Health Policy Insight: Do you agree that hospital A&Es are currently under real pressure?

Simon Stevens: Definitely. The NHS holds itself to a very high standard. No other major industrialised country in the world over the past year has managed to treat 9 out of 10 of its patients within four hours in an A&E department, but we have. The same with providing 9 out of 10 of our citizens with routine surgery within 18 weeks.

But that doesn't mean we can just carry on as we are.

Pauline Philip (who runs one of the country's best performing A&Es) and Cliff Mann (outgoing president of the Royal College of Emergency Medicine) are now leading urgent and emergency care redesign, together with Keith Willett and their counterparts at NHS Improvement.

As Pauline has shown at Luton, success requires changes both inside and outside of hospitals themselves.

That's got to be linked to the redesign of acute medicine and the interface with primary care. This is part of a broader paradox about workforce: with increasing sub-specialisation, we have more physicians, but lower participation rates in the acute on-call take. Small and medium sized hospitals in turn says this threatens the viability of ther A&Es.

At a recent Royal College of Physicians event on their Future Hospital Project, they spoke about the need for more generalism in medicine, and broader participation in acute medical inpatient care.

Remember: we make 300 million visits to GP practices each year, compared to fewer than 25 million A&E attendances. Headlines about hospital deficits obscure the fact that over the past decade, primary care's share of funding has fallen, while hospital consultant numbers have expanded three times faster than GPs.

If general practice fails, the NHS fails. That's why implementing the GP Forward View should matter as much to hospitals as it does to GPs.

Sustainability and Transformation Plans are about getting everyone round the same table to plan for this, including social care, engaging widely with the public and patients in doing so.

And while of course we have a focus on A&E and elective care, actually there's far more going on across the National Health Service than people pay attention to. Claire Murdoch and Cally Palmer, our new national leaders on mental health and cancer at NHS England, are both going flat-out, and getting real traction.

Despite all of the pressures, the outcomes data are clear, and anybody who knows what they’re talking about would say that the quality of care on offer to the people in this country, for the vast majority of conditions, is better now than it has ever been.

HPI: Are STPs a 'workaround' to the fragmentation of the 2012 Health and Social Care Act? Is the growing gap between de facto NHS structures, and how the legislation describes them, a problem in a mature democracy?

SS: All this is being done for a purpose; not for its own sake. The test is: do these changes contribute to care quality and financial stability, and the broader health of that population?

We are moving firmly into the service improvement and implementation phase, both locally and nationally, having done much of the strategic design. STPs are one vehicle for this.

While nothing that's being done is legally inconsistent with the statutory framework we've inherited, the way we tackle today’s challenges is clearly evolving.

The NHS is a team effort. It's 28 years since I started work in the NHS, and the system's checks and balances have evolved over that time. I don't think anyone, including me, would say that there's a shortage of accountability - to the public, to our boards, to Parliament and to the elected government.

HPI: Has "the NHS been given the funding it asked for"?

SS: Well, let's stick with the facts.

On the plus side, we said in the Five-Year Forward View that an upfront 'kickstart' was needed for 2016/17, and for this year: yes, we got that.

That's allowing us to cut hospital deficits this year by more than two-thirds; absorb nearly £1 billion of extra pension costs; and make a start on mental health, primary care and service redesign.

We also said that in five years time the NHS would be needing a real terms annual funding increase of between £8-21 billion. The Spending Review settlement for that year, 2020/21, is at the lower end but within that range.

So that's the position for year one and year five.

But as we've said previously, the then-Chancellor's deficit reduction target meant we didn't get our proposed funding profile for 2017/18, 2018/19, and 2019/20.

So as things stand, the middle years of the SR are obviously going to be tougher than what we originally asked for following the Five-Year Forward View.

That's why it's so critical we do everything we can to sort our finances this year, ahead of next year and the year after.

Our previous evidence to the Health Select Committee also made clear that we've got less capital investment than envisaged by the Five-Year Forward View; social care isn't keeping up with demand, and local authority prevention services are under pressure.

So it's a mixed picture. Given the circumstances facing the country, these are choices for elected governments to make, weighing up what the NHS has asked for versus other priorities.

But as I said at the NHS Confederation conference in June, let's not rewrite history in the process.

And let's acknowledge that since we're now facing a tougher challenge than set out in the Five-Year Forward View, there will inevitably be pressures, choices and controversies as the NHS copes with these constraints. Frontline staff, clinicians and local NHS leaders need full national backing and support in doing so.

