Running NHS England was always going to be tough, but was he ready for this? Simon Stevens talks about funding, reshaping healthcare and his personal crusade against obesity.
When Simon Stevens returned from America to lead NHS England two years ago, many managers saw him as someone who understood the NHS and could lead it through choppy waters.
Two years on, those choppy waters have been whipped up by a force ten storm. But in NHS England’s offices in south London, Stevens remains upbeat. His body language is relaxed and he continues to show passion for the job and a firm grasp of the detail.
The good news is that Stevens thinks highly of NHS managers, quoting the celebrated industrialist John Harvey Jones’s claim that the Victorians would be putting up statues to NHS managers as they did for engineers and civic leaders. The bad news is that there’s little prospect of pay rises to come and the Carter review is likely to lead to even more scrutiny of providers’ management costs. Managers will have to develop a new style of leadership and work in different ways.
All in this together
“The reason most of us came into NHS management was that we believe in what the NHS represents and the importance of effective leadership in driving improvements in care,” he says. “It’s easy for that fundamental reality to be obscured, but that’s what NHS managers bring to work every day of the week.
“There does need to be a sense that we are all in this together with frontline staff and, indeed, the public,” he says, and to preserve this feeling, reforms are needed. “I don’t think the cause is advanced when criticism can be made of redundancy, expenses or revolving doors.”
Stevens is particularly keen on working with young people coming into NHS management, claiming that the NHS graduate management scheme is still among the most popular in the country. Working with trainees “puts you in touch with your inner 22-year-old,” he says. “You think back to the reasons why it is such an attractive thing to do… Perhaps the proof of the pudding is that some of the most committed and brightest young people want to become – and do become – NHS managers.”
Funding falling short
There was speculation that Stevens would resign last November if George Osborne’s spending review failed the ‘five tests’ Stevens set for meeting the NHS’s needs. “That’s not a threat I made,” he insists. “But I set out the stall very publicly and said, having been very clear about my criteria, I would be very clear about whether they were met.”
So does he think Osborne’s settlement passed the five tests? Only in part. His request for new money to be front-loaded was met, as were his demands for political support for “realistic but broad” reforms, and for new demands on the NHS to be aligned with when the new money becomes available.
But Stevens admits his requirement for investment in social care has not yet been met and remains “unresolved business”. While he welcomes the “back-loaded” £1.5bn new money for the Better Care Fund, Stevens insists a new consensus on integrating health and social care needs to be in place by 2018. He also says the jury is still out on public health, where much will depend on the success of the government”s obesity strategy.
What will not happen under the Five Year Forward View (5YFV), Stevens’s blueprint for NHS up to 2020, is more organisational change. “However imperfect the particular arrangements may be at any particular point of time, it doesn’t matter what national architecture you choose,” he says. “There’s no right answer, but there is a wrong answer – and that is changing your mind.”
While many will be delighted by this promise of organisational stability, the number of NHS managers in provider organisations is unlikely to remain stable. Lord Carter has proposed that many trusts make significant management cuts, with a new cap of 7% of total costs by 2018, tightening to 6% by 2020.
“It’s worth reminding people that we probably have the leanest [healthcare] management infrastructure of any industrialised country already,” says Stevens, adding that CCGs and NHS national bodies have made major cuts in the last few years. “I don’t think that distracts from what I understand to be Pat Carter’s findings on provider management costs, which is that there is a pretty big spread.”
He suggests, it’s “not unreasonable” to ask “why the variation exists and whether that’s reasonable or not… it would be wrong for operational managers not to also think in the same terms that we are thinking across the NHS.”
Shifting the “institutional mindset” which has dominated the NHS for the last 25 years, will be one of the biggest challenges for NHS leaders, he says. As the emphasis shifts from improving routine surgery and waiting times towards managing long-term conditions, Stevens wants to see “triple integration” between physical and mental health, hospitals and primary care services, and social care and the NHS. And with most of the new NHS money coming through the sustainability and transformation fund, Stevens warns that funding will largely be decided by the quality of the shared plans for geographical areas due to be drawn up this summer.
“We need to take a more geographical view, to say what are we trying to do in Devon, or what is the right answer for the North East, or what are we trying to do for conurbations around the West Midlands? That is really quite a profound leadership challenge,” he says. “If people don’t come together and answer the questions that have been brushed under the carpet for years on end, they won’t get their share of the money.”
