People will die because of the Government’s decision to focus on competition rather than quality in health care.— Richard Horton, editor, The Lancet
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What Sustainability and Transformation Plans (STPs) will mean in practice will vary from one ‘footprint’ to another. What is clear across the board though is that STPs will fragment the NHS and have a major impact on services. Analysis by the i newspaper suggested STPs will lead to the closure of 19 hospitals, including 5 acute ones, and the loss of nearly 3,000 jobs due to plans for a more ‘agile’ workforce.
In addition, while STPs are expected to bring about collaboration across different organisations, they have to do this despite the fragmentation and organisational complexity brought about, for the most part, by the Health and Social Care Act (2012). Individual NHS providers are under considerable pressure from regulators to improve their organisational performance, which means focusing primarily on their own services and finances rather than working with others for the needs of the local population. (https://www.kingsfund.org.uk/topics/integrated-care/sustainability-transformation-plans-explained)
Changes to services
According to the Nuffield Trust, judging by the discussions they have had with STP leads and others, examples of ideas being considered include:
i) significantly changing hospital services, including
- where patients are cared for (e.g. a planned 20% reduction in the number of hospital beds);
- the partial or complete closure of community hospitals;
- the re-thinking of outpatient services (e.g. changing referral routes with direct access to some services, or having hospital specialists working in primary care settings); and
- the downgrading of some A&E departments and hospital sites, with emergency services split from elective (i.e. planned) care.
ii) significantly changing primary and community services, including
- a shift from individual general practices towards ‘at-scale’ federations of practices and other primary care specialists, responsible for 30,000 to 50,000 patients;
- the development of new models of care, such as various kinds of accountable care organisations
iii) significantly changing approaches to prevention and health improvement, including
- the use of social prescribing, i.e referral to non-medical support in the community, such as help with employment or with increasing physical activity. (See ‘Social prescribing’ in our Explanation of Terms for more details.)
iv) significantly increasing efficiency, especially
- closing the gap between funding and service costs (such as ‘reorganising’ or centralising pathology services or back office functions; eliminating unnecessary testing, and rethinking thresholds (such as the level of pain a patient experiences) before providing referrals or treatment.
(For more information, including views on whether these changes are feasible within the time scale or will bring about projected savings, see http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/nt_initial-learning-stp-process_web.pdf).
Findings from a 2016 study of 99 Clinical Commissioning Groups (just less than half those across England) show widespread concerns about the impact of STPs. Of the cutbacks planned over the next 18 months,
- one in three CCGs expect to close or downgrade Accident and Emergency departments, (According to the National Health Action Party, in 2013 there were 140 full A&E hospitals in England but STPs will mean that soon there will only be between 40 and 70 left (http://nhap.org/the-biggest-attack-on-the-nhs/),
- one in five CCGs expect to close consultant-led maternity services, forcing women in labour to travel further,
- more than half CCGs intend to close or downgrade community hospitals,
- 46 per cent of CCGs are planning an overall reduction of inpatient NHS beds,
- one-quarter expect job cuts in hospitals, and
- almost one-quarter expect to close inpatient paediatric departments. (http://www.telegraph.co.uk/news/2016/10/30/almost-half-of-nhs-authorities-to-cut-hospital-beds-and-third-to/)
Freedom of Information requests have shown that simply drawing up draft STPs has cost ‘footprints’ millions of pounds, money that has largely gone to private consultancy companies, like PwC.
On top of this, the British Medical Association (BMA) has said that implementing STPs will need significant capital investment. More than half of the 44 ‘footprints’ have told NHS England that they would each need £100 million up front in order to make changes. In response to Freedom of Information requests asking for estimates of the cost of implementing their STPs, replies from 37 ‘footprints’ give a total of £9.53 billion. It’s unclear where this money will come from, especially as much of the money allocated to the Department of Health for capital projects is being used to cover large hospital deficits.
According to the BMA’s chief, STPs
“…. are fast becoming completely unworkable and have instead revealed a health service that is unsustainable without urgent further investment, and with little capacity to ‘transform’ in any meaningful way other than by reducing the provision of services on a drastic scale.”
Changes to the workforce
The NS5YFV document states that the NHS will develop the use of less qualified and lower paid healthcare staff, such as physician associates (PA) and nurse associates (NA). The evidence showing the effectiveness of these roles is generally of poor quality and often anecdotal. Proposals to employ PAs instead of experienced nurses, for example, have been justified by some on the grounds that there are ‘too many professional limits’ on nurses by professional bodies. Currently, there is no mandatory registration for PAs or NAs although regulatory bodies are considering this. Both the British Medical Association and Royal College of Nursing have warned that PAs and NAs should not be used in place of fully qualified physicians and nurse but there are concerns that this warning will be ignored. And there are fears that these new roles may affect equality of treatment – that those patients directed towards PAs are more likely to be elderly and otherwise vulnerable, while other less vulnerable, more articulate patients will manage to see a doctor.
Opportunities for the private sector
STPs will open up new opportunities for the private sector. The NHS Partners Network, a trade organisation for independent (predominantly private) sector providers of clinical services, gives one indication of this. It notes that, as public funding is increasingly limited, the NHS will need to consider how it can supplement existing sources of funding with external investment: it points out that the private sector is well positioned to fund new or remodelled services. It is unclear if it’s referring to more Private Finance Initiative projects, known to cost the NHS dear, or the setting up of accountable care organisations. But it’s a matter of concern that at least one of the vanguard sites for NHS England’s STP programme is planning to set up a special purpose vehicle (SPV), essentially a new ‘shell’ company, in order to take on much of the planning – and in theory the risk – of providing services for the local health economy. (The use of SPV’s has been central to public-private partnerships like PFIs as a way of getting private finance – often at exorbitant rates of interest – to cover the cost of constructing new premises, and then to manage contracts for soft facilities such as cleaning or catering, often for excessive fees. The SPV generally takes over ownership of assets (such as the NHS building and/or land) until the loan is paid off.)