HPI: The bottom line is that the NHS' "we need more" versus the government's "we're giving you what you asked for" dialectic isn't really moving us forward?

SS: Yes, as this week's Economist magazine argues, there's no doubt that over time, a well-functioning NHS needs to be better funded.

But that argument is ultimately more likely to succeed if, in the meantime, the NHS can show results from its own work to redesign services; integrate care; and drive out the inefficiency that every patient, ward nurse, GP and junior doctor can still see.

What's more, a lot of what we're now changing about the NHS is needed come what may, given the sort of care we now need to offer, as compared with our task in 1948.

That's why there's still such wide consensus about the FYFV's 'triple aim' agenda of improved health, improve care, and improved value.

HPI: Taking recent controversies at Southern Health, St Georges, Staffordshire and elsewhere, should trust boards give departing chief executives big payoffs?

SS: No: sadly, some of these situations have not been handled well, and at Southern Health, patients and families have been let down and public confidence undermined.

It's true that there has never been a more complex time to be a health service leader. But that can't justify examples of what can come across to other far less well-paid NHS staff as self-serving behaviour.

And managers won't be able to tackle excessive agency pay rates for other disciplines if management 'interims' are hired at inflated multiples. While there are now national controls to stop this, it'd be better if they never had to be used.

HPI: The recent Workforce Race Equality Survey data recently out finds that real problems persist. What action needs to follow?

SS: Those data do reveal shocking differences between employers. It was released through the NHS Equality and Diversity Council (which I co-chair). Its point is to set a baseline for people as an impetus to action.

It proves that some employers have got this right, so it is the 'art of the possible', as well as being the right thing to do.

I have a hunch that there will be a correlation between trusts’ WRES performance and their reliance on temp agency staffing and other costs.

And I suspect it turns out that being a fair employer for BME staff also improves quality of patient care, and will help with other operational matters too.

HPI A question sourced from Twitter, from a surgeon: as we can't afford to treat everything, what should we ration?

SS: What sometimes gets lost in these debates is that the amount of planned surgery the NHS is funding and surgeons are doing grows each year. In aggregate, the NHS will again be funding more operations this year than we did last year.

So the real question is: where do we choose to expand the range of surgical interventions?

Some of that is just driven by the population ageing: orthopaedic joint replacements and cataract extractions will inevitably increase. In other areas, surgery is changing: interventional radiologists and cardiologists bringing a natural evolution of medical practice.

Then there are other potential growth areas where we have to make more explicit choices about where extra money goes. Would expansion of bariatric surgery be beneficial? Yes. But at the expense of broader action on determinants of health, like the diabetes prevention programme we've just funded? That's the debate ...

HPI: What about Vale of York CCG's - now withdrawn - plans to limit operations for obese smokers?

SS: We should not and cannot have blanket bans on particular patients such as smokers getting operations. That would be inconsistent with the NHS Constitution.

But since major surgery poses much higher risks for severely overweight patients who smoke, and the benefits of surgery can be lower, GPs are right to make sure these patients first get support to lose weight and try and stop smoking before their hip or knee operation.

HPI: When will the NHS get the promised Brexit £350 million a week?

SS: Well, presumably that'll be a decision for government to take nearer the time, and we haven't yet 'Brexited'. The Leave campaign explictly promised at least £5 billion of extra funding a year to "save the NHS" by 2020.

Others have pointed out that it's critical for public trust and the future of our country that voters don't feel misled, particularly on an issue as important to them as this.

HPI: Some lobby groups are saying the NHS can't now make more savings: what's your view?

SS: I don't think that is what they're arguing, but either way, let's not kid ourselves that the NHS has 'maxed-out' on efficiency. That's demonstrably untrue.

Yes, the NHS is probably the world’s cheapest high-quality health system, but there are still major gains to be had. Care is still too variable (see Rightcare and the new CCG assessment framework), procurement is fragmented (think Carter), and assets used ineffectively (NHS Improvement's work on sorting unsustainable services is now urgent).

In a tax-funded health service - where every pound saved can be reinvested in better care - this is an ethical imperative for every clinical director and NHS manager.

HPI: Finally, the new beard ... ?

SS: Well, it's just what happens after a few weeks in the Arctic on a Russian nuclear ice breaker, minus a razor. Bad packing!

And now my kids insist it stays a few weeks more ...

Previous Health Policy Insight interviews with Simon Stevens
August 2015
January 2015
April 2011
July 2009
Speech to the Kings Fund on US-UK lessons, April 2009