London presents a puzzle for advocates of place-based systems of care. The capital is home to specialist services and hospitals of world-class standards working alongside many innovative primary care and community health services.
Local authorities and clinical commissioning groups (CCGs) in some of London’s boroughs are leading the way in integrating health and social care services and exploring how they can improve population health. Despite these achievements, sustainability and transformation partnership (STPs) in London are less advanced than in many other parts of England, and none has yet progressed to become an integrated care system.
Our new report, Sustainability and transformation partnerships in London: an independent review was commissioned by the Mayor of London. Our research shows that London’s STPs have spent much of the last year trying to overcome the challenging process by which they were introduced. The tight deadlines for submitting STPs meant that the involvement of local authorities and other stakeholders left much to be desired. Not only this but also the content of the original plans raised concerns that STPs were a means of cutting services rather than improving care, and they were widely perceived to be NHS-centric.
The capital’s STP leaders have sought to allay these concerns by revisiting some of the assumptions on which the original plans were based. Proposed cuts to hospital beds in some STPs have been dropped in recognition that these cuts are not realistic in the context of population growth and pressures on acute hospitals. All STPs are focusing on developing services in the community, including general practice and community health services provided by NHS trusts. They are also supporting moves to integrate health and social care services being led by borough councils and CCGs.
The cluttered organisational landscape in London creates difficulties in building effective partnerships both within the NHS and with other stakeholders. Alongside the large numbers of NHS commissioners and providers, borough councils and the Greater London Authority, many other bodies are involved in work to improve health and care. They include academic health sciences centres and networks, the Healthy London Partnership, Public Health England (London), and commissioning support units.
There have been specific challenges in engaging teaching hospitals effectively in the work of STPs. These hospitals care for patients from across London and beyond, and their attachment to the areas in which they are located is often weaker than that of local hospitals and other NHS services. Much more needs to be done to draw on their expertise and involve their staff in delivering the ambitions of STPs, learning from examples like the Montefiore Health System in New York which illustrate what can be achieved when the leaders of academic medical centres reach beyond the walls of their hospital and play a leadership role in integrating care and improving population health.
The puzzle of STPs in London is partly explained by the uncertain position they occupy between the Mayor and the GLA on one hand, and borough councils and the city of London on the other. Lacking a clear focus on meaningful communities, STPs have yet to establish themselves as collaborations that can make a positive difference to the populations they serve. As coalitions of the willing, their impact hinges on the ability of partner organisations to find common cause, rising above their organisational interests to see the bigger picture.
A major difficulty in doing this is the legacy of competitive behaviours between NHS providers and transactional relationships between commissioners and providers. As well, variations in financial performance do not make it easy to move towards shared responsibility for NHS budgets in the footprints covered by STPs. This is illustrated by the existence of large deficits in King’s College Hospital NHS Foundation Trust and Barts Health NHS Trust alongside surpluses in neighbouring providers such as University College London Hospitals NHS Foundation Trust and Guy’s and St Thomas’ NHS Foundation Trust.
Our report argues that the Mayor of London has a major role in working with the NHS, London councils and other bodies to provide London-wide leadership, building on the recently published health inequalities strategy. This includes work on prevention and population health which is underdeveloped in STPs. The imminent appointment of a London regional director across NHS England and NHS Improvement should help in filling the growing strategic vacuum that has opened after abolition of the strategic health authority in 2013. Plans to undertake a strategic review building on Lord Darzi’s previous reviews of the NHS in London are timely in this regard.
If STPs are to succeed, the resources of academic health sciences networks, the Healthy London Partnership and other bodies should be aligned behind their work; leaders of teaching hospitals must step up to the plate; and local authority involvement needs to be on a par with that seen in Greater Manchester where a history of joint working in local government explains the faster progress made in its health and social care partnership. Above all, each STP must develop a compelling vision that is widely shared and understood – and focused on using resources to improve health and care.