easier. And it will be a miracle if we get through the next two winters before the 2015 election without the NHS being back on the front pages for all the wrong reasons."

Significant appointment

One senior NHS figure likens its significance to the recent appointment of Mark Carney as governor of the Bank of England. But there is also the fact that the health secretary, Jeremy Hunt, for reasons of necessity and judgment, is being "much more hands-on and interventionist" than his predecessor, Andrew Lansley, ever imagined when his health and social care bill proposed freeing the health secretary of direct responsibility for the NHS.

In addition, the creation of so many separate organisations in the NHS – such as regulator the Care Quality Commission, and Public Health England, each with its own remit, power and responsibilities – means that much of the chief executive's job these days is spent meeting and negotiating with his counterparts there.

Both those factors underline that the job on offer is not chief executive of the NHS – it is chief executive of what was until a few months ago called the NHS commissioning board. "It's much more limited in scope than the job Nicholson did, and could be more frustrating," says Ham.

Sir Malcolm Grant, chair of NHS England, and his five fellow non-executive directors are leading the search for Nicholson's replacement, though Hunt's right of veto means the DH's permanent secretary, Una O'Brien, has been and will be involved throughout. The nine executive directors, including Nicholson, have no formal role in the process. Whoever gets the job will still "need to demonstrate their ability to have a grip", Grant told the Health Service Journal in August, but will have to accept that the role has diminished. "The new role, I would say, is one of advocacy, inspiration and leadership," he added – that is, not of running everything.

Grant initially hoped to shortlist candidates in September or October and unveil the person chosen soon after. But the plans have been thrown into disarray because, as one source very close to the process said, "no one has applied – well, no one who they want to apply, no one of what they see as the right calibre". As a result, potential applicants now merely have to express their interest.

That is of potential benefit to Simon Stevens, who advised Alan Milburn as health secretary from 1997 to 2001 and then Tony Blair as prime minister from 2001 to 2004. Well-placed senior sources say both David Cameron and Grant see Stevens – president of global health and group executive vice-president at UnitedHealth, the huge US private healthcare firm – as the best person for the role. He is well regarded in the NHS for his ideas and collaborative working style; remembered as the co-author of the NHS plan in 2000, which kickstarted Labour's massive investment in the service; and widely seen as an original, but also practical, thinker about healthcare.

Stevens also appeals because he is messianic about the NHS's need to change dramatically, and to keep changing, in order to survive as a publicly funded system that can cope with rising demand. In a paper last year for the right-of-centre thinktank Reform, he asked: "As digitisation opens the way for profound changes in how medicine and healthcare is delivered, will the NHS embrace or resist the new possibilities presented by personalised medicine, nano-robots, vaccinations against virus-inducing cancers, tissue engineering and neuro-assisted devices, to name but a few of the technologies that are headed our way? Doing so holds out the prospect of important advances in health and wellbeing, but will mean weaning the NHS off anachronistic models of care delivery."

One former colleague says: "He's a smooth operator – clever, charming and politically smart. He is someone from the outside but still in the know. He has been successful across the pond but kept in touch with the NHS and political scene here. He would be a popular choice in the NHS, and has no skeletons." Another adds: "He's very much not ideologically driven, despite having worked in politics for some time. Despite his Labour past he was Andrew Lansley's preferred candidate to become NHS chief executive when the coalition began in 2010." A well-placed source close to the appointment process says simply: "It's Simon Stevens's to lose."

Big earner

However, it is unclear whether Stevens wants the job. He moved to America when he began working for UnitedHealth in 2004, is settled in Minneapolis, has an American wife and US-born children, and is paid much more than the £211,000 that Nicholson currently earns. Senior NHS figures doubt that he will take the job. If he does, though, the NHS will be getting someone who publicly backed Lansley's radical overhaul of the NHS, is a critic of the national pay-bargaining arrangements with NHS staff, and an enthusiast for expanding the role of private providers, which many health organisations oppose.

Insiders have assumed the job was likely to be a contest between Stevens and Mark Britnell, another reforming senior NHS figure who works in the private sector, as global head of health for KPMG. Unlike Stevens, though, Britnell is very keen on the role and has been discreetly lobbying those he feels may help his cause. "He's a very serious player," says one friend. "But he's a bit 'Marmiteish' in the NHS – people either really like him or really dislike him. Would he get the same followership from NHS people as Stevens?" Grant was impressed enough with Britnell in the spring to approach him about becoming Nicholson's deputy but was irritated when his overture ended up in the media.

Other potential candidates being discussed at the highest levels of the NHS include Bernard Tyson, chief executive of Kaiser Permanente, the not-for-profit California-based outfit that offers affordable healthcare to 9 million Americans, runs a chain of hospitals, generates $50bn (£30.8bn) annual income and employs 180,000 staff.

Closer to home, three hospital trust chief executives Hunt has saluted as "outstanding" NHS leaders – Dame Julie Moore (University hospitals Birmingham), Sir Robert Naylor (University College London hospitals), and David Dalton (Salford Royal) – are also in the running. However, someone who knows all three says none of them is interested because "none of them see the job on offer as being a step-up, because it's no longer really a whole-system post".

There is increasing speculation that if Grant and Hunt do not secure someone who they consider to be the right person, the NHS's national medical director, Sir Bruce Keogh, will be asked to take up the role on an interim basis until a permanent appointment is made, possibly not before 2015. The Guardian