Comment on STPs

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 Chair of the British Medical Association’s Council said

“The STP process  has turned into a mess because of the overwhelming need to reconfigure, to make impossible savings demanded by an unrealistic government.”
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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.”

(https://www.bma.org.uk/news/2017/february/nhs-needs-9-5-to-transform?imgdoctors)

The President of the Royal College of Emergency Medicine fears that

“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. 

May 2017

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