Simon Stevens presides over Europe’s biggest employer, a budget of about £130bn and an organisation whose place in the British psyche has been described as akin to a national religion. But arriving to meet the head of England’s NHS for lunch in the gritty Elephant and Castle district of south London is to be reminded of the unglamorous business of state-funded healthcare, for all its epic scale and cultural resonance.
In a week’s time, after seven years in charge, he steps down — two years later than he originally envisaged, he explains as we walk from his office to one of his favourite neighbourhood restaurants; after coronavirus engulfed the world, he stayed on to lead the NHS through its most testing time.
His force of intellect and sinuous political skills have sometimes irked ministers. And he has had a gargantuan challenge. The service has missed performance targets by ever-wider margins on his watch as hard-won funding settlements have failed to keep pace with soaring demand from an ageing and growing population.
Yet Stevens, who turns 55 next month, has proved himself one of the most formidable figures in the 73-year history of the NHS. As health adviser to Tony Blair in the early 2000s, he embraced market disciplines to ginger up the health service, jarring the sensibilities of a public system historically resistant to the private sector. In recent years he has pushed for radically better collaboration between different parts of the health and care system.
Now he has had to steer the NHS through the worst of the pandemic, ensuring that, unlike some European health systems, it was never overwhelmed. He might be forgiven for looking drained. In fact, even in the last days of his tenure, he seems energetic and engaged, his sleeves rolled up both literally and figuratively.
Our destination is Kaieteur Kitchen Original, whose ebullient Guyanese owner, Faye Gomes, greets Stevens as an old friend and brings us each a glass of homemade punch: mine is tamarind, with a sharpness that is refreshing on a humid summer’s day. He opts for ginger beer.
As we sip our drinks, he tells me that after graduating from Oxford in philosophy, politics and economics — he was a contemporary and friend of Boris Johnson’s, and like the prime minister became president of the Oxford Union, although Stevens supported Labour — he spent a year in Guyana, working on agro-industrial diversification projects and developing a love of the South American country and its culture.
To my relief, Faye intends to spare us the dilemma of ordering, describing an array of subtly spiced dishes that will be served family-style for us to share.
Stevens’ earliest introduction to the NHS might have deterred some from darkening its doors in adulthood. A developmental problem affecting his hips landed him in hospital for a long period as a boy. But he seems untraumatised.
“By the time you’ve been in hospital for several months, you’re highly acclimatised and I actually greatly enjoyed it. My only regret was that there was a series of shared toys that you could use, and kids took turns . . . There was one Etch A Sketch on the ward and the day I was sent home was the day that it was my turn to get the bloody Etch A Sketch!”
Born in Birmingham, Stevens attended a comprehensive school in Berkshire after moving south with his family, before winning a scholarship to Oxford. As we await our meal, it emerges that he owes his start in the NHS to Margaret Thatcher. The then-prime minister had commissioned businessman Sir Roy Griffiths to consider how the health service could be run more efficiently. One result was a graduate entry programme. His application was, Stevens says, “one of the best decisions I’ve ever made”.
Fast forward about 25 years, and then-prime minister David Cameron was personally involved in the effort to recruit him to become NHS chief executive. But he was earning a far larger salary as president of global health for UnitedHealth, a US health company, and enjoying life with his American wife, a public health specialist, and young family in Minneapolis. “I obviously thought very long and hard about it and I asked myself two questions: is the job do-able, and can the NHS prosper . . . and obviously convinced myself that the answers to both of them were yes.”
The key challenge of his stewardship has been to transform the way the NHS works in an era that is no longer about “episodic care” but keeping people well over decades, especially those with multiple long-term conditions. When it was founded in 1948 the average life expectancy for men was 65. Now nearly a fifth of the population is above that age. Health systems in all industrialised countries are going through this same transition, moving from “reactive” to “anticipatory” care, he says.
His signature solution has been the establishment of “integrated care systems”, designed to bring together different parts of the NHS, as well as local government and the voluntary sector, to improve the health of local populations and tackle inequalities. They are a work in progress and the pandemic, I suggest, has shown just how far the country remains from fully realising that vision, brutally exposing the unequal impact of the virus on poorer communities.
There is a limit, he acknowledges, to what formal healthcare can achieve. “The layers of the onion . . . stretch out to things that are obviously beyond a healthcare system’s direct control, including the obesogenic food environment that children and poorer communities are exposed to . . . Countries where more than half the population are overweight have had 10 times more Covid deaths,” he says.
The food and drinks industry, he suggests, is increasingly recognising the price it will pay if it fails to adapt to the changing investor and public mood. He mentions Vimto, a fruit cordial whose manufacturer issued a profits warning after Saudi Arabia and the United Arab Emirates, where it is popular, imposed a soft drinks tax.
Kaieteur Kitchen Original
Castle Square, Elephant Road, London SE17 1EU
One tamarind punch, one ginger beer punch: complimentary
Guyana traditional pepper pot £6
Kaieteur Kitchen special spinach rice £6
Curry mutton £3.50
Fried plantains x2 £7
Spinach in a coconut sauce £3
Stew pepper pumpkin £3
We briefly break off as our own, transparently nutritious, food arrives. As we tuck in to souse, a kind of soup made with cows’ feet that is considerably tastier than it sounds, and pepper pot, a glorious concoction made from melt-in-the-mouth beef that Faye tells us is traditionally served on Christmas morning, we turn back to the pandemic.
The UK has suffered one of the highest death tolls in the world through multiple missteps. Stevens has spent many years inside or close to government. What went wrong? The NHS’s own response, he is quick to declare, “will benchmark well against any health service in the world”; other lessons will emerge from the eventual inquiry.
