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 thegeographical ‘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). Anamed individualhas 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. The intention is for the plans to now be assessed by national NHS bodies, and used to form the basis of new operational plans for NHS organisations and contracts between commissioners and providers. 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 thatgrowing financial problemsin 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 aplace-based approach to planning and delivering health and social care servicesis the right thing to do. This should also include collaboration with other services and sectors beyond the NHS to focus on thebroader 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 suggests 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 anNHS environmentthat 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.

Will STPs deliver benefits for local populations?

We won’t know the potential benefits of STPs until the plans are finalised and agreed. We are currently analysing the content of publicly available STPs and will publish our findings early in 2017. The plans cover a broad range of themes. This includes 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.

Whether or not these ambitions can be delivered is yet to be seen. Developing new models of health and social care takes both time and resources. Yet 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. Cuts to local government budgets also make the ambition of prioritising prevention more challenging.

STPs include ambitions to improve care in specific services areas – such as cancer care or mental health services – as well as supporting and developing the health and social care workforce. Attention is also being given to the changes needed in the supporting infrastructure for NHS services – such as IT systems and NHS buildings.

Some areas are exploring changes to acute and community hospital services as part of their STP including proposals to consolidate services and reduce the number of beds. These proposals 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.

Local leaders have also been asked to show how their plans will deliver financial balance for the NHS in their area – a theme that has become more prominent as the STP process has gone on. National leaders in the NHS 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 services back into balance as quickly as possible. While closing gaps in NHS finances is undoubtedly important, there is a risk that plans for developing new models of care and prioritising prevention – things that are unlikely to deliver financial savings in the short term – will take a back seat.

Where next?

STPs provide an important opportunity for improving health and care services in England. 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 are now carrying out work to analyse the content of the plans.

For more information, please contact Hugh Alderwick, Senior Policy Adviser to Chris Ham: