Sustainability and transformation plans (STPs) explained

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Sustainability and transformation plans (STPs) were announced in NHS planning guidance published in December 2015. NHS organisations and local authorities in different parts of England have come together to develop ‘place-based plans’ for the future of health and care services in their area. Draft plans were produced by June 2016 and 'final' plans were submitted in October. These plans now need to go through a process of assessment, engagement and further development. But what do STPs really mean? And what will they mean for the NHS and for local populations?

What are STPs?

STPs are five-year plans covering all aspects of NHS spending in England. Forty-four areas have been identified as the geographical ‘footprints’ on which the plans are based, with an average population size of 1.2 million people (the smallest covers a population of 300,000 and the largest 2.8 million). A named individual has led the development of each STP. Most STP leaders come from clinical commissioning groups (CCGs) and NHS trusts or foundation trusts, but a small number come from local government.

The scope of STPs is broad. Initial guidance from NHS England and other national NHS bodies set out around 60 questions for local leaders to consider in their plans, covering three headline issues: improving quality and developing new models of care; improving health and wellbeing; and improving efficiency of services. Leaders were asked to identify the key priorities needed for their local area to meet these challenges and deliver financial balance for the NHS. The plans needed to cover all aspects of NHS spending, as well as focusing on better integration with social care and other local authority services. They also needed to be long term, covering October 2016 to March 2021.

The timelines for developing STPs and the process for approving them have been somewhat fluid. The original deadline for submitting plans to NHS England and other national NHS bodies was the end of June 2016. But this deadline was pushed back to the end of October 2016. Additional planning requirements have also been added as the process has gone on. As of 16 December, all 44 plans submitted in October are now publicly available. From April 2017, STPs will become the single application and approval process for accessing NHS transformation funding, with the best plans set to receive funds soonest. For more detail on timescales, see our STP timeline.

What do STPs mean for the NHS?

STPs represent a shift in the way that the NHS in England plans its services. While the Health and Social Care Act 2012 sought to strengthen the role of competition within the health system, NHS organisations are now being told to collaborate rather than compete to respond to the challenges facing their local services. This new approach is being called ‘place-based planning’.

This shift reflects a growing consensus within the NHS that more integrated models of care are required to meet the changing needs of the population. In practice, this means different parts of the NHS and social care system working together to provide more co-ordinated services to patients – for example, by GPs working more closely with hospital specialists, district nurses and social workers to improve care for people with long-term conditions.

It also recognises that growing financial problems in different parts of the NHS can’t be addressed in isolation. Instead, providers and commissioners are being asked to come together to manage the collective resources available for NHS services for their local population. In some cases this may lead to ‘system control totals’ – in other words, financial targets – being applied to local areas by NHS England and NHS Improvement.

This all represents a very new way of working for the NHS. At The King’s Fund we’ve argued that taking a place-based approach to planning and delivering health and social care services is the right thing to do. This should also include collaboration with other services and sectors beyond the NHS to focus on the broader aim of improving population health and wellbeing – not just on delivering better quality and more sustainable health care services.

How have STPs been developed so far?

The process of developing STPs so far has not been easy. The pressures facing local services are significant and growing, and the timescales for developing the plans have been extremely tight. Expectations and timelines for the plans have changed over time, guidance has often arrived late, and there have been inconsistencies in the approaches taken by different national NHS bodies. Leaders have also faced practical challenges to working together on the plans. STP footprints are often large and involve many different organisations, each with its own culture and priorities. Progress made on the plans in different areas is highly dependent on local context and the history of collaboration between organisations and leaders.

Our research in 2016 suggested that local leaders have found it difficult to meaningfully involve all parts of the health and care system – particularly clinicians and frontline staff – in developing the plans. The involvement of local authorities has varied widely between STP areas, ranging from strong partnership between the NHS and local government to almost no local government involvement at all. Patients and the public were largely absent from the initial stages of the planning process.

One of the biggest challenges facing local leaders is that STPs are being developed in an NHS environment that was not designed to support collaboration between organisations. The legacy of the Health and Social Care Act 2012 looms large over the STP process; in many ways, STPs represent an imperfect ‘workaround’ to the fragmented and complex organisational arrangements in the NHS created by the 2012 Act. But making this workaround actually work in practice is difficult when the previous rules of the game still apply – and are often strictly enforced. Leaders of NHS providers, for instance, find themselves under significant pressure from regulators to improve organisational performance. This means focusing primarily on their own services and finances rather than working with others for the greater good of the local population.