The NHS Partners Network suggests that the private sector can offer much needed extra capacity – for diagnostic services, for example, or for home health care and care home services to support patients’ discharge from hospital and avoid readmission – all without capital investment from the NHS. The Network also says that the independent sector can offer management, procurement and planning skills to those involved in developing STPs, and provide support with redesigning services – such as implementing new care models like Multi-Specialty Community Providers.
Information coming soon
Sustainability and Transformation Plans (STPs), like the Five Year Plan for the NHS that they aim to deliver, are being implemented both at speed and at scale. They have given rise to serious concerns, not only among those living within the ‘footprints’ but also from far more unexpected quarters.
For example, the former head of NHS England’s Commissioning Policy has described the timescale for drawing up STPs as ‘ridiculous’, ‘kind of mad’ and ‘shameful’: she suggested that hastily drawn up plans were likely to be about ‘blue sky thinking’ rather than reality and allowed no time for genuine patient involvement.
STPs have been described as “a marriage of two debts (health and social care)” and that “to respond to a funding crisis by reorganisation is at best foolhardy, at worst grossly negligent”. In addition, there are fears that STPs will bring about the demise of Clinical Commissioning Groups (CCGs) and general practice (http://www.pulsetoday.co.uk/views/blogs/stps-could-spell-the-end-of-general-practice/20033847.blog).
A study of 200 NHS Finance Directors found that 84% feared that the aims of STPs would not be deliverable and that the quality of services will decline.
A King’s Fund report based on interviews with senior NHS and local government leaders found, among other concerns about STPs, that the focus so far has been on planning, with footprint leaders fearing that they will not have the skills to implement the plans in practice. They were also concerned that plans have not been ‘stress-tested’ to see if the assumptions on which they’re based are sound. In addition, plans have been developed from the top down, despite the rhetoric about local ownership. Guidance from NHS England was said to be inconsistent, ambiguous and arrived late, if at all. Because deadlines for plans were tight, those interviewed said that it had been difficult to get meaningful involvement from patients and the public, local authorities, clinicians and other frontline staff. And it’s not clear who in future can be held accountable for how services are delivered, given new, collective or cross-boundary ways of working.
The Chief Executive of the NHS Confederation – the membership body for organisations that commission and provide NHS services – has claimed that while STPs are being called for at a time when funding is tight, they are not about cuts: rather, they are about “modernising services to match people’s changing needs”. However, others see that ‘transformation’ is about saving £22 billion by 2020 and that this will inevitably lead to hospital closures and cuts to local services. In addition, transformation could drain irreplaceable assets from local Trusts (‘surplus’ NHS land and buildings are having to be sold off in the name of ‘efficiency savings’, with money from sales going to the Treasury).
“The STP process has turned into a mess because of the overwhelming need to reconfigure, to make impossible savings demanded by an unrealistic government.”.
He also raised concerned that balancing the books is taking priority over patient care and the development of policies based on evidence. In a more recent statement, he adds that the STPs have been drawn up without proper consultation and are dependent on the ‘footprints’ securing up front capital that is not available. In addition, the plans are unravelling and the government appears to have nothing to put in their place.
The BMA is concerned that instead of offering a chance to address some of the NHS’s problems, such as unnecessary competition, expensive fragmentation and buildings and equipment often unfit for purpose,
“…. these plans have become a vehicle for £26bn of covert savings – yet another crippling blow dealt by a Government with a vicious austerity agenda and lacking the gumption to come up with properly funded solutions for a health service in crisis. There is clearly nowhere near the funding required to carry out these plans and it appears that NHS England and NHS Improvement have probably known that for quite some time. The STP project is built on the least stable of foundations. These plans are fast becoming completely unworkable and may have been a waste of time and effort in an NHS desperate for help.”
“These plans that are emerging via different routes, if true, are potentially catastrophic and will put lives at risk. A number of systems around the country are already at breaking point and this will be the straw that breaks the camel’s back for them. Others that previously were just coping will become unstable and unsafe.”
He adds that the many problems facing A & E departments (such as staffing shortages and overcrowding) will not be resolved by cutting the number of hospital beds: patients don’t just disappear.
In all this, it’s local health systems (the ‘footprints’) that will have to take responsibility for the mismatch between demands for improvement and inadequate funding. And as the Centre for Health and the Public Interest points out,
“This means that the resulting decision-making is governed by no statutory rules: it is not clear who will be accountable for the results in terms of service provision, or the accompanying redeployments of public funds, or the conflicts of interest and opportunities for fraud which the process is liable to generate.”
At least one clinical commissioning group (CCG) – City and Hackney – has raised the issue of whether the local process for developing a STP is undemocratic. CCGs are legal entitities set up by the Health and Social Care Act of 2012 with the apparent aim of ensuring clinical leadership in decision-making. Proposals for the North East London footprint’s STP (covering seven local CCGs including City & Hackney) would allow decisions on the plan to be made, behind closed doors, by just two CCG chief officers, so removing both public scrutiny and clinical control, with the voices of the other CCGs in the ‘footprint’ excluded. At the same time, when drawing up an STP, it’s not clear whether those on the boards of new ‘footprints’ such as North East London (which are not legal entities) have the authority to trump the decision-making of CCGs (which are).
Analysis by the Nuffield Trust finds that moving care out of hospital – a key element of STPs – will be extremely difficult to realise. ‘Shifting the balance of care’ towards the community requires appropriate resources, such the right workforce in the community. But, for example, there are currently shortages of doctors and nurses working in primary care, and many GP practices are closing. Looking at a number of existing initiatives that aimed to avoid hospital admission or make it easier to discharge patients from hospital, the Nuffield report states that only a minority were able to show savings and some were likely to increase overall costs. They state that while out-of-hospital care may be better for patients, it’s unlikely to be cheaper for the NHS in the foreseeable future. It concludes that is unlikely that the aim of moving care out of hospitals will be extremely difficult to realise without additional investment in out-of-hospital care.
