In late 2014 NHS England published its 5 year plan for the NHS (2015-2020). This aimed to deal with the growing pressures on health and social care services and the lack of funding to match this. The plan, called the Five Year Forward View (FYFV), proposed fundamental change to the NHS, including the development of new ways of delivering care (‘new care models’) which, it claimed, would improve quality and productivity while cutting costs. The new care models were to allow ‘integrated care’ and the dismantling of traditional organisational 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).
The changes this plan announced are to be massive: according to NHS England (NHSE),
What’s more, they were to be implemented rapidly and extensively.
The first step was taken in 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 (http://www.nationalhealthexecutive.com/News/final-june-stp-deadline-watered-down-to-work-in-progress/142862) – required the setting up of 44 new ‘local health systems’ or ‘footprints’ across England in what it called ‘place-based planning’ (i.e plans 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.
Then, in March 2017, NHS England published Next Steps on the Five Year Forward View (NS5YFV). This required ‘footprints’ to set up (or morph into) Sustainability and Transformation Partnerships (ST Partnerships) to implement the STPs. Each ST Partnership has to bring together organisations working in primary care, mental health services, hospitals and social care with a view to integrating their services and carrying out the FYFV.
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 through moving towards the development of Accountable Care Organisations. (For more details of Accountable Care Organisations, see our page on new models of care.)
Sustainability and Transformation Plans (STPs)
In responding 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
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,
‘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 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 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 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 are 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 will bring about 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:
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 mentioned earlier, 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
ST Partnerships’ plans vary across the country 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 serious 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 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. In addition, the shape of these plans in some areas may be heavily influenced by consultancy firms like PwC.
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 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.