Seven big questions facing STPs

What are the opportunities and challenges in implementing sustainability and transformation plans?

1. Is it possible to convince the public, local authorities and other stakeholders to lend support to STPs when controversy has accompanied their development to date?

STP leaders and their teams deserve credit for the progress they have made on their plans to date, despite a demanding deadline and shifting requirements. The limited time available made it difficult to meaningfully involve all parts of the health and care system in developing the plans. Local government involvement varied widely.

Despite some recent attempts to explain STPs in plain English, there is a significant communications challenge in engaging the public in the rationale for STPs and what they mean for them. An urgent priority is to proactively involve staff, patients and the public – as well as politicians, local authorities and the third sector – in further developing and implementing STPs.

A huge effort and adequate resource are now required to engage in genuine consultation on the content of STPs, and explain the case for change against likely opposition. This will require the leadership of STPs to be strengthened. STPs remain fragile and nascent additions to a cluttered landscape, and their place in the governance of the NHS needs to be clarified.

2. Is it realistic to plan reductions in the capacity of acute and community hospitals when many of these hospitals are currently operating at their limits?

Some of the demand on hospitals could be met more appropriately in other settings – for example, by providing alternatives to hospital admission and supporting earlier discharge. Long-term reductions in the number of hospital beds in England over previous decades have been achieved in part by developing these alternatives at a time when there is growing recognition that hospitals are not always the safest environment in which to care for patients.

But hospitals are currently under significant pressure. A&E attendances and emergency admissions to hospital are on a rising trend, delayed transfers of care are at record levels, and bed occupancy rates are above 85 per cent. Services outside of hospitals are also under major strain – with growing pressures in general practice, district nursing, mental health, and adult social care.

Proposals to reduce capacity in acute and community hospitals will only be credible if there are coherent plans to provide alternatives in the community. This must involve collaboration between the NHS and local government to use existing health and social care services more effectively and to fill gaps in provision. It will also require additional investment in these services. Work under way to test the assumptions on which STPs are based should test rigorously any proposals to reduce hospital capacity.

3. Where will the resources and staff be found to invest in services in the community, including social care, to deliver more care closer to home?

Additional resources for the NHS made available in the 2015 Spending Review are primarily being used to reduce deficits, mainly in acute hospitals, rather than to invest in services in the community. Earmarked funding is required to implement proposals to strengthen services in the community and to cover double-running costs, given the central importance of these proposals in STPs.

There are, of course, opportunities to use the staff and resources currently available in the community more effectively. This is already happening in many areas – for example, through the vanguards involved in the new care models programme, which are working to achieve greater integration between general practices, district nurses and related staff, and mental health services. STPs in a number of areas set out ambitions to extend the work of the vanguards by redesigning and expanding services in the community.

Yet even if community services can be redesigned at scale, we doubt whether all of the ambitions of STPs can be delivered without protection of public health funding and more funding for social care, which has a critical contribution to make in achieving the aims of the Forward View and STPs.

Recognising these constraints, our view is that the vanguards offer the best prospect for the NHS to strengthen community-based services with the aim of moderating demand for hospital care. They should build on previous examples within the NHS where this has been done, and on international experience in places such as Canterbury District Health Board in New Zealand and the Southcentral Foundation’s Nuka system of care in Alaska.

4. Are plans to reconfigure specialised services by concentrating some services in fewer hospitals necessary and desirable?

Proposals in STPs to reconfigure acute and specialised services continue a series of changes in the provision of hospital services that have been under way for many years. These proposals aim to address quality issues and workforce constraints. The financial sustainability of services is also identified in STPs as a factor behind the proposals.

Evidence on the impact of major reconfigurations on quality of care is mixed, and is strongest in relation to specialised services such as trauma, vascular services and stroke care. Evidence that reconfigurations produce financial savings is almost entirely lacking.

The need to explore ways of improving clinical care by changing where specialised services are provided is well understood in many parts of the NHS. The argument that quality of care may be improved by concentrating specialised services on fewer sites, especially when there are shortages of clinical staff, needs to be articulated more clearly and consistently. Failure to do so means that people will not always receive the best possible care.

