Many of these changes are welcome. First, though the NHS has reverted back somewhat to organisational plans rather than the whole health economy – or place-based approach – aimed at by STPs, the guidance does make clear that these plans should nonetheless be consistent with STP plans. While this will no doubt raise lots of operational complexities, it does look to embed the cross-system working STPs were supposed to help enable.
Second, the guidance seems to reflect a greater degree of common oversight from NHS England and NHS Improvement (perhaps with their own national STP?) – trying to ensure the two organisations speak together with one voice. This is consistent with NHS Improvement’s single oversight framework which also looks to align the national bodies more closely amongst other things.
Third, the STPs themselves are evolving. This includes introducing STP-level control totals for finance, opening the door for local areas to re-balance the financial targets across their constituent members. There are also signs that the centre will accept some re-drawing of STP boundaries, at least over money. While again there will no doubt be major operational and governance issues in making use of these freedoms, evolution is likely to be better than another revolution as the NHS increasing (but not instantly) moves towards place-based systems of care. However, while the guidance is clear that ’what makes most sense for patients, communities and the taxpayer should always trump the narrower interests of individual organisations’, it sits increasingly awkwardly with a world of supposedly independent NHS organisations and their boards; not to mention an oversight system still reliant on the accountability of individual commissioners to NHS England, and individual providers to NHS Improvement. With STPs apparently here to stay, sooner or later the increasingly uneasy tension between the rapidly evolving place-based system and the organisation-based statutory framework will have to be addressed.
Fourth, the national bodies are trying to break out of the annual planning treadmill and have issued a two-year planning round backed by two-year contracts, a two-year tariff, Commissioning for Quality and Innovation (CQUIN) and Clinical Commissioning Group (CCG) quality premiums. Particularly when trying to bring about transformational change, providing greater certainty is essential and something many have been asking for. This is all the more impressive given that the occasional reference to the Department of Health and HM Treasury suggests there must have been a lot of behind-the-scenes negotiation to get this out.
Finally, for as long as I can remember the regular launch of the guidance in the run-up to Christmas (22 December last year, with some major building blocks coming out even later than this) has widely been recognised as too late. So bringing the launch forward by three months to 22 September has bought everyone valuable extra time.
So are there any downsides? Well, getting out the guidance early was arguably necessary for the NHS to have any chance of planning its way out of the current financial and operational malaise. However, it is certainly not sufficient. What is asked of the NHS remains breathtaking: to maintain (or recover) performance, to manage its finances, and to push forward on transformation. And all of this without any real growth in its budget (as 2016/17 was the good year for growth), and with demand continuing to rise relentlessly.
The guidance also carried on some arguably less than helpful behaviours; most obviously it is a very long document indeed once the annexes are included – only serving to increase the demand on those tasked with seeing it through. More significantly, it also maintains and reinforces the central grip that has become so noticeable. So the Sustainability and Transformation Fund is here to stay, and remains primarily tasked with deficit support rather than transformation – given out retrospectively only if trusts meet their finance and performance targets. The centre also remains very keen on plans, detailed monthly trajectories, controls and sanctions, and will be issuing a new set of metrics to cover STP performance as well. On top of this, various pots of money are held back or ring-fenced to encourage local areas to do as they are instructed; whether on mental health, general practice, diabetes or delivery of the digital agenda.
The reliance on central control is noticeable in other areas too. Though the nine national ‘must-dos’ have been carried forward in name from last year, the detail underpinning them has in some cases become longer and potentially more difficult to tackle. So while many might argue that elements of the mental health, general practice, cancer and maternity strategies were right to add as ’must-dos’, in the current climate just adding these to a long list of other things the NHS must already do (which includes seven-day services, by the way) represents wishful thinking. Short of a miracle, the NHS cannot do everything.
However substantial NHS planning guidance has become these days, it is hardly the place to kick off the increasingly necessary debate about what the NHS can afford within its current financial settlement. But is it a debate that is becoming increasingly hard to avoid.