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Sustainability and Transformation Plans – What are they good for?

Even though the strategic direction of the NHS in England under Simon Stevens seems to me to have been pretty sensible, I am not convinced by the latest instalment: ‘sustainability and transformation plans’ (STPs).  Something feels not quite right, (not, I should stress, that I have any inside knowledge; this is just my impression as an observer).

Although suffering from being a health driven rather than whole systems, approach, the Five Year Forward View (5YFV) seemed to address the key drivers for improvement.  While it has been summarised in a number of different ways, the formulation I prefer is that used the press release announcing it which identified how action needed to be taken on four fronts:

  • Prevention and tackling the root causes of ill health
  • Giving patients more control over their own care and new support for carers and volunteers
  • New models of care built round the needs of patients rather than professional divides, integrating primary and secondary care, physical and mental health and health and social care
  • Investment in innovation, technology and workforce

As a shorthand, I like to think of these as:

  • prevention (including social determinants of health);
  • co-production (with an equal role for patients and the public);
  • services and integration; and
  • innovation and technology.

In December 2015, NHS England’s planning guidance required the production of five year Sustainability and Transformation Plans (STPs) alongside the one-year operational plans.  The STPs sit alongside a Sustainability and Transformation Fund, designed to help “get hospitals back on their feet, support the delivery of the Five Year Forward View, and enable new investment for critical priorities such as primary care, mental health and cancer services.  The key feature of the plans is that they are to be about ‘place’ rather than individual institutions.

I have three, overlapping, concerns: about the geographical units on which the plans are based; the extent to which the plans are to be locally determined; and their scope, the extent to which they will embody a whole systems approach.  In sum, this questions what they are really designed for and what they are actually likely to achieve.

My first concern was about the geographical units, or ‘footprints’, that the plans were to cover.  These were supposed to be locally determined, but I have my doubts.  Are these really the areas people relate to or have the CCGs been leaned on to come up with them?  Certainly there was no time or mechanism to involve the public in that decision.  There are to be 44 areas that don’t match any of the other jigsaws dividing the country – local authorities, CCGs, local area teams or even CSU areas.

Of course, no geographical division will ever be exactly right.  There will always be overlaps in service provision, cross boundary flows and conflicting reasons for any particular size and shape.  However these look suspiciously like the sort of area you would choose if you were looking to make structural change in health service provision.  Like concentrating specialist care in centres of excellence (as with the reorganisation of stroke services, initially in London and Manchester).  Not that that is necessarily a bad thing in itself.

My second concern is about the extent to which they are locally determined.

Although ostensibly bottom up, in that health service commissioners and providers have to come up with the plans, it seems to be a largely top-down process (though maybe that’s just the normal NHS way?).  The plans are to be assessed and reviewed in July, and presumably if they’re not ‘right’ they will have to be rewritten.  Plans which do not match the central requirements will not attract their share of funding from the new pot of money.  Also, areas that don’t meet the grade, as determined centrally, will receive ‘support’ as necessary.

Although there is a nod in the guidance to harnessing the energies of (as opposed to engaging or working with) patients and citizens (guidance (pdf), p.4), there seems to be limited opportunity within the process for that to occur, since plans have to be submitted by June.  (To be fair, if an area already has good, established engagement, it would be possible to talk to those who are fairly closely involved, but I suspect that in reality that will be the exception.)

My third concern is about how far the plans represent a ‘whole systems’ approach.  The planning guidance says (p.4) that:

“The STP must also cover better integration with local authority services, including, but not limited to, prevention and social care, reflecting local agreed health and wellbeing strategies.”

Perhaps this has to be said because of the statutory duty to take account of those strategies, but the arrangements for STPs gives little confidence of any genuine intent to relate to the JHWS’s.

Although ‘system’ is used quite a lot in the guidance, and ‘health and care’ system several times, this seems to refer just to the health services, both commissioners and providers.  Social care and the voluntary sector get a cursory mention but it’s really about getting a combined plan across primary and secondary care and CCGs rather than looking at the whole health and wellbeing system (which would need much closer involvement of all local government services and the rest of the public, voluntary and private sectors).

Yet the Joint Health and Wellbeing Strategies (JHWS) are existing, statutory plans, based on clearly established areas with governance structures, designed to take a whole systems approach.  Why is NHS England trying to bypass them?  Because they haven’t achieved much?  Because they are seen as being too subject to local interests?  Because they are not big enough areas to take into account the issues they want these plans to address?

So, what is this really all about and what is it likely to achieve? Is it really about finance – a way of distributing the sustainability and transformation fund?  Or is it about reorganising health services (new models of care, centres of excellence, etc.)?

And what aspects of the 5YFV is it most likely to support?  How will it contribute to each of the four ‘fronts’ identified above?

It seems to have most relevance for ‘services and integration’, reorganising what each acute trust does and moving services from hospitals to community services.

There may also be opportunities for technological change (e.g. ICT interoperability), though this probably needs to work at a range of levels from national to very local, anyway.

In relation to ‘prevention’, it seems unlikely that plans at this scale and put together in these timescales will be able to achieve much change.  In theory it might galvanise the constituent Health and Wellbeing Boards, but equally it could generate defensiveness from being conscripted into a health planning process at short notice.

As for ‘co-production’, it’s hard to see these plans having much impact.  Is meaningful change really likely to be driven by a process and geography that is not associated with any institution that local people will recognise or understand?

So in short, it is hard to see it meeting its stated aim of contributing substantially to the 5YFV.  It appears to be a way of allocating some additional funding so as to correct the balance sheets, get the capsizing service quality righted and make some high level reorganisation of services.

If so, that’s not an unreasonable objective.  The fact that it’s missing half of the picture – the difficult things that could make a big difference, like prevention, involving the public, a whole systems approach – might not matter if those things are happening elsewhere.

However, the risk is that it detracts from other work.  Perhaps it will work better in some parts of the country than others, where genuine relationships already exist.  But trying to create ‘system’ change on new geographies, within a tight timescale, establishing new relationships and the trust necessary to make hard change happen, seems at best ambitious.  At worst, it could divert attention from other good work, its new plans could interfere with other projects and it could confuse existing priorities.  So while it may achieve some good, albeit within a narrower range of objectives than advertised, there is also a worrying risk of distraction, disruption and distortion to the whole system.

Postscript:

Since writing this, I’ve come across a blog post by Stephanie Edusei, which makes some similar points (rather more concisely and coherently!): https://www.linkedin.com/pulse/sustainability-transformation-plans-footprints-planning-edusei

PPS:

Resources from the King’s Fund on STPs: http://www.kingsfund.org.uk/projects/sustainability-and-transformation-plans

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