The refresh of the Five Year Forward View had some headline messages which HSJ explored in detail on Friday. But just as important was what the document and its reception tells us about the future nature and direction of NHS policy.

Theresa May and Jeremy Hunt owe Mr Stevens big time

Imagine the reaction if a government minister had announced elective waits were to be sacrificed to save the failing emergency care system. It would have generated career-damaging headlines which even a resilient politician like Mr Hunt would have struggled to shrug off. It certainly would never have generated a comment piece in, of all papers the Guardian, headlined “Let’s applaud the NHS boss with a plan”.

The prime minister should now know how badly she needs Mr Stevens

Not only did Mr Stevens offer himself up as the bringer of bad news – he delivered it in a way which mitigated many of the negative messages and managed to get some focus on the positive elements of the refresh package.

He appeared on the dreaded 8:10 AM slot on Radio Four’s Today programme and was grilled for 20 minutes. After crashing both the sports and half hour headline slots, presenter Sarah Montague gave up exhausted – having not laid a glove on the NHS England chief.

There will be more bad news to deliver before the next election and having Mr Stevens to front it will be the gift that keeps giving for a Brexit-distracted government.

A £5bn increase capital funding would constitute an appropriate ‘thank you’

Almost uniquely for a public servant Mr Stevens is as much a master at short term political tactics as he is at long term service strategy. His strong line with Number 10 over false spending claims earlier this year did not result in his sacking, but in the chancellor confirming the May/Hammond government’s commitment to “the Stevens plan”.

In his interview with HSJ, Mr Stevens referred to the £325m of capital committed for sustainability and transformation plans in 2017-18 as a “down payment” on the further sums the chancellor – in a highly unusual move – said he would provide in the autumn budget.

The NHS England chief executive declined HSJ’s invitation to say how much capital STPs would require. Much will depend on phasing and the exact scoping of STP proposals NHS England is conducting over the next four months. However, Mr Stevens did comment that Sir Robert Naylor’s review of the NHS estate, published on Friday, represented “a useful quantification of the requirements and opportunities”. Sir Robert placed a “conservative” £5bn price tag on the STP’s capital aspirations.

Mr Stevens also side-stepped HSJ’s inquiries about any proposed bid for increased revenue funding this autumn. But the strategy of persuading the government it would be an appropriate 70th birthday present for the NHS, while also making sure NHS funding does not slip into real terms decline in 2018-19, remains in place.

No more places to hide for the sector’s back-sliders

It is worth remembering we are only one year into the Forward View period, but already there is a noticeable change of tone. Mr Stevens was at pains to stress the purpose of the refresh was not to have “a philosophical argument about 2020”, but to focus the service’s collective mind on what can be achieved between now and March 2019.

Quite how blunt his message now is can be seen in the very last paragraph of the refresh’s “funding and efficiency” section.

“Organisations and geographies” are accused of “living off bail outs arbitrarily taken from other parts of the service”. They are ordered to “confront the difficult choices” and to scale back “spending on locally unaffordable services”.

The nine efficiency must dos which precede that paragraph were described by Mr Stevens in his HSJ interview as “the difference between success and failure in 17-18”.

“Hard-nosed” decisions on which STPs to back with his limited resources will be based as much on whether plans “accelerate their performance”, especially on emergency and urgent care and financial recovery, as on the part they play in realising the Forward view vision or whether they are already a high performing health economy.

A good way to win NHS England’s favour and some of that new capital funding will be to drive through proposals to split “hot and cold” emergency and elective services. This is now seen by the centre as a way of both improving both emergency care performance and, crucially, returning financially-struggling hospitals to the black once elective capacity is no longer hampered by unplanned admissions.

Mr Stevens is not afraid to go back to achieve progress

Such is the NHS England chief’s power he feels able to recalibrate the service’s policy direction on the fly in a way no health secretary would dare to do. Indeed, during his Today interview he damned the government’s own 2012 Health and Social Care Act as an irrelevant miss-step (“moving deckchairs”) which his reforms were now correcting.

He has effectively given up on the goal of creating a meaningful number of accountable care organisations any time soon, instead placing his faith in “accountable care systems” which will increasingly have their own budgets and take on a greater a proportion of staff now employed by the NHS England and NHS Improvement.

It is as if the service is being reset at around 1989 before it is moved onto a more radical future. The key will be to make sure the service does not remain stuck with a 1980s mindset, an approach many in the service still might feel more comfortable with.

And last, but for once, not least…

Mental health really has achieved “parity of esteem”

Think back. Can you remember a time when mental health got more money and struggling elective care did not? The investment came in child and adolescent mental health services, which is close to the PM’s heart, but the refresh makes it clear more than once that – unlike in the past – cutting mental health spending is one trade off that should not be countenanced despite the service’s travails.

This does not mean all the sector’s problems will be solved in an instant, there are decades of under-investment to make up for after all. But the refresh joins the small list of NHS announcements – headed by Enoch Powell’s “water tower” speech – which mark a real turning point for mental health.