Our view is that some reconfiguration proposals in STPs will be both necessary and desirable, whereas others will require detailed review to ensure that they stand up to scrutiny. All will have to handle the inevitable trade-offs between access, quality and cost, and each case needs to be considered on its merits.

5. Can these and other changes be implemented at sufficient scale and pace given the ambitions of STPs, the need to consult on plans, and other requirements?

Major service changes have to go through established processes of consultation before they can be implemented. This means that STPs are the beginning of a conversation with the public, staff, local authorities and other stakeholders, rather than the last word. The more ambitious the changes they propose, the longer and more challenging this consultation process is likely to be, unless those affected have been involved from the outset and have a well-developed understanding of the rationale behind proposed changes.

There is a parallel here with the transformation of mental health services from the 1960s. The progressive shift away from the former asylums to mental health care in the community did not occur through a ‘big bang’ but rather a succession of clinical and policy changes implemented over 30 years or more. These changes were underpinned by a combination of factors, including investment in double-running costs to allow new services to be developed before the asylums closed.

Our view is that the timescale associated with the Forward View is much too optimistic in relation to its most ambitious goals. Recent examples of service changes in the acute sector that have led to improvements in care have taken at least two to three years to negotiate and implement. Other service changes have taken much longer. A realistic expectation would be for those STPs that include major reconfigurations (and are most advanced in their planning) to be in the process of being implemented by the end of the period covered by the Forward View.

6. Will the legal framework in which STPs have been developed and the changes they propose act as a barrier to progress?

STPs are a conscious ‘workaround’ by national bodies of the complex and fragmented organisational arrangements that are the legacy of the Health and Social Care Act 2012. They have no basis in statute, and their proposals need to be endorsed and supported by the boards of the NHS organisations involved.

There is a risk that these proposals will be challenged – through judicial review and other means - by those who oppose them, which would introduce further delays to the implementation of planned changes. So it’s important that STP governance and decision-making processes are formalised to align the ambition to collaborate in STPs with the sovereignty, accountability and legal duties of the boards of NHS organisations and local authorities.

Proposals that involve the reconfiguration of acute services may also have to navigate the requirements of the 2012 Act relating to patient choice and competition. These requirements include referral to the Competition and Markets Authority (CMA) in cases where service changes restrict choice and competition, which could result in delay.

Our view is that there is a need to revisit the 2012 Act in the very different circumstances that exist today, with the aim of amending those aspects of the Act that are not aligned with the direction now being taken by the Forward View and STPs. The sections of the Act relating to market regulation would particularly benefit from review, both in relation to the role of the CMA and requirements on commissioners to use competitive processes in procuring new care models. There is also a need to recognise more formally the role that STPs are expected to play alongside the boards of NHS organisations and local authorities.

7. Will the proposals included in STPs be sufficient to close the care gaps identified in the Forward View, or at least make substantial progress in so doing, and enable the NHS and local authorities to live within the funding available to them between now and 2020/21?

As the STPs submitted in October 2016 are reviewed and strengthened, it will be essential to stress-test the financial as well as clinical assumptions on which they are based. Leaders of the NHS nationally and locally are under intense pressure to demonstrate that they are able to sustain existing services and begin the process of transforming care outlined in the Forward View. Their desire to set out ambitious aims for the future is understandable, but ambition needs to be leavened with realism about what can be achieved and over what timescale. Over-promising and under-delivering would not be helpful at a time of heightened media and political interest in the NHS.

Our view is that with exceptional leadership and commitment at all levels, STPs should provide evidence by 2020/21 that the NHS and its partners have embarked on a process that, over a longer timescale, holds out the prospect of closing the care gaps identified in the Forward View. STPs may also provide comfort that in transforming care, they are enabling the NHS to achieve financial stability. As we have argued, the capacity and capability of those working on STPs will need to be strengthened for this to happen, and there must be absolute alignment between NHS England and NHS Improvement, both nationally and regionally, in their approaches to the performance management of organisations and of the local systems of which those organisations are a part.

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