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Sir Nigel Resigns

15th March 2006

15032006_SirNigelCrisp1.jpgSir Nigel Crisp KCB, permanent secretary at the Department of Health and Chief Executive of the NHS, resigned on 7th March 2006 to take early retirement at the end of the month. Sir Nigel will be given a peerage.  He has been asked by the Prime Minister, the Secretary of state for International Development and the Secretary of State for Health to review how the UK's experience and expertise in delivering health services can be used to support the developing world.

In a message to NHS and departmental staff Sir Nigel said he was proud that the NHS had achieved or exceeded challenging targets, and that at the front-line old hierarchies were breaking down and practices changing. 

He said that 'not everything has gone well'; he acknowledged his accountability for problems, but took credit for achievements.

'The timing of my retirement is right for the NHS' said Sir Nigel. The NHS needed a Chief Executive who could give leadership over several more years, allowing new leaders to be appointed in the Department, in Strategic Health Authorities, and in Primary Care Trusts at the same time, working together to continue reform and improvement.

Did he jump?

Sir Nigel told The Times that he had walked, not been pushed. But he acknowledged that he would have preferred to go when the service was “on the up‿. He insisted that the decision was his, and that he had not been forced out by ministers, says the Health Service Journal (HSJ). Describing the last financial year as ‘bumpy’, Sir Nigel told HSJ that he took the decision not to see through the current reforms after talking to close colleagues in recent weeks.

Sir Nigel denied that his resignation was a result of a controversial nine months for the department, starting with the publication of Commissioning a Patient-led NHS in July; or that he had lost the confidence of senior managers in the service ‘despite all the anonymous quotations’ says the HSJ.

Both the Prime Minister and the Secretary of State for Health, Patricia Hewitt, have also insisted that the choice was Sir Nigel's. The Prime Minister pointed out that he had recommended Sir Nigel for a life peerage and that 'he did not do that lightly' as he could only recommend life peerages like this one 10 times in a Parliament. Patricia Hewitt likewise denied claims that Sir Nigel was a fall guy for the predicted overspend for 2005/6.

Or was he pushed?

A number of papers said that Sir Nigel Crisp was "forced" to quit as chief executive of the NHS in England. The Daily Telegraph said he was also forced to carry the can for its financial crisis while the Daily Mail described him as the "fall guy". Sir Nigel Crisp was given a peerage to ease his early departure after Tony Blair was said to have become anxious that the NHS had “taken its foot off the pedal‿ said the Times.

At prime minister's questions in the Commons, David Cameron demanded to know whether Sir Nigel Crisp had been sacked, saying that the record NHS overspend was the latest sign of mismanagement. He accused ministers of trying to avoid the blame for financial problems in the National Health Service.

Sources close to government also cast doubt on Sir Nigel’s insistence that he was not pushed to resign. The HSJ reported that one source said the fact that he has been given a peerage and a report to write on African healthcare for the Department for International Development points to hard negotiation by a man unwilling to leave. 
 
Sir Nigel had survived a reshuffle of senior executives in January after forecasts that hospitals were heading for debts of £623 million. Insiders linked the fresh urgency from Downing Street to the appointment in December of Professor Paul Corrigan as Mr Blair’s health adviser. Professor Corrigan is said to have believed that a shake-up of executives at the very top was necessary, said the Times.

What have been the difficulties in the NHS?

His departure, however massaged, represents failure on several fronts, says the Times.

The present financial crisis in the NHS, despite seven years of record investment, is highlighted by many sources as one of the key issues for the NHS - and for Sir Nigel. The government predicted a possible deficit of £620 million back in December, but by the end of the month the NHS deficit could be as much as £800 million, says the Guardian, though ministers are declining to publish up-to-date figures.

NHS finances had failed to show signs of recovery between December 2005 and January 2006, a time of year when deficits traditionally shrink. This year they grew, indicating a loss of control. Health spending has increased by 40 per cent since 1997, yet in some areas the spectre of rationing hovers says The Times.

Many health trusts have cut posts or brought in recruitment freezes.  Operations are being delayed and wards closed as they struggle to balance the books. Niall Dickson, chief executive of the King's Fund, said Sir Nigel had been under pressure from the government over the deficits. The real problem is that ministers do not seem to have realised or, as some suggest, they were not told until late in the financial year just how extensive the problems were.

There is no single reason for the overspend but there is one common factor affecting both hospitals and the primary care trusts that commission their services. All have been subjected to the iron discipline of meeting the government's priorities for reducing waiting times, says The Guardian.

Sir Nigel also seem to have lost the confidence of his political masters and his senior staff; Patricia Hewitt's decision to call in management consultants from McKinsey to advise on the structure of the health department was hardly a vote of confidence in Sir Nigel says the Times. With many strategic health authority chief executives due to lose their jobs in the latest merger plans, loyalty to him ceased to have much value. ‘You need to maintain the confidence of middle and senior NHS managers and that had eroded' says the HSJ. The 'final straw' came earlier this month with news that the Department of Health had miscalculated the tariff used to pay hospitals for services, provoking fury among finance directors and NHS Managers.

