I have noticed something about 'The £15-20 Billion Man' Sir David Nicholson, chief executive of the NHS.

He’s still here.

This is, in itself, fairly surprising, given the flagrant resurgence of tensions between himself and SoS Lansley that were evident at last week’s health select committee evidence, and as discussed, before that.

To recap: it is quite extraordinary that a civil servant who describes his political master’s White Paper thus - ”If you’d asked me back in May if this was a good time for a major NHS reorganisation I’d have said, ‘don’t bother’ … it has added significant risk to the system”. – and who answered health select committee chair Stephen Dorrell’s question ”Are you confident those clusters of PCTs will be redundant in the end of this period?” by saying ”That’s a matter for the national commissioning board" remains in post.

But remain in post he does.

Why?

One conceivable option is that he stays because SoS Lansley is simply too weak to sack him. As we revealed, and many others have noticed, the liberation theology of SoS Lansley is being given an ecumenical once-over by Conservative policy policeman Oliver Letwin, joined by Lib Dem coalition cop Danny Alexander.

Another possibility is that somebody, somewhere has decided that Sir David knows where we are going.

And if that is the case, then an absolute fact is with us: the route to wherever we are going next will be through a period of ”Stalinist controls”.

That is what Sir David does. He does Stalinist controls.

He was candid about this when speaking to the NHS Confederation conference in 2009, telling them that he was part of a generation of NHS managers who got on in their careers by achieving their numbers.

Nicholson-watchers will of course recall that when he first took the national stage as NHS chief executive after the interim tenure of his mentor and friend Sir Ian Carruthers, David (as he then was, pre-knighthood) urged audiences to “look out to their communities, not up to Whitehall”. It was scarcely six months until this modulated into the rather more honest “look out to your communities AND up to Whitehall”.

The slight problem for those trying to follow Sir David’s amended advice is that they end up loking like Marty Feldman, which frankly is not a good look.

There is an intrinsic tension in Sir David’s desire to ”start to grow the new system out of the old one”, and the realistic chances of developing what is needed for the coming system. PCTs will merge at scale, and by February 2011 it seems that there will be around 35 of them.

The wages of the public sector winter: frozen
Recent days have seen more responses issued to NHS Employers’ suggestion that the pay increments in Agenda For Change should be frozen for two years, in return for a guarantee of no compulsory redundancies.

Wages are the major cost pressure in any significant organisation, and the NHS is no exception. The principle of Agenda For Change – linking pay progression to a skills escalator – is a something-for-something deal that should have been able to work.

Unfortunately, it relied on competent and effective HR and middle-management. Schoolboy error.

But national pay deals – such as this - have no place whatsoever in the logic of a liberated NHS. And we heard much from various ministers and DH great and good about how QIPP could not be just about old-school salami-slicing – such as this.

Liberation feels very far away. Freezing increments might save money, fairly useful, cashable saving – but there are problems.

If there is seriousness about reshaping the system and moving services out of acute trusts and into community settings, that is going to involve making people redundant. They might not be redundant for long, but they will be redundant.

And if anyone thinks sweetheart deals can be struck here (or indeed in PCT staff), they should be keenly aware that the stated mission of the Co-operation and Competition Panel will be training incredibly beady eyes on them. To say nothing of NHS Partners Network.

No honest discussion of what is coming next can miss the NHS cost-saving rhyme – “shed heads and beds”.

So if you genuinely have to to ‘shed heads and beds’, then getting it right is inevitably a local matter. And if this is not a local matter (as this call implies), then everything we are supposed to think is a reason for moving to a liberated NHS is wrong.

Oh dear.

Show me the way to go home ...
Do you know a way out of this impasse, Sir David?

’Yes, the way out of this impasse is through a period of tight Stalinist controls …’

Oh. Right. Better make some notes, oh, damn, this pen’s run out? Where’s the stationery cupboard, Sir David?

’Absolutely. The way to the stationery cupboard is through a period of tight Stalinist controls …’

Yes. OK. On second thoughts, I think I’ll just go to the pub. Do you know the quickest way to the Red Lion, Sir David?

’Well, the quickest way to the Red Lion is through a period of tight Stalinist controls …’