STP leaders face major challenges in transforming care and balancing budgets

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The NHS in England is in the final stages of developing five-year sustainability and transformation plans (STPs). These plans are the product of work by providers and commissioners in the 44 areas identified as the ‘footprints’ for planning purposes. Local authorities have contributed to the STPs to varying degrees but involvement of other stakeholders has been limited, and as yet there has been no public consultation.

STPs are important in that they require NHS organisations to work together on plans to transform services and deliver unprecedented improvements in efficiency. They are an example of the place-based systems of care that we have argued offer the best hope of the NHS dealing with growing financial and operational pressures. STPs challenge many of the assumptions on which the Health and Social Care Act 2012 was based, in particular that competition should be used to improve performance.

Our assessment of draft plans shows that, in the absence of eye-watering efficiency improvements, there will be a financial gap running into hundreds of millions of pounds by 2020/21 in most of the footprints. Organisationally based cost improvement programmes will continue to contribute many of the improvements that are needed, alongside smarter procurement, savings in back-office costs and reduced spending on agency staff. Yet even with these measures, it will not be possible to achieve the financial balance expected by national regulators.

Partly because of this, more radical options are being considered to enable the NHS to continue operating within the funding promised by the government in the Spending Review. These options include re-configuring acute hospitals to concentrate some services such as A&E and maternity on fewer sites, in the hope of reducing duplication and releasing resources. Plans are also being developed to cut the number of beds by closing community hospitals in some areas and reducing the size of general hospitals in others. Much work is going into examining how these and other system-wide changes can add to what individual organisations are able to deliver in terms of improved efficiency.

The proposed bed reduction plans assume that services outside hospital will be strengthened, to avoid admissions where possible and enable patients to be discharged more quickly. It is not yet clear whether the funding and workforce can be found to invest in community services on the scale required, especially with social care facing further cuts (our forthcoming report looks at the impact of social care cuts on older people in particular). Our research has found growing pressures in both general practice and district nursing which need to be addressed urgently if care closer to home is to become a reality for more people.

Equally important is whether plans to reduce beds are credible when demand for hospital care continues to increase. Our most recent quarterly monitoring report shows A&E attendances and emergency admissions on a rising trend, and delayed transfers of care are also increasing. The demands created by older people with frailty (for whom hospitals may be the only realistic option when a crisis occurs) account for much of the increase in hospital use. Integrated care models, such as those put in place as part of the vanguard programme, aim to offer alternatives to hospital – but it is too soon to know if they can do so at sufficient scale and speed.

Hospital leaders have told me that workloads this summer have been similar to those experienced in winter, with bed occupancy more than 90 per cent and extra winter capacity kept open to enable them to cope. They worry what will happen if there is a harsh winter combined with more cases of flu than experienced in recent years. The extent of operational pressures raises important questions about the credibility of STP plans that require reductions in beds and possibly hospital closures to deliver financial savings and release nurses and other staff to work in the community. Failure to reduce demands on hospitals may yet prove to be the Achilles heel in many of the plans.

For all of these reasons, STPs should therefore be read with a degree of healthy scepticism when the final versions that are submitted in October are published. Collaboration between NHS organisations when planning for the future is very much to be welcomed, but must be based on a realistic assessment of both the services needed to meet changing population needs, and the time it takes to transform these services to make them fit for the future. Just as important is realism about savings that can be achieved by reducing reliance on hospitals and strengthening services in the community – and how quickly they can be realised.

These issues have become more prominent as STPs have evolved – from being plans primarily about how to transform care, to plans that also have to show how the NHS will balance its books towards the end of a decade of austerity. NHS leaders will have to do a lot of heavy lifting to achieve both objectives, and in the process garner the support of the organisations and communities affected. They have to do so with the knowledge that use of NHS funding increases to reduce deficits has left limited resources to pump-prime new care models, and that resources for capital investments to support the reconfiguration of acute hospitals are in short supply.

The other big challenge is to put in place the governance and leadership to implement changes that affect services across different organisations, when governance and accountability are focused on organisations and not systems. Working with leaders on the development of an STP in one footprint recently, I ventured the thought that they were swimming against the tide in seeking to collaborate in a system designed to promote competition. Actually, it often feels like they are attempting to undertake synchronised swimming against a rip tide, given the requirement for many different organisations to reach agreement in a context in which national regulators are not always consistent in their dealings with commissioners and providers.

