THE ANDREW DAVIDSON INTERVIEW: Nigel Crisp - Donnish and amiable, the NHS's boss nevertheless has a conviction and expertise that could transform the state monolith - Europe's biggest employer - into a model of cellular efficiency, if he can lure the right managerial talent. A man who likes a challenge, then ...

by Andrew Davidson
Last Updated: 31 Aug 2010

Donnish and amiable, the NHS's boss nevertheless has a conviction and expertise that could transform the state monolith - Europe's biggest employer - into a model of cellular efficiency, if he can lure the right managerial talent. A man who likes a challenge, then ...

Who'd be boss of the NHS? 'Well,' says Nigel Crisp, smiling softly, 'my father's line was to offer me commiserations and point out that the only person with a worse job was the chairman of Railtrack ...'

And look what happened to him. Crisp heaves a little laugh and then gazes wanly out from behind steel-rimmed specs. He goes on: 'Of course, I got this line again last week at a breakfast meeting with the Conservatives. The only job worse than mine, they said, was IDS's, running the Tory party, yunno?'

He laughs softly again, a pensive look briefly shadowing his pudgy features.

And then he moves on. Crisp, the quietly spoken health service chief who smiles like a civil servant and thinks like a philosopher, does a lot of moving things on, punctuating his speech with little 'yunno's' and inquisitive 'eh?s' as if constantly revving the engine of his own motivations.

He has been chief executive of the NHS for two years now, pushing things forward in his own genial, diligent manner, generally unnoticed, as is often the way with health service bosses. He replaced Alan Langlands, the Glasgow-born sailor's son who ran the service under both Conservative and Labour administrations from 1994 to 2000.

Langlands, a resilient pragmatist, had the gruff stolidity of an old-style trade union leader. Crisp, Cambridge philosophy graduate, one-time Trebor manager and son of an ICI boss (bearer of those commiserations), seems more like a donnish vicar by comparison. Despite 17 years' experience in health, as general manager, Trust chief executive and regional authority director, he seems almost too amiable to have taken on what many perceive to be the toughest management job in Britain.

Yet appearances can be deceptive. Tall, fleshy, still young-looking at 51, with his light hair pulled roughly sideways and an ill-fitting suit that buttons tight at the tummy, Crisp may appear bland, but he made his name as a hospital boss, merging institutions, pulling recalcitrant staff together towards the same goals, and he carries a conviction and depth of knowledge that can suddenly take you aback. He is also rather adept at turning the general to the personal and back again, an essential talent in an organisation like the NHS, where everyone is an end-user and the world queues at your door to tell you their stories. Management-by-anecdote, as he wearily describes it, is the bane of his life.

His preferred defence, I suspect, is to work on the principle 'forewarned is forearmed'. He quickly extracts from me that, as my father was a hospital consultant, my niece is a GP and my youngest daughter is epileptic - and hence has seen rather a lot of the NHS - I have my own very particular experience of the service. After that, he makes reference time and again to hospital politics, hire and retention of GPs and provision of care for epilepsy. He even apologises that epilepsy is not an area of health prioritised in his current management plan. In the end, after spending a couple of hours with him, it is hard not to be won over by the way he blends attention to detail with the lightest of human touches.

Which is what you would want from an NHS boss, of course. He is also, I would guess, pretty good at working towards targets. For instance, he's set up our meeting, in his long, fourth-floor Whitehall office decorated with his daughter's abstract canvases, with a clearly designated purpose: to use MT to whip up a bit of positive spin aimed at prospective management hirings. He wants to kick out the bad old images of haphazard decision-making and hopeless decay that dog the NHS; he wants more and better managers to think about coming into the service; and he wants to get everyone switched on to the idea of 'making a contribution'.

In short, he wants us all to think about the challenge of managing in the public sector as something that is far more fulfilling and intellectually interesting (gulp) than any Daily Mail leader writer or Casualty scriptwriter would ever dare allow. His message is simple: the NHS, at last, has got money to spend. Come and help manage that expansion.