But the greatest failure is the lack of strategic oversight of the Government’s health reforms, says the Times. Many of the individual ideas are sound. But their introduction has been rushed and haphazard, producing unanticipated results and grotesque waste.  Reform followed reform with no pause for a proper strategic assessment said the Guardian.

How has Sir Nigel's performance been rated?

Praise

The Prime Minister, Tony Blair, has been lavish in his praise, saying that Sir Nigel has served with 'distinction and honour'. In reply to promptings from David Cameron he said that "No one believes the NHS is not better today than it was eight or nine years ago".  The reduction in waiting times have been singled out by many as one of Sir Nigel's biggest achievements. Patricia Hewitt, Health Secretary, echoed Mr Blair's assessment that Sir Nigel had served 'with great distinction'. 

Dr Gill Morgan, chief executive of the NHS Confederation, said that Sir Nigel has led the introduction of an enormous reform programme which 'will see the NHS transformed into a 21st century system'. She also commended his work on issues like black and minority ethnic career progression and support to health services in developing countries - 'where his personal commitment and leadership has ensured action.'

RCN General Secretary Dr Beverly Malone said that the RCN recognises that Sir Nigel Crisp 'has made an important contribution to the NHS' and has demonstrated 'real leadership.' Healthcare Commission chief executive Anna Walker said that Sir Nigel was the 'key architect' of the NHS plan.

And temporary successor Sir Ian paid tribute to Sir Nigel’s ‘outstanding personal contribution to the NHS’, saying that he has left a tremendous legacy, reports the HSJ. In a letter to Sir Nigel, acknowledging his resignation, cabinet secretary Sir Gus O'Donnell paid tribute to the ‘towering leadership’ Sir Nigel had shown over the last five years.

Mixed Messages

Sir Nigel Crisp had made a highly significant contribution to the NHS and he leaves it in a much better state than when he took over, but there are severe financial difficulties in the health service which threaten to derail the reforms, said Kings Fund chief executive Niall Dickson.

Jeremy Millar, interim Chief Executive of Institute of Healthcare Management said that 'it would be churlish of the Institute not to acknowledge that Sir Nigel has led some significant improvements in the Service', although 'many Institute members have been forced to make cuts in an effort to balance the books.  Many have had to leave the Service themselves.' 

Mr Bernard Ribeiro, President of The Royal College of Surgeons of England concurred that Sir Nigel can reflect with credit on the personal contribution he has made to a number of achievements in the NHS, particularly over the last five years but that acknowledging 'accountability for the serious financial problems that beset the service' was an honourable and refreshing attitude.

Others were not so free with their praise; The Chairman of BMA, whilst not commenting directly on Sir Nigel, stated 'there are clearly problems in the NHS and we look forward to working with his successors to help tackle these problems in the most appropriate way.'

And there was anger in some quarters at his "gold-plated" early retirement package and pension, "topped with a peerage", as the Daily Express puts it.

What Next?

Sir Nigel's role will now be split in two: Sir Ian Carruthers, who is the Department of Health's acting director of commissioning, and chief executive of Dorset and Somerset and Hampshire and Isle of Wight strategic health authorities is taking over as acting NHS chief executive, and Hugh Taylor, the director of strategy and business development, promoted in January from DoH strategy and business development group director to become Sir Nigel’s deputy, will become the acting permanent secretary.

Most greet the appointments with enthusiasm; the Kings Fund says Sir Ian is a highly experienced manager with an excellent track record and represents 'a safe pair of hands'. “Sir Ian Carruthers is well known in the service and his wealth of experience in the NHS makes him ideal in the interim role as NHS chief executive‿ said Dr Gill Morgan, chief executive of the NHS Confederation.

Sir Nigel said that while merging both jobs into a combined role was appropriate in 2000 when he took the helm, ‘proper consideration’ should now be given to permanently establishing two separate roles.' The HSJ reports government sources as saying, however, that the job would not be split in the long term.

No 10 acknowledges that its reform programme will intensify next year with the extension of patient choice. The crisis may deepen after 2008 when the record increases in spending end in the next round of the spending review, says the Guardian. Sir Ian said in the HSJ that over the next year, organisations in surplus would have to contribute to offset the deficits of their peers, as part of a ‘collective’ effort to get NHS finances back in balance next year.

Health Secretary Patricia Hewitt said she should be judged on resolving the financial crisis in NHS in the wake of its chief executive's resignation, on BBC Radio 4 she said that "What I'm focusing on is making sure that we go on delivering the improvements in patients care - the 18 week maximum from GP referral to operation that we've promised by the end of 2008; However, in the next reshuffle 'Sir Nigel is not the only senior figure in the Health Service who should be moving on' says the Times.

Many are concerned about the instability the departure of Sir Nigel may cause, and indicate that this may be a good time to pause and reflect on the state of the NHS and the speed and direction of reform. The Kings Fund said that 'the last thing the NHS needs now is more uncertainty and instability.'

'Like revenge, the judgment of history is a dish best served cold and the Crisp-Bacon legacy may seem more favourable a few years hence, always assuming that the whole reform process does not become derailed'  says Niall Dickson, Chief Executive of the Kings Fund.

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