Exceptional skill and effort on the part of STP leaders will be needed, both to agree credible plans and ensure their implementation. The first stage of our research into the development of STPs is nearing completion, and we shall be reporting the results in November. STPs are here to stay, and lessons learnt this year will help to inform how they should be strengthened in future.

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John King

Ethos Health Ltd
Comment date
02 October 2016
Strong article but my question is with no whole systems decision tools, collaborative working processes or complex care evidence bases, what is the KF view on the solution to overcoming the perennial cultural, organisational and incentivisation barriers to developing such STP plans (let alone delivering them)?

Gus Cairns

Retired Volunteering as Patient Rep and Governor,
NHS England or anyone who will take me on
Comment date
30 September 2016
I have been trying to get Patient Involvement in STP's since the first guidance came out in December 2015 which said patient and public involvement was an integral part of planning for STP's . Then a rehash of Guidance in May and another in September all saying Public Involvement . .That was just an expensive smoke screen though because privately NHS England were ordering STP CEO's and Coms Teams not to publish the June Submissions and not to let anyone see the October Submissions in case the country went up in arms about the inevitable cuts that are coming .I see publication is down for the week of Christmas so people will be too interested by Christmas to notice an old Government ruse get bad news out of the way around a holiday time . Oh well Healthwatch are in Councils Pockets as they commission them . Councils are in STP's so healthwatch are conflicted in this

Paul Bunting BSc MSc

Retired NHS professional,
Comment date
26 September 2016
The noble aim of combining planning of NHS and care home services begs the questions, which have not been answered, where the money will come from and who shall pay for it. A combined aim apparently is to make everything more money efficient when there is no evidence it can be. Such a plan without adequate resources and proper understanding of where money can be saved if such saving is possible is unlikely to succeed. There needs to be a stay on implementation while we work out the costs and resources, and there has been no public engagement to get public support for these plans. The Government has already restricted the funds to the NHS while claiming to give the NHS more money and here is a re-organistion of such substance that usually requires an Act of Parliament to get the support of politicians across the political spectrum. Why is it being done on the quiet?

Christopher Wood

Consultant HIV Physician,
North Middlesex University Hospital
Comment date
19 September 2016
Professor Ham, thank you for your detailed, but much understated piece - notwithstanding the statement about STPs that..... 'they are attempting to undertake synchronised swimming against a rip tide'!

The reality is that the current plans and timescales being imposed on STPs are reckless and dangerous. There should be an IMMEDIATE MORATORIUM called on STPs and other similar major re-organisations of the NHS that are in the pipeline. STPs may well be fine in theory - and that is debatable - but as you clearly state they are not a short-term answer to austerity and quickly delivered savings. In their current incarnation - with the expectation of immediate savings and transformation occurring in a fraction of a financial year they are a reckless and dangerous absurdity. The only sane solution is a moratorium. They NHS and its funding need a proper overall review with some bridging funding made available to meet the immediate needs of the NHS deficit and a proper cross-party/stakeholder consultation to decide its future. The need for the Acute sector cannot be 'wished away' as you make clear in your piece. I suspect that a lot of recent health policy has been made by fantasists in denial that acute illness really exists. The acute sector has been mistakenly marginalized since - at least - the introduction of the fatal Lansley 'Health and Social Care Act' and the Darzi report. It will take years of coordinated planning and investment to get prevention and social care to the point where they can make a real impact on Hospital Activity and the more acute and severe manifestations of ill-health. This certainly will not happen while the current mania for major uncoordinated and unfunded interventions is indulged by the detached and unaccountable elites currently making health policy. The leadership and vision that the NHS needs is completely lacking from the Secretary of State for Health, the DoH and NHS England - otherwise why would any serious Health Policymakers be endorsing the unsightly haste with which STPs are being pushed forward? It is a dangerous collective delusion in the context of an engineered funding crisis, collapse of workforce morale, years of austerity cuts and an arrogant policy-making elite who have no interest or respect for 'evidence', 'piloting' or consultation. I have to try and hope that many of them are likely to be well meaning, but many others seem to have serious problems with the original 'mission' and aims of the NHS and are impatient and opportunist in their desire to re-fashion it into something that I believe the great majority of the population that the NHS serves would find very disturbing.

