Simon Stevens: the man charged with saving the NHSBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6895 (Published 18 November 2014) Cite this as: BMJ 2014;349:g6895
- Gareth Iacobucci, news reporter, The BMJ
Simon Stevens’s appointment as the chief executive of NHS England in April was widely welcomed by a health service looking for bold and intelligent leadership. Some have bestowed on him an almost messianic ability to cure the NHS of all its ills, but Stevens does not betray this weight on his shoulders as he cheerfully greets The BMJ at his south London office.
Described as “dazzlingly bright” and regarded as one of the United Kingdom’s leading thinkers on healthcare reform, Stevens was understood to have been Prime Minister David Cameron’s first choice to succeed the outgoing David Nicholson in the role.1 This, coupled with a longstanding belief in the NHS, convinced him to return from the United States, where he had worked for the health insurance giant UnitedHealth since 2004.
Before this, Stevens’s career began in NHS management before a spell in New York as a Commonwealth Harkness fellow in public policy and later as a health adviser to the then prime minister, Tony Blair, from 1997 to 2004. Stevens was one of the architects of Labour’s 2000 NHS Plan, which transformed the service’s fortunes through a substantial programme of investment and reorganisation. Although the economic climate is far gloomier today, Cameron is clearly hoping that Stevens’s experience and aptitude can steer the NHS away from the edge of the cliff that it currently finds itself on.
Now eight months into his tenure, Stevens has been proactive in identifying how to fix a service that is struggling to control demand against an unprecedented financial squeeze and an ageing population with a growing number of long term health conditions.
The fruits of Stevens’s first half year’s work are captured in NHS England’s Five Year Forward View,2 3 a new vision for an integrated health and care service that he hopes will transform the NHS’s fortunes over the next half decade.
He has advocated the widespread adoption of new models of healthcare delivery that would reshape the way the NHS in England operates. He wants public health and prevention to be scaled up dramatically and historical boundaries between hospitals and general practice to disappear. The plan is not overly prescriptive but suggests the way forward for NHS hospitals to take control of general practice services or for groups of GPs to head up multispecialty provider groups that include consultant specialists.
Empowering local teams
So what is he trying to achieve?
“There is a triple fragmentation that we’re trying to overcome: health and social care, physical and mental health, and primary and specialist care,” he explains. “The desired result is twofold: improved outcomes and improved sustainability of services.”
While Nicholson was famed for his command and control style of leadership, Stevens has focused on empowering local areas to lead change themselves, albeit with support from the centre to turn their ideas into action. So unsurprisingly the plan has received widespread approval, notwithstanding some searching questions about how it can be implemented in such straightened financial times.
Stevens has acknowledged that staff pay restraint cannot continue to be the main driver of efficiency savings and that more radical service change is now critical. But, given his rush to get on, The BMJ asked him how much evidence of effectiveness local areas would have to produce before they introduced new models of care.
Some areas, he explains, are “already right on the cusp” of radical service change, such as Yeovil in Somerset, parts of Birmingham, and Northumbria. He says that areas in this first category will have to “stress test” their ideas for deliverability but will then be free to pursue them and produce the evidence as they progress.
At the other end of the spectrum, parts of the country where services have faced longstanding financial pressures and quality issues already have the evidence that change is needed, he says. In this second category, he adds, “It’s pretty obvious to people that the status quo is not viable . . . We’re almost going to have to start with a blank sheet of paper and say, ‘What would a redesigned service look like?’”
When asked what this approach would mean for NHS hospitals and foundation trusts that cannot bring their finances under control, Stevens suggests that there should be more shared responsibility for unsustainable services across local health economies, rather than standalone services being penalised.
“In some geographies, we’re going to have to change how we think . . . so that rather than having individual institutions in special measures, we say we’ve got to solve this on a shared basis across this town or county . . . We can’t just point the finger at the individual hospital or provider—we’re going to have to have quite a substantial rethink about the totality of healthcare here.”
He does not mention hospital closures explicitly but says that this approach means putting into play things that would previously have been regarded as “not the way we do things” in the NHS when it comes to the rigid distinctions that exist (between hospitals, general practice, and community services).
