STPs: will they be deliverable?

Roger-KirbyAs winter approaches, NHS managers in England will be even busier than usual. Handling the increased volume of emergency admissions to hospitals and juggling demands for beds will be as tough as ever. On top of that will be a raft of meetings discussing the potentially most radical shake-up of health services in decades.

The sustainability and transformation plans (STPs) being produced in 44 local areas of England are seen as vital ingredients in the redesign of care to cope with increasing patient demand. The plans will focus on trying to moderate that demand and treat more patients away from hospitals. But there has been no denying that some of the plans will see closures of accident and emergency units and hospital wards, concentrating services on fewer sites.

The STP process has got off to a difficult start. Accusations of cover-ups and stealth cuts have been fuelled by the King’s Fund report, which said local health teams had been asked by the NHS nationally to keep the plans out of the public gaze.

Local campaigners, fearing closures, are gearing up to take to the streets to defend local hospitals. There could be a winter and spring of discontent ahead.

A bigger question raised by the King’s Fund report was whether the STPs would be deliverable. Local health leaders have enough on their shoulders with the day-to-day running of services, never mind managing ambitious and sometimes controversial transformation plans.

Investment for a shake-up of local care provision will be hard to come by in stretched budgets. Will these STP plans be deliverable? Post your views on this blog.

Comments (9) Add yours ↓

    The lack of GP provider input allowed no challenge to the delusion shared by NHS England, commissioners and the hospital sector that General Practice is inefficient and can take up the entire capacity that drives the hospital sector deficit. That they believe they can do so without the necessary funding going into General Practice means that STPs will snatch failure from the jaws of an opportunity to restructure the delivery of healthcare in a new and efficient way. This lack of insight will spoil the ship for a ha’porth of the tar.

    November 30, 2016 Reply
  2. Peter Littlejohns Professor of Public Health

    David Nicholson the previous Chief Executive of the NHS is reported as describing the Health and Social Care Act of 2012 as “a reorganisation so big that you can see it from outer space.” Continuing the astronomical analogy Sustainability and Transformation Plans (STPs) are like 44 large meteorites heading your way. The chances are that most will burn up before having any impact but some may cause local disturbances. While the rhetoric is about improving quality and not seeking to reduce costs no one is being fooled – certainly not the public. The timing of the STPs is all to do with the increasing realisation that the efficiency savings that were expected to supplement the small increase in NHS funding have not materialised. Combining this with increasing demand and severe cuts to social care budgets means that the NHS is facing its greatest challenge ever. While the STPs may ease pressure on the hospital sector over time they are very unlikely to achieve the sort of short term savings that are needed to balance the books in the next few years.

    In his BMJ editorial in 1998 Albert Weale, a professor of political science and public policy stated

    “the basic principle of the NHS is simply that comprehensive, high quality medical care should be available to all citizens on the basis of professionally judged medical need without financial barriers to access. Yet in the face of increasing healthcare costs this basic principle threatens to become what logicians call an inconsistent triad; a collection of propositions, any two of which are compatible with each another but which, when viewed together in a threesome, form a contradiction. Perhaps we can have only a comprehensive service of high quality, but not one available to all. Or a high quality service freely available to all, but not comprehensive. Or a comprehensive service freely available to all, but not of high quality. Each of these three possibilities defines a characteristic position in the modern debate about healthcare costs and organisation”

    Politicians’ reluctance to acknowledge this inconsistent triad and their refusal to discuss the first 2 propositions means that we are moving inexorably to the last option – a service whose quality slowly deteriorates causing disillusionment in staff, anxiety for patients and perhaps the concept of the NHS itself under threat.

