Surviving the Storm: The Simon Stevens Interview

Simon Stevens has had to push back our interview: a last minute meeting about the Covid vaccinations programme has been added to his diary. That’s understandable, I tell him as he apologises; he probably spends quite a lot of time talking about vaccinations lately. Stevens, who is approaching his seventh anniversary as chief executive of NHS England, has helped manage one of the fastest initial Covid-19 vaccine rollouts in the world.

Around 15 million people have now received their first jab, with more than 90% of those aged 70 and above having taken up the offer. “We thought it might be more [like] three-quarters,” Stevens admits. “Hopefully we’ll continue to see strong uptake as we move into younger age groups.”

He recently visited Newcastle’s Royal Victoria Infirmary to mark 12 months since the first two Covid admissions in the UK in January 2020. “It’s been non-stop ever since,” he recalls, commending the work of all those in the beloved (if beleaguered) institution he oversees in the last year.

The health service was creaking before it faced the worst pandemic in modern history. Was he scared when the number of Covid-19 hospitalisations hit 33,000?

“Yes.”

He describes watching the acceleration of the second wave, from 500 hospitalisations in September, to a third of the NHS’s total bed capacity being allocated to severely ill Covid cases last month: “These are very alarming circumstances.”

So far, there have been 100,000 coronavirus patients admitted to hospital in 2021.

The toll on health service staff has been immense: even when Covid rates were lower over the summer and early autumn of 2020, they were catching up on the backlog of non-urgent cases and increased mental health presentations.

“One of the legacies [of Covid-19] has got to be both a recognition of the brilliance and dedication of NHS staff, and a commitment to make sure that we have the workforce we will need for the future.”

Stevens is heartened by what some call the “Nightingale effect”: the influx of interest in those who want to study nursing. Last autumn saw a 27% increase in the number of undergraduates starting nursing degrees, while Ucas data released last week shows what Stevens calls an “extraordinary, unprecedented” 32% increase in applications to study nursing. For mature entrants into nursing (aged 35 and over) the increase is 39%.

This is interesting, I say, as a survey of nursing staff across the UK undertaken by NursingNotes and Nurses United UK last December showed that a third said they were likely to leave within the next 12 months; 15% put this down to poor work-life balance, and 11% cited poor mental health. How does one address that kind of potential exodus of staff?

“It’s very important that people do get that workplace support, including psychological support, team-based support, and that people can see, sort of a brighter future,” Stevens says, pointing to the boosted investment in continuing professional development.

“But in actual fact, the retention rate has improved over the course of the last 12 months; more people have committed to staying and working,” he continues.

“Those are important points that we have to pay very careful attention to. But I think, in practice, a lot of what employers are doing locally will make a big difference.”

He adds: “Of course having just gone through the worst pandemic in a century, and the most intense operational pressure in the 72-year history of the NHS, it’s quite right that staff are feeling ... under significant stress and pressure. And that is not just [due to] the intensity of it, but also the extended duration of the pandemic.”

Stevens announces that part of the solution to the growing mental wellbeing concerns for NHS staff will be the launch of 40 dedicated support hubs across the country. Modelled on the Greater Manchester Resilience Hub – set up to help all those affected by the 2017 Manchester Arena terrorist attack – NHS staff will be encouraged to call the hubs directly for support.

There will then be onward referral to online and one-to-one expert help, including from qualified mental health clinicians, therapists, recovery workers and psychologists. Crucially, hubs will proactively contact staff groups deemed most at-risk and in need of support.

There has already been a £15m boost to mental health support for NHS staff last October, and Stevens believes that the “extra reinforcements arriving in the form of future staffing” will help staff retention. He’d also like to give staff more freedom to problem solve, keeping “the permissive ‘can-do’ spirit of the pandemic throughout the NHS”.

When it comes to the vaccination programme, Stevens says it is “speed times precision” that has kept them on track so far. As well as needing to deliver a second jab to the vast majority of the initial 15 million vaccinated, the NHS is aiming to offer a first jab to a further 17 million people by 30 April, covering all those aged over 50 and adults with underlying health conditions. Maintaining high uptake of the vaccine is one of three challenges Stevens identifies for the next stage of the vaccine rollout – the second sprint, as he dubs it.

“There’s quite a sophisticated job for GPs to do over the next three or four weeks, with this 6 million or so people at higher risk with an underlying health condition, in actually targeting them, reaching out to them, and calling them in for their vaccination, which logistically is more complex than simply saying, ‘if you’re aged 65 and above, here you go’,” Stevens explains.