The bulk of the country will fall into a third category “where people actually have some degree of freedom in terms of the strategic choice they make,” he explains. In these cases, “some tweaking around the edges” may be sufficient, but he admits that different parts of the system may have opposing views on what changes need to be made. “You have to think how to structure that conversation to try and generate a sensible consensus,” he adds.
Stevens says that the areas that could produce the best evidence for service redesign fall into a fourth category: new towns or areas with rapidly expanding populations, such as former brownfield sites. In these places, he says, “We do have an opportunity to almost design from scratch what a 21st century health service would look like rather than just having to tweak legacy models of care.”
“Mr Insurance USA”
While Stevens’s challenging plans have been mostly well received by the NHS, there is a faction, particularly on the political left, that believes that his UnitedHealth background and his role as the architect of Labour’s pro-market changes to the NHS will increase the focus on competition and privatisation.
Former colleagues have insisted that the caricature of “Mr Insurance USA” is wide of the mark and that Stevens is “absolutely committed” to the NHS in a way that “transcends all other considerations.” They say that this, rather than any desire to be a missionary for corporate interests, is what prompted his decision to return from the US.4
Stevens remains pro-competition, but he appears more driven by pragmatism than ideology when asked whether he expects the proportion of NHS care delivered by private firms to substantially increase under his watch.
“The figure quoted is that 94p of £1 of care is delivered by NHS providers. For some things, patient choice is going to create some permeability there, but that’s not going to be the central driver of change or improvement,” he says. “My firm prediction is that the vast majority of care will continue to be provided by NHS providers.”
He adds, “When you look at what we’re trying to do for some of these more integrated models, as long as you’ve got a reasonable basis for demonstrating that integration is going to give you the improvement and efficiency dividend that you want, then it’s a perfectly reasonable decision not to expect competition to be the vehicle that will drive that change.”
Increased NHS funding
Regardless of whether his stance on the use of markets is aligned with that of the current government, Stevens could not be accused of kowtowing to politicians in his first few months in charge of the NHS. Ahead of next May’s general election, the Five Year Forward View has thrown down the gauntlet to the next government by asking for an additional £8bn (€10bn; $12.5bn) above inflation over the next five years to help fund the required service changes.
With the economy still fragile, no party has yet committed itself to such a funding uplift. But with a political deftness clearly gained in Whitehall, Stevens has set out his stall by outlining how the NHS can achieve a large share of the identified £30bn of efficiency savings. By doing this, he has shifted the emphasis to the politicians to respond.
“I think we were pleased that all three parties saw that the direction of travel aligned with the broader consensus about how healthcare should develop,” he says. “In terms of answering the question of whether they produce £8bn by 2021, that’s something that they will have to choose when to and whether to.”
“There is a set of things that the NHS can do to make the contribution [to efficiency savings]. There are some things which aren’t in our gift, either because they are in partnership working with others, like local authorities, or they require broader changes in the policy of whoever happens to be in government, including public health and some of the changes in prevention.”
Stevens acknowledges that the NHS must do more to “stand up and be counted” in ongoing debates on public health. When pressed on where he stands on minimum alcohol pricing and plain tobacco packaging—two policies that the current government has backed away from, despite evidence of their effectiveness—he offers a studied yet honest response. “Speaking personally, I would certainly support tobacco plain packaging,” he says.
“On minimum pricing, there is an argument that actually changing the excise duty would be a more effective way of achieving the result. But the question is: is that permissible under the European rules? Obviously Scotland is in dispute on that as well, so there are some things to be worked through.
“But at the right time we will certainly be out there advocating on things we think will make a difference.”
Seven day service
Stevens seems to possess the mettle to challenge, coupled with the intuition to know when and where to apply it. He may soon have to put these attributes to the test, as NHS England considers how to fulfil its medical director Bruce Keogh’s vision for a seven day service. Stevens is quick to acknowledge the current pressure that NHS staff members are working under and says that no one will have to work seven days under the Keogh plan. But he declares that the service has “an ethical obligation” to take forward the plan, given the evidence now available showing higher death rates at weekends.
