Sustainability and transformation plan

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In March 2016, NHS England organised the geographical division of England into 44 Sustainability and transformation plan areas (or footprints) with populations between 300,000 and 3 million, which would implement the Five Year Forward View. These areas were locally agreed between NHS Trusts, local authorities and Clinical Commissioning Groups. A leader was appointed for each area, who is to be responsible for the implementation of the plans which are to be agreed by the component organisations. They will be "working across organisational boundaries to help build a consensus for transformation and the practical steps to deliver it".[1] During 2017 the use of the acronym STP shifted, so that it was used to signify Sustainability and transformation partnerships.[2] In February 2018 it was announced that these organisations were in future to be called integrated care systems, and that all the 44 Sustainability and transformation plans would be expected to progress in this direction.[3] The ten pioneer systems were described as nascent and fragile by the Health Select Committee in May 2018.[4]

Areas[edit]

The geographical configuration differs in some respects from previous NHS arrangements – Regional Hospital Boards, Regional Health Authorities and Strategic Health Authorities – because the configurations have been locally agreed, rather than imposed from the centre. They vary very considerably in size, the largest having more than ten times greater population than the smallest.[5]

Staffing[edit]

Three of the leaders are from local government: Sir Howard Bernstein, the chief executive of Manchester City Council, David Pearson the director of adult social care at Nottingham City Council, and Mark Rogers, the chief executive of Birmingham City Council and president of the Society of Local Authority Chief Executives and Senior Managers. The remainder are NHS managers.[6]

Finance[edit]

The NHS planning guidance for 2016-17 states: “For many years now, the NHS has emphasised an organisational separation and autonomy that doesn’t make sense to staff or the patients and communities they serve… System leadership is needed.” It also suggests that the financial problems of individual organisations are no longer critical. What is important is the financial situation of the organisations in each area considered together.[7] Each area is required to produce a Sustainability and Transformation Plan by end of June 2016.

In February 2017 the National Audit Office produced a report suggesting that plans to save millions of pounds ‘may be optimistic’, that there was poor oversight of the various initiatives and that progress with integration plans had been slower and less successful than planned. £5.3 billion spent through the Better Care Fund in 2015/16 had not delivered value for money. Furthermore, there was ‘no compelling evidence’ to suggest that integration would lead to financial savings or less use of acute hospitals.[8]

£325 million capital funding for the strongest plans was announced in March 2017 but Sir Robert Naylor concluded that at least £10 billion would be needed to deliver proposed plans and make NHS facilities fit for purpose. His review suggested that £6 billion could be raised by selling NHS land and buildings.[9]

Development[edit]

Simon Stevens described the progress made in December 2016, saying that the most advanced areas were "capable of combining the purchaser and provider, the commissioning and provider function, a la Frimley Health”. In some cases he expected a "governance partnership of the relevant statutory bodies" which in some cases might become integrated organisations. But in some areas there were only proposals, not yet progressed into plans. He proposed to give the most advanced money and authority to progress their plans. NHS England would organise national support programmes, particularly for “primary care provider development”, support urgent and emergency care systems, rather than to individual organisations, and set up clinical standardisation and productivity initiatives under professors Timothy Briggs and Tim Evans.[10]

Plans released in March 2017 propose at that all plans should evolve into accountable care systems with "clear collective responsibility for resources and population health" and some control over devolved funding for mental health, cancer and general practice. Between six and ten STP areas are to be launched as accountable care organizations.[11]

A survey by the Chartered Institute of Public Finance and Accountancy in September 2017 found that of 56 organisations who responded to a survey 55 did not believe that joint working between local government and health organisations would be fully achieved in the next 5 years. They also found that there was no funding for plans to increase preventative work.[12]

Accountability[edit]

Steven Broomhead, the chief executive of Warrington Borough Council, complained to NHS England in July 2016 that decisions were being made "without any local transparency". He said changes to where people receive services and what services they receive needed "local scrutiny and local community involvement".[13]

Care in the Community[edit]

It is planned to transfer patients to care in the community. This may lead to improved care in some cases but the King's Fund claims not all community care plans are credible because there are insufficient services outside hospitals and there is insufficient money to provide more. The King's Fund fears reducing hospital beds will increase the strain on hospital services which were overstretched during the 2016–2017 winter. Professor Chris Ham of King's Fund maintains transferring services to the community is a potential improvement in many cases and plans should be considered on their merits. Ham maintains further transfer to the community cannot be done without extra funding and urges the government to invest in community services.[14] The Nuffield Trust reported that some STPs were planning up to 30% reductions in some areas of hospital activity - going against trends which have persisted for the last 30 years. They conclude that out-of-hospital care may be better for patients, but it is not likely to be cheaper for the NHS in the short to medium term.[15]

Reaction to proposals[edit]

According to Dr Brian Fisher, "STPs are driven by the Treasury. They are focused on reducing NHS spend. (...) Unless STPs meet the funding demands of the Treasury, the plans will not be approved and areas will not receive any transformation money."[16] An article by the King's Fund states, "Allocations from the fund for sustainability and transformation must be agreed in advance with HM Treasury and DH’." The same article states that the spending review, "is both ring-fenced and needs HM Treasury agreement to unlock."[17]

