It's time to save STPs from themselves

Tue 20 Dec 2016

Without more honesty, stability and time, we risk throwing away a once-in-a-generation opportunity to transform health and care services, says MiP chief executive Jon Restell.

MiP was an enthusiastic supporter of the Five Year Forward View. Now we see the Sustainability and Transformation Plans (STPs) as a once-in-a-generation opportunity to change our care system for the better.

Our views are shared by many managers. As one of my colleagues notes on this site, the vast majority of managers “see the logic of trying to unify the system and address the particular needs of the communities they serve”. And as one of our members, writing in the Guardian, said: “The benefits of STPs could be huge. The whole system is short of money, and we have a growing and ageing population with increasingly complex needs: to have any chance of sorting this out, we must integrate health and social care services – and STPs have sparked some real collaboration. We’re bringing together people who’ve been plugging away at different aspects of the same problem for years, and there’s huge enthusiasm.”

But as members took stock at our conference, it started to look like we might be throwing away this once-in a generation opportunity.

While being optimistic, we have always been realistic and sceptical. No MiP member believes the funding gap of £30bn can be closed by 2020-21 through efficiency gains of £22bn. Not only were the efficiency claims overblown at the time but some of the Forward View’s other assumptions have unravelled. The baseline was out because the NHS started with a £3bn deficit, not a balanced position. There have been cuts to public health and social care services, and some drastic reductions in capital funding. And all this is before we even think about Brexit and inflationary pressures.

And certainly no one now believes that the extra money (whether you choose to believe the government or the Health Select Committee about how much it is) will be anywhere near enough. The extra sum needed is probably closer to £20bn than £8bn, with a sizable extra bucket of transitional funding and more time for transition.

These are the financial gaps. But there are other gaps – in stability, engagement and accountability – which could prove just as fatal to STPs.

Money woes, regulatory and performance pressures are destabilising more and more providers. Unstable systems generally don’t transform themselves well. Then there is public and staff engagement (and I include engaging with leaders here). With a few notable exceptions, it has simply not been good enough. The perception of secrecy has contaminated the STP brand before launch. And then there is accountability. STPs have done good work in bringing a new kind of conversation to local health and care systems and analysing the big local challenges. But what happens next is less solid, with many system leaders blithely thinking that we can achieve the impossible. The unreality of some plans begs unavoidable questions about accountability and the capacity to deliver.

As a result of all this, political pressure is building. It’s possible to sense the start of a retreat from the big decisions. Many of us are feeling that it’s a bit like Groundhog Day. Will STPs in the end boil down to another restructure of commissioning and a poorly-executed back office rationalisation?

Let’s hope not. Now is the moment to launch a campaign to Save Our STPs. Here are four campaign objectives:

  • Honesty as well as optimism from NHS and other local leaders about the money and the scope for efficiency gains. NHS leaders must be clear that despite their best efforts the funding gap will remain.
  • Stabilising the system, with extra money for social care and NHS community services as a priority.
  • A full year to allow thorough public and staff engagement, with a political understanding that, after that, local systems will make the tough decisions.
  • Accountability and delivery mechanisms with bite and bark to implement those tough decisions, a transitional find to support local transformation and decent support for local leaders.

Unrealistic? Perhaps. But more realistic than the present hopes for STPs. If we want to grab this once-in-a-generation opportunity to change our care system, let’s go for it. Save Our STPs!

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