In this context, incentives for NHS providers to work together can be weak. The very real danger is that organisations take a ‘fortress mentality’ instead, acting to secure their own future regardless of the impact on others. The dissonance between place-based planning and the continuing focus on organisational performance in the NHS is therefore stark.

What are the main themes in STPs?

The plans cover a broad range of themes – ranging from prevention and primary care to specialised services in hospitals. All STPs include proposals to strengthen primary and community services and to integrate NHS and social care services more closely around the needs of patients. The plans also describe ambitions to improve the broader health and wellbeing of the populations they serve – for example, by encouraging healthy behaviours.

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Whether or not these ambitions can be delivered is yet to be seen. There are, of course, opportunities to manage care more effectively in the community. But developing new models of health and social care takes time and resources – both of which are in short supply. Additional funding for the NHS (made available through the Sustainability and Transformation Fund) has been, and remains, primarily focused on reducing NHS deficits rather than transforming the way services are delivered in the community. Cuts to social care and public health budgets also make the ambition of prioritising prevention more challenging.

STPs include ambitions to improve care in specific services areas – such as cancer or mental health services – as well as supporting and developing the health and care workforce. The plans also include ambitions to reduce unwarranted variations in care and improve productivity. STPs also give attention to the changes needed in NHS infrastructure – such as IT systems and NHS buildings – to support their ambitions to transform services. The changes needed to NHS organisational arrangements and incentives are considered too.

Some STPs propose changes to acute hospital services. These changes include proposals to centralise some acute services and to deliver care through networks of hospitals. Some plans also propose reducing the number of acute hospital sites within an STP footprint. Quality issues, workforce constraints and financial pressures are all identified as reasons behind these proposals, which will need to be assessed on a case-by-case basis. Evidence on the impact of major reconfigurations of acute hospital services in the NHS on quality and costs of care is mixed.

Some STPs project a reduction in the number of acute hospital beds in their area as a result of the changes they propose. NHS 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 strain – with growing pressures in general practice, district nursing, mental health, and adult social care. In this context, proposals in STPs to reduce capacity in acute hospitals will only be credible if there are coherent plans to provide alternatives in the community. This will require additional investment in these services.

All STPs also describe plans to close gaps in NHS finances – a theme that has become more prominent as the STP process has progressed. National NHS leaders are under pressure from the Department of Health, Number 10 and HM Treasury to reduce NHS deficits, and this has been translated into pressure on local STP leaders to show how their plans will bring NHS finances back into balance. The desire of local leaders to set out ambitious aims for doing this is therefore 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.

Where next?

STPs provide an important opportunity for improving health and care services in England. Proposals to integrate health and social care services more closely and invest in prevention in particular should be given high priority in all parts of the country.

The reality is that the plans submitted in October represent just one part of a longer-term process of improvement in the NHS, rather than the final word on how services will change. This process must continue, and the current plans need to be ‘stress tested’ to ensure that the assumptions underpinning them are credible and the service changes they propose can be delivered. Realism is needed about what the plans are able to achieve within the levels of funding and timescales available. Honesty will be needed in communicating these messages to politicians and the public.

The key priority for STP leaders in the short term is to strengthen involvement in the content of the plans – particularly among clinicians and other frontline staff, local authorities, and patients and the public. The next job will be to equip staff with the skills and resources needed to implement the improvements in care described in the plans. Leadership and governance of STPs at a local level will also need to be strengthened. The focus of the process so far has been on planning, but the real challenge lies in turning the plans into reality. Changes to incentives and performance management in the NHS are likely to be needed to overcome the barriers that get in the way.

Find out more

The King’s Fund has carried out research to track the development of STPs in four parts of the country. The findings are available in our publication, Sustainability and transformation plans in the NHS: how are they being developed in practice?

We have since carried out work to analyse the content of the plans, the findings of which are in our latest publication, Delivering sustainability and transformation plans: from ambitious proposals to credible plans.

For more information, please contact Hugh Alderwick, Senior Policy Adviser to Chris Ham: h.alderwick@kingsfund.org.uk