Editorial Wednesday 3 June 2015: Rough transcript of Simon Stevens' speech to the NHS Confederation conference

Simon Stevens transcript

There was no text for this speech, so this is a very rough transcript, far from carved on tablets of stone

It's been a year since last we met, and a lot of water under the bridge. We have seen rising demand, and had a difficult winter. But that's not the whole or main story, which is an amazing one of daily acts of kindness across this country by clinical staff and NHS managers. And we should avoid denigrating managers: the people in which we trust the stewardship of our national treasure the NHS. Difficult times require courage and bravery to reach the future.

And the NHS has for first time in its 67-year history set out its stall and charted its own destiny in the vision set out in the 5yfv. And we got both the political and financial support to back it. I was determined that in this election campaign, country should not sleepwalk past those important choice.

And it's not my 5yfv, but our 5vfv, and it's had legitimacy because it touches into a consensus of the NHS's staff about how the NHS needs to change.

Despite electoral sturm und drang, there remains a consensus among citizens on the need for the NHS. The level of change required is inspiring, daunting and energising. Someone told me that 'rough seas make for great captains'. I said, 'yes; also seasickness and lifeboats'. But that's not the right image for the path ahead.

Talking to professional groups, it's clear that there are two blind alleys in the here and now that we must avoid as we go forwards.

One: all happy talk about the future without squaring up to real pressures of today

Two: a fantasy of someone buying us few more years of the status quo. I'm here to tell it as it is. Have to take collective action on changing service provision now: we don't  have five years. Do nation & ourselves a disservice to pretend we do.

So our guide should not be St Augustine 'oh Lord, make me virtuous, but not yet'. I prefer David Bowie: 'tomorrow belongs to those who can hear it coming'.

So how do we do the next bit of the journey? In four steps:

1. get onto a financially sustainable basis this year.
2. soup-to-nuts redesign of urgent and emergency care provision
3. change the national debate and terms of trade on prevention - for government, people and society
4. develop new way of working locally and nationally so NHS is more than sum of parts working together

Money and financial sustainability
I see no likelihood additional NHS cash this year, so we must manage with allocated cash. Needs a big team effort. Must get right the next annual commissioning round on level of funded activity and capacity planning. Bluntly, this didn't happen with enormous sophistication last year, making us have challenging conversations with CCG colleagues and suggest realism of 2-3% increase of acute commissioning this year. Need to use next several weeks to get these realistic and balanced.

Secondly, we must be committed to collectively addressing cost drivers. Temp staffing, as you know, is the single largest cause of provider deficits: last year, £1.8 billion against plan. It is 1. entirely understandable, 2. Ringo (Editor's note: I didn't get this bit, so all such gaps in this transcript are 'Ringo') and 3. unsustainable.

We know from Mid-Staffs that care crises came because we lacked nurse numbers, and so there's been use of agency and recruitment/training lag. But we have also not as yet having exercised our considerable collective purchasing power to convert agency vacancies into well-paid, permanent flexible jobs. We know it's worse for care quality to have a constant succession of non-permanent staff whoo don't know the hospital or routines. So we must take substantial action if we are to have a chance if helping providers square the circle of quality, access and money. Temp staff is the first area of national muscularity. You'll also have seen the edicts on management consultancy, Monitor will be writing to all acutes and CCGs.

So we need realistic set of activity and workforce plans, and we need to use our collective muscle to tackle the deficits.

Thirdly, we've got to be realistic on the new national asks for next year and beyond (this is a note to myself). Jane Cummings is to look at new nursing guidelines for urgent and emergency care and vanguards. In other similar areas, it's incumbent on national leadership bodies to get these things right.

Fourthly, we have to deliver on the national standards emergency, cancer, and righting inequality regarding mental health. Sir Bruce Keogh is to review RTT and extending London and south-west ambulance services' initiatives for change.

There are parts of the country where health economies are in serous imbalance, and have been for years - if not decades. Our 'success regime' is for structured intervention to get these places onto a sustainable footing. We've tested to destruction the traditional approaches (or theory) that more powerpoint slide decks; switching CEs; short-term bailouts work: if that were going to succeed, it would have done so by now. Recognising that this medicine may not be successful, we're identifying and naming the first three success regime areas: north Cumbria, Essex and north, east and west Devon.


Collectively, success regimes in these three areas will bring full range of freedoms to bear, not just for individual organisations, but with things such as maybe multiple year financial control. We need to be more radical in these areas. This needs political backing, which I expect we will get, but extant care provision models need to evolve for dealing with these knotty problems.

Over the next five years, we face a huge task to put the NHS on a financially sustainable footing, and our argument is that it needs AT LEAST £8bn extra a year by the end of the decade. That's less than historical post war period, but more than it's had in the last five years and more than the rest of the public sector over past five years, and it would have been similar whoever had won election,  based on their stalls as set out.

There are enormous benefits to tax funding healthcare, but consequently NHS income is leant on the health of economy: we still run a deficit of 5% of the GDP budget. If we ramp funding up this £8bn, we will be bigger, serving more people and doing so substantially better.


What does this £22bn of efficiencies mean? Not cuts, but facing a number of additional demands over & above extant one - how can we get as much headroom as we can for the rising number of patients we want to serve?

Three main buckets of thought
We need to think in three major buckets. One: redesign fundamentally how care is provided; two: focus more intently on demand side and prevention, moderating the rate of demand growth if not absolutely reducing it; three: first and foremost, make as good use of our annual £113bn as possible. We're more efficient than we were five years ago and more efficient than most other countries (according to the Economist Intelligence Unit), but we still have substantial efficiency opportunities.