Crikey. Your country needs you? 'I want to promote management in the NHS as a professional job, in some ways harder than those in other sectors, but an attractive career option,' he says, steepling his fingers. 'And I suspect there are a lot of people out there who would like to do a job that makes a difference.'

And I suspect he's right. He's got the figures to back it up: 60 applications for every slot on the NHS graduate entry general management scheme, 4,000 expressions of interest and 1,100 applications for the 50 places going on its recent Gateway mid-career entry scheme. Something is going on out there that you don't see in your average hospital soap. The Government, which has promised the biggest-ever leap in NHS funding - shifting overall health expenditure from 6.8% of GDP pre-1999 towards a target of 8% - is pouring money into the service and, just maybe, the public is beginning to respond.

'I think the money helps, but it is about more than just that; it's about why the government has prioritised health. Public services are higher on the agenda everywhere,' says Crisp gently. 'And we have got some policies which, for a number of people, make sense.'

But is he getting the right sort of managers? That's a tough one. Crisp is battling perceptions as much as anything else at the moment, which may explain why - after two years of low profile - he is giving interviews and has become a frequent letter-writer to newspapers and magazines, correcting stories, challenging assumptions. 'Nigel has always been very PR-conscious,' says one doctor who worked with him. 'He takes that very seriously.'

But Crisp has also got a huge task to accomplish; not just ensuring that the new money is seen to be spent wisely, but also keeping the service performing day-to-day, stopping the decay, motivating Europe's biggest workforce - 1.1 million staff - and preventing the different interest groups (doctors, nurses, managers, porters, cleaners, technicians ...) from tearing each others' throats out.

Just keeping tabs on what is going on would stretch most people. Crisp has even more on his plate than his predecessor, since he's taken on two roles - NHS chief executive and permanent secretary to the Department of Health - that were previously kept separate. Yet as a man who, to his former hospital colleagues, often seemed part wonder-manager, part civil service-style mandarin, he may just have found his niche.

He's certainly ambitious to improve management. He has established a modernisation agency within the NHS, with a pounds 150 million annual budget, to pinpoint areas to change. He has expanded the reporting system, giving more local control, so that instead of about 650 NHS organisation CEOs reporting to eight regional directors, who report to him, it is now 650 reporting to 28 strategic health authorities reporting to him, plus four senior directors.

Good idea? It's hard to tell at this stage. You can, however, imagine a politician dismantling it all, shouting: 'I've taken out a whole layer of bureaucracy ...'

Then there's the foundation hospital concept, which he is pushing. This is a highly controversial idea, under which good managers at better-performing trusts get more freedom to operate - a legacy, according to those who've worked with him, of his own experience as a hospital boss. It also reflects the fact that the whole thing is too big now to be run centrally with any efficiency.

Most of all, it is a thought-out approach. 'Nigel is a thinking man,' says Sir Brian Smith, the industrialist who chaired BAA and Cable & Wireless and was Crisp's trust chairman at Heatherwood and Wexham Park hospitals in the late 1980s. 'He may appear diffident at first, but he's not. He's very thoughtful, and he likes to listen.' And then he acts.

But Crisp faces formidable problems in persuading successful private-sector managers to make the leap. Why should anyone mid-career seriously think of chucking in a good salary, nice working conditions and great perks for a high-stress job in the NHS?

Crisp, clearly, is ready for this one. 'Well, first, the range of experience they will get in the public sector is huge. They will be coming into a much more complex environment. They will have to manage stakeholders and local politics as well as deal with straightforward management decisions about prioritisation and so on. So, even if you came just for a year on secondment, it would be a very rich experience.

'Second, for a lot of people, this is about contributing something, about aligning your personal motivations with what you do for a living, being able to say: 'This suits me, I am pleased to be doing something worthwhile.'

'And third, this is intellectually fascinating. You can at one time be dealing with exquisitely difficult scientific issues about genetics and so on, and at another dealing with crucial matters of life or death, or at least helping clinical people deal with them. There is a lot of scope for pressure, but also for it being a fascinating job.'

But isn't the truth that managing in the NHS is much more mundane and frustrating than that? Trying to sort out where your cleaners have gone or why the hospital food is so terrible or what the consultants aren't telling you, or ...

