Simon Stevens played a pivotal role in securing a £20bn funding boost ahead of the 70th birthday of the NHS. With its finances on a more stable footing, the NHS England chief executive wants to use this moment as a springboard to ensure the health services’ long-term future. He talks to Sebastian Whale.
Photography by Louise Haywood-Schiefer
The National Health Service was celebrating its 40th anniversary when a twenty-something Oxford University graduate by the name of Simon Stevens arrived for his first day of work. Three decades later and the same man now finds himself as chief executive of a health service marking its 70th year.
“Working in the NHS, you get to see all of the brilliance of the NHS, but you also of course know the NHS isn’t perfect. And so, over those 30 years, there have been huge changes and improvements,” he says.
In recent months, Stevens has played a pivotal role in ensuring the NHS secures the birthday present right at the very top of its wish list. In June, prime minister Theresa May announced an extra £20bn a year for the health service in real terms by 2023, amounting to a 3.4% annual increase on average. After nearly a decade of constrained rises around the 1% mark, services were being pushed to breaking point.
During this period, Stevens, a highly astute and effective operator, was not afraid to speak out about the need for a fresh cash injection into the NHS. Is he happy with the new agreement?
“I’ve been very clear that what this settlement gives us is the benefit of certainty for the next five years and it clearly marks a meaningful improvement on the constrained funding that we’ve been having to operate under because the economy tanked in 2008,” he says.
“In a publicly-funded health service, the availability of public funding is a function of how well the British economy is doing. So, as the economy has begun to improve, that now creates the opportunity for a better-funded health service, which is obviously something I am very supportive of. Therefore, it’s also very important that the prime minister is so clear in her support for the funding as well.”
He adds: “If I didn’t think this was a workable funding settlement, then yes, I have in the past felt a sort of obligation to speak up. But, equally, when you get a workable funding improvement which this clearly is, then I am very happy to be clear about that too.”
RELATED CONTENT
Stevens’ tone on the extra funding is considered. He has a sign in his office, painted by one of his children, with a phrase he used in his first speech as chief executive of NHS England: “Think like a patient, act like a taxpayer”.
His pragmatism is for good reason: the burden of new funding will likely fall on the taxpayer and ministers have also been told, according to reports, that there is no fresh money for anything else.
“Everybody in the health service recognises that not only is it right to fund the health service properly, but in doing so we are making a call on taxpayers’ resources. So, we’ve got an enormous responsibility to be wise stewards of this additional investment,” Stevens says.
The NHS has been taking steps to improve efficiencies, with plans to save £190m a year on low value medicines and £100m on over-the-counter medicines. Savings have been made from NHS England’s core budget, and NHS Improvement anticipate efficiencies of up to 25% on current costs through a central procurement programme.
“Three things can be true at the same time; first of all, we are overall one of the world’s most efficient health services and we, on just about any efficiency measure, compare very well with France or Germany, the United States, other industrialised countries,” he says.
“But the second fact is we still do have inefficiency and waste in the National Health Service, and because we’re an NHS, every pound we save we can reinvest in better patient care. The third truth is that, even going hammer and tongs at efficiency, we still as a result of a growing and ageing population, needed more funding which we’ve now got.
“So, I think it’s right that this funding commitment has been made. But it’s also right that the health service steps up and ensures that we are being very disciplined in using that resource to drive better care for patients across the whole country.”
“We have an enormous responsibility to be wise stewards of this additional investment”
Separate funding increases for social care services are expected later this year, which many see as a necessity to alleviate pressure from the NHS. And as the health service will not receive the newly announced funding until April, Stevens says steps are being taken to mitigate against a repeat of last year’s winter crisis, which he argues was partially down to an eight-year high in flu rates and pressure from care services.
Though the new cash marks, as he puts it, a “gear change” in government spending, historically the NHS has enjoyed annual increases of around 4%. Stevens, who was appointed to his post by David Cameron in 2014, was a policy adviser to two health secretaries and Tony Blair during the New Labour government, where average real increases in NHS spending were between 5% and 6%.
“One of the problems with NHS funding over the last 70 years has been its volatility. So, we bounce off the banks between boom and bust and that makes it very hard to plan services. It actually makes for a less efficient service, having that level of volatility,” he says.
“After an extended period of low funding growth, it ends up having an impact on your ability to retain staff, so then you spend more on expensive temporary agency staff. Hospital maintenance budgets get raided to support day-to-day services.
“But equally, when you then flip to very rapid and large funding increases, the risk is that that is inflationary. So, actually, it is far more efficient for the taxpayers to steadily fund the health service year by year by year between the 3% and 4% mark, than it is to bounce off the banks.”