Stevens suggests modelling this collaborative approach on what has happened at the top of the NHS. The 5YFV, for example, was not just an NHS England product, but the collective view of NHS leaders from many national organisations. He wants the NHS to “explicitly” show chief executives that “collaborative behaviours” will be rewarded – as opposed to behaviour aimed at topline growth and expansion, which tended to be recognised in the past. “At points, that has indeed been a legitimate approach,” he says. “But for the challenges that face us now, that is unlikely to be the right answer.”
The small number of failing trusts – those in special measures, or with serious financial or quality problems – present particular management challenges, he says. “If you are the chief executive of one of these you must feel like a dog being wagged by many tails, whether it’s inspection, the training requirements for junior doctors or recruiting and retaining staff.”
He is clear that simply bringing in new management teams is not the answer. He suggests some smaller hospitals need to reinvent the clinical model, especially with respect to medical specialties, and change relationships with primary care.
He does not rule out service changes but says mergers and closures are not always the answer, especially as many struggling trusts are coastal or in remote areas and need to continue to provide a range of acute services. “Other countries have found ways of producing clinically-viable, high-quality and financially-sustainable small hospitals,” he adds. “That’s not just a question of merging with your next door neighbour, because for some of them there isn’t a next door neighbour. There is a huge job of work to be done to reimagine what is a viable, smaller acute hospital.”
Being taken for a ride
Stevens blames much of the current financial pressure on the growing use of agency staff – a problem he attributes to the cuts in nurse training places five years ago, restrictions on overseas recruitment (now partially lifted), and the post-Francis focus on minimum staff numbers and its enforcement by the Care Quality Commission.
“Put these things together and it’s not surprising at all that we’ve seen this massive increase in temporary staffing costs,” he says, warning the bill could reach £4bn this year.
The NHS now needs to act collectively and avoid “being taken for a ride,” he says. “Each individual trust had been left to sink or swim. We have not been harnessing the ‘N’ in National Health Services, and saying: ‘we will not be picked off one by one’. We are wasting an enormous amount of money which could be far better spent… The opportunity cost of NHS managers not tackling these issues is enormous.”
A slimmer NHS
Stevens’s passion for tackling obesity is well known, but his ambitions go far beyond encouraging NHS staff to eat more healthily. Does he see a slimmer country as his legacy? “We know that obesity is a great threat to our health as grown ups and kids,” he says. “There’s no magic wand but there’s a series of things which can be done to wind the clock back. There is nothing God-given about this.”
“We have, in many cases, obesogenic working environments… we need to do something about that.”
The NHS, as Europe’s largest employer, has a big role to play, he says. He plans to create explicit financial incentives for NHS employers to invest in staff health and wellbeing, beginning in 2016-17. “We have, in many cases, obesogenic working environments. We have stressful conditions. We don’t provide tasty, healthy, affordable food options for people working night shifts – we need to do something about that.” Adapting Gandhi’s quote, he adds: “We have got to be the change that we want to see across the country.”
With coffee shops and convenience stores in many hospitals, this looks like an uphill struggle. But it can be done, Stevens insists, referring to one hospital where a major coffee chain was persuaded to change its offering after talks with a public health director.
“There are opportunities on a rolling basis as contracts come up for renewal, but these vendors will see – if they are going to win contracts across the whole of the NHS they’re going to have to change how they operate. In just the same way as we would no longer tolerate smoking or selling cigarettes on NHS premises, we have to help with the nudges to reduce the obesogenic environment across the NHS for staff, visitors and patients.”
Despite taking a considerable pay cut when he moved from the US to the UK, Stevens volunteered an additional 10% reduction on his predecessor’s salary. Since then, the challenges facing him – including nosediving NHS finances and ever-increasing scrutiny of care quality – have only grown bigger. Did he think the job would be this tough?
“I came back with my eyes open,” he insists. “I've spent the bulk of my 27-year career in health services either in or around the NHS. I had a fundamental understanding of the challenges in the NHS.
“The existential crisis moments in the NHS’s history since 1948 have all been a function of times when there were crises in the British economy. It was pretty clear that whoever was the government, it was going to be a very difficult time for the NHS – but at the same time, paradoxically, there was a consensus that the NHS needed to change.”
The challenges of guiding the NHS through that upheaval – and changing the eating habits of a nation – now look more daunting than ever. But they are the kind of challenges Simon Stevens seems to relish.