The Nuffield Trust think tank claims many suggestions would fail to implement government financial targets and involve a "dauntingly large implementation task". Sally Gainsbury of the Nuffield Trust said many current plans involve shifting or closing services... "Our research finds that, in a lot of these kinds of reconfigurations, you don't save very much money - all that happens is the patient has to go to the next hospital down the road. They're more inconvenienced... but it rarely saves the money that's needed."[18] There will be a shift from inpatient to outpatient care but critics fear cuts that could put lives at risk, that the plans dismantle the health service rather than protecting it, further that untested plans put less mobile, vulnerable people at risk. By contrast, NHS England claims that the plans bring joined-up care closer to home. John Lister of Keep Our NHS Public said there are too many assumptions, and managers desperate to cut deficits were resorting to untried plans.[19] A survey of ninety-nine clinical commissioning group chairs and accountable officers conducted by the Health Service Journal in October 2016 found very little confidence that the plans would deliver.[20]

An article in The Guardian suggests possible substantial benefits from the plans. The system as a whole lacks money and an ageing English population has growing complex requirements. Health and social services need to be coordinated, STP's got people working enthusiastically together. The article suggests NHS England 'made up the policy on the hoof' and managers were under pressure to produce plans fast. NHS England gave fragmented guidance, coming in bursts with frequently insufficient time for responding to requests. There are fears secrecy within the NHS is hindering effective public discussion and without public discussion there is a risk of later delays, protests, judicial reviews. The Guardian argues that full-time leaders are needed who will not put the interests of their own department before the needs of the whole and will send money where it is needed.[21] Another Guardian article questions whether the plan might be to prepare for greater privatisation after 2020. Transferring services from hospitals to the community will only work if there is spare capacity in the community and GP's are already overstretched. There are too few NHS staff generally to enable the reorganisation.[22]

Critics are concerned that the plan will involve cuts but supporters insist some services will be cut while others will be enhanced. Senior Liberal Democrat MP Norman Lamb accepted that the review made sense in principle but stated: "It would be scandalous if the government simply hoped to use these plans as an excuse to cut services and starve the NHS of the funding it desperately needs. While it is important that the NHS becomes more efficient and sustainable for future generations, redesign of care models will only get us so far – and no experts believe the Conservative doctrine that an extra £8bn funding by 2020 will be anywhere near enough."[23]

Plans were generally kept secret until December 2016. 43 out of 44 were published by December 2016. Oxfordshire, Buckinghamshire and Berkshire was, at that stage, still in dispute. One local manager described keeping plans confidential as 'ludicrous' and another said the 'wrong judgement call' had been made. Another person spoke about being in meetings where, 'real people' like patients and the public were not involved. The King's Fund reported the public and patients were mostly absent from plans potentially involving large scale service closing. Chris Ham of the King's Fund described suggesting out-of-hospital services and GP's could take over work now done by hospitals as a “heroic assumption” since both are under too much pressure. Some councils that disagree with the secrecy have published plans on their websites.[24] [25] Funds that should have gone to easing transition of services after closures instead went to plugging other NHS deficits.[26]

Sir Bruce Keogh defended the process in December 2016 saying "I think in a number of areas, {services} will look very different. But what we have to be really careful about is that they serve the needs of patients and the local community. People are always up for change, but they fear loss, and I think that those who are proposing the change have a duty to explain to the local communities why those changes offer an improvement."[27]

Organisers of a protest march in London where tens of thousands of people took part fear the Sustainability Transformation Plans are a "smokescreen for further cuts". Hospital services could be cut in nearly two thirds of England and some hospitals will be completely closed. During the march Jeremy Corbyn said, “There are those waiting on trolleys and those who are desperate to get into an A&E department waiting hours for treatment. It is not the fault of the staff. It is the fault of a government who have made a political choice.” Corbyn also said, "The Tories and the coalition before them managed to cut taxes on big business. Don't let them tell you there's no money for the NHS. There's no excuse for it... the money is there if you collect the taxes properly to fund it and pay for it." Len McCluskey of Unite stated, hospitals, GPs, mental health, ambulance and community services are on their knees". Dr David Wrigley of the BMA said, "As a doctor I see day to day the serious pressures in the NHS due to the funding cuts from the government."[28][29]

There is concern that plans are being introduced hastily without evidence that they will be effective. Dr Mark Porter of the BMA said money was "wasted" and changes "rushed through without appropriate evidence".[30] According to the Local Government Association only 21% of councillors they surveyed in 2017 felt sufficiently engaged in their STPs, and less than 25% were confident that their STP would deliver on its objectives or bring benefits to the local community.[31]

The King's Fund in September 2017 described plans to cut hospital beds as ‘undesirable and unachievable’, pointing out that the UK has fewer acute beds relative to its population than almost any other comparable health system.[32]

According to Sir David Sloman the purpose of these plans is to focus on population health – helping people to achieve their maximum potential – rather than treating people when they get sick.[33]

