End of an era: Simon Stevens steps down as boss of NHS England

Sir Simon Stevens’s departure as chief executive of the NHS marks the end of an era. Pity his successor. The “to do list”, or perhaps more accurately the “still to do list” is enormous.

Stevens has been, by any measure, by far the most effective and powerful chief executive of the NHS, of whom there have been, in one form or another, eight since 1985. If the test for “who have been the greatest health ministers?” is that they found the NHS as one thing and left it as another, Stevens, as a chief executive rather than a minister, passes that test easily.

Simon Stevens’ talents enabled him to use NHS England’s independence

From his arrival seven years ago in April 2014 there has been real consistency of purpose. From his initial diagnosis that the NHS’s key problem was the separate silos in which it had largely operated since 1948 – hospitals, GPs, community services – the drive has been to create properly integrated care, with that integration requiring far closer, and far more effective, working with social care. The Integrated Care Systems that the NHS has been developing over recent years will be his great legacy – if they can be seen through to full fruition.

On the way, Sir Simon – aided by Jeremy Hunt, the health secretary for most of his tenure – worked his way around Andrew Lansley’s largely disastrous Health and Social Care Act of 2012 which sought to take the “choice and competition” model of running the NHS to ludicrous extremes. He did so by effectively ignoring it. That he was able to do so was down to three factors. His partnership with Hunt (even if, at times, tense) who rapidly recognised the Act’s problems. The creation of NHS England as a statutorily independent board – the one good bit of the 2012 Act, even if it has operated very differently to the way it was envisaged. And Sir Simon’s own talents, which enabled him to use that independence. First to ensure that the drive for integrated care was not knocked off course. And second as a public bully pulpit to get the NHS more money than it would otherwise have got through the long period of austerity.

The NHS has performed remarkably during the pandemic

A fine tactician and even better strategist, he was a better politician than the politicians. He harnessed the Brexit campaign’s bus slogan of “£350m a week for the NHS” to defuse right wing hostility to the NHS when, short of money, its waiting time performance was slipping. And he used it again, marshalling facts, figures and the public’s love affair with the service to get it only its second long term financial settlement for the NHS’s 70^th birthday in 2018 (he had a hand in the first in the 2000s). It was not all he wanted. Some of the things essential to support it are still missing – a long term capital plan, a workforce plan and the long overdue reform of social care. But, as he made the public case for the birthday present, and Hunt the private one, it is highly doubtful if anyone else could have achieved what he did.

If there is a criticism it is that he was probably a better strategist than manager and the surprise might be that only relatively recently did he appoint a proper chief operating officer to help better implement the drive for Integrated Care Systems. There has been real progress. But slower than he would have hoped. It is decidedly varied, with much still to do. And then, of course, there is the pandemic.

The eventual public inquiry will ask questions. Not least about the discharge to care homes of thousands of patients, untested for Covid-19, as the NHS cleared the decks to cope. There will be other instances where things did not go well. But through a mixture of central guidance and phenomenal local initiative the NHS has performed remarkably. Not just in handling the flood of patients that, if the government had acted earlier, first in March and then in September last year, should have been smaller. But also by running rapid clinical trials to debunk ineffective treatments and find better ones. The vaccination programme speaks for itself.

Simon Stevens’ successor faces enormous challenges – and greater ministerial interference

So why does it feel like the end of an era? Because Stevens’s successor is unlikely to have the freedom of manoeuvre that Sir Simon, by sheer force of intellect, personality and knowledge carved out for himself and used so effectively. The government is planning NHS legislation that – unless Parliament stops this part of it – will give the secretary of state new powers of direction over NHS England. His successor may well face ministers who try to micro-manage. Whether that played any part in his decision is unknown. He says he originally planned to go last year.

The challenges his successor will face are enormous, even without a significant third wave of the pandemic. Waits for treatment were over-long before Covid-19 but a mighty additional backlog has built up, and it is far from clear that the government grasps just how much money and time (many billions and several years) it will take to get waiting times back to acceptable levels. Staff are exhausted. There are too few of them in key areas. Integrated Care Systems remain a work in progress. Both during and after the planned legislation there is much technical work still to be done about precisely how they will function in future. They should be Sir Simon’s legacy, but they could dribble away into the sand. And it feels like the end of an era because, from his days as an NHS trainee and manager through his hugely influential role as first Alan Milburn’s and then Tony Blair’s health adviser in the 2000s, it feels almost as though he has always been there. His successor may surprise us. But only very rarely do big beasts on his scale come along.

This article has also been published at www.kingsfund.org.uk