In summary, I believe that there needs to be an immediate moratorium on STPs and other major NHS re-organization, including the increasing role of the private sector. Bridging funds need to be made available to consolidate safe healthcare in the short-term while these issues are being sorted out to mitigate the impact of the current chaos. The debate will need to start with a public debate about the amount spent on Health in the UK as a proportion of GDP, in order to ensure that 'affordability' for the NHS is decided by the population at large with a clear view of the wider political and other factors and choices that help to define 'affordability' and the 'limited' funding for the NHS.

The King's Fund and the Nuffield Trust have already provided sufficient dispassionate and well-researched data and analysis to inform many of these issues and help start the process. However, unless the brakes are put on the current inchoate jumble of proposals and policies, the impact on the NHS and the nation's health will take years to unravel and will be the cause of much unnecessary human suffering. Sincerely yours, Dr Christopher Wood. (With over 30 years service in the NHS, nearly 20 of those as a Hospital Consultant)

Emma Whitby

Chief Executive,
Healthwatch Islington
Comment date
15 September 2016
Within the Healthwatches across North Central London we are baffled by the secrecy surrounding these plans. Communicating the aims and perceived benefits of any potential change will be essential. Why NHS England want to keep local people so far removed from this planning makes no sense at all.
We will be aiming to keep our local communities informed as information becomes available @HWIslington

Jane Young

Disabled service user,
Comment date
14 September 2016
I suspect that pressures on hospitals can be reduced by:
- increasing funding to GP services, so patients can actually get appointments;
- staffing NHS 111 with medically qualified staff (I understand the service often refers callers to A&E, which may not be clinically necessary);
- co-locating OOH GP services & A&E;
- increasing funding for proper mental health services (not just the IAPT sticking plaster);
- bringing NHS community services & social care together for older people;
- providing social care to working age disabled people in a way that maximises independence and ability to work;
- giving warnings to patients who use A&E services inappropriately;
- employing social workers and housing officers at GP surgeries and A&E depts;
- imbuing DWP with common sense (not going to happen!)

In other words, we won't reduce pressures on NHS unless we take a whole system approach that takes account of health, deprivation/food poverty, benefits, housing, mental health etc. Increasingly brutal social security policies alongside the proliferation of poorly paid, insecure jobs, the housing crisis and the massive underfunding of social care are all increasing mental ill-health and pressure on health services. It's a political and societal issue, as much as a health issue, with the NHS trying to pick up the pieces. It's not sustainable or easy to solve.

kevin riley

Retired Public Sector Solicitor and User and active Supporter of Doctors and Nurses working in the NHS,
Self Empoyed
Comment date
13 September 2016

-Chief Executives and senior managers accounted for only 2.35 per cent of the 1.318 million staff employed by HCHS and GP services across the NHS in 2015" (Source * HCHS = Hospital and Community Healthcare Services.

Therefore 50% of the total amount spent by the NHS on employing staff is being spent on only 2.35% of the individuals employed – by the NHS namely the 165+ Chief Executive and other senior “managers “in each of the now “free from democratic control” NHS Foundation Trusts. (Source National Audit Office).

A gross disparity between operational and non-operational “service delivery” staff, that would never be tolerated in any other “service” industry - let alone one dealing with (literally) life or death situations on a daily basis.


Kevin S. Riley Solicitor (Ret.)

Stella I. Tsartsara

South East Europe Healthcare
Comment date
12 September 2016
Well said Caroline about the community collaboration.
For the resources you may need more OT, social workers than nurses who are needed to supervise specially LTC.
But this each STP would be able to judge on their own.

BTW, Dr Ham, how the Scottish have resolved the need for Place based care (which is the future everywhere not just England) ?


Community matron,
Hounslow and Richmond community Trust
Comment date
12 September 2016
I've read this article and question how the community can swim against the rip tide of we can't get sufficient nurses in the community to meet this agenda. Duplication of roles , professional competition as a result of contracts for commissioned services. We have all got to think of the community as one team how can we meet this agenda together and take out the competition that the policies have created.

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