Similarly, a report by the National Audit Office concluded that there is no convincing evidence to show that integration of health and social care saves money and reduces hospital activity.
A critical review of STPs by the School of Health and Social Care, South Bank University points out that there are almost no examples in STP documentation where the costs of the STP process itself are set out. Exceptions to this are North Central London and Surrey Heartlands. If the figures that these STPs provide are typical the critical review that at least £5m per year will need to be spent per STP, amounting to a total annual sum of at least a quarter of a billion pounds.
The NHS England’s Five Year Forward View (FYFV) that set out plans for the NHS from 2015 to 2020 estimated that the NHS would need an extra £30 billion by 2020 to deal with growth in healthcare need, the emergence of new treatments, and so on. Of this figure, the FYFV suggested that the government should provide £8 billion, while £22 billion could be found from within the NHS through further ‘efficiency’ measures’. In effect NHS England was demanding ‘productivity gains’ of 2-3% each year between 2015 and 2020. This is highly ambitious compared with the kind of efficiencies achieved by the wider UK economy or the health care systems of other countries. These ‘efficiencies’ may also bring safety risks in a service where every ounce of fat has already been cut.
Analysts have calculated that instead of the £8 billion asked of the government, total health spending in England will rise by only £4.5 billion in real terms between 2015/16
Of the £22 billion that the Five Year Forward View expects the NHS to achieve through ‘efficiency savings’, these are to be found, for example, by
- restructuring the NHS (again) through introducing new models of care that share similarities with Accountable Care Organisations (ACOs) found, for instance, in the US. ACOs aim to reduce costs by bringing in economies of scale and introducing higher thresholds for treating patients, although the evidence for reduced costs is mixed;
- restructuring the NHS workforce through bringing in new, more ‘flexible’ roles carried out by less qualified, cheaper staff, and weaker rules about pay and conditions (such as a significant reduction in real term salaries for many staff); and
- reducing red tape and reduced waste.
A report by the Centre for Health and Public Interest (CHPI), published in May 2017, assessed seven key assumptions on which the plans for achieving the efficiency savings were based and found them to be unrealistic. Key findings are that:
- The vast majority of this year’s up-front funding earmarked for transforming NHS services (£1.8bn out of £2.1bn) has instead been spent on reducing hospital deficits. This leaves only £300 million available for the NHS to invest in achieving its efficiency targets.
- Last year hospitals were only able to find recurrent cost savings of 2.8% and yet average targets of 4% and 4.2% have been set for this year and next. NHS Improvement has admitted that targets of 4% in previous years were unrealistic.
- A 1% pay cap on NHS staff wages will be hard to maintain with national average earnings expected to grow by 2.9% a year and inflation at 1.9% a year. A 0.9% real wage cut amidst 6% staff shortages is unlikely to hold.
- Social care is expecting a funding shortfall of £3.5bn by 2020/21. Less social care provision will mean longer stays in hospital for older people who are well enough to leave and higher costs being passed onto the NHS.
Efficiency savings are to be ensured by a carrot-and-stick approach: in 2016 NHS England directed that the NHS in England will be divided into 44 new ‘local health systems’ or ‘footprints’ and that each will produce a ‘Sustainability and Transformation Plan‘ (STP). Each footprint will show in its STP how it will transform the way it plans and delivers health and care services in line with the FYFV. But most importantly, each ‘footprint’ is expected to show how it will cut expenditure and stay within budget through, for example,
- moderating ‘demand’ (reducing patients’ use of services),
- increasing productivity (cutting the budgets for service providers, reducing the pay bill, reducing the number of hospital beds etc), and
- generating income (potentially from private patients or selling land).
The Health Secretary has made it clear that Trusts must balance their books or their governing boards could be removed. An extra £1.8 billion ‘transformation fund” for the NHS that George Osborne announced for 2016-17 is only available to NHS trusts that promise to meet a huge range of demands, including moving to ‘seven-day services’. It’s feared that even if footprints can meet NHS England’s demands, much of the funding they might receive will have to go on reversing financial deficits.
In May 2017 secret NHS England plans were circulated among top NHS officials suggesting a new way of cutting costs called the ‘capped expenditure process’. NHS spending is to be capped in about 14 areas of England where there are the biggest NHS deficits and where financial targets are unlikely to be met in 2017-18. In these areas, NHS leaders have been told to ‘think the unthinkable’ and introduce changes that are usually avoided as too unpleasant, unpopular or controversial not least because they will impact on the quality of patient care.
- lengthening waiting times for planned care, even if this breaches the standards set out in the NHS Constitution.
- stopping NHS funding for some treatments, such as those considered ‘low value (…); delaying the funding of some newly approved treatments; and extending the limits on IVF treatment
- Closing wards and theatres, reducing staff while trying to maintain enough emergency care capacity to deal with winter pressures
- Closing or downgrading services
- Selling NHS estate such as land and buildings.
- Stopping prescriptions for some items,
- Cutting financial support to patients with serious, long-term medical problems and disabilities.
NHS Providers, the organisation that represents NHS Trusts, has responded by saying the proposals represent the biggest threat to the NHS’s ability to treat patients since it was set up in 1948:
“Some of the proposals could challenge fundamental expectations shared by NHS staff and the public about what the health service is there to provide. We can not do that without a full and proper debate”.
To find information about planned cuts to NHS services in your area, and what you can do about this, visit https://healthcheck.nhsfunding.info/fundournhs.
updated November 2017
‘We Own It’ provides a straightforward way of writing to your local councillors to ask them to ensure that your local Sustainability and Transformation Plan is made public, and urge them to refuse to sign or cooperate with it. See https://weownit.org.uk/act-now/stp-plans.
