Chris Ham: Sustainability and transformation plans - where next?

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Speaking at our breakfast event on 21 February 2017, Chris Ham presents key messages from our report, Delivering sustainability and transformation plans.

Transcript

Delivering STPs from ambitious proposals to credible plans. I think many of you will know, we published this report back in November.  This was our first analysis.  And it focused on the process of developing the plans between about this time last year and the autumn.  We didn’t get into the detail of what the plans are proposing because at the time we wrote this report the plans hadn’t been finalised.  We had seen drafts during the summer but the work was ongoing and there was a very tight timescale and deadline.  So that was about the process and we were quite challenging and quite critical of how the plans had been developed, with limited engagement and consultation outside a small group of NHS leaders, with little opportunity for colleagues in most parts of local government or indeed members of the public to be involved in the process, and that was behind the concerns we expressed.  But on the basis that then as now we believe STPs are the right thing to do in their ambition to bring together NHS organisations around their common concern with a population and a place, and not just to do so within the narrow NHS family, but to extend involvement through local government, the third sector and other partners too.

So that was what we said back in November, and as I say we’ve gone on now to read and review and synthesise what are the big themes in STPs? And here they are, I’m not going to go through these in any detail, I want to say just one or two things before moving on to some of the opportunities, and also the challenges.  Can I say we did a press briefing on our report last Thursday and I know we have colleagues from the press here?  The messages in the report are quite nuanced.  So this isn’t a report that says STPs are all good or STPs are dreadful, it’s highlighting what we think are the positives in STPs, but also the real concerns about moving from these ambitious proposals to credible plans.  So I hope that nuance and the concerns will emerge alongside the continuing support we have for the principal at STPs and what they are trying to achieve.

The big themes are particularly those at the top here. The aspiration to invest in and further develop the primary care and community services across the full range encompassing general practice, district nursing, social care and many other contributions.  The aspiration in line with the forward view to put much more emphasis on prevention and early intervention both between the NHS and local government and more widely, proposals too to change the role of acute hospitals and more specialised services which I will come on to talk about in more detail.  But there is much, much more besides in all of the STPs essentially because STPs were given some guidelines on what should be included, and they pretty faithfully followed those guidelines in producing the plans.  And the plans we’ve analysed are those which were submitted last October/November, conscious that the thinking has moved on, even in that short space of time since those plans were submitted.

So we are analysing what was said in the plans, but we also acknowledge that further work has been done, and some of those proposals are now off the table, others are back on the table. Let me then focus on the opportunities and challenges and the content of the plans.  So we have been arguing at the Fund and many of you in the room have done the same for much more focus on services provided out of hospital and the full range of primary care and community services, essentially because the well publicised difficulties in the NHS and social care have come about because of ever rising demand for acute hospital care when resources have been increasing much more slowly.  So the key challenge is how to provide effective alternatives for those people who could be cared for in their own homes or closer to home and of course that must involve better use of the resources we have got.  And there are many of those resources if you think about the staffing and the funding that goes into the community based services defined broadly, but there is very little new resource.

The additional funding provided under the spending review for the NHS is primarily going into reducing hospital deficits. And the plan the time the forward view was written for a transformation fund, EMR, to support investment in new services such as these, there is very little left over for that further investment.  On hospital services a number of the plans but not all have plans to cut back on capacity to reduce the number of hospital beds, both community hospital beds and acute hospital beds.  In a small number of plans, there are proposals to close whole hospital sites, but they’re very much the exception rather than the rule.  Our concern here is the obvious one.  We are coming out hopefully of a winter when hospitals have been stretched to their limits and often beyond their limits, when bed occupancy has been much higher than the 85% that is thought of as being the safe limit.  We don’t think it’s credible to propose to cut back on acute hospital beds until there is a prior investment made in the community services to give confidence that there are appropriate alternatives available before those bed reductions occur.  And David Pearson is from one of the areas where the STP does propose to cut back on hospital beds and David you may want to comment on this aspect in your contribution?

Third issue is the reconfiguration of acute and specialised services, so not talking here about cutting capacity, but changing the role of acute hospitals and sometimes specialist hospitals to concentrate services where the evidence suggests that might deliver better outcomes. We think every case needs to be considered on its merits.  Some of these examples that are in the plans are well known, they have been on the agenda for a very long time.  There will be good evidence to support those proposed reconfigurations in some cases and much less evidence in other cases.  But the principal, given the well known workforce shortages, of trying to provide the best possible care whether we’re talking here about A&E and maternity services or more specialised services like stroke and trauma care.  By concentrating scarce staff and scarce resources in a smaller number of hospitals able to deliver care to the best possible standards recognising often that will be unpopular and it may involve longer travel times for some people, that’s a debate we cannot avoid.  And one thing we’re saying in our report is where there is a strong clinical case for change, politicians need to support that both at a local level and at a national level.  If they don’t, the risk is that we’re trying to maintain unsafe services in too many hospitals, even though those hospitals are often valued by the public.

