In late 2014 NHS England published its 5 year plan for the NHS (2015-2020) that aimed to deal with the growing pressures on health services and the lack of funding to match this. This plan, called the Five Year Forward View (FYFV), proposed fundamental change to the NHS, including the development of new ways of delivering care, such as ‘new care models’ which, it claimed, will improve quality and productivity while cutting costs. The new care models are to allow ‘integrated care’ and the dismantling of traditional boundaries, such as those between the NHS and social care, and between GP and hospital services (see our page on the FYFV’s proposals for more details). These changes will be massive: according to NHS England,
The ‘redesign’ of these systems is to be implemented rapidly and extensively. The first step was taken in 2015 with the selection by NHS England of 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 – NHS England 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. The rationale initially appeared to be about the improvement of services, but over time it’s become clear that it’s predominantly about ‘efficiency savings’ (such as reducing services). As NHS England says
New local health systems or ‘footprints’
The directive Delivering the Forward View – for which NHS England has no legal authority (http://www.nationalhealthexecutive.com/News/final-june-stp-deadline-watered-down-to-work-in-progress/142862) – requires the setting up of 44 new ‘local health systems’ or ‘footprints’ across England in what is called ‘place-based planning’ (i.e plans cover an entire health area rather than a single organisation). Footprints are 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 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.
In some ways these footprints are similar to the Strategic Health Authorities (SHAs) that were abolished by the Health and Social Care Act (2012) although, unlike SHAs, ‘footprints’ have no statutory footing and so are not subject to the same level of scrutiny. A further difference is that SHAs were not expected to make financial savings. Now, saving money is becoming the first priority.
Bizarrely, these local health systems or ‘footprints’ are not actually ‘systems’. There are no legal or other structures that connect the organisations or people involved, no procedures for dealing with disagreements, no planning expertise and little time (most of the people involved already have heavy workloads). And while NHS England may have the power to compel them to comply with their requirements, this is not the case for those bodies responsible for social care – local councils – that are also included in ‘local health systems’.
Nonetheless, each ‘footprint’ has been 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)
Draft STPs were drawn up with considerable secrecy: NHS England told ‘footprints’ that they couldn’t make their plans public. This may have been because most introduce highly controversial changes to services. As NHS England’s Director of Commissioning Operations for North Midlands is reported as saying
Nonetheless, despite the secrecy, a number of STPs were leaked or became clearer through Freedom of Information requests, and since December 2016, each footprint’s draft STP has been 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, may also be 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 – 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,
‘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. (See our page on the proposals of the FYFV which includes an explanation of these new models of care.
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 will be available to those ‘footprints’ whose plans meet the financial control targets agreed with NHS England. In contrast, just £200 million will be available for plans to improve efficiency, such as the introduction of new models of care.
Overall, STPs will become the single application and approval process by which cash-strapped ‘footprints’ will have access to ‘transformation funding’ from 2017/18 onwards. But if a STP fails to show sufficient ‘financial discipline’, not only will the footprint be denied access to this funding, it could be put in special measures and have its leaders replaced.
STPs will also be assessed on additional measures besides finance, such as whether they plan to expand the use of integrated personal budgets (especially for maternity, end-of-life and elective care); whether they will participate in the national roll out of the Healthy NHS programme to improve the health of the ‘footprint’s’ workforce; or how they will work towards the implementation of ‘seven day’ services.
iii) Lack of legitimacy
Until recently, the nature and extent of changes that STPs are to bring about would have had been backed by government white papers, formal public consultation, policy guidance, primary legislation and statutory instruments. In contrast, the transformation of the NHS represented by STPs and the new care models programme they introduce are only by order of the Chief Exec of NHS England.
What’s more, the changes being introduced are at odds with existing legislation, such as the parts of the Health and Social Care Act (2012) that introduced compulsory competition in the NHS. On top of which, the development of each ‘footprint’ is led by an ad hoc group of people drawn, for example, from CCGs, providers and local authorities: as an organisational body, the footprint has no formal existence, no statutory authority. The obligations and accountability of its members are unclear.
STPs will vary but all are expected to involve significant reconfiguration of health services. According to NHS England, any proposal for such restructuring, in addition to being affordable, has to satisfy four tests, namely:
- Strong public and patient engagement.
- Consistency with current and prospective need for patient choice.
- Clear, clinical evidence base.
- Support for proposals from commissioners.
There are concerns that the STP proposals for reconfiguring services do not satisfy these tests. For example, 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. 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 has been minimal (see our page on Patient engagement and consultation) In addition, STPs are not being developed by CCGs, local authorities or other bodies that are under statutory requirements to consult, but by a new organisational form – a ‘footprint’ – that has no formal existence. This means that the obligations and accountability of footprints are unclear and that STPs have no legal basis.
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 finds the claim that STPs will save £26 billion from NHS and social care budgets is 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;
- 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 serious 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.