Despite massive re-organisation of the NHS as a result of the Health and Social Care Act of 2012 (HSCA), more radical change is now taking place, providing a further step towards privatisation as well as the means to implement cuts.
The latest restructuring is based on the benign-sounding idea of ‘integrated care’. But this is not integrated care in the sense of joined up care that’s carefully planned around individual patients. Instead its about a group of service providers (and maybe commissioners) combining to provide almost all services for a defined population.
The emergence of this kind of integrated care can be traced to the World Economic Forum (WEF), which describes itself as the International Organisation for Public-Private Cooperation, “providing a platform for the world’s leading 1,000 companies to shape a better future.” In 2012 the WEF carried out a project looking at the financial sustainability of national health services due to factors like “the growing burden of chronic disease” and “raised patient expectations”. The project lead was Simon Stevens, then Vice President of the United Health group (a transnational corporation based in the USA), and its report was co-authored by McKinsey (a global management consultancy firm also involved in drawing up the HSCA of 2012).
The preferred strategy put forward by the WEF report was to deliver more services with fewer resources, primarily by shifting health systems towards ‘integrated care’ – in effect reinventing the delivery of health care by introducing models of care that ‘manage demand’ more effectively and eliminate inefficiencies and waste. This strategy now informs the approach of NHS England (NHSE).
NHSE’s The Five Year Forward View and new models of care
Simon Stevens moved from United Health to become Chief Executive Officer of NHSE in April 2014, just six months before it published its Five Year Forward View (5YFV). This document promoted integrated care, describing how the delivery of NHS services was to be completely and rapidly redesigned through new models of care that dismantled traditional organisational boundaries – such as those between the NHS and social care, or between community care and hospital services.
The main models of care outlined were:
- The Multispecialty Community Provider (MCP) model, in which GPs and other community based health practitioners (e.g. district nurses, pharmacists) form an organisation that provides most out-of-hospital care for a registered list of patients, with a delegated responsibility for managing the health service budget for their registered patients. This would bring so-called ‘horizontal’ integration.
- The Primary and Acute Care System (PACS), where a single organisation provides GP and hospital services, together with – for example – mental health and community care. These were described as similar to the Accountable Care Organisations seen in other countries like the USA.
These models of care were supposed to provide a way of improving quality while cutting costs ( although evidence is mixed from the USA about the impact of ACOs on quality and cost). Both MCPs and PACs were to be funded by a ‘whole population budget’. This is a fixed or lump sum that will be paid to providers to cover the cost of almost all healthcare services for a defined population, over a set period (probably 10-15 years), irrespective of the care that is actually needed or provided: treatments will be limited to what is affordable within the budget.
The first step towards implementing the redesign of the NHS was taken at the end 2015 with NHSE selecting 50 pilot or ‘vanguard’ sites to introduce the new care models programme. Then, at the beginning of 2016, before these vanguard sites were fully up and running – and certainly before any evaluation had been done – NHSE produced a new directive. Called “Delivering the Forward View: NHS planning guidance 2016/17 – 2020/21“, it required the creation of new local health systems, each of which would develop a Sustainability and Transformation Plan (STP) that would put the FYFV into practice.
New local health systems or ‘footprints’
The directive Delivering the Forward View – for which NHS England has no legal authority – required the setting up of 44 new ‘local health systems’ or ‘footprints’ across England in what it called ‘place-based planning’ (i.e planning to cover an entire health area rather than a single organisation). ‘Footprints’ were to bring together ‘clinicians, patients, carers, citizens, and local community partners (including the independent and voluntary sectors), and local government through health and wellbeing boards. These new local health systems – the boundaries of which may roughly mirror those of county boundaries – are expected to transform the way that health and care services are planned and delivered for local people. The populations that they will cover range from 300,000 (for example in West, North and East Cumbria) to nearly three million people (as in Greater Manchester). On average they will incorporate three or four local councils and about five Clinical Commissioning Groups (CCGs). But ‘local health systems’ will not be responsible for all planning eventualities and it is recognised that different footprints will have different needs.
These ‘footprints’ share some similarities with the old Strategic Health Authorities (SHAs) that were abolished by the Health and Social Care Act (2012) although SHAs were not expected to make financial savings. Now, cutting costs is the first priority.
A further difference is that, unlike SHAs, ‘footprints’ have no statutory basis or accountability and so are not subject to the same level of scrutiny.
At the time of publishing Delivering the Forward View, there were no legal or other structures that connected the organisations or people involved, no procedures for dealing with disagreements, and little planning expertise among those expected to meet NHS England’s demands (expensive consultancy firms had a field day). And although NHS England could compel health care organisations to comply with their requirements, this was not the case for those bodies responsible for social care – local councils – that were also part of ‘footprints’.
Even so, each ‘footprint’ was asked to produce – with scant notice – a five-year Sustainability and Transformation Plan (STP), showing how local health and social care services will become financially ‘sustainable’ and transformed in line with the Five Year Forward View by 2021.
Sustainability and Transformation Plans (STPs)
In response to Delivering the Forward View, ‘footprints’ were to draw up their draft STPs with considerable secrecy: they were told by NHS England that they could not make their plans public. As NHS England’s Director of Commissioning Operations for North Midlands is reported as saying
“STPs are not meant to be published at all. They should not go to Board meetings. Some of them contain very radical things… These are highly political and highly contentious. Once they’re washed off and the national messages are gathered together, they will be published.”
Nonetheless, despite the secrecy, a number of STPs were leaked or some details became known through Freedom of Information requests. Then, eventually (December 2016), each footprint’s draft STP was published (see https://www.england.nhs.uk/stps/view-stps/), although not necessarily with the relevant appendices giving the important financial details. (These details, when available, were usually pretty impenetrable.)
