STPs: where are we now and what happens next?

Sustainability and transformation plans (STPs) have now been produced by NHS and (sometimes) local government leaders in 44 parts of England. The plans are important, setting out the proposed direction for health and care services over the next five years. But they been developed at significant speed and, for the most part, without the involvement of frontline staff or patients. They also propose major changes to services that will be unpopular with politicians.

For those in need of a primer: STPs were introduced in NHS planning guidance published in December last year. NHS organisations and their partners were asked to work together to make plans for the future of health and care services in their area. The plans needed to cover three broad themes: improving quality and developing new models of care; improving health and wellbeing; and improving efficiency of services. First drafts of the plans were produced in June and ‘final’ plans were submitted to NHS England in October. We have been carrying out research in four STP areas and will be publishing the first tranche of findings from this work in just over a week’s time.

The task of developing the plans has not been easy. Timescales have been tight. Expectations have shifted over time. And the challenges facing local services are significant and growing. National leaders in the NHS are under pressure from the Department of Health, Number 10 and HM Treasury to reduce NHS deficits, and this has been translated into pressure on local STP leaders to show how their plans will bring NHS services back into balance as quickly as possible. This pressure has grown as the process has gone on.

The plans have also been developed in an NHS environment that was not designed to support collaboration. The legacy of the Health and Social Care Act 2012 looms large over the STP process; in many ways, STPs represent an imperfect ‘workaround’ to the fragmented and complex organisational arrangements in the NHS created by the 2012 Act. But making this workaround actually work in practice is difficult when the previous rules of the game still apply – and are often toughly enforced. NHS providers, for instance, face strong incentives to improve their organisation’s own performance and only weak incentives to collaborate.

This has made the already difficult process of developing STPs even more challenging. And it’s important to recognise that the ability of local leaders to overcome these challenges is far from equal. Progress on the plans varies widely depending on local context – including the nature of relationships between senior leaders, the history of collaboration between organisations, and the size and complexity of the STP footprint. This means that some of the plans submitted in October are much less ‘final’ than others – and all will need further work and engagement before they can be implemented.

NHS England had hoped to check the 44 plans before making them public later in the year. But four STPs – two in London, one in Birmingham and one in the north east – have been published early by local authority leaders amid growing criticisms of the process and its lack of transparency. More areas are likely to follow suit.

These plans provide a taste of what will follow. They highlight the severity of the financial pressures facing NHS services. In north-central London, for instance, the combined NHS deficit ‘if nothing changes’ in how services are delivered is estimated to be £876 million by 2020/21. The gap in Birmingham’s plan is estimated to be £712 million, including a £130 million deficit in adult social care services.

They also demonstrate the major service changes being considered by NHS leaders. In south- west London, for instance, the plan proposes a cut in the number of acute hospitals from five to four or three. In the north east of England (in Durham, Darlington, Teesside, Hambleton, Richmondshire and Whitby), plans are being made to consolidate acute medical services and close accident and emergency (A&E) services at one of their major hospitals. In both cases, the changes are projected to save money and improve care quality.

The plans also include ambitions to prioritise prevention, strengthen primary and community services, and develop new models of care between the NHS and local government. We have argued elsewhere that doing this is the ultimate prize on offer for STPs.

But the risk is that these ambitions will be drowned out by bitter public debate about changes to acute hospital services, despite evidence suggesting that major acute reconfigurations rarely save money and sometimes also fail to improve quality. As a recent debate in the House of Commons showed, changes to hospital services are also likely to face opposition from politicians – particularly given next year’s local government elections and the lingering possibility of an early general election too.

So the STP process is at a precarious point. What will happen next? The reality is that the plans submitted last month represent the start of a longer-term process of improvement rather than the final word on how services will change. This process must continue, and the current plans need to be heavily ‘stress tested’ to ensure that the assumptions underpinning them are credible and the service changes they propose can be delivered. Realism is needed about what the plans are able to achieve within the levels of funding and timescales available. Honesty will be needed in communicating these messages to politicians and the public.

