David Cameron and health secretary Jeremy Hunt will dominate the process of selecting the chief executive of NHS England. Photograph: Andrew Parsons/PAApplications for the post of NHS England chief executive close this week. The winning candidate will be made or broken by their ability to negotiate the politics of health policy.
While choosing the successor to Sir David Nicholson is nominally in the hands of NHS England chair Sir Malcolm Grant, in reality he will be sidelined from the process. Health secretary Jeremy Hunt will be in control, and Downing Street will be all over it. In terms of the Conservatives' electoral chances, this appointment is as important as the governor of the Bank of England.
Like the Bank of England position, this is a role with an international profile, which will be filled after an international search. But the central role of politics in the job is a complicating factor when looking for candidates overseas. Even the chief executives of major healthcare companies, for example, may find the political environment of the health service tough to negotiate.
The importance of political skills to the new post is ironic, given former health secretary Andrew Lansley's intention to take the politics out of the NHS by establishing the then Commissioning Board at arm's length from the secretary of state.
With Hunt issuing instructions directly to the chief executive, the position of NHS England board chair is looking increasingly irrelevant, and this has not gone unnoticed in either NHS England or the Department of Health. Grant has had an impressive career in both academia and public service, but he is struggling to find a role for himself in this position.
The new chief executive's political skills are likely to be most tested in trying to align ministers, regulator Monitor and the financial and quality realities of the acute sector to deliver rapid and massive changes to hospital services.
There is a substantial risk that the incoming leader will find their way blocked for almost two years by a health secretary who sees the political imperative of blunting Labour attacks over the NHS as more important than ensuring the long-term quality and sustainability of the NHS. This will leave them answerable for the problems, but unable to implement solutions.
In the repertoire of skills required to lead NHS England, the element of theatre must not be neglected. The resurgence of backbench power in the Commons in the past three years means that death by select committee now stands alongside a misjudged appearance on the Today programme as a route to instantaneous reputational collapse.
Listening to Nicholson on the Today programme some weeks after the publication of the Francis Inquiry's final report into the Mid-Staffs scandal, you could hear the tension in his voice. He knew that if he got it wrong, he would be out.
The intense scrutiny which goes with the job – including, in Nicholson's case, spiteful intrusion into his private life – is just one reason why it requires extraordinary levels of personal resilience. At some point you will be battered; accusations of not knowing and not caring, or of costing lives, will almost certainly come your way.
With all this low politics and high profile, it is easy to forget the small matter of commissioning. The tone and actions of chief executive will determine whether the command and control approach personified by Nicholson continues to reassert itself, or whether the spirit of Lansley's reforms – GPs close to their patients shaping the local health economy – is encouraged.
Liberating the potential of clinical commissioning groups may well entail difficult discussions with ministers about the operation of competition laws in the NHS. Since this is one of the strongest areas of Labour attack, there is again the risk of paralysis when what is needed is action.
And finally there's the bit that really counts for NHS staff and the people they serve – being an inspirational, transformational leader with a relentless focus on patients. Any takers?
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