STPs have to cover all areas of activity currently commissioned by CCGs and NHS England, including specialised services and primary medical care. They also have to ensure better integration with local authority services, including prevention and social care – and who would argue with that? But at heart, STPs have to:
1. Improve sustainability by achieving financial balance: Each ‘footprint’ is expected to cut expenditure and stay within budget through, for example,
1. Improve sustainability by achieving financial balance:
Each ‘footprint’ is expected to cut expenditure and stay within budget through, for example,
2. Maximise efficiency through transforming services:
‘Delivering the Forward View‘ argues that “local NHS systems will only become sustainable if they accelerate their work on prevention and care design”, including the implementation of the new models that increase out-of-hospital care proposed by the FYFV.
Of these priorities, plans for ‘sustainability’ are given the most weight: Of the £1.8 billion earmarked for STPs for 2016/17, a total of £1.6 billion was to be made available to those ‘footprints’ whose plans met the financial control targets agreed with NHS England. In contrast, just £200 million was available for plans to improve efficiency, such as the introduction of new models of care.
Overall, STPs were to become the single application and approval process by which cash-strapped ‘footprints’ would have access to ‘transformation funding’ from 2017/18 onwards. But if an STP failed to show sufficient ‘financial discipline’, not only would the ‘footprin’ be denied access to this funding, it could be put in special measures and have its leaders replaced.
STPs were also to be assessed on additional measures besides finance, such as
- whether they will expand the use of integrated personal budgets (especially for maternity, end-of-life and elective care);
- whether they support the national roll out of the Healthy NHS programme to improve the health of the ‘footprint’s’ workforce; and
- how they will facilitate the implementation of ‘seven day’ services.
iii) Lack of legitimacy
Until recently, the nature and extent of changes that STPs were to bring about would have had been introduced or supported by government white papers, formal public consultation, policy guidance, primary legislation and statutory instruments. In contrast, the transformation of the NHS that STPs and the new care models programme they introduce are only by order of the Chief Executive of NHS England.
What’s more, some of the changes being introduced are at odds with existing legislation:
There are two sorts of change afoot – things which are in the Health and Social Care Act 2012 or other legislation, but which are simply being ignored or changed on the ground; and new ideas which don’t figure anywhere in the Health and Social Care Act 2012 or other NHS legislation, but which are being done anyway. (http://blog.policy.manchester.ac.uk/posts/2016/09/the-nhs-reform-reorganisation-and-the-risks-of-rushing-into-changes-without-proper-scrutiny/)
On top of which, the development of each STP was led by an ad hoc group of people drawn, for example, from CCGs, health service providers and local authorities: as an organisational body, the ‘footprint’ has no formal existence, no legal authority. Nonetheless, NHS England (itself not a statutory body) expects them to impose decisions on organisations that do have statutory authority and accountability (such as CCGs and local authorities). For example, in March 2017 Simon Stevens (Chief Executive of NHSE) told the House of Commons Public Accounts Committee that
We are going to formally appoint leads to the 44 [Sustainability and Transformation Partnerships]. We are going to give them a range of governance rights over the organisations that are within their geographical areas, including the ability to marshal the forces of the CCGs and the local NHS England staff.
In addition, as non-statutory bodies, the new ST Partnerships are not required to undergo internal or external audit. Consequently,
Decision-making is likely to become less transparent. Public consultations, board meetings and formal, open ways to make decisions and to challenge them are likely to be replaced or subverted by backroom deals and horse-trading. (http://blog.policy.manchester.ac.uk/posts/2016/09/the-nhs-reform-reorganisation-and-the-risks-of-rushing-into-changes-without-proper-scrutiny/)
iv) Lack of public involvement and consultation
NHS England, CCGs, NHS foundation trusts and NHS trusts are all under a duty to make arrangements to involve patients in:
- the planning of commissioning arrangements (NHS England & CCGs) or provision of services (NHS foundation trusts and NHS trusts);
- the development and consideration of proposals for changes in the way those services are commissioned/provided which would have an impact upon the range of services available or the manner of their delivery; and
- decisions affecting the operation of those commissioning arrangements/services which would have such an impact.
However, patient involvement in the development of STPs before their submission to NHS England was minimal (see our page on Patient engagement and consultation) In addition, STPs were not developed by CCGs, local authorities or other bodies that are under statutory requirements to consult, but by a new organisational form – a ‘footprint’ – that had no formal existence. This means that their obligations and accountability are unclear.
iv) Lack of financial credibility
There are growing doubts about the credibility of STPs as cost saving measures. A review of the 44 ‘footprints’ by the British Medical Association found the claim that STPs would save £26 billion from NHS and social care budgets to be unrealistic:
- most savings depend on the injection of capital up front in order to update or build new health facilities – but this money is not available. It’s estimated that, collectively, ‘footprints’ will need £9.5 billion of capital funding to create the infrastructure necessary to deliver the STPs;
- In the UK there is virtually no evidence to suggest that the large scale reshaping of hospital services will improve NHS finances;
- Although most STPs claim that they can cut costs by moving services out of hospitals, research suggests otherwise, especially within five years;
- to be in line with NHS England’s five year plan, public health and prevention have to be priorities for STPs. However public health and prevention are now the responsibility of local authorities, whose budgets have been seriously cut in recent years;
- it’s expected that savings can be made by providing more care in the community, but many STPs don’t consider where funding for extra work in the community will come from.
In addition, the many STPs have been drawn up in large part (and presumably in their own interests) by private consultancy firms like PwC, with ‘footprints’ each shelling out millions of pounds for their services.
Accountable care systems and accountable care organisations
Subsequently, Next Steps on the Five Year Forward View (NS5YFV), published by NHSE in March 2017, required ‘footprints’/STPs to morph into Sustainability and Transformation Partnerships (ST Partnerships) to implement the STPs and create integrated (or accountable) care systems.
As with ‘footprints’, these Partnerships have no statutory basis: according to the NS5YFV, they “supplement rather than replace the accountabilities of individual organisations”. How they work will vary across the country – although the government’s preferred ways of integrating services is first through ST Partnerships evolving into accountable care systems (ACSs), with some of these eventually becoming accountable care organisations (ACOs).