Crisp brushes that aside. 'I think there has been a sense of frustration in the past that what you're doing is managing decline, yunno? Now we're managing expansion, by anyone's definition.'

And what about stability? We've had internal markets introduced, then removed; we've had layers of bureaucracy sliced out, then put in; we've had institutions bundled together; soon we are going to have foundation hospitals set apart - a move that one doctor described to me as 'great if all chief executives had Nigel's talents, but not all do ...' Don't managers get cynical eventually, thinking that anything they are asked to implement is just going to be changed a couple of years down the line?

'No,' says Crisp, 'I understand the frustration over constant change, but where we are now, in terms of the basic building blocks, is where we will stay - both the PM and the secretary of state have said so. The basic architecture will be there for the next three to five years.'

But, he continues, there has to be some flexibility, hence his drive to re-organise around key issues. They include improving access to services; improving services and outcomes for cancer, coronary heart disease, mental health and old people; reducing health inequalities and more. Crisp has formalised the targets with a written code of conduct for managers, enforcing professional standards and accountability, and an explanatory guide, Managing for Excellence in the NHS, which sets his stall out in digestible form. Both were sent out in October.

Then there's action to bring in the new talent at all levels, encouraging clinicians to apply, middle managers, young managers, black and ethnic minority managers, specialists. Plus more leadership training for senior managers, more career management and succession planning. It's quite a programme. But what is he looking for from the new recruits?

Added skills, it seems, in procurement, planning and focus. What about the perception that only a certain sort of manager thrives in the NHS, that consensus rules, and that - this is brutal but what many in the private sector think - some public-sector managers just tend to be a bit wet?

Crisp's face hardens. 'Yeerrrs,' he says slowly, thinking hard as to what the right response should be. In the end, he doesn't really deal with it, simply saying that 'of the private-sector managers who have come in, those that have worked best have twinned themselves with those who know the system'. In other words, the problems of perception are theirs, not the NHS's. 'You have to adapt your style to the location,' he says, 'and the single most different thing to the private sector is the multiplicity of goals.'

Others in the service say the problem is more likely to be morale. One senior clinician I spoke to said Crisp is not like most other managers, he is far more skilled at playing the system, and many of his colleagues are simply demoralised by the demands placed on them by Whitehall: 'What is lamentable is that some of these guys have been treated very badly, there is a climate of fear that is quite striking.'

Crisp will have his work cut out just motivating those already there.

Can he do it? He is unusual for an NHS boss in that he has had line management experience in the private sector, which he can, perhaps, bring to bear.

Though Crisp produced nothing more than mints in three years at Trebor, his task involved sorting out new methods of production that increased employee satisfaction - a relevant aim. His efforts worked, although one upshot was that they increased managerial stress and complexity, a fact some may read with foreboding.

But Crisp clearly loves complexity. 'At Trebor,' he grins, 'the goals were how many sweets to a certain specification you could turn out at what labour cost in what time-scale and to what production target. If the production line broke down you were thick in ... well, sugar, for one thing, but deep in shit too. Whereas in the public sector, particularly in the NHS, you have got a multiplicity of goals and you cannot forget some of them. You can prioritise some, but you mustn't let the others go backwards.'

That, he says, is the fascinating part, and it's telling that he expects everyone to share his attitude. His CV includes those years at Trebor - a management role he took because of his interest in 'employment issues' - which he parleyed into a job with voluntary organisations then a jump into the health service at 33. He'd already done a few years after university as a youth worker on a tough council estate outside Liverpool.

Once in the NHS, he moved from running a unit for those with learning difficulties to swiftly ascending the management ladder, heading the merger of the Wexham Park and Heatherwood hospitals in Berkshire, then the more famous John Radcliffe and Churchill hospitals in Oxford. His own career, you suspect, has been motivated by nothing more than the search for the intellectually 'fascinating' and complex.

But then his is a bright mind of a liberal bent, nurtured in the security of a well-off family. He was brought up in the north-east, where his father, an industrial chemist, was a senior ICI manager, later posted to America.