The most important priority for STP leaders in the short term is to strengthen involvement in the content of the plans – particularly among clinicians and other frontline staff, local authorities, patients and the public. Collaboration to improve services and manage limited resources is the right thing to do. But this collaboration must extend to those responsible for delivering those services, as well as the people who pay for and receive them. The next job will be to equip staff with the skills and resources needed to make these improvements happen in practice. The focus of the process so far has been on planning, but the real challenge lies in turning the plans into reality.

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Comments

#548557 Helen Organ

I ant to hear more about the STPs

#548558 Daniel Casson
Head of Business Development
Jewish Care

The process has been top down without public involvement. Hugh, when calling for greater collaboration you call on a strengthening of the "involvement in the content of the plans – particularly among clinicians and other frontline staff, local authorities, patients and the public".

You miss out a vital section - those of us involved in social care who are subsidising the public purse by millions supporting people in their own homes, in places they live with housing with care and in the community. Without realising that community is vital for supporting our health and social care structure the STPs will follow the same path of integration without real co-production and collaboration.

The NHS has been turned on its head since 1948 with the original power of the consultants being passed down to more consultative bodies. Now is the time for revolution, for community to be involved as a building block of health and social care.

#548559 Occams Razor

What is it about Greater Manchester's STP that was done well as all seems pretty quiet in that part of the country?

Was it because their STP was effectively published a year ago and little is new?

#548560 George Coxon
Portfolio of roles across H&SC
Various

It take a brave person 'in the system' as it were to speak out about the impact and risks placed upon the public, patients and H&SC providers arising from cuts upon cuts amidst perpetual new slogans and acronyms generated from the so called 'centre'. I was not so long ago a loyal servant of the high command of NHS senior management but have now migrated back to a level of 'real' front line care work with a multiple range of part time jobs including owning care homes affording me some freedom to respond to QIPPs, FYFVs, Vanguards, New Care Models and STPs with a healthy independent scepticism. I am able to reaffirm my clinical skills and lead by example I believe in direct contact with some of our most vulnerable citizens who deserve the best care we can offer. I still have some faith in making positive impactful noise, instilling enthusiasm and kindness in my staff being inspired by them and inspiring in return as much as I can. The embedding of curiosity in how we look after our residents in my care homes and creating a strong culture of belief based on respect & ownership is the essence of reflection and improvement? If STPs don't feel real to us all and genuine capturing hearts and minds being simply another form of dressing up a justification for lack of investment in essential care and treatment then my efforts to retain optimism and trust will diminish as will that of many of my determined and proud fellow advocates for innovation and sustainable services. Too many disingenuous double speaking by the self interested is creating more cynicism and burnout of good people I've got ideas and energy for the 'in it together' principle but sharing risk and putting best or common interest first must prevail. As must meeting true costs of care and investing not disinvesting in such areas as social care or mental health.

#548590 Allan Hargreaves
Manager
irrelevant to the subject

Unfortunately this debate is always cast in terms of "investment" versus cuts. Surely the starting point should be a really open debate on:
1. what we as a nation are willing to spend on the combined LA and health budget.
2. how we can most effectively bring together these 2 budgets.
If we don't do this, the issue of improving overall efficiency will be lost in strident political debate of the worst kind.
This issue is fundamentally apolitical, and it is completely wrong to politicise it.
As the KF's own study has shown, what we spend on health is roughly in line with what other advanced economies (except of course the US) spend.

#548716 Mac Cock
Chief Operations Officer
Carers Association Southern Staffordshire

There doesn't seem to be any consideration for informal Carers , who provide the majority of care in our communities with little recognition or support for what they do. They save the NHS and Local Authorities £ millions, but rarely get acknowledged or given a break. The Care Act has increased the opportunity for them to be assessed but not necessarily gain support. What difference will STPs make to Carers?

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