Simon Stevens: “The NHS has an enormous responsibility to be wise stewards of this additional investment”

The NHS 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, though perhaps not quite as fresh-faced, 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.

Perched on weathered chairs that would look at home in any Shoreditch bar, we find ourselves on a sixth-floor balcony at Skipton House, the NHS’s HQ in south London’s Elephant and Castle. The Palace of Westminster is one of many landmarks that make up the panoramic view of the capital’s skyline, set against an endless sea of blue sky. Stevens is jacketless in a crisp white shirt and tie, his prominent beard now a thing of the past.

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. Last month 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, the British Medical Association warned 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. At the beginning of 2017, he famously said Theresa May was “stretching it” by claiming the government was exceeding the health service’s funding requirements set out in his five-year forward view. 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.”

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. Try though they might, the government’s claim that a Brexit dividend will help meet the commitment is heavily disputed. So, much of the burden will likely fall on the taxpayer. 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 also been made in the NHS England core budget.

“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 continues.

“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.”

A report in the Guardian claimed that Philip Hammond, the Chancellor, demanded Stevens’ public approval of the settlement before signing off on the money. Is that true? “As I say, I’m more than happy to be supportive of a significant funding increase for the NHS which will enable us to now develop a long-term plan for improvements on conditions like cancer and mental health and other critical services.”

Separate funding increases for social care services are expected later this year, which many see as a necessity to alleviate pressure on 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 three and four per cent mark, than it is to bounce off the banks.”

Moves to take a longer-term view on health policy and spending are gaining pace at Westminster, with Health and Social Care Committee Chair Sarah Wollaston among those in favour. Is this something Stevens supports?

“Because the NHS matters so much to people across the country; it’s there when our children are being born, it’s there when our loved ones are seriously ill, it is intensely personal, but it’s also about the conversation we have as a country about what kind of country do we want to be. So, it’s not only unsurprising, it’s inevitable and in some ways welcome that there is strong political interest in the future of the National Health Service,” he says.

“As it happens, what we’ve seen is a recommitment to the national consensus that the country wants a vibrant, albeit continuingly changing National Health Service. The events of the past week are a further testament to that.”

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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 care and mental health; focus on population changes and the “increasing” needs of children.

With the demands of an ageing populace on the NHS well known, officials are keen to highlight other areas where services are being strained. It is for this reason that Stevens has 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 is likely to be much higher than has official 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 within the past week had 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 as alongside the epidemic of young people’s mental health and distress, we’ve got this epidemic of childhood obesity. These are the two new challenges facing our children’s generation.”

He adds: “There is a higher rate of genuine 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.

“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 medications that would be prescribable.

“But 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 policymaking. The evidence points in different directions on those two questions.”

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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. What people are interested in are carefully targeted adjustments to the framework.

“In a democratically accountable National Health Service, these are matters for parliament to decide and our elected representatives, even though as the NHS we welcome the opportunity to contribute to that discussion.”

Thrown into the mix is the UK’s exit from the European Union. The NHS, which is Europe’s largest employer, 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 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.’”

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