Who’s Afraid of the STP?

NHS reorganisation

In 2015 we had the NHS 5 Year Forward View which set out some kind of strategy and was deployed quite well to try for extra funding.  Most of the aspirations in the 5 Year Forward View were noble enough and the suggested approach such as it was made some sense. Of course the 5 Year Forward View was denounced as privatisation but the reality was that words like choice, competition and private were not prominent.  The era of St. Simon largely erased the legacy of LaLa Lansley.

We now have a 3½ Year Forward View as not much has actually been achieved so far.  Reality in delivering the 5 Year Forward View depended on adequate funding for public health, health education and social care – none of which is within the remit of St. Simon and none of which is being done – in fact the opposite.  It also depended on £8bn pa of extra funding by 20/21 which was promised but which has already been shown to actually be only £4.5bn. 

And the assumptions made to justify claims of reengineering the system and increasing efficiency to make £22bn of savings have been shown to be retreads of old claims and about as likely to result in success as previous attempts. Much of the funding supposedly set aside for “transformation” was simply used to pay off deficits. Pay restraint continues to be the main source of savings.

In a vain attempt to get 5 Year Forward View back on some kind of track we are now returning to targets and terror as set out in the most recent publication from NHS England with NHS Improvement. This is the “reset” and has new sorts of failure regimes, financial targets and threats to sack everyone not above average. Quality is risked, waiting times allowed to rise, finance is again king. No attention is wasted on wider system issues like collapsing social care.

Nothing remotely useful will come out of this reset based on assessment, target setting and enforcement.  Complex financial incentives combined with threats to sack anyone who fails to meet the control targets won’t work.  The culture of top down bullying implied by targets & terror will trickle down to staff and increase issues around recruitment, retention and motivation.

More promising is the work around Sustainability and Transformation Plans. These sound like a good idea, bringing together commissioners and providers, healthcare and social care, primary and secondary care, mental and physical, local authorities and CCGs (possibly Public Health) – making them at least appear to be trying to work together. It starts an area based approach and puts more nails in the coffin of LaLa’s regulated competition model. It allows new models for care delivery including integrated ones (both commissioner/provider integration as well as primary/secondary care integration). Tough issues around governance and accountability are yet to be addressed but pragmatism around collaboration appears to be likely.

But it’s complicated as the 44 Sustainability and Transformation Plans to be signed off by NHS E and NHS I in October are built on the 150 Health & Wellbeing Plans overseen by Health and Wellbeing Boards and drawn up as part of the Better Care Fund process; still very much (£6bn) in play. These BCF plans are to get complete integration of health and social care by 20/21.

Somehow someone has to reconcile the 55 Year Forward View with the Department’s Mandate; 44 Sustainability and Transformation Plans, 150 Better Care Funds, plus plans from Public Health England, Care Quality Commission, Health Education England, annual commissioning plans from CCGs and plans for providers filed with various regulators – plus any plan for reconfiguration, success regimes or in response to regulatory action. No shortage of plans.

Anyway looking at some actual Sustainability and Transformation Plans is a bit worrying. They are pretty much alike in showing the serious financial gap, indicating wide variations in funding and outcomes and issues around care quality and waiting time performance. They all promise more care closer to home, better integration, better management of long term conditions, less hospital admissions, savings in back office, support and management costs. They are all pants. The assumptions being made about financial savings are based on vapour – not backed by any solid evidence just aspirations and hope. No Sustainability and Transformation Plan so far has been honest enough to set out the gap that REMAINs after all reasonable steps have been taken to reduce costs and bring efficiencies. The best any area can hope for is to slow the rate of increase in costs not reverse a remorseless trend – as Nigel Edwards recently told the Health Committee – nowhere in the world has managed to bend the curve.

But there could be a way Sustainability and Transformation Plans can morph over time into something like Area Care Boards, if issues around funding are addressed and if the ludicrous reset is ignored. Major changes can be made without another top down system wide reorganisation so long as everyone holds their nerve. A good test case could be Manchester. The plans Labour were making pre 2015 could be dusted off and scaled down. Well worth a try.

So bin the targets and terror of the reset and have a more honest start on the 5 Year Forward View- 

  • The funding for our care system is inadequate – in the NHS this leads to longer waits, less safety and worse outcomes and stress in the workforce.  In social care it means denying hundreds of thousands of people the chance for independence; and puts further burdens on carers and voluntary organisations.
  • As described above the “system” is hopelessly incoherent; there are multiple national bodies all with their own remit and governance.  There are multiple local bodes that all have some illusion of independence.  Then there are local authorities.  Nothing joins up so there is no system oversight and control at any level.  Who do you shout at?  The underpinning legislation from LaLa is simply being ignored with fingers crossed.
  • The measures being used to drive efficiency don’t work. Nowhere is the world has managed to bend the curve of emergency admissions; demand management has never been shown to have any long term benefits;  diverting care closer to home does not actually save any money; long term pay restraint has multiple unpleasant consequences; slashing capital funding is ultimately counterproductive; better procurement, shared services, outsourcing are probably more trouble than the advocates admit.  Big gesture moves like reconfiguration and mergers or complex commissioning models (Staffordshire, Cambridge etc) are almost always shambolic.

So get real.

A whole new approach is vital if we are to maintain and improve our care system.  The 5 Year Forward View and the 44 Sustainability and Transformation Plans are fairy tales at the moment.