Next is giving priority to prevention. Nobody I’m sure would argue against that, but can it be done, and can it be done especially when the public health budgets now controlled by councils are under huge strain and in many places are being cut because of the funding settlement for local government.  Closing the funding gap as well as improving services is a key priority in all of the STPs, because STP leaders were told they needed to submit plans that showed how that funding gap would be closed by the end of this parliament.  Our assessment is that some progress has been made on that in almost all plans, but very few of them have a really convincing financial plan to underpin the service plans.  Not surprising, money is incredibly tight this year and next year in the NHS, much tighter in local government, and I know some of the plans have looked at the funding gap in social care and it’s work in progress as to how that funding gap will be closed as well as the potentially very big NHS funding gap.

So what about making the plans happen? The subtitle of our report we thought quite a lot about and its intent is to say the plans from October are comprehensive and wide ranging.  The NHS and its partners cannot deliver all of the proposals in the October plans.  Every area we are recommending should now decide what are the top two or three big priorities that need to be given attention and focusing on those with the resources available.  Engaging meaningfully back to what we said in November with a range of stakeholders, the brand of STPs has been damaged by the imperfect process that was put in place in the development of those October plans, and that’s going to be difficult to make up.  So we think now the NHS needs to get its act together around this wider consultation and make it meaningful to give more confidence.  These plans haven’t just been developed by a small number of NHS leaders, but they have been tested and improved through consultation.

Consultation has to happen on these plans, but there’s an urgency in taking some of them forward, how to square that circle between scale and pace of implantation around the urgency, but the need for time for proper meaningful consultation. STPs are a workaround of the most complex and fragmented set of organisational arrangements I can remember in the many years I have been working with for and alongside the NHS.  They are a workaround because the leaders at a national level have said we don’t want to argue for another top down reorganisation to streamline and simplify.  But as a workaround they’re bumping up against the 2012 Act, and some of the provisions in there, particularly part three around market regulation, the role of the CMA in looking at proposed mergers, and indeed the proposals and the requirements on CCGs to go out for procurement in developing new care models.  There is a collision here between what we very much support which is the expectation of collaboration and partnership working in developing STPs that has to be the right way to go given the current climate, but still the statutory framework which was designed with a very different purpose in mind.

And there’s a real tension there that I think is experienced at a local level as the plans move from being proposals into implementable plans. And then the issue around the leadership and governance of STPs, they have been sort of run on a wing and a prayer so far.  People have stepped out of their day jobs like Jane and David to provide the leadership with support from other colleagues.  Can that continue, what more needs to be done to strengthen leadership, to clarify the governance, who takes decisions on the implementation of STPs?  STPs have no legal status, they are simply a meeting of leaders from organisations that do have legal status, there is the start of a conversation.  STPs can’t take any decisions to implement their plans because they have no legal basis to do so, those decisions have to be taken by commissioners and by providers.  Does that need to be changed, and what other capabilities are needed to move from these comprehensive plans into something that can be delivered in practice?

So, last couple of slides. We start from the position, the forward view has been widely supported and welcomed, and from the Fund we both supported and welcomed it.  STPs are imperfect.  There have been many flaws in the process of getting from where they started to where we are now, but despite the imperfections they are the best hope.  I don’t think there is a plan B other than working through and strengthening what’s going on in STPs.  So all areas must explore ways of using what they have, the existing investment in community services, as well as the opportunities to invest more where transformation funds exist to support that further investment.  And we call in our report for national and local politicians to be brave, to back STPs where the case for change has been made.  Those words are really important because clearly where the case for change has not been made, it would be unrealistic to have that expectation.  But when we are looking, particularly at the changes to acute and specialised services, long overdue, how long has there been a debate in south west London around changing the role of acute services?  How long has there been a debate up in Shropshire about the role of Shrewsbury and Telford?  I could go on around the country.

These are not new issues. STPs have brought them to the fore, but they have been issues under debate for a very long time indeed.  And now is the time because of the pressures on the system to make some progress where the evidence supports that.

So finally let’s have ambitious plans, but let’s be realistic about how many of the proposals can be taken forward, over what period of time. There is the potential here to stabilise the NHS, and we heard yesterday about the continuing deficits and financial problems.  But it requires the right leadership, at the national level, not just at the local level.  And a recurring concern we hear is that NHS England and NHS Improvement don’t always send out clear and consistent messages about their expectations of the NHS and local government.  Sometimes it’s clear at a national level but the message gets diluted when you come down to a regional level and this isn’t going to work unless that changes.  And we don’t argue primarily for additional funding because at the Fund we have done that before, but clearly the pace and the scale of implementation will require more funding for social care, that remains the highest priority in our view.  And we believe the claims of the NHS will also need to be considered carefully, because if you look at the projections in the spending review, next year is going to be tough, the two years after are going to be impossibly tough.  So more resource as well as how can we use what we have got better?

I would like to thank colleagues Hugh Alderwick, Phoebe Dunn, Helen McKenna and many others who have been involved in working with me in writing this report and all the other resources that will be going up on our website to try and communicate and convey these messages. So that is what we are saying.  I would now like to pass on to Jane.

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