The development of sustainability and transformation plans (STPs) is central to the NHS policy agenda, and it is expected that they will continue to play an increasingly prominent role in planning services and managing resources around places and populations.
London’s health and care system differs from systems in other parts of England because of its size, diverse population and the presence of major teaching hospitals with national and international roles.
Place-based working in London needs to reflect these distinctive characteristics as well as the organisational complexity of the NHS and the contribution of local authorities.
Many of the ambitions set out in London’s STPs are being delivered at the level of neighbourhoods and boroughs and across boroughs, building on established and developing collaborations between the NHS, local authorities and others.
STPs have a role in tackling issues that lend themselves to action across bigger geographical footprints, such as the configuration of acute and specialised services. Some issues will require collaboration between STPs and across the whole of London.
London is experiencing rapid demographic growth, workforce shortages, and severely constrained NHS and local authority funding. This creates a challenging environment for STPs to operate within.
STPs in London have spent much of the past year trying to overcome the challenging process by which they were introduced. Their leaders have focused mainly on the internal workings of the partnerships, building external relationships and addressing gaps in staff and public engagement.
Local government involvement in STPs is variable and, in a small number of places, non-existent. This reflects the difficulties STPs experienced at their outset, the concerns of some local authorities that STPs are a vehicle for cuts and privatisation, and a perception that STPs are NHS-centric.
The bed-modelling and financial positions that were set out in or inferred from the original plans no longer form the basis of the work being done in London, in recognition of the fact that some of these plans were unrealistic in the face of rising demand for care and anticipated population growth.
There are many examples of service changes across London, often in individual boroughs or across boroughs. STPs have helped to facilitate some of these changes.
The priority now is for STPs to build on this work and demonstrate how they can make a positive impact on issues that require action on a larger scale. They also need to communicate more effectively the contribution they are making to improving health and care.
Teaching hospitals need to be engaged more effectively in the work of STPs, recognising their expertise in providing specialist care and in contributing to population health improvements and integrated care.
The Mayor has a major role in working with the NHS, London councils and other bodies like Public Health England, building on the foundations that STPs have laid. This includes work on prevention and population health, which is underdeveloped at STP level, and where there are lessons from other global cities.
A review is needed of how different bodies can best work together to improve health and care. The review should clarify how the London Health Board and Strategic Partnership Board can work with the new London region being established by NHS England and NHS Improvement and with STPs.
As part of this, work is needed to establish how the resources of the Healthy London Partnership, Public Health England, Health Education England, academic health science networks (AHSNs) and other bodies can be more closely aligned with the work of STPs.
The London-wide reviews led by Lord Darzi in 2007 and 2014 should be revisited and refreshed to address concerns we heard that there is a growing strategic vacuum in London resulting from the abolition of the strategic health authority in 2013 and fragmentation in London-wide leadership of the NHS. We understand that the Strategic Partnership Board has agreed that work needs to be done to fill this vacuum.
About this report
This independent report was commissioned by the Mayor of London. The views in the report are those of the authors and all conclusions are the authors’ own.
This work follows a previous independent report published by The King’s Fund and Nuffield Trust in September 2017 (also commissioned by the Mayor of London), which analysed the content of London’s sustainability and transformation plans and the financial and activity assumptions underpinning them (Ham et al 2017b). It also builds on The King’s Fund’s wider work on STPs in England (Ham et al 2017a; Alderwick et al 2016) and the development of integrated care systems (ICSs) in some areas of the country (Charles et al 2018; Ham 2018).