Background: Nicholson leads the UK’s National Health Service and has been in healthcare for 30 years. He took over the NHS six months ago and is now running one of the largest organisations in the world with 1.3 million employees.

I’m absolutely passionate about healthcare and improving health services. I was taken by the Catalan minister’s speech, particularly the similarities between UK and what’s happening here. I’m sure that all of us have some understanding of what she was talking about.

The key issue is how we deal with our constituents, our patients, our staff and our communities. How do we get all three of those constituents signed up to what you want to do. I’d love to tell you that we’d got that, but we’re not there yet. I hope to show you the dilemmas and dynamics of the UK system.

Being chief executive of NHS is a fantastic opportunity - if NHS was an economy it would be 33rd largest in the world - apparently having an armed forces isn’t an option

I’m going to talk about some of the transformation we’ve achieved so far and the change we’re looking to make now and the future.

There are three primary challenges - Equity; High Quality and Responsive Services; Controlling Costs - and all are interplaying in all of the systems that we operate and at various times in history we seldom get all three working together. Historically we’ve been strong on equity and up until the 1990s very strong on cost control - the problem has been quality and responsiveness.

We have been monopoly suppliers with little competition within the NHS or with the private sector. The private sector in England has been “fat and happy”. We started trying to deal with the issue of capacity. We’ve had quite some success with the NHS plan starting in 2000. We’ve had significantly more money from government and we’ve grown by a third over the past few years. And hand in hand with that is the development of national targets. Particularly waiting times and accelerating the number of staff coming into organisations. But increasing capacity is not enough.

We’ve had improvement but not enough to meet demand. And increase in capacity does not address the biggest issues: demography - big changes in the ways that populations are structured - getting older and increasing numbers with chronic conditions. The second big change is increases in patient expectations - they expect top quality services, and thirdly technology - for example most diagnostic tests are hugely portable.

The way we’re going to transform the system comes in two ways - we’re changing the way that we treat patients with much more emphasis on community and local primary care. At the same time we’re changing the delivery system, going from a nationalised industry to a more devolved market based system.

How do you drive that transformation? I could say that I drive it all from Whitehall, but that wouldn’t be true. My experience of change leads me to five things to think about:

Incentives & Levers
We’re introducing a payment by results system in secondary care. Most acute hospitals now derive much of their income this way. And we’re introducing plurality of provision, bringing new independent providers into the system to increase capacity and competition.

Connecting reform to our people
Most obviously the contracts we’ve developed for staff are increasingly showing local flexibility. A significant proportion of GP’s pay is tied to outcome measures. We’re also much clearer with consultant staff on the things that they must do to link their pay to reform.

Enablers
For example the national programme for IT, which is not just about technology but also about improving services for patients.

Leadership and Behaviors
Really good leadership makes an enormous difference to the way health systems move forward and develop. We’re putting a lot of emphasis on leadership.

Empowering patients and staff
These reforms are not the playthings of technocrats, they are there for ordinary front-line staff to use to help them to take the service forward.

We have had some big financial problems in the meantime. We’ve had this for some time, but we’ve had a less transparent system until now and the issues have been hidden. We’re now making progress towards a surplus this year and next.

These reforms are painful for all of us in the Health Service as we try to drive things forward. We did try some of this before under the previous Conservative Government, but as resistance became difficult we lost our nerve and the reforms went into the sand. So now this is the time when we have to hold our resolve and push on with the changes. While going through this change we’ve still managed to improve satisfaction, so there’s clearly much to be gained.