We've tolerated far too much clinical variation, failed to use our collective financial muscle, and done too much go-it-alone as individual institutions, and given too many vetos. Look at the (introductory) film of Darwent: a very well-run hospital, though with an inflexible, high-cost PFI. And they're just up the road from Medway. Compare and contrast. I found it surprising to be told about Darwent's wonderful new, half-used path lab which they've been trying to persuade Medway to share, but were told 'nein, danke'. How do we accept this?

Sometimes, we're pennywise and pound-foolish, nowhere more than in investment for general practice, who, if they're able to offer £1/3bn of offset savings in acute - which sounds compelling. Sometimes we've foreclosed conversation on cost drivers, as requiring change in parts not in our gift. If litigation not working well, or we're not getting best value on medicines procurement, or there are alternative ways of education, timing and workforce development, then these are conversations we must have.

How can we mobilise on this change? Could get national system leaders - Davids Bennett and Behan and Duncan Selbie and I and others - to produce a 'how to do it' document: "here it is!" But that's the David Brent approach. The alternative proposition (and I should say that we system leaders have some well-developed hypotheses on problems!) bis that we seek solutions at three levels. National level, individual organisational level, and quite a lot collectively at NHS front line level. And we'll need structured dialogue to uncover issues, debate them and get solutions coming through.

It needs collaboration: we're collectively committing with national organisations to a start process for front-line leaders, patient groups other partners, asking them to work with us and Carter review and feed all of this into the next spending review, to converge with the next financial planning round. Come the autumn, we can then nail the game plan for delivering the big building blocks of efficiency over 2016-20.

That how we will approach task, which we'll lead getting on with national level tasks.

And we mustn't fall into the trap of thinking that it's all about money, but about the kind of health and care system we want. We need to get it to be sustainable, backed by efficiency, but we have to fundamentally redesign care and get serious about prevention as well as care redesign.

Our big idea is effectively the Don Berwick 'triple aim'. We need a triple integration, blurring the boundary betwene primary and secondary care, combining more aspects of physical and mental health care provision. We've seen great innovation possibilities in care homes in the Vanguard pitches. Now we're moving on to acute redesign, in success regime economies but it's broader.

We need to learn lessons from last winter pressures, and we need to quite substantially redesign urgent and emergency care. Your child's ill at a weekend: is it A&E, 999, 111, urgent care cantre? We've got to join up urgent and emergency care better. Any of you who want to come and play on urgent care redesign have to apply by July 15 (and the form's easy, you could do it on the buss). We want to try to simplify the urgent care spaghetti.

On NHS Change Day I learned about the experience of a young woman with learningg difficulties. And we have got to shut some remaining inpatient learning disability beds, and on learning disabilities, we have not finished the job. We need a closure programme for long stay institutions, with more power in the hands of families: we're rolling out the work towards this with CCGs.

We've ggot to get serious on sustainability, serious on redesign. Health is what we're after. Healthcare is what we do if health goes wrong. And I make no apology for being lippy about what we need to do, and about the H in NHS. And I hope you as local leaders will feel empowered to stand up and make health prevention and promotions arguments to local representatives, on this agenda that we will set with DH and Public Health England, not just on the traditional villains of alcohol and fags but also obesity.

It's a striking figure that 1 in 10 kids at primary school is obese, and 1 in 5 will be when they leave. As a society, we are doing something very wrong for our children, and we know that unchecked, this means a rising tide of future diabetes cardiovascular disease and cancer - which is avoidable. Are we as the NHS going to stand by and prepare to treat burden of illness, or rattle cages and agitate for something different?


We need to start a national conversation as parents. We need the food industry to get serious about product reformulation, and we need a national diabetes preveention programme. None of this work will produce a big health economic pay-off this year or next, but cumulatively in 5-10, it's vital. So I ask if you'll join a public health campaign to change the weather and terms of trade on these issues.


As Rob Webster said, this degree of change engages us in change of relationship with communities and carers. We need this at all levels, and to help In mental health task force, Paul Farmer of Mind is helping us to lead, as Harper Kumar is in cancer.

The only way the NHS will make do and improve is if we come together, nationally and locally. When people asked why Sony didn't come up with the iPad or iPod, when they had the Walkman, and all the components and knowledge, they found that Sony's internal sociology had been made too compartmentalised, so the right people didn't come together. Nationally, I and colleagues meet nationally in the NHS leadership board, all severn, and we'll need to collaborate to develop care quality models more coherently and efficiently over the next five years.

Tomorrow afternoon on this stage, the seven system leaders show our lovely relationships (and I mean that).

Here's another big risk: if we focus on 'me and mine' in tough times, we may destroy the efforts of 'us and ours'. And we have the most abundant resource: the abundant goodwill of frontline staff. So this is why we need what Rob outlined: a revivified approach to frontline staff. And  we're working with Health Education England and the chair of the equality and diversity council. And I mentioned this last year, but I'm still shocked by the systematic filtration of individual organisations not tapping into and making full use of their BME nurses staff and leaders and other protected groups. We need to be much more open to wider group.

And in staff's reported trust in communications with senior leaders, we can celebrate it being better than it was five years ago, when it was 30 percent. Now it's up to 37 percent, but that's still only just over one-third who think it's good.

In conclusion, to redesign and rewire the NHS is a huge agenda. Likewise to change the public conversation about health and prevention will be tough, and time is not our friend. But this is for a high purpose.

And we have three big advantages: we have a plan; the NHS is up for it; and we have the 54 million people of this country on our side.