Richard Smith: Simon Stevens, chief executive of NHS England, live


When Simon Stevens, chief executive of NHS England, was buying his Sunday papers a few weeks ago he encountered an elderly woman complaining that her newspaper didn’t contain the television section. It did, as the newsagent pointed out to her before asking her, “Would you like me to walk you home?” Stevens was struck that this was a “dementia friendly community” in action. He followed the story by emphasising that the traditional “factory model of health and social care” will not solve society’s problems, including the rise in dementia. Without a redesign of health and social care services, the NHS will not be sustainable. “We don’t exclusively own the problem or the solution,” he said.

As he spoke on Tuesday night to a packed room of mostly senior people from every part of the health sector, Stevens stood with nothing between him and the audience, spoke without notes or a PowerPoint presentation, started by telling stories, spent most of his time answering questions, joked easily, used everybody’s first name, got some of those in the audience to answer the questions, evaded some questions so cleverly that even the questioner didn’t notice, and played the audience as skilfully as any top flight stand up comedian.

The meeting was the tenth anniversary of the Cambridge Health Network, which brings together people from across health—the NHS, government, charities, universities, the private sector, and social care. Stevens spoke at the first meeting of the network, back when he was health adviser at No 10 to former prime minister Tony Blair.

Stevens’s first story was about how he spent a recent Friday night with a GP out of hours service in the east end of London. There he saw the extreme pressure on frontline services, but also saw how we have created a “chaotic, complex, Heath Robinson service” of 999 calls, 111 calls, urgent care centres, A&Es, and the like that cause “mass confusion.” The answer can’t be more and faster, but must be redesign.

Stevens also recently spent an afternoon chatting to people with learning disabilities. We may think, he said, that we have modern, responsive services, but he heard “shocking stories” from the people. He concluded that people with learning disabilities lack power and that too many services lack “moral legitimacy.”

The need for transformation

The need for transformation—not doing it more but doing it differently—was one of the themes of the evening. The NHS in England is going to have to become something different to survive as a service that covers everybody, that is free at the point of care, and that offers equal quality care for all. Redesign is not another administrative reorganisation, most of which were “displacement activity.”

What about the workforce, particularly nurses? Stevens was gently tough on this one. He regretted that Agenda for Change had not led to the workforce redesign that was hoped for a decade ago, and said that while more nurses in hospitals might be a good thing, it shouldn’t be at the expense of nurses in the community or other needed staff.

The NHS will be pursuing three timelines over the next six months, said Stevens. Firstly, during the winter it must maintain the performance the public expects, and not let A&E or surgical waiting times get out of control. Secondly, it must be sure to get itself into position to be able manage the financial year of 2015/16. Thirdly, the NHS will publish a “forward view” that lays out strategic choices for the next five years. Some of the choices will build on the advantages of the NHS, but others will tackle “blind spots,” such as neglecting the role of the employer and the workplace to promote health. And the NHS itself, he observed in passing, needs to do far better in promoting the health of its own staff. The usual thing, he added, is for the first of these activities to crowd out the second, which in turn crowds out the third, but that can’t happen now.

Has commissioning worked, and will it work?

We’ve had commissioning for 10 years in England. Has it worked? Might it work better in the future? In fact, it’s been going not for 10 years but for 23, pointed out Stevens—somebody who expects his managers to “know their numbers.” He accepted that it hadn’t achieved enough, but he has high hopes. He referred to a poll of clinical commissioning groups in the Health Service Journal, showing that most CCGs are being bold in their thinking. Come back in 10 years’ time, he told the questioner, and we will “blow your socks off” with what we’ve achieved through commissioning.

Stevens wants integrated personal health and social care budgets. They potentially have the ability both to shift the power relationship—empowering those patients with the biggest problems—and to reshape services more effectively than a top down redesign. Asked about potential problems, he said that the devil would be in the detail, and that he was more interested in achieving depth rather than breadth in the next year or two. Local government, which is much more financially constrained than the NHS, would, however, like to go much faster, seeing the budgets as a way to shift resources from health to social care.

Being a leader

Leaders, I strongly believe, must put themselves in front of the people they lead, particularly when times are hard, and they must get to every part of the organisation they lead. Stevens has been out in the NHS—often in the most unglamorous parts—constantly since he started in April, and he was very comfortable in front of the potentially tough audience of the Cambridge Health Network.

But leaders must also be ready for anything, and he described at the start of his speech how he’d just been on the BBC Jeremy Vine radio show, expecting to be asked about closing the £30bn gap in NHS finances and responding to Mid Staffs. Instead, the first question was, “What was your relationship with your mother like?” Stevens readily confessed that this was a far harder question to answer on air. It’s encouraging that the leader of the NHS’s mother will keep him right.

Richard Smith was the editor of The BMJ until 2004. He is now chair of the board of trustees of icddr,b [formerly International Centre for Diarrhoeal Disease Research, Bangladesh], and chair of the board of Patients Know Best. He is also a trustee of C3 Collaborating for Health.

Competing interest: RS has known Simon Stevens for 20 years, and worked with him and for him at UnitedHealth. Staff from UnitedHealth cannot have any work related dealings with Stevens for a year. RS is still employed by UnitedHealth, but has no responsibility for what happens in Britain. He works with centres in low and middle income countries.

This article was originally published on BMJ.