Simon Stevens' first interview: parts of the NHS must be 'completely reinvented'

The NHS England chief executive cautioned service leaders not to be “hidebound” by current “regulatory or policy designs” when setting their plans to meet the challenges of the next five years.

Speaking to HSJ in his first major interview since joining NHS England, he said the commissioner-provider split could change, that clinical commissioning groups would need to “prove themselves” but that he wanted to give them “every chance to succeed”, and he would take a “pragmatic” view of competition in the NHS.

Mr Stevens, who took up his post in April with significant backing in both Whitehall and the health service, claimed “attaching our staffing to our bricks and mortar and to our traditional ways of doing things has got us to a very ossified set of services”.

Break from the past

He placed particular emphasis on the need for a radical break from the past in health economies with ingrained quality and finance problems, including those where trusts cannot reach foundation status.

“Rather than talking about failing institutions, perhaps we need to talk about pressurised health economies and community wide alternative solutions or models, rather than just singling out the hospitals,” he said.

“In some cases it’s going to mean we’re going to have to completely reinvent what we mean by a hospital, by a local hospital.

“We’re going to have to say that the division between what consultants do in hospitals [and] what GPs do in community settings, that is going to be dissolved.”

He highlighted the potential of accountable care organisation models, in which one or a group of providers is given a single budget to serve a specified population, often adjusted for quality and efficiency delivered, with delegated financial risk and benefit.

While he said there was “real value” in having separate commissioning and provider functions, this did not “for all time have to be the split that we currently have”.

He said, for example, an area could “create a unitary provider group that might take delegated financial risk” and run “combined hospital, primary care [and] community services”.

Mr Stevens is also exploring how “multispecialty groups” - out of hospital providers bringing together specialist and primary care doctors - could take shape.

He said: “We’re going to have to find new ways of blending funding streams in order to expand primary and community health services, and do so for defined populations in particular geographies.”

Mr Stevens indicated he was open to significant change and variation in commissioning structures, as well as delivery.

He said the NHS had for years been “pretending we’ve got uniformity in administrative structures”, and this had masked “differences in clinical services, and in heterogeneity of populations”.

“There are many things the ‘N’ in the NHS should stand for, but uniformity of frequently changing administrative arrangements does not have to be one of them,” he said.

Pressed on whether he would endorse specific structural changes, such as the creation of a non-geographically defined commissioner, he said change for its own sake would be “a distraction”.

However, he added: “In the context of a five-year forward view about what it’s going to take for a particular community, then we certainly should not be hidebound by the particular regulatory or policy designs that we’ve got in place.”

Prove themselves

Mr Stevens said he wanted to “back CCGs and give them every chance to succeed”, but on the prospect of health and wellbeing boards gaining influence at the expense of CCGs as they would under Labour health policy, he said: “CCGs have got to prove themselves, [HWBs] have got to prove themselves.

“At the moment [HWBs] are about to have another £1.9bn vested in them [under the better care fund policy] and so… by their fruits we shall know them.”

He said his approach would mean “relaxing some of the constraints or assumptions about what’s required for sustainability in different geographies”.

He believed NHS leaders were “up for” radical changes, including to medical staffing and contracting rules and practices.

“The status quo is clearly not working in a number of parts of the country,” he said. “At that point you either say it’s time to do something differently, or people are just faced with the more typical response, which is that services have got to close.”

Mr Stevens joined NHS England - encouraged to do so by prime minister David Cameron - from his role overseeing the substantial global operations of insurance giant UnitedHealth. He is better known in the UK for his time as health adviser to Tony Blair from 2001-04, and before that in the Department of Health.