Current ambitions for NHS reform rest on Sustainability and Transformation Plans (STPs). These aim to bring local leaders together to create cohesive systems of care that are proactive, not reactive, with a focus on prevention and care being delivered in the community rather than in hospitals. They also aim for health and social care systems to properly exploit technology. All this will save time and money and deliver better quality care.
In their current form, STPs are not going to work. Reform's report, Saving STPs – achieving meaningful health and social care reform, published today, sets out the changes that need to be made for STPs to succeed.
What have STPs achieved?
One of the most encouraging consequences of STPs is that they have brought local leaders together to have conversations they would not otherwise have had. Some of the areas which have made the most progress are those with a history of working together and a strong regional identity, such as in Greater Manchester, which was already working on its plan following the devolution of its annual £6 billion budget for health and social care.
For example, Greater Manchester is planning to concentrate acute care delivery in four high-acuity centres (previously spread over twelve hospitals) to focus expertise and iron out variations in care, making the service safer and more cost effective. Devon has created combined electronic patient records to support integration of health and social care and remove the need for patients to repeat information multiple times. In Morecombe, providers, commissioners and authorities have agreed joint health outcomes for the area in a Memorandum of Understanding forming a co-operative they are describing as an Accountable Care Organisation.
The challenges
Despite these positive developments, there are three key challenges to be addressed if the STPs are to succeed as they must.
Limited engagement
Engagement of all stakeholders is crucial to whole system working. However, the STP process so far has been dominated by Clinical Commissioning Groups and NHS providers (hospital trusts). A survey of 614 GPs and consultants in London found 66 per cent of GPs and 53 per cent of consultants had not even heard of STPs. Some local authority representatives were being expected to represent other local authorities or were only consulted on parts of the plan. The NHS England direction to not publish plans until approved has created a veil of secrecy which has angered the public and inhibited constructive consultation and involvement. There is concern politicians will withdraw support for controversial decisions. Coverage of mental health in the plans has generally been insufficient.
An inconsistent vision
STP participants have reported contradictory messages from NHS England (focused on delivering the whole Five Year Forward View) and NHS Improvement (focused on balancing the books in the short-term). There have even been mixed messages within the organisations themselves. One interviewee suggested confusion arose from deliberate constructive ambiguity created at the top with the intention of allowing local areas to find their own solutions conflicting with the upward looking culture of the NHS further down the line.
Lack of executive authority
STPs have struggled with the lack of authoritative leadership. STPs are made up of autonomous organisations, each with their own statutory responsibilities and each held accountable to their own regulatory bodies. This presents challenges to collaborative working when organisation-level interests conflict with those of the STP as a whole. Local leaders are also unclear as to what extent they can lawfully engage in anti-competitive practice as they move towards integration.
Funding does not enable collaborative working either, with fragmented budgets and misaligned incentives. For example, acute care funding is activity based. The role of funding systems to influence behaviour is fundamental. As one interviewee noted, "The money is the money".
Saving STPs
Reform's report sets out five key steps to solve these problems.
1) STPs should design their own local health outcomes for which every organisation in the STP is accountable. This would align incentives so that all organisations are working towards the same targets and thereby support collaboration. Setting these objectives locally means that they can be responsive to local priorities.
2) STPs should take a 'one-system, one-budget’ approach. NHS, social care and public health budgets should be merged across the STP and commissioned by a single body. This would give the STP the executive authority it needs and enable resources to be directed to where they can have the most impact on supporting a healthy local population.
3) Commissioners need to regularly evaluate whether providers are delivering on outcomes. Where these are consistently not delivered, services should be decommissioned and broken up to allow smaller providers to bid. Contracts should come up for renewal at regular intervals. These principles are essential to prevent a situation of health monopolies that are too big to fail.
4) NHS Improvement should publish guidance clarifying how current legislation surrounding competition applies in the context of STPs. This will give local leaders the confidence to design integrated services in their areas.
5) STP footprints should have elected leaders who are held to account by the public. The public and NHS employees need to be on board with the plans.
STPs have the potential to deliver the health and social care system needed but successes so far have been despite rather than because of the frameworks in place. These five recommendations are the key to unlocking the potential of STPs and enabling them to succeed as they must.
