Pragmatic Stevens focusses on keeping his vision alive

He knows better than anyone that the money promised (but not yet delivered) by this tottering government is barely adequate to stabilise performance, let alone drive improvement.

His indepth interview with HSJ was littered with caveats about what can be achieved. There was some Stevens swash-buckling that a “radical repurposing” of parts of the service, robust renegotiation of drugs costs with the pharmaceutical sector or a new GP contract could deliver some big wins, but time and again the NHS England chief was cautious in his ambitions.

He noted the public will expect something back for the increased taxes they will soon have to pay, but also stressed the “inescapable facts” of the service’s financial, workforce and performance problems which will have to be considered when deciding priorities and levels of ambition.

On waiting times, he said: “Nobody wants to go back to the position we saw 20 years ago.” Note the comparison is with the very start of the New Labour years when access was at very rock bottom, not 15 or 10 years ago when funds had started to improve it. On elective waits, he declared “we’re not going back to a situation where hundreds of thousands are waiting years for their routine operations”. Currently official figures say there are well under 5,000 people waiting longer than one year – so Mr Stevens has left the service quite a lot of wriggle room.

On mental health and cancer, as well as no doubt in other areas, Mr Stevens is very clear the most significant change will come during the last, yet unfunded, half of the 10 year plan period, often because the necessary workforce will not be ready until then.

Reading between the lines it appears the NHS England chief’s thinking runs along the following lines: the new funding package enables the NHS to achieve the existing commitments which emerged from the Five Year Forward View process, such as the recommendations of the cancer and mental health task forces and the GP Forward View, while also preventing financial and performance meltdown.

In the meantime, the debate about the outcomes achieved by the NHS compared to other health systems which has received so much attention during its 70^th year will continue to run – now in the context of ambitious objectives set out in the 10 year plan – putting Mr Stevens in a stronger position to argue for the circa 5 per cent uplift which is necessary to achieve real transformation.

Smart choices and doing the right thing

While he waits, Mr Stevens is pushing an agenda of incremental gains and a focus on niche areas where a little money might go a long way. He is also clearly planning to use the period to retool much of the service’s incentives and targets in readiness for a time of greater munificence.

He told HSJ: “We need to make sure the focus of clinical leaders and team managers over this next period is as much on outcomes improvement and service redesign [as recovering performance]. And to do that we need to make sure the goals that are promulgated through the system, the incentives and indeed the financial flows, and all the reinforcing support is helping move the whole service in that direction too.”

He also said: “We’ve got to make smart choices about the biggest improvement in population health and population outcomes we can get, given the funding and workforce we’re going to be working with in five or 10 years.”

Aware of the complaints the service will make about the current structure of the system, he described the possibility of changing legislation to speed the introduction of integrated care as “somewhere between” a ’nice to have’ and a ‘must have’. In other words: if a way of achieving it is possible, then great, but if not, the focus on service change must be maintained.

Mr Stevens is also increasingly keen for the NHS to be seen to be doing the right thing. Hence the focus on learning difficulties, homelessness, societal barriers to good quality healthcare and giving the NHS a more active role in reducing health inequalities.

He knows that most determinants of health lay outside the control of the NHS, but he has the money to do more than most and a bully pulpit as the leader of the UK’s best loved institution to keep hammering home the message on issues such as childhood obesity and the damage social media can do to the mental health of young people.

There is one other implication of Mr Stevens’ wise prediction that it will be well into the next decade ”before there are step-change improvements in NHS care quality” and that is he will probably not be there to claim his share of the glory.

While the NHS England chief told HSJ that he was “completely committed to this next phase of what the NHS can do for the people of this country”, when asked if it was “in it for the next 10 years”, he replied: “I think that would be stretching it.”