Simon Stevens is impatient to get on with realising the forward view. He will identify those leaders he can trust to help him deliver, and back them in the face of what may be fierce local opposition

Thrumming just below the surface of Simon Stevens’ latest wide ranging interview with HSJ was an often barely concealed impatience to begin to realise the promise contained within the Five Year Forward View. He described NHS England as being “sleeves rolled up… entirely focussed [on] delivery”, while time and again praising those leaders in the service who were confronting the most difficult decisions head on.

If the NHS lets internal power struggles grind on at glacial pace it will run out of money and time

In particular he extolled those leaders whose focus was as much on the first part of “sustainability and transformation” planning as the latter.

He has been meeting STP leaders in what he called a “fantastic informal talent management exercise” and claimed to have been most “impressed” with those who had the “clarity” and “honesty” to see that many of the spending decisions made over the last few years were not appropriate in context of the tightening financial envelope and the need to reconfigure services – and were making the necessary changes.

In contrast, those that had not been woken by the strong smell of a burning financial platform were the subject of Mr Stevens’ disapproval which, it is not hard to imagine, is even stronger in private.

This is a frustration often felt by those at the top of the tree about local NHS leadership when times get tough (often matched, of course, by mutual irritation with the centre). But Mr Stevens’ mental sorting of the visionary wheat from the backsliding chaff has a more important consequence.

Playing ball

The forward view proposals and the NHS England strategies covering high profile areas such as cancer and emergency care were always going to end in often controversial reconfiguration of services and, in some cases, organisations.

If the NHS lets the usual internal power struggles grind on at their normal glacial pace before proposals are finally put out to public consultation it will run out of money and time. To avoid this, local health economies will be given strictly limited time to reach consensus on reconfiguration plans. Should they fail, Mr Stevens told HSJ that NHS England will step in to “call” the decisions.

To make that call Mr Stevens must first identify those he can trust to deliver and back them in the face of what might be quite fierce local opposition. His comments about creating a “safe harbour” for leaders “who are going to drive that process” strongly indicate this; as does his granting of “permission” to those “honest” STP leads prepared to “press the reset button” on inappropriate spending decisions.

Local leaders could end up on the outside looking in when the big decisions get made

Pressed for proof of his backing for brave local leaders, Mr Stevens singled out Lancashire Teaching Hospitals Foundation Trust chief executive Karen Partington for making the “right decision about what was needed in Lancashire” and downgrading Chorley’s accident and emergency unit. As is often the case, such a benediction from a senior figure may prove a mixed blessing; to date, Ms Partington’s line is that the A&E change is temporary.

In contrast, leaders who are not perceived to be behaving in the correct way, for example by failing to “play ball” by undermining the agency cap or resisting an acceptable control total, can be expected to be on the outside looking in when the big decisions get made. It would also not appear to be wise to treat the STP process as a “bidding exercise”, especially to make calls on the malnourished central capital budget.

It is not uncommon for healthcare leaders to believe that, should they fail to win the day, they can at least exercise a veto on ideas they oppose. For some that assumption may now prove to be mistaken, as STPs are signed off and driven home.