The principle of the STP process is sound. After the disastrous destruction of planning arising from the Health and Social Care Act, the notion of bringing together providers and commissioners within a recognisable geographical area is a good one. Ignoring or actively subverting the failed market approach brings some sense at last.
Sustainability and Transformation Plans set out to offer opportunities to explore options and collectively find solutions to various health and social care challenges. They also give the chance to join up health and social care, and involve local authorities much more – potentially key in an era of wider devolution. But any sensible approach has been high jacked by the switch to driving savings to meet ludicrous financial control totals – which are driven from totally unrealistic levels of funding.
Despite attempts to impose secrecy we do now have some information about one third of the 44 STPs with summaries or draft plans or leaked documents of various sorts giving a chance to see some themes and trends. No STP has yet been published; they only have meaning if the accompanying schedules of workforce, estates and finances are attached.
Not publishing has not stopped the conspiracy theories and claims of swathes of the NHS being denuded of services. The rumours and claims are far worse that the reality.
Given there is widespread support for the principles behind the STPs any actual plan must show:-
- A long term approach
- A place base approach.
- Flexibility around organisational forms.
- Cooperation not competition
- Better allocation of pooled resources decided locally
- Attention to prevention and determinants of poor health
- Better, joined up, care pathways.
- Care closer to home, or in the home
The major concerns that have already been identified with most of the Sustainability and Transformation Plans are:-
- Goals are no longer clear – money or quality?
- Ludicrous approach so far with secrecy and lack of engagement with staff
- No joined up thinking from the national leadership
- Mostly very poor linkage with local authorities (despite claims)
- No proper accountability for delivery
- Inadequate funding of social care
- Inadequate funding of NHS
- Highly unlikely assumptions about productivity gains
- Lack of capacity to plan and implement anything on this scale
- Being imposed to save money not improve services
- Written and developed by management consultants not NHS or LA staff
Since this is about care then the obvious starting point is always the workforce. What skills are needed to make the new models of care reality; how does this link to staffing numbers and with what terms and conditions. It’s the key to the whole approach. So leaving aside the clinical, financial and delivery risks then the major risks identified around the workforce are from:-
- Continuing failures in workforce planning – stress, bullying, discrimination.
- Failures to recruit and retain the necessary staff/skills
- Further outsourcing especially of “back office” services
- Further attempts to outsource or award lead provider contracts in primary/community care
- Attempts to down band and downgrade jobs and job substitution
- Reduction in jobs (mostly unlikely!)
- Further fragmentation through tendering of services and complex procurement
- Creation of new care models through organisations outside public sector.
Although they appear to have mostly been written very badly from a comprehension perspective, it is worthwhile to read each STP, although it is pointless to focus on any of the financial statements as they are all dubious. The fact that every STP brings magical financial balance to everyone everywhere at the same time and to the £ should generate scepticism of the methods being used. (Would have been nice to see a few that said we have done our best but we are still a bit short.)
The most basic question is simple enough. If the funding is available, if the planning is done well, if the new models of care have the desired effect, if there is enough time and if there is genuine partnership working the – will the STP result in a care system that is obviously better than the one currently in the locality? Usually the answer has to be – yes – so this is about feasibility not desirability.
There are probably 2 or 3 STPs that are emerging as both credible and desirable. There are clearly going to be a majority which tick the required boxes, suggest the right answers but which will never succeed; even the people who wrote them appear to accept this. Finally a few will be obviously bad, asking for investment that will not happen or making claims for agreement amongst parties that then signal they actually do not agree.
It is worth saying yet again that Sustainability and Transformation Plans change nothing at all in terms of statutory duties and requirements. All STPs will have to go out to some kind of consultation after some kind of independent expert assurance has been applied. Any formal proposals to make changes to clinical services, like any other reorganisation, can only be properly implemented through a long and complex set of requirements around business cases, consultation and more. Many will start to fall apart as soon as they are examined. Legal challenges are almost certain, corners have already been unwisely cut and more mistakes in process are inevitable.
In the interim while we wait publication there are already many scare stories and the save our XXX campaigns are underway. The idea that the NHS will suddenly become brave enough to implement highly unpopular changes is a bit far-fetched – the record is terrible. Some kind of alliance with local authorities that have over many ears been forced into making unpopular cuts and riding out the public disapproval is not really going to help – every politician will back the protestors when the time comes, as they always do.
The most dangerous STPs are those that look credible but which are based on flawed assumptions or are simply wildly over optimistic. These will launch but then crash with potentially highly damaging consequences.
So looking a bit more closely, Sustainability and Transformation Plans essentially have to contain:-
- Current state of care system (including social care, public health, etc) – should link to local strategic needs analysis and local council plans
- Current financial situation – projected gap by 2020/21.
- Local specifics – drivers for change
- Service issues
- Development of proposals – engagement so far
- Prevention –
- tackling social determinants
- primary – preventing conditions
- secondary – mitigating severity of existing conditions
- Joining up out of hospital care – social care, primary care, community care
- Reconfiguration of acute services/possibly tertiary
- Joined up urgent/emergency care
- Efficiency/improved productivity measures within providers
- Efficiency measures in commissioning system
- Other system wide efficiencies
- Prevention –
- Analysis of risks
- Accountability and Governance
- Next steps
So anyone who does read a STP might like to look for answers:-
- Does the STP read as if it has been written for general understanding or just NHS insiders?
- Does it describe clearly what would be better after the STP – for patients, for staff, for system?
- Does it read as if there has been some input from patients groups, local staff, communities, voluntary organisations?
- Does it address those local issues that are already identified (Trusts in special measures, failed commissioners, long waits etc)?
- Does it explain what will happen under realistic assumptions about funding as opposed to the unrealistic one they must all apply?
- Does it explain where the funding for the management of the changes will come from? Capital funding? Double running costs?
- Does it explain how implementing the changes proposed will be subjected to consultation, tried out first then rolled out at scale?
- Does it explain who will be responsible for what in terms of delivery; are patients, public and staff involved in the management of change?
- Does it explain how in a more integrated system decisions will be taken (and by who) about allocation of funding?
- Does it explain what is expected of regulators (like CQC) and national bodies (like NHS Improvement/Monitor) in responding to local changes?
- Does it explain how the many complicated programmes will be managed – how will enough clinical expertise be released? Will it all be run by KPMG?
- How reliable is the data on which the plan is built? What contingency scenarios have been explored where data is poor?
- What proportion of the claimed savings depends on national action like imposed pay restraint?
- How many jobs will be lost, how many new jobs created, how many jobs changed significantly? How will this be carried out
- Where is the GANTT chart? Who updates it? Who manages dependencies, risks and issues?
- And is all this to be honest, open and transparent – as required but ignored so far?
For those brave enough to dig a little deeper then maybe:-
- How many of the proposals have actually been tried successfully before locally? elsewhere? anywhere?
- How realistic are the cost savings from the usual unicorns of merging organisations, reorganising services, sharing back offices, forming chains and federations, outsourcing pathology etc, when they have all been tried before with limited success?
- Have the same improvements (such as reducing length of hospital stays) been counted two or three times or more?
- Where is the clinical leadership to ensure Right Care and other schemes to reduce variation are explored then implemented?
It would be helpful to hear suggestions for other questions to ask.