In essence, while ACSs can take many different forms, what they have in common is a defined population, a uniform payment system and a focus on health outcomes. NHSE describes an ACS as a locally integrated health system (possibly a part of a ‘footprint’), within which NHS organisations – often in partnership with local authorities – take on collective responsibility for the health of a defined population and the resources to deliver care services, while making savings – for example by targeting patients at risk of avoidable hospital admission. An ACS is expected share savings, as well as risk and any losses, across the system.
ACSs are expected to have more control over the operation of the health system in their area. They are part of a more general shift required by NHSE towards ‘demand management’. This means creating a health service that operates on a fixed budget (based on a set amount per head of the population in a defined area) and controls access to services by limiting treatments to what ‘affordable’ within this budget. This approach runs counter to the basic principle of the NHS – to provide appropriate treatment to all, based on clinical need.
In June 2017, Jeremy Hunt had announced the first eight ‘shadow’ ACSs, as a step towards more integrated care. The eight pioneer ASCs will have to determine what accountable care means for them and shape it out of existing independent organisations (https://www.hsj.co.uk/sectors/commissioning/the-commissioner-next-steps-for-stps-part-1-towards-accountable-care/7016284.article) They will be expected to take the strain off A&E departments, invest in general practice and improve access to quality cancer and mental health services. They have, in principle, agreed a draft Memorandum of Understanding (MOU) with NHSE that will, among other things, sign them up to
- reducing the growth of use of NHS services, and
- achieving a single financial control system – something the MOU acknowledges will “inevitably be bumpy in terms of its impact on the financial position of individual organisations”.
According to the British Medical Association, the main difference between an ACS and an ACO is that, with ACOs, there is a single contract with a single provider that will make most of the decisions about how to allocate resources and design care for its local population, including decisions on changing the method or point of service delivery. This single provider could be an NHS organisation or a private company that may sub-contract other providers. Both sit outside current legislation. With both ACSs and ACOs, individual health care organisations within the scheme are asked to set aside their own interests for the good of a wider system. This may prove difficult, especially as some providers within the system will be private companies whose agenda will be incompatible with this approach. There are also indications that ACOs have found it difficult to develop governance arrangements that are able to hold their partners to account as a collective.
A major element of NHSE’s FYFV is the increased use of IT – e.g. to prevent admissions and support out of hospital care. And both ACSs and ACOs are heavily dependent on software and information technology, for example to store patients’ records, enable the sharing of patients’ data across health care systems, or collect data relating to treatment costs and revenue margins etc. Recent research on ACOs in the USA has found that over $100 billion has been spent on such technology over six years, without any notable return on investment: there is no change in the quality of care or the cost of care that the ACOs provide. Physicians are also increasingly dissatisfied with the software they have to use to support safe, evidence based care. Apparently, one-third of the organisations in a Pioneer ACO Program in the USA are dropping out because, despite their investments in software and information technologies, they are unable to quantify the quality of care and financial risk for managing patients in the ACO.
For more information, see our page on ACOs.
… and private sector involvement:
Updated August 2017
Health and social care services are two sides of the same coin, even if the NHS has had a higher public profile. Roughly one in three people have some kind of relationship with social care services, which provide care, support and safeguards for those in our communities with the highest need, as well for as their carers.
The Department of Health has called for the integration of health and social care systems, partly to deal with increasing pressure on services faced with inadequate funding. NHS England expects the NHS to make £22 billion of ‘efficiency cuts’ by 2020, while money for adult social care fell by nearly a third between 2011 and 2016. A further £6.1 billion will be taken from councils by 2020.
There have been several moves over as many as 20 years to integrate health and social care, including
- the transfer of £2.7 billion from the NHS to local authorities over the four years to 2014-15, to promote better joined-up working (the 2010 Spending Review),
- the creation of the Better Care Fund in 2013, which required NHS clinical commissioning groups and local authorities to pool some of their funding and produce joint plans for integrating services. In 2015-16, the total pooled was £5.3 billion. The Better Care Fund is not new money and most of it comes from the NHS, withdrawn from hospitals in the hope that better services in the community will lead to fewer people being admitted for acute hospital care.
- the publication of the Five Year Forward View (FYFV) by NHS England (NHSE) in 2014, with plans to achieve a financially sustainable and integrated health and care system through, eg new care models, by 2020. The FYFV outlines seven new care models that ‘integrate services around the patient’, including, where relevant, social care. These models are currently being developed across England, initially with 50 ‘vanguard’ test sites, with the highly optimistic aim of saving £900 million and reducing growth in hospital activity from 2.9% to 1.3% by 2020-21.
- NHSE’s Delivering the Forward View (2015) that carved the NHS in England into 44 ‘footprints’ (Sustainability and Transformation Partnerships), each charged with improving the integration of health and social care services within its borders.
The barriers to integrating health and social care are considerable. To begin with, England has legally distinct health and social care systems. The Department of Health and Social Care determines health and adult social care policy, while the Department for Communities and Local Government is responsible for local government finance and accountability.
Health and social care systems are also funded differently, and may serve different populations. Local authorities within a ‘footprint’ fund social care services while health services are funded on the basis of the size of the lists of patients registered with GPs. Not all residents within one of the new ‘footprints’ will be signed up with a local GP (for example, as the boundaries for GP practices are being dissolved, individuals may choose to sign up with a practice that happens to fall within a different ‘footprint’). This means there are situations where there could be no health service funding for unregistered patients who are, at the same time, eligible for local authority social services. For this reason alone it’s hard to see how health and social care services can be integrated.
