His starting point was that after seven years of unprecedented constraint, 'the NHS can no longer do everything that is being asked of it.' With NHS funding increases in 2018-19 set to fall close to zero, he warned of services retrenching and retreating, waiting lists growing, and staffing levels falling. Planned improvements in priority areas of care such as cancer and mental health would not materialise, and the failure to provide additional funding would mean, in his view, turning back a decade of progress. Stevens made clear that the elected government has the responsibility for deciding the NHS budget but added that politicians should be honest with the public about the consequences of their decisions.1
These arguments are familiar, but the sight of the chief executive of NHS England articulating them on a public platform is not. Stevens suggested that one way of increasing NHS funding would be for the government to honour the commitment made during the referendum on EU membership by the Leave campaign and provide the NHS with an additional £350 million (€390 million; $460 million) a week. Although the government did not respond directly to Stevens’ speech, a tweet by Nick Macpherson, former permanent secretary at the Treasury, asserting that it was 'time for Mr Stevens to step down as an unelected public servant if he wants to campaign for more NHS funding'2 reveals how Whitehall mandarins are likely to have felt.
The decision of Stevens to go public on discussions about NHS funding is explained partly by the opportunity offered by the forthcoming budget to provide additional resources and partly by the apparent unwillingness of the Chancellor and Prime Minister to engage seriously with the concerns he and others have raised. From the highest levels down, the government is preoccupied with Brexit, leaving limited time and attention for other public policy concerns. Uncertainty about the economic consequences of Brexit is also constraining the Chancellor in the decisions he is weighing ahead of the budget.
Equally important is lack of sympathy in the government for the claims being made for additional public spending. An indication of this was the speech by the home secretary, Amber Rudd, in which she scolded chief constables and police and crime commissioners for arguing for more resources to prevent and fight crime.3 Jeremy Hunt seems more sympathetic to the arguments being advanced for additional investment in the NHS but is reliant on the Chancellor and Prime Minister to find the wherewithal.
Stevens’ decision to speak out might yet have consequences for his position, although as a public official accountable to an independent board he cannot be removed directly by politicians. His willingness to speak so frankly reveals the depth of his concerns about the prospects for the NHS and a sense that now may be the last opportunity to avert a crisis in care. If the government ignores these concerns, it cannot say it was not warned when others, including the Care Quality Commission, have argued that the NHS is overstretched and facing the likelihood of declining standards of care.4
The government’s difficulties in recent weeks, and questions about its future, help explain why Stevens’ intervention did not receive greater coverage in the media. His speech was made on the day that Priti Patel resigned as international development secretary, and speculation about her position dominated the news during the day. The decision of news editors to lead with this story rather than concerns about the future of the NHS – concerns that have direct consequences for the entire population – reflects the febrile atmosphere in Westminster and the fragility of the government.
The noise around the travails of the government should not drown out the signal that Stevens sent in his speech. As the NHS approaches its 70th anniversary, the government and the public face some hard but unavoidable choices. Analysis by the King’s Fund, the Nuffield Trust, and the Health Foundation has argued that an additional £4 billion will be needed in 2018-19 to sustain services and provide a down payment on the additional £20 billion required between now and 2022-23. More resources also need to be found to shore up social care and to avert further damaging cuts to public health budget.5
Stevens has thrown down the gauntlet and challenged the government to respond.
- 1. Rimmer A. NHS should be 'first port of call' for potential Brexit savings, says Hunt. BMJ2017;359:j5191. doi:10.1136/bmj.j5191 pmid:29118003.
- 2. Pym H. NHS battle for money: Where will it end? BBC News 2017 Nov 9. http://www.bbc.co.uk/news/health-41929328
- 3. Dodd V. Amber Rudd lambasts police chiefs over extra funding demands. Guardian 2017 Nov 1. https://www.theguardian.com/uk-news/2017/nov/01/amber-rudd-lambasts-police-chiefs-over-extra-funding-demands
- 4. Care Quality Commission. The state of health care and adult social care in England 2016-17. www.cqc.org.uk/publications/major-report/state-care
- 5. Nuffield Trust, King’s Fund, Health Foundation. The Autumn budget: joint statement on health and social care. 2017. https://www.kingsfund.org.uk/publications/autumn-budget-2017