He was sent to boarding school aged eight (hence no trace of the north-east accent), excelled academically, as did his two sisters - one now a computer systems analyst, the other a chemist. He read philosophy at Cambridge, which gave him, he says, 'the best training for spotting bullshit at 25 paces'. Then he offers me a little lecture on Aristotle. Is that the life-experience of many in the NHS, I wonder?

But those who know Crisp say that, despite the privileged background and mandarin tastes - house in the country in Berkshire; hobbies: landscape gardening and tennis - he has always been good at winning people's trust at all levels. 'Nigel has a very strong intellect, but he wears it very lightly,' says Dr Chris Bunch, former medical director at the Oxford Radcliffe Hospital. 'He also loves challenges, he'd take on very difficult situations, and he just has a knack for sitting in meetings where people are polarising and defusing the situation by talking common sense.'

And he has always worked by putting himself about, especially among the doctors, who he has been struggling to win over recently with a new pay agreement. 'Nigel never spent his time in the office,' says Dr Sunil Liyanage, his medical director at Heatherwood Hospital. 'He was always out talking to the porters or the nurses. But he had the doctors onside too. He attended all the medical staff meetings and always made a contribution, which a lot of chief executives don't.'

Crisp has brought the same on-the-hoof style to the post of NHS CEO, travelling the country every Friday, checking out different units. 'I do it partly because it is important that I know the NHS better than anyone else in the country, and partly because of the issue of management-by-anecdote. I like to check things out. If someone tells me that intensive care is getting better, well, I have been to 40 intensive care units in the last year and actually it is. Someone tells me A&E is getting better too; well, I've been to 40 of those and some are, some aren't, yunno? You need to know that kind of stuff.'

Because, of course, forewarned is forearmed. Does he have a vision of what he wants to achieve? Yes, he says: to pull the NHS in around national standards, to provide a national framework to decentralise around, and to get services free to everyone in the country, regardless of whether they stem from the NHS, the not-for-profit sector or the private sector.

And all linked up with data flowing from one bit to another. 'Twenty years ago, we couldn't have done this; there wasn't the money nor the IT, and we didn't do things nationally.'

It is a complex vision, centralising some things, decentralising others, but then it is a complex service. Crisp, by all accounts, has good relations with Tony Blair and the health minister, Alan Milburn, but politicians are acutely conscious of how the state of the NHS influences voters. Too much decentralisation and ministers may feel they have lost control over something rather important to their job prospects.

That, according to some, continues to be Crisp's biggest problem - not just ensuring that the new money isn't soaked up by pay awards, but managing the politicians' desire to control everything. 'I think it must be a very lonely job for Nigel,' says a doctor friend. 'The politicians are so hands-on, they have an agenda of their own and, frankly, most of us are very suspicious of it.'

Crisp, who is off to see Milburn after our meeting, blinks when I put it to him: you're not the boss, the politicians are; your plans could be ripped up in a moment. 'We have just got the most fantastic settlement the NHS can dream of,' he retorts, '7.5% growth in real terms over five years, taking us up to where we ought to be, recovering the position we have lost over the years. That could only have been achieved by a heavyweight politician or two, yunno? It is the most tremendous achievement.'

He smiles. 'Anyway, you could sit in this job and wish the politicians away, but you would be being naive.'

And he arches his eyebrows knowingly. So, anyone looking for a career change?

< crisp="" in="" a="" minute="" 1953:="" born="" 14="" january="" ,="" county="" durham.="" educated="" at="" uppingham="" school="" and="" st="" john's,="" cambridge="" 1973:="" estate="" worker,="" halewood="" community="" council="" 1978:="" production="" manager,="" trebor="" 1981:="" manager,="" cambridgeshire="" community="" council="" 1986:="" general="" manager="" for="" learning="" disabilities,="" east="" berkshire="" 1988:="" general="" manager,="" later="" chief="" executive,="" heatherwood="" and="" wexham="" park="" hospitals="" 1993:="" chief="" executive,="" oxford="" radcliffe="" hospital="" 1997:="" south="" thames="" regional="" director,="" nhs="" executive="" 1999:="" london="" regional="" director="" 2000:="" chief="" executive,="" department="" of="" health="" and="" nhs="">

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