But he questions, in any case, the notion of an immutable pecking order for national responses. “There were different starting positions, in terms of the scale of the diagnostic capacity available in certain countries . . . and so those who were thought to have got it cracked 15 months ago, six months later, maybe not so much . . . and we are, by far and away, the most successful of the large industrialised countries in getting vaccines to build this wall of immunity for our population.” (The point is made with typical Stevens brio since it is he who has led that campaign after being charged with the responsibility by Johnson.)
But Britain’s public services have long deified efficiency, I suggest. Did years of tight funding settlements compromise the UK’s ability to respond when Covid hit? Stevens demurs, pointing out that even countries with more generously funded health services have come under extreme pressure over the past 18 months. However, he is clear that the health system can no longer be run as “hot” as it has been. The UK entered the pandemic not only with fewer beds, nurses and doctors than many comparable countries, but a lack of buffer stocks of personal protective equipment and other vital goods.
“One of the things [the pandemic] will have shown policymakers is something that I think people in the NHS have been saying for quite a while. Which is that if you define efficiency as running services very hot through a very lean approach to capacity [and the] supply chain, then your ability to withstand external disruptions and shocks is diminished.”
As to the progressive reduction in bed numbers over the past 20 or 30 years that left the NHS scrambling (successfully) to secure the necessary capacity for coronavirus patients, that too has had its day, he suggests. “We’ve probably reached an inflection point where that trend is unlikely to continue.”
Yet Stevens suggests the flexibility and agility the NHS showed during the pandemic — repurposing parts of hospitals to provide critical care, and staff rapidly retraining to learn new skills — will also become a permanent feature.
Waiting lists for non-urgent hospital treatment stand at a record 5.3m and Sajid Javid, appointed last month as health secretary, recently suggested they might reach 13m — the kind of territory in which the compact between Britons and their health system may start to fray.
Stevens says firmly: “We’re not heading for a 13m waiting list if we choose to do something about it, which I’m absolutely convinced both the government and the NHS will do.”
With the right resources, including for diagnostics, he suggests, the backlog could be cleared “over the next 30 to 36 months, provided there is clarity that the health service is given the tools to get on and do it”.
He makes clear that the government has a choice about how it uses what he terms the “post-Covid dividend”. Decorously throwing down the gauntlet to the current administration, he says the health service has needed and received significant extra funding as part of the pandemic response over the past 18 months. But as the crisis wanes over the next year or two, not all of it will be needed.
“So that will create headroom and then the government will have a choice as to how much of that headroom freed up by diminished Covid costs are deployed to dealing with the backlogs of care. Not just routine operations, but also new mental health needs, long Covid and other services. And what proportion of the headroom is deployed to dealing with wider pressures on the public sector balance sheet.”
His hope, Stevens adds, is “that we can return to short waits for care. Because that was one of the signature achievements of the NHS during the 2000s and, as a result, public satisfaction with the service nearly doubled.” The latter point is a canny sally, perhaps calculated to resonate with a government that put the NHS at the centre of its successful pitch to traditional Labour voters in the 2019 general election.
More food has arrived. I sample the mutton curry and, urged on by Stevens, spinach in a coconut sauce, which is delightfully creamy. Another couple has arrived to eat in the small white-walled space, decorated with black and white photographs of Guyana that spark nostalgic memories for Stevens, and there is a busy hum emanating from the kitchen.
We turn to the organisational challenge of piloting the NHS supertanker. One lesson he has learnt, he says, is that there will be crunch points “when you have to decide that you’re not just going to take your external environment as a given, but instead you’ve got to make the weather”.
One particular meteorological convulsion comes to mind, ignited by a speech in 2017 where he suggested the government should honour the pledge made by the EU referendum’s victorious Leave campaign to pour extra money into the NHS. It was the audacious gambit of a secretary of state rather than a bureaucrat and reportedly infuriated both Number 10 and the Treasury, but it seemed to work: the following year then-prime minister Theresa May unveiled a five-year funding settlement of an unusual generosity given squeezed public finances.
As I ask about this, for a split second an expression of glee flashes across Stevens’ face. It is important, he says, “to know what your own personal North Star is”. Would he have resigned had he not secured the funding?
“You should never make those kinds of statements, because they’ll be regarded as threats. But, in your own mind, you have to know the circumstances under which you feel something is sufficiently important that, if you can’t see that through, then you should make a move.” I’ll take that as a yes.
All democracies, I suggest, are now grappling with the question of how to balance individual responsibility with continued restrictions as the world seeks an accommodation with the virus. We are speaking four days before England is to drop almost all remaining curbs: what is the correct balance?
The public, he says, has “generally, and overwhelmingly, been incredibly responsible through this pandemic. And I think on the one hand, there’s fatigue. On the other hand, I think if Covid has taught us anything it’s that we shouldn’t be too certain of ourselves in terms of whatever the next three or six months might look like. So I think continuing to be open and flexible is going to be an important thing to get right.”
Flexible about the possible need to reimpose some restrictions? In a remark that sounds pointed given Johnson’s public espousal of the “i” word, he says: “I think the word irreversible about anything is probably best not used.”
This month Stevens took a seat in the Lords, the UK’s upper chamber, taking his title from the city of his birth. Where does he intend to focus his energies? He will not be drawn. So no back seat driving? “I’ll be selective on those areas where I think I can make a contribution.”
To successive governments in thrall, however reluctantly, to Stevens’ decades-long dominance of the public sector landscape, that may sound more like a threat than a promise.
Sarah Neville is the FT’s global health editor
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