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STP leaders face major challenges in transforming care and balancing budgets

With NHS sustainability and transformation plans hitting the headlines recently, Chris Ham discusses how the plans are shaping up and the challenges in developing new care models and delivering unprecedented improvements in efficiency.

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.