The other crucial elements will be for the 1,500 vaccination centres across the country to stay “firing on all cylinders”, and the government to deliver vaccine supply as expected. As he put it to the Prime Minister at a No 10 press conference not 18 hours before we speak: “give us the tools, the vaccines, and we will finish the job”.

Stevens does take issue with some of the maths that has been flying around – doubling the total number of vaccinations administered over the next 11 weeks does not mean a million doses will be given a day, even if you average it out, he says. “The pace that we can go per day will depend on supply,” he adds.

After April, the country will move into the “marathon” section of the inoculation campaign: vaccinating the rest of the adult population plus any further boosters that might be required for new variants in the autumn. He seems to take slight umbrage at my suggestion that the vaccines’ impact on transmission will provide the route out of lockdown.

“Transmission is an important part of it, but the strategy for prioritising vaccines through the Joint Committee on Vaccination [and] Immunisation has been to focus on reducing [the] individual’s risk, particularly hospitalisation and death,” Stevens explains.

“You save lives, and you reduce hospitalisation risk by focusing on the groups that we have been focusing on so far. And then as you move to the wider adult population, you’re obviously protecting individuals; the expectation is you will also reduce transmission.”

Numbers of hospitalisations with Covid-19 are now dropping, with 18,000 Covid in-patients today. But it is not time to get complacent. “The April peak last year was 19,000,” Stevens points out.

“So although that number [has come] down very sharply over the last several weeks, it is still an extraordinary pressure on the service right now. Which again, is partly what makes the vaccination programme so remarkable: that [it] has been delivered at the same time as the NHS has been under the most intense pressure in our history.”

A source of pride for Stevens is the role of NHS research into Covid treatment. He points to the low-dose steroid dexamethasone, which was trialled in UK hospitals and is now successfully being used to treat severe Covid around the globe. “That is estimated to have saved 650,000 lives worldwide … an extraordinary contribution that, indirectly, the NHS will have made.”

The ability to use discretion will help take some of that pointless bureaucracy out of the system.

Another shining light has been the flexibility of both staff and the system, he says, meaning there were 50% extra critical care beds available at the latest peak of pressure. “We have seen the NHS at its most agile and committed best,” Stevens reflects. “In a way that perhaps will have confounded some of the critics [of] the NHS ... [it’s] been very nimble and flexible.”

In previous appearances in front of the Health and Social Care Committee, Stevens has questioned similar perceptions of the ‘red tape’ in the NHS, defending the health service’s comparatively low spend on administration costs. Will the new health and social care white paper help trim the fat further?

Stevens explains there are two main issues – fragmentation and bureaucracy – that this white paper looks to deal with, focusing on the statutory regime in which the health service operates.

On the first issue, he says: “[Currently if] two hospitals want to work closely together or indeed merge organisationally, they are subject to review by the Competition and Markets Authority, which a lot of people think doesn’t make much sense, given we’re actually trying to join up services, particularly [for] an ageing population with multiple health needs.”

Instead, he would like the NHS to move away from a “repair model of sorting a patient out for one particular condition, and then job done”, to a joined-up approach for related conditions across the service.

The second reform would address issues such as procurement procedures. Stevens says: “Some of the procurement rules the health service has been subject to [mean that] instead of being able to bring a service together, you actually have to tender out different parts of it.

“There was an example a while ago...where a local clinical commissioning group had to go out to tender for 90 minutes a day of GP services between 6:30pm and 8pm, because 6.30pm was when the core GP surgery’s service ended and 8pm was when the out-of-hours service kicked in.

“So there was this 90-minute gap, and they couldn’t just arrange to fill that 90-minute gap, they [had] to go out to tender. That sort of thing really makes no sense. So the ability to be able to use some discretion as to when to do that will help take some of that sort of pointless bureaucracy out of the system as well.”

There are other improvements that do not need legislative change, but are instead part of the NHS’s 10 year long term plan, such as levelling up so called “postcode lotteries” for obesity services and mental health support.

On the latter, Stevens is well aware of the impact of the pandemic on the growing mental health crisis in the UK. “One of the things I’ve done since being NHS chief executive is [make] sure that, each year for the last five years, mental health investment [has gone up] faster than the overall NHS budget,” he says.

We have seen the NHS at its most agile and committed best.

“The chancellor allocated an extra £500m for mental health from April, and we will have to use a meaningful part of that – particularly for children and young people’s mental health services, including eating disorders, where we’re seeing a big increase in the number of people coming forward needing help.”

With ONS data from January showing record levels of reported low mood since the start of the pandemic, and anxiety at its highest since April 2020, it seems clear the NHS and its staff will be under strain for many months to come.

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