Stevens and others will spend the next six months sketching out priority areas for health and the NHS for the next decade. These will include improvements in cancer and mental health; focus on population changes and the “increasing” needs of children.
With the demands of an ageing populace on the NHS well told, officials are keen to highlight other areas where services are being strained. It is for this reason that Stevens called on social media companies to share the burden of mental health issues in young people. He says the level of undiagnosed mental health problems and distress among young people is likely to be much higher than has previously been recorded – and we must begin to look at root causes.
“There is a growing awareness that alongside some of the positive aspects of children’s online experience and social media, there are some important negatives,” he says.
“We’ve just had the WHO recognise gaming addiction as a new disorder. So, this is something that has got to be looked at by schools, by social media companies, in just the same way.”
This, alongside the “epidemic” of childhood obesity, are two “very significant concerns” facing our children’s generation, Stevens says.
“There is a higher rate of mental health distress and at the same time as that’s become part of the public dialogue and stigma has reduced, people are willing to come forward. So, we’ve got both of those going on at the same time,” he says.
“The consequence is that as a result we’re going to need a major ramp up under any scenario of young people’s mental health services. That’s got to be one of the big things that comes out of the long-term NHS plan.”
This concern for the mental well-being of youngsters prompted Stevens to warn against the decriminalisation of cannabis, which was raised amid a debate on the use of marijuana in medical treatments.
“These are two separate debates and we should have an entirely evidence-based look at whether there are compounds derived from cannabis that are effective for certain health conditions. There is some evidence to suggest that that’s true. Conditions such as multiple sclerosis, chemotherapy induced nausea and so on,” he explains.
“But we’ve got well established processes for the medical experts reviewing that and then if necessary seeking approval for license to medications that would be prescribable.
“That is a separate debate than sending a signal to young people that cannabis is safe when for around 10% of people it would become addictive and the psychiatrists are very clear that there is a causal effect for some young people with psychosis.”
In light of that, what is his message to politicians, including William Hague and Ed Miliband, who are calling for cannabis to be legalised?
“My message is let’s be evidence-based in our public policy making. The evidence points in different directions on those two questions.”
“We’re going to need a major ramp up under any scenario of young people’s mental health services”
Now the question of funding has been resolved – if only for the short-term – Stevens can continue planning for the NHS’s future. As he undertakes this not inconsiderable endeavour, he believes that change in legislation could be needed as health and social care services integrate.
“There are elements of the current statutory framework that if we could evolve would take out some of the administrative cost in the health service, some of the requirements on the contracting, some of which is a result of EU procurement law. So, after we leave the European Union, one of the flexibilities we will clearly have then is the ability to take a hard look at some of that as well,” he says.
“But, having said that, I don’t think most people in the health service want to see another top-down reorganisation with all the cards thrown up. I think what people are interested in are carefully targeted adjustments to the framework.”
Thrown into the mix is the UK’s exit from the European Union. The NHS will be writing to “every hospital and NHS employer” to make sure they are aware of the three requirements for EU citizens to remain in the UK, as set out by home secretary Sajid Javid in June. Stevens also welcomes the decision to drop the cap on visas for foreign doctors and nurses.
Growing training opportunities for people in Britain is one of the main challenges Stevens identifies for the future. “In the meantime, we’re going to need to continue to supplement those staff with dedicated, highly skilled health professionals from other parts of the world,” he says.
“But this is not a new thing. We’re celebrating the 70th anniversary of the SS Windrush. That began a wave of staff who were there in the health service right from the get go. By the early 1970s, we had a position where nearly a third of doctors in the NHS were born and trained from outside of the UK.
“So, we have always mainly relied on people from here wanting to come and work for the NHS, supplemented by a small proportion of international staff. Pragmatically, that’s what we’re going to need to do for the next 10 years as well.”
The NHS is a different beast to the institution that Stevens joined 30 years ago, let alone the organisation that was founded in 1948, when 33,000 people were in hospital with tuberculosis. Now, it would be a handful – if that, Stevens says.
Today, hip and knee replacements are available on the NHS, patients can undergo minimally invasive brain surgery, “major breakthroughs” have taken place in medicines for heart problems. There is no reason, Stevens adds, to think that this progress is not going to accelerate, especially with the move towards precision medicine.
“When we come to celebrate the 80th birthday of the National Health Service, I have no doubt whatsoever that we will look back to where we stand today and we will have seen enormous advances in many of the big killers and disablers facing the country. We will have done that because we would have used this 70th anniversary as a moment to say ‘yes – full speed ahead’.”