Rebecca Malby, Professor of Health Systems Innovation, London South Bank University.

London South Bank University’s recent critical review of the 44 new Sustainability and Transformation Plans (STPs) (1) sought to find out if they provide a credible basis for sub-regional (population-based and place-based) transformation. The report is not a commentary on whether there should be STPs, but on how they are set up to deliver the level, pace and scale of change required.

1. Do we know what STPs are supposed to be?

Firstly, it is somewhat unclear whether the STPs are the actual plans, the people implementing the plans (usually a ‘Board’), or a generic terms to cover all. There is also a lack of clarity on the authority and accountability of the STPs. In this absence, the NHS is setting up structures which tend to be based on their own hierarchical model, with significant additional bureaucracy, rather than working on a lean partnership approach.

There does need to be planning and strategy across health and care, but that is not the same as setting up a delivery organisation. The current legislation does not enable the NHS to collaborate and coordinate at the level required to plan across the STP footprint, as the NHS infrastructure is currently set up for competition. The existing culture in the NHS does not actually support collective decision-making, but rather a 1:1 hierarchical relationship between the ‘centre’ and the delivery arms, with short-term orders and instructions. This will not enable the level of change required to meet populations’ health needs.

2. The evidence for change

The starting places for the STP plans are often not grounded in reality: i.e. the actual financial position of the health system. The NHS Five Year Forward View envisages an efficiency requirement of £22 billion by 2020/21 for a ‘do nothing’ scenario, but individual STPs vary in the scale of their financial deficit problems from £131m to £1.4bn; and there is real variation in how transparent they are (with key information hard to find), and what level of risk assessment has been done (if any at all). This means that some plans cannot be realised, and there could be solutions implemented that even make things worse.

The plans must be informed by population health intelligence and the evidence of what change in the organisation and delivery of care will work for the identified local problems.

3. Is this an NHS plan only or a strategic plan with local government?

Collaboration is really hard when there are very different accountabilities in the NHS and local government, and when the STPs nationally have been driven by NHS England, and not jointly with the Department for Communities and Local Government. This means that the STPs are not ‘owned’ at the outset by local government - although they are a key partner in deciding what can be done and how, including how they use their own resources.

There has to be clarity about the partnership between health and local government to deliver the plans, with the authority to do this. The issues facing local populations require joined-up planning. The policy makers and the ‘centre’ have to be clear about overall expectations, but must then leave service design and delivery to local partnerships.

4. Solving NHS problems

Fifty per cent of STPs involve reductions in acute beds and A&E departments. However, as the STPs are intended to be a collaboration between health providers and local government, the considerable reductions in acute care beds will put a strain on these relationships. Local councillors, working on behalf of their local populations, are likely be in opposition where these plans are about reducing hospital capacity, and matters that are the sole responsibility of the NHS should be dealt with through the normal consultation process, rather than through the collaboration.

5. At what scale should change happen?

There is a lack of clarity in the STP plans about at what level of population/geographical footprint the model of service delivery resides – i.e. whether the work is best undertaken at a borough level, across a particular health system (CCG or group of CCGs), or at sub-regional footprint - and who has managerial control for each type of system.

In the NHS this could mean that the plans will tend to be ‘pulled’ up to a higher delivery level rather than devolved to the lowest scale, to be solved through local partnerships with local people. The plans should work from the bottom up in terms of where the solution best resides, rather than top down.

6. Costs

It is unclear how much the STPs are costing to develop and implement. There is the possibility that the plans will cost £5m per STP per year (based on the ones that have declared their costs). Given the lack of clarity in terms of scale, authority and accountability, the cost of the whole STP implementation process is bound to be high, as infrastructure is put in place patchily, requiring leaders and managers to ‘muddle through’. Clarifying the role, function, accountability and authority of STPs will reduce their ‘implementation’ costs.

In addition there are legitimate costs associated with generating the intelligence and investigating the evidence that underpins the plans. This could potentially be more usefully provided by Academic Health Science Networks rather than large external consulting companies, as is currently the case.

7. Immediate Gain

One area where there could be immediate resource gains is collaboration over workforce planning, but, unfortunately, two-thirds of the STPs have no detailed workforce plans. This should be resolved immediately.

Since our LSBU report was published, the scope of STPs seems to have narrowed to being more of a savings plan, but without a delivery mechanism. There is a danger that STPs will stop developing a vision of what future services could look like with real changes in self-care, healthcare delivered in the community, and joined-up primary, secondary and social care services. Instead, the financial regime is taking hold, with the risk that radical transformation of services will be packed up and put on the top shelf.

8. The Future

The next phase in STP development will be to formalise partnerships across the health system and in some cases the social care system (Accountable Care Systems) and in sub-geographies, to develop formalised shared governance structures in the form of Accountable Care Organisations. This will bring a formal interdependent accountability that reflects how people use the services provided by the full range of partners. It will also reflect how high-performing health systems across the world are organising with individual ‘parts’ ceding territory to a new formal collaboration. Laying the foundations for this next level of change may pose many further structural and organisational challenges, especially if attempted too quickly, and even before the new STPs have had a chance to bed in.

Reference

(1) Boyle, S., Lister, J., Steer, R. (2017) Sustainability and Transformation Plans. How serious are the proposals? A critical review, London South Bank University, London. https://beckymalby.files.wordpress.com/2017/05/sustainability-and-transformation-plans_lsbu_31_may_2017.pdf