“Certainly in urgent and emergency care [a seven day service] will make a difference to patients, given the data that we now have suggesting much worse outcomes and higher mortality rates at weekends,” he says. “Now we know that, we can’t ignore it or hide behind issues of pay negotiation,” he adds firmly.
He admits that it will be difficult to square the need for seven day working with current levels of payment for working antisocial hours.
“At the moment, the NHS is spending £1.7bn on antisocial payments,” he says. “At the current way of paying for that it is hard to see how it will be affordable any time soon to provide the kind of support for patients through the week that would cut the mortality rate, so I think there is going to have to be some give and take on all sides over the course of the next several years to bring about an improved solution for patients.
“That is ultimately a conversation for the Department of Health with affected staff, but speaking for the kinds of service improvement that everyone wants to see, we don’t think that’s an issue that can be ducked indefinitely.”
Ducking the big issues does not seem to come naturally to Stevens, which, given the multitude of challenges he faces, is a definite advantage. Ministers and healthcare professionals alike will hope that his restless impatience to make change happen will enable the NHS to emerge stronger through these times of unprecedented turbulence.
Born in Shard End, Birmingham, 1966
Educated at St Bartholomew’s Comprehensive School, Oxford University, Strathclyde University, and Columbia University (where he was a Commonwealth Fund Harkness fellow in public health policy)
Worked as an NHS manager, including general manager for mental health services at North Tyneside and Northumberland and group manager of Guys and St Thomas’s hospitals in London
Served as health policy adviser to the Labour government and Prime Minister Tony Blair between 1997 and 2004. Helped develop the NHS Plan 2000
Held various roles with UnitedHealth between 2004 and 2013, including its chief executive officer for Medicare, president of UnitedHealth Europe, president of global health, and group executive vice president
Previously served as a trustee of the health think tank the King’s Fund, a director of the Nuffield Trust, local Labour councillor in Lambeth, and a visiting professor at the London School of Economics
Joined NHS England as chief executive on 1 April 2014
Mid-term report on Simon Stevens
Sam Everington, GP in east London and chairman of NHS Tower Hamlets Clinical Commissioning Group
“It’s really good to hear somebody recognising that the challenges that the health service faces are going to be sorted by a bottom-up approach of engagement with clinicians in coming up with the solutions. There is a recognition of the importance of primary care being part of that solution, whether it’s actually supporting more patients to have their care managed closer to home and in their home or just to try to control specialist costs, which have gone up enormously in the past seven years, in parallel with resources in primary care going down, despite the increased workload.”
Len Fenwick, chief executive of Newcastle upon Tyne Hospitals NHS Foundation Trust
“He’s beginning to reinforce the authority to secure whole person care that’s proved elusive since the birth of the NHS in 1948. It’s one hell of a challenge. He is progressive yet preserves values. There is always a risk of throwing the baby out with the bathwater, and he’s clearly aware that there is in fact tremendous achievement to build on.
“He is articulating a time for change and is endeavouring to influence transitional arrangements. It’s been a radical shift in terms of NHS England’s leadership. We had a command and control mantra, which has moved right across the divide into partnership influence and direction.
“There is a risk of being bottomed down to a common denominator. But he instils confidence and demonstrates competence.”
Andy Cowper, health policy commentator and editor of Health Policy Insight
“One of his main achievements in the first six months in post has been to deliver no big surprises. His set piece speeches and the Five Year Forward View show what people who have followed his career would expect: insightful, intelligent analysis of the problems, and a total lack of ‘one size fits all’ solutions.
“The near universal acclaim for the Five Year Forward View is some achievement in an NHS which, under the 2012 Health and Social Care Act, devolved operational control from a centralising Department of Health to what you might politely call a multipolar approach. Unsurprisingly, this ‘who’s in charge?’ syndrome has meant that relations between commissioning and regulatory system leaders have had moments of some tension. Simon has handled this well: he is good at politics.
“His appointment was welcomed almost universally, raising a worrying spectre of health policy groupthink. At some point, he may even make a deliberate mistake, simply to confound the ‘Simon Stevens is the messiah’ tendency.”
Cite this as: BMJ 2014;349:g6895
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.