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
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.