Legal considerations[edit]

STPs are not statutory organisations so any changes resulting from the plans most be implemented by their component bodies, and those bodies may be required to conduct public or staff consultations, or, in the case of foundation trusts, ballot their governors. Local authorities have the power to call decisions in for scrutiny. The Health and Social Care Act 2012 provisions may also require approval of proposals from the Competition and Markets Authority.[34]

References[edit]

  1. ^ a b "The leaders chosen for 41 of England's STPs". Health Service Journal. 30 March 2016. Retrieved 8 April 2016.
  2. ^ Hammond, Phil (20 September 2017). "STP realities". OnMedica. Retrieved 19 November 2017.
  3. ^ "ACSs get a rebrand as NHS England seeks 'next cohort'". Health Service Journal. 2 February 2018. Retrieved 2 April 2018.
  4. ^ "Integrated care: organisations, partnerships and systems". Parliament.uk. 11 June 2018. Retrieved 11 June 2018.
  5. ^ "Mapped: The 44 confirmed STP footprints". Health Service Journal. 8 March 2016. Retrieved 20 April 2016.
  6. ^ "Just three of new sustainability and transformation leaders from councils". Public Sector Executive. 31 March 2016. Retrieved 20 April 2016.
  7. ^ West, Dave (15 April 2016). "The Commissioner: So much for the whole system". Health Service Journal. Retrieved 20 April 2016.
  8. ^ "NHS vanguard plans to save £900m by 2020 'optimistic', says NAO". Commissioning Review. 8 February 2017. Retrieved 11 February 2017.
  9. ^ "Naylor review: NHS needs £10bn increase in capital funding". Health Service Journal. 31 March 2017. Retrieved 15 May 2017.
  10. ^ "Some STPs are becoming 'integrated organisations', says Stevens". Health Service Journal. 7 December 2016. Retrieved 25 January 2017.
  11. ^ "All STPs to become accountable care systems under latest NHS plans". Health Care Leader. 30 March 2017. Retrieved 2 May 2017.
  12. ^ "Almost all STP bodies reporting poor joint working". National Health Executive. 21 September 2017. Retrieved 3 October 2017.
  13. ^ "NHS reform plan 'arrogant' says Warrington council boss". BBC News. 2 July 2016. Retrieved 2 July 2016.
  14. ^ Schraer, Nick Triggle and Rachel (21 February 2017). "Hospital cuts planned in most of England" – via www.bbc.co.uk.
  15. ^ "Shifting the balance of care: Great expectations". Nuffield Trust. 1 March 2017. Retrieved 16 July 2017.
  16. ^ "NHS reform: Why sustainability and transformation plans could be dangerous - GPonline". www.gponline.com.
  17. ^ "How will services access the new Sustainability and Transformation Fund?". 14 January 2016.
  18. ^ NHS cuts 'planned across England' BBC
  19. ^ Plan to 'transform' NHS could lead to downgrade of major London hospitals The Guardian
  20. ^ "Survey finds few local leaders confident STPs will deliver". Health Service Journal. 25 October 2016. Retrieved 20 December 2016.
  21. ^ NHS plans could bring benefits but we're barred from telling the public The Guardian
  22. ^ The NHS secret is out. And local communities won't like it The Guardian
  23. ^ NHS plans 'not just about closures', bosses insist The Guardian
  24. ^ NHS bosses 'trying to keep cuts secret' BBC
  25. ^ NHS plans to close hospitals and A&E departments kept secret from the public, investigation finds The Independent
  26. ^ NHS cuts: Why they terrify people in power BBC
  27. ^ Pym, Huw (21 December 2016). "NHS transformation plans: Cuts or change for better?". BBC News. Retrieved 22 December 2016.
  28. ^ "NHS protest: Tens of thousands march against 'hospital cuts'". 4 March 2017 – via www.bbc.co.uk.
  29. ^ Johnston, Chris; agencies (4 March 2017). "'Defend NHS with all your might', Corbyn urges demonstrators" – via The Guardian.
  30. ^ Triggle, Nick (28 June 2017). "A&E cuts will hit 23m people, doctors say" – via www.bbc.co.uk.
  31. ^ "We have no confidence in transformation plans, local government tells NHS". OnMedica. 5 July 2017. Retrieved 23 August 2017.
  32. ^ "Related Content Blogs The incredible invisible bed crisis 24/01/2017 News Report reveals impact of financial cuts on patient care 14/03/2017 NHS spending should match best of Europe, say doctors 06/03/2017 STP proposals to cut beds not credible without community investment 21/02/2017 Hospital beds numbers down 20% in a decade 20/02/2017 Bed cut plans 'undesirable and unachievable', warns think tank". ONMedica. 29 September 2017. Retrieved 23 December 2017.
  33. ^ "David Sloman: STPs are refocusing attention on population health". Health Service Journal. 26 October 2017. Retrieved 24 December 2017.
  34. ^ Hill, David (27 October 2016). "STPs must stay the right side of the law". Health Service Journal. Retrieved 20 December 2016.

External links[edit]

  • NHS SOS article by James Meek in the London Review of Books