However, in addition, the NHS is free at the point of use, while social care is means tested and only free for those with a high levels of need and few resources. Greater involvement of local authorities in health service provision increases the risk of new charges for what were previously free NHS services. For instance, at the moment, current regulations for local authority public health services such as health checks, open access sexual health services, and child health surveillance don’t allow individuals to be charged for these services. This is because the health secretary chose to prohibit charging, and not because it’s been legally prohibited by parliament. As local authorities face more and more cuts, there’s a risk that new regulations will be brought in that bring the prohibition of charging to an end.
Many argue that in order to bring about the integration of health and social care both need to be fully funded and that social care needs to be brought into the public sector, provided on the basis of need and free at the point of use.
In the current scenario however, there is little to no robust evidence to show that integration leads to better outcomes for patients. The Department of Health and the Department for Communities and Local Government have not tested this kind of integration at scale and can’t show that any ‘success’ seen so far is sustainable or due to integration. There are some international examples of successful integration (for example, what’s known as the Canterbury model of integrated care in New Zealand) but this has been achieved in the context of very different legal and organisational environments.
Plus, according to the National Audit Office, there is no compelling evidence to show that integration of health and social care in England leads to sustainable financial savings or reduced hospital activity. There are some positive examples of integration at the local level, but so far there is no evidence of systematic, sustainable reductions in the cost of care as a result of integration.
On top of which, embedding new ways of working across organisations can take many years due to the different cultures and working practices that exist across the NHS and local authorities – even where there is strong commitment, integration may take as long as 20 years. NHSE expects huge strides towards the integration of health and social care services within a faction of this time scale.
As mentioned on other pages, NHS England (NHSE) has divided the English NHS into 44 local health systems (‘footprints’), now described as Sustainability and Transformation Partnerships (ST Partnerships). NHSE expects these Partnerships to evolve into what were initially called Accountable Care Systems (ACSs) but, from February 2018, have been renamed as Integrated Care Systems (ICS) – perhaps because the term ‘accountable care’ had become rather toxic.
Although similar to ACSs, ICSs are not exactly the same: new guidance from NHSE, for example, suggests that some financial arrangements will be different. But it still seems to be the case that some, if not all, ICSs will be encouraged to become Accountable Care Organisations (ACOs) over time. Notably, the NHSE guidance makes no reference to ACOs, currently the subject of two judicial reviews and a public consultation in response to widespread concern from the public and bodies like the House of Commons Health Select Committee.
What were Accountable Care Systems?
An Accountable Care System was an evolved version of a ST Partnership, with responsibility for the health and resources for a defined population. An ACS differed from an ACO, partly because existing commissioning contracts remained in place. Commissioners, together with a network of providers across different services, entered into an alliance agreement and committed to managing resources together, along with agreeing governance arrangements and how to share risk and gain.
In return for providing ‘joined up, better coordinated care’, it was claimed that ACSs would have more control over the operation of the health system in their area. In reality, they provided a means by which national bodies (the Treasury, the Department of Health, for example) could assert more control, especial with regard to finances and performance.
Organisations within ACSs needed to share their workforce and facilities “where appropriate”, and create an “effective collective decision making and governance structure” – not easy, given that an ACS couldn’t replace the individual accountability of the organisations within it.
NHSE’s ambition was for ACSs to cover half the population of England by 2020, something it acknowledged would be a complicated transition, requiring a staged implementation.
First wave of ACSs (now ICSs)
By June 2017, Jeremy Hunt had announced eight ‘shadow’ ACSs, due to be formally designated for 2018-19. These were Frimley Health (including Slough, Surrey Heath and Aldershot), South Yorkshire & Bassetlaw (covering Barnsley, Bassetlew, Doncaster, Rotherham, and Sheffield), Nottinghamshire (with an early focus on Greater Nottingham and Rushcliffe), Blackpool & Fylde Coast (with the potential to spread to other parts of the Lancashire and South Cumbria at a later stage), Dorset, Luton (with Milton Keynes and Bedfordshire), Berkshire West (covering Reading, Newbury and Wokingham), Buckinghamshire.
These shadow ACSs agreed, in principle, a draft Memorandum of Understanding (MOU) with NHSE, signing them up to
- finding ways to control the uptake of services (or “more assertively moderating demand growth”);
- meeting quality targets;
- setting up appropriate governance, and
- accepting significant changes to how finances are controlled.
Each individual organisation within an ACS must remain accountable for remaining within the ‘financial control total’ set for them by NHSE and NHS Improvement to ensure that that any financial deficit providers had was reduced to zero. . Agreeing to deliver a control total was a condition of access to the Sustainability and Transformation Fund.
The introduction of financial control totals for all NHS providers in 2016/17 (regardless of whether they were in deficit or not) meant a dramatic extension of central control. These controls govern how an organisation uses its own reserves, and enforce a range of other conditions from the centre (ie NHSE and NHS Improvement) – for example, they dictate how to manage annual leave, short-term sick leave as well as issues of financial management.
But in addition, in order to facilitate the pooling of resources across providers within the ACS, these providers must also be accountable as a collective for achieving a ‘system control total’ (equal to the sum of the control totals of all organisations within the system). The MOU acknowledges that this new approach to financial control will “inevitably be bumpy in terms of its impact on the financial position of individual organisations”.
As some have suggested for ACOs, new systems like ACSs may mean substantial changes to the role of Clinical Commissioning Groups (CCGs). It’s possible that CCGs will remain responsible for
- ensuring that ACSs are commissioned in order to provide maximum value;
- setting the required population-level outcomes; and
- holding ACSs to account for delivery.
But providers (NHS or private) could take on the delivery of, or contracting for, all NHS and local authority funded health and care services. Providers could also be responsible for ‘integrating’ primary, community and hospital services. Not only this, as an ACS developed, existing contracts could be amended to require providers to agree to the transfer of the supervision of their contract to another provider – or to the system’s Care Integrator (potentially a private company) in place of the CCG.
From February 2018 the eight existing ‘shadow’ ACSs (now ICSs) will face new regulatory oversight and financial arrangements.
