Thinking like a patient, acting like a taxpayer - the Simon Stevens approach to the NHS

In a recent letter to The Guardian 71 senior NHS leaders warned that the NHS will become "unsustainable" unless politicians set out clearly how they will modernise and fund the service. They stated that "the services we commission and run are not designed to cope with the care needs of the 21st century," due to an ageing population, the growth in the numbers of those with lifestyle-related conditions and healthcare costs running 4% above normal inflation at a time when the NHS is expected to deliver huge budget savings.

Their core message that the way in which services are delivered needs radical reform reflects the view of the new chief executive of the NHS, Simon Stevens. In his speech to the NHS Confederation’s annual conference (4 June 2014) Stevens said that the NHS has arrived at a defining moment in its history when it needs to move from analysing the challenges to developing the solutions.

He highlighted three areas which, in his view, NHS leaders need to focus on in order to “future proof” the service and improve patient care…

  • A more sophisticated commissioning system based on patient outcomes;
  • Accelerating the redesign of care delivery;
  • Exploit the potential offered by personalised medicines and more use of new technologies such as e-consultations, remote monitoring etc.

He talked about the need for NHS leaders to think like a patient in terms of the care and support required, but also to act like a taxpayer in determining what was affordable and ensuring value for money outcomes.

However, Stevens will need to overcome several hurdles if he is to translate his vision into reality.

The first is funding. The NHS in England is half way through the £20bn efficiency saving target set by Steven’s predecessor, David Nicholson. Early gains have been realised which means achieving further savings in future years will be far from easy. There have been predictions that the hospital sector will finish the 2013-14 year in deficit.

The problem for Stevens is that overall funding for the NHS is ultimately a decision for politicians, not NHS England. Even if the Nicholson efficiency targets are met, growth in demand for healthcare services will require tough choices about what the NHS can provide free at the point of use. Yet, as the letter to The Guardian highlighted the main political parties are reluctant to grasp this particular hot political potato.

The second is local decision making and service delivery. Stevens has consistently called for far greater local flexibility within the NHS in order to meet the particular health and social care needs of individual communities. However, that means Stevens can lead, inspire and encourage, but ultimately others, over whom he has no direct control, have responsibility for implementing the transformation in the way in which services are delivered.

Allied to that he has inherited a highly complex and fragmented healthcare structure poorly understood by many of those who work in it let alone the patients it is meant to serve. Decision making and responsibilities have been diversified which may be the correct approach, but it does make it more difficult for the NHS chief executive to steer the NHS juggernaut in the direction he thinks it needs to go.

Thirdly he needs to keep his political paymasters on side. The Health Secretary, Jeremy Hunt, is widely regarded as an interventionist Minister who is keen, for obvious reasons, to demonstrate to the electorate that the NHS in England is safe in his hands. That, of course, begs one of the fundamental questions raised during the debates about the Lansley reforms: who ultimately is in charge of the NHS and the services it provides? Lansley argued that the Government’s role is to set out what is required through the NHS Mandate and it is then the responsibility of NHS England to deliver. However, in practice, lines of responsibility are blurred - particularly in the eyes of patients and the electorate.

In recent weeks, Simon Stevens has described in greater detail his vision for the NHS including an end to the mass centralisation of services; greater provision through community based hospitals and more “generalist” doctors working alongside consultants. He now needs to persuade healthcare professionals, commissioners, politicians and the public that his vision is one they should support and help implement.