Analysing STPs in London: service reconfiguration, finances and leadership

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Earlier this year the Mayor of London, Sadiq Khan, asked The King’s Fund to undertake an independent assessment of London’s five sustainability and transformation plans (STPs). Together with colleagues at the Nuffield Trust, we reviewed the content of the plans and their assumptions about the use of hospital beds and the impact of proposed service changes on NHS finances. We checked our thinking with STP leaders and a few other stakeholders, including colleagues from local government.

Our report published today finds many similarities between London’s STPs and those produced in the rest of England. There are shared ambitions to give greater priority to prevention and early intervention and to strengthen and redesign services delivered in primary care and the community. There are also plans to reconfigure hospital services and, in some cases, to concentrate specialist services in fewer hospitals to improve outcomes.

More contentious are proposals in some of London’s STPs to reduce the use of hospitals and cut the number of beds. Our detailed assessment of these proposals concludes that even if additional investment is made in community services, cuts on the scale proposed are not credible. Indeed, with the population of London projected to increase in coming years, heroic efforts will be needed to manage rising demand with existing capacity.

Equally questionable are proposals to close an expected financial gap in the NHS in London of more than £4 billion by 2020/21. Our analysis found a worrying lack of detail on how this gap would be filled and unrealistic assumptions about the level of efficiency savings that could be delivered. Some of the STPs submitted in October 2016 acknowledged that more work was needed on their financial plans, and this task has become more urgent with the introduction of the capped expenditure process.

Despite these reservations, we believe that STPs offer the best hope for the NHS and its partners to plan together for the future. As in the rest of England, much more needs to be done in London to engage with partners in local government and other sectors and to involve patients and staff. The leadership and staffing of sustainability and transformation partnerships also needs to be strengthened as the focus shifts from planning to implementation.

In London and elsewhere, the proposals in STPs will require co-ordinated action at different levels if they are to make a difference. Not everything has to be done by the partnerships; much can be achieved at a more local level in neighbourhoods, boroughs and groups of boroughs working together to integrate care and improve health for the populations they serve. The Mayor’s distinctive contribution is his ability to look across the capital and to provide civic leadership on issues that affect everyone.

With the powers currently available to him, the Mayor can:

  • provide leadership on the prevention of ill health and tackling health inequalities
  • support changes to the delivery of NHS services where the clinical case for change has been made
  • work with the NHS to make better use of its estate
  • support the NHS to tackle workforce shortages and to address concerns about the impact of Brexit on EU staff working in the NHS
  • develop London as a global leader in life sciences
  • provide leadership on and oversight of the work being done by the partnerships.

The STPs submitted last October are best seen as a starting point for debate; some have already moved on and further work has been done to test their assumptions. Our report contributes to that process and we look forward to working with NHS leaders and their partners in the next stage of development.

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