Integrated Care Systems
New planning guidance from NHSE and NHS Improvement (NHSI) published in February 2018 reinforced the move towards what it calls ‘system working’ through ST Partnerships and the voluntary roll-out of ICSs over the year 2018-19. It described ICSs as those systems
in which commissioners and NHS providers, working closely with GP networks, local authorities and other partners, agree to take shared responsibility (in ways that are consistent with their individual legal obligations) for how they operate their collective resources for the benefit of local populations.
The guidance clarified that it is now using the term ICS as a collective term for existing ‘shadow’ ACSs and the devolved health and care systems in Greater Manchester and Surrey Heartlands.
ICSs are expected to focus on
- managing population health (e.g. improving the health of a defined group, rather than focusing on individuals’ health needs),
- delivering more care through redesigned community and home-based services,
- taking collective responsibility for financial and operational performance, and
- ‘more robust’ arrangements between organisations within the system.
Instead of operating as separate bodies, each organisation within an ICS should sign up to a plan for operating as a single system that incorporates relevant CCGs and providers, and establishes a common approach to things like income, expenditure, workforce, and activities. This focus on an overall system rather than individual organisations within a system allows NHSE and NHSI greater oversight or control.
Each shadow ICS is expected to produce a plan that will deliver its ‘system control total’, (“the aggregate required income and expenditure position for providers and CCGs within the system” as decided by NHSE and NHSI). Failure to draw up appropriate plans or comply with a system control total will mean loss of access to funding. Notably, organisations within an ICS will be responsible among themselves for resolving any disputes arising from the ‘system control total’.
The King’s Fund has rather muddied the waters by introducing a sub-category – Integrated Care Partnerships (ICPs). They use the term ICS to refer to a body evolving from an ST Partnership in which various organisations come together voluntarily to plan and commission services across a geographical footprint. Within that area there will be a number of ICPs, each comprised of a range of organisations that will deliver services to more localised areas.
For more details, see https://keepournhspublic.com/resources/resource-cabinet/ (see Accountable Care Organisations and Systems section)
updated February 2018
The march on 4.3.17 drew about 200 to 250 thousand people from across the country to protest against underfunding of the NHS and the cuts in services proposed by Sustainability and Transformation Plans.
Public engagement generally describes a continuous process in which initial plans from government or similar bodies are shared with the public and other relevant groups to allow their input from the earliest possible moment. Notably, guidance on public engagement from NHS England states that
“Particular emphasis should be given to engagement with people who are less frequently heard and who experience the greatest inequalities in health outcomes.” https://www.england.nhs.uk/wp-content/uploads/2016/09/engag-local-people-stps.pdf)
However, public engagement is often informal and there are some concerns among civil society groups that it’s a rather meaningless activity: those planning changes may have minimal discussions with random groups and present the outcome as if they have made extensive opportunities for input from the public.
In contrast, there is a statutory requirement for NHS bodies to formally consult with patients, the public, other stakeholders and relevant committees when considering a substantial change in the provision of a service (such as the closure of a hospital or department like A & E). Clinical Commissioning Groups (CCGs), local authorities, NHS trusts, NHS foundation trusts and NHS England all have separate, but similar, obligations to consult or otherwise involve the public.
For instance, the NHS Act (2006) requires CCGs and NHS England to ensure public involvement and consultation in commissioning processes and decisions, including the involvement of the public, patients and carers in:
- planning of commissioning arrangements, such as the allocation of resources, and
- proposed changes to services which may impact on patients, such as the way in which services are delivered or the range of services available to them.
And NHS England’s guidance states that adequate time must be allowed for consultation and response where significant changes are being made to services. In addition, consultation must take place while the proposal is still at a formative stage and not after a decision has already been made. Sufficient information must be provided to allow for intelligent consideration and response, and adequate time must be given for consideration and response. Finally the result of consultation must be carefully taken into account.
STPS, patient engagement and consultation
NHS England’s guidance on involving local people in the development of STPs states that it expects all ‘footprints’ to engage with local people through bodies like Healthwatch and other patient and public groups in order to discuss and shape their proposals at every stage of their development. However, draft STPs – unless leaked – were not publicly available before they were submitted to NHS England in October 2016.
In fact, STP footprints are not statutory bodies and so have no legal duty to involve the public in planning or decisions that will have an impact on services. Instead, it is individual NHS organisations within a footprint (CCGs, local authorities, NHS trusts and NHS Foundation trusts) that are legally obliged to consult or otherwise involve the public – if only to avoid legal challenge. Similarly, NHS England has a duty to involve patients in decisions about changing the way that services are commissioned or provided, where changes will affect the extent or way in which these services are delivered. (https://www.england.nhs.uk/wp-content/uploads/2016/09/engag-local-people-stps.pdf). However, this has not happened.
Footprints began to publish their STPs from 21st October 2016 onwards, and all were supposed to be published by December 15th 2016. However, CCGs’ draft operational plans for the years 2017/18 and 2018/19 (which, among other things, must show how CCGs and providers will support the delivery of STPs) had to be submitted to NHS England by 24th November. And the deadline for NHS England to sign off CCGs’ final operational plans (aligned with the signing of contracts for services for the years 2017/18 to 2018/19) was 23rd December 2016. In other words, there was no time for meaningful public consultation between the publishing of STPs and the first step towards putting these plans into effect. This may leave STPs open to legal challenge.
What you can do
- Sign the government petition calling for the NHS to be properly funded, and for the STP programme to be scrapped: https://petition.parliament.uk/petitions/165948 .
- Visit http://www.stopthestps.org.uk/home/4593142849 for up-to-date-information and resources for those wanting to take action against their local STP,
- Visit http://www.healthcampaignstogether.com/pdf/Resource%20pack.pdf for a resource pack giving information on how to find out what your local STP proposes, or how to make a Freedom of Information request. If you belong to a political party, this resource pack also provides the wording for a motion to submit to your local branch.