The Stevens Factor – our man from Consett

Posted by Avril Rhodes and David J Hunter

Simon Stevens, the Chief Executive of NHS England is not as he seems. Behind the urbane witty manner, the man who likes, apparently, to speak without visual aids, is a man of real steel. Well, Consett steel actually, as at home speaking about his early experiences of working at the then Shotley Bridge General Hospital, as defending the NHS before the Public Accounts Committee and leading five year forward views. We have two gems here, someone who knows north-east England and relishes speaking almost exclusively about public health, despite the enormity of the operational responsibilities he carries, and definitely a force to be reckoned with, as his vertical rise from junior manager to CEO, via advising the Blair government at No 10, testifies.

Simon Stevens: a man of Consett steel

We shall soon be entering manifesto season. At his recent Centre for Public Policy and Health lecture at Durham University Queen’s Campus, whilst it wasn’t called a manifesto the audience were given an insight into six key priorities on Mr Stevens' mind, some of which built on the five year forward view released in October. Not in any kind of order these were:

1. Re-conceptualising what we mean by the NHS – the NHS is now a pensioner, in organisational terms but is still revolving around dealing with problems as they arise, with too little spent on underlying prevention. It seems to be hard enough to co-ordinate the different services currently provided, let alone stepping up to a new level where there is no difference in health and social care, and any aspect of policy that affects life chances, and health and wellness, is integrated both in planning and delivery. But this is a goal that means a fundamental re-orientation of what’s provided, how and where.
2. What about the unexploited advantages of primary care? The division between primary and secondary care in the UK, which has deep historical roots that pre-date the NHS is both a barrier, in terms of setting up a division that wouldn’t be recognised in some other countries, and also a positive, in providing personalised care, close to home. But what about the areas where primary care is all too thin on the ground, the unpopular parts of the country where GPs don’t want to work – the so-called ‘inverse care law’ which Stevens invoked. Can this be fixed through the development of a population-oriented primary care system?
3. The NHS is a major buyer and employer and has a sizeable economic footprint in local communities. Back in his Consett days, the steel works had recently closed and the NHS took up some of the fall out as the local and large employer of alternative resort. This lesson has not been lost on Stevens. The NHS should be able to influence poverty and health through its own economic position in each locality.
4. Work needs to be done on ensuring people get and stay in high quality jobs. The NHS can support this (partly linking back to the third point) through what it does as an employer but also could have a much stronger role in health interventions whilst people are at work. Unsaid at the time, but the workplace is somewhere people spend a lot of time, so why not? The NHS needs to set an example in being a good employer itself, but to its shame falls short, for example in the management of shift systems, or provision of healthy eating options at work. This was definitely a ‘can do better’ on the report card.
5. Local Authorities have come back in from the cold with their new (or is it re-gained?) responsibilities in public health. There is an awakening to the scope local government could have, arising from the debate about devolution in England, set off by the Scottish referendum, and even within their existing powers, local authorities can reach the parts the NHS can’t reach in affecting population health and well-being. 
6. And finally, what about the planning of new cities and towns? These could provide a test bed for working out new ways of place-shaping and designing health and wellness into the built environment and also new ways of delivering the NHS, given the blank sheet these major developments offer.

Let’s see how many party political manifestoes pay attention to these ideas in the Spring of 2015.

Haste ye back?

Posted by David J Hunter, Professor of Health Policy and Management, Durham University and Fuse Deputy Director

Many in the North East will be wondering how their region will fare if Scotland decides to go its own way on Thursday.

Some may be heard to say: ‘if you’re going can we come with you’?  Others might sullenly fear the worst, with our region caught between a hungry new nation impatient to prosper and chart a different course on the one hand, and an England which seems captive to the huge suction pump that is London hoovering up all before it and drawing in talent and resources from across the UK – or what was the UK.   

Where might health policy figure in the scheme of things post-referendum?  Will it fare better under independence? Or will things remain much the same or possibly deteriorate?

Financially, the Scottish NHS has always fared better than its English counterpart, enjoying higher per capita funding.  But spending on health services is not the only factor affecting health status.  Despite the extra funding, Scotland’s health remains stubbornly poor and generally inferior with higher mortality – hence the label the ‘sick man of Europe’.

Of course, with less funding for health care it might be worse.  But it’s more complicated than that. 

Perhaps liberated from the shackles and centralising tendencies of the UK (or London to be more precise), Scotland will be able to restore the public realm or invest in ways which will demonstrate that an austerity economic model can be replaced by a social model of development.

We know from Marmot’s work and WHO’s health strategy for Europe, Health 2020, that tackling the social determinants of health demands a whole of government and whole of society approach. 

Being able to achieve such joined up thinking and work across a whole system is much easier (in theory at least) in a small country.  And there are certainly signs that Scotland wants to be innovative and tackle health differently with its recently departed Chief Medical Officer, Harry Burns, extolling the virtues of asset based approaches and talking about wellness rather than ill-health.           

The Scottish government has been something of a cheerleader in public health policy having been quick to follow Ireland’s lead on banning smoking in public places long before England.

More recently, it took the lead in introducing a minimum unit price for alcohol although whether the policy will survive the EU single market rules remains to be seen. But where England dithers, Scotland appears willing to take bold action.

The real issue is whether an independent Scotland can do more to improve health and tackle inequalities than it can under current devolved freedoms and from others to come which are promised following a No vote.  

The answer is complicated.  After all, what does independence actually mean in our global world where paradoxically everything is interdependent at a time when nations and regions seek greater freedoms.  Are these opposing forces reconcilable?   Or will independence prove to be a chimera with Scotland even less able to realise its social justice aspirations?

Those voting with their heads will endeavour to weigh up the pros and cons and bring evidence to bear on their decision-making.

Those ruled by their hearts will not be swayed by an evidence base which is fiercely contested and offers no definitive answers.  They will be tempted to take the risk believing they have nothing to lose with the status quo and retention of a 300 year old Act of Union holding little appeal. 

But will the politics and the policies be so different in the end or just their packaging and presentation?   Can an independent Scottish government shake off the neoliberal embrace to which all governments since, and including, Thatcher have been enthral? 

In a global economy, no country is an island and to keep at bay, never mind hold to account, the rapacious transnational conglomerates, including the big consultancies and ‘advisers’ and lobbyists that are busy hollowing out the public realm in England, demands both vigilance and political courage of a kind that will tax the most socially enlightened politician.  

This is the true nature of the experiment underway in Scotland regardless of whether it achieves formal independence after the referendum or some form of ‘devo max’.

Can Scotland break with the Anglo-Saxon tradition and replace it with an ethos marked by collectivism, reciprocity and a commitment to public services? 

Or will it buckle under the pressures of global capitalism and dance to its tune?                

Yes or No, Scotland promises to be a fascinating laboratory for years to come for health policy-watchers.