    December 1, 2016 Reply
  3. Christopher Smallwood former Trust Chairman

    Professor Littlejohns has hit the nail on the head. The government refuses to accept that the NHS is chronically underfunded, but it clearly is as financial provision expands at 0-1% pa whilst demand for healthcare rises at 5%. As year succeeds year, obviously pressures steadily increase and the quality of care deteriorates. Since in addition, healthcare must continue to be free and comprehensive, the prospect of continuing deterioration is unavoidable.
    The government’s response is to demand unattainable cost savings, the latest attempt to deliver which takes the form of 44 STPs. Among the reasons this initiative will fail are: the political opposition which will arise when reconfigurations are proposed for particular areas; the lack of facilities in the community to enable hospitals to discharge patients blocking beds; and the lack of additional finance to enable the investments to be made to make a reality of joint planning of health and community services. The STPs are supposed to produce plans which work within the budgets currently planned which are quite obviously wholly inadequate.

    The approach of planning these services together in STPs could be a sensible one, but it does not escape the basic need for billions extra for the NHS every year. If this can’t be provided from taxes, other sources of finance must be tapped, or the standards of healthcare in the UK will become woeful indeed.

    December 2, 2016 Reply
  4. Albert Weale Emeritus Professor of Political Theory and Public Policy

    it is a necessary condition of balancing out the conflicting demands to which Peter Littlejohns refers that there be a realistic way of ensuring that there is an appropriate return for the marginal cost of engaging in any particular line of activity. NHS England proposes to reduce the tariff as a way of squeezing ‘efficiency savings’ out of the system. In this respect they are behaving like the planners in the old Soviet style economy, paying no attention to the underlying costs of the activities in which the NHS is engaged. In these circumstances, the deterioration of quality is inevitable, as it was with goods produced by the SOviet economy.

    December 2, 2016 Reply
  5. Roger Kirby Professor of Urology

    Cutting hospital beds as part of radical plans to transform the NHS and social care would further increase pressure on GPs and emergency medicine departments.

    That is the warning from doctors who are concerned that a project aimed at reshaping health services will simply make further cuts to local services rather than driving genuine improvements.

    It comes after health managers in Nottinghamshire published their STP (sustainability and transformation plan), one of 44 similar projects taking place across England to devise a plan for more integrated care.

    Analysis last week revealed that the STP process involved making around £22bn of savings over five years nationally – and in Nottinghamshire health leaders need to plug a £628m gap.

    December 3, 2016 Reply
  6. Roger Kirby Professor of Urology

    The Government is asking the NHS to ‘deliver the impossible’ – demanding higher standards while cutting funding.

    That is the warning from the organisation that represents NHS trusts in England which said the unrealistic demands could ‘destabilise’ hospitals this winter and that the quality of patient care is already deteriorating.

    NHS Providers chief executive Chris Hopson told the organisation’s annual conference in Birmingham on Tuesday that the health service is becoming less resilient and that the deterioration in services was likely to accelerate owing to the crisis in social care.

    Mr Hopson said: ‘The Government has said there will be no more money. The Government and our system leaders have said that the NHS still has to deliver everything that is being asked for.

    ‘When you run a system under as much pressure for as long as we have been running the NHS, it becomes much less able to absorb the shocks that any health system has to absorb – the winter flu outbreak, closure of a couple of care homes, a few experienced GPs retiring and being replaced by more risk-averse locums.’

    Mr Hopson also said the pressure on staff and leaders in the NHS was ‘intolerable’ and morale was eroded.

    He said: ‘The invisible bond of mutual trust and faith between the Government and NHS system leaders, on one hand, and frontline leaders, on the other, is starting to fray.’

    December 4, 2016 Reply
  7. Roger Kirby Professor of Urology

    Tower Hamlets GPS:
    The NHS is facing an unprecedented financial crisis. The proportion of GDP spent on the NHS is going down year on year and is one of the lowest in Europe. Most acute hospital trusts are in deficit and the proportion of the NHS allocation spent on general practice is at an all time low at a time when work is being transferred from secondary to primary care. There is also a workforce crisis in general practice. Young doctors are not choosing it as a career and older doctors are leaving. The situation is such that a recent GPC survey revealed that 84% of GPs feel that their workload is either excessive or unmanageable. This is not safe for patients.

    On this backdrop, the ‘sustainability and transformation plans’ mandated by NHS England will demand £22 billion of ‘savings’ across the NHS in England.

    We believe that it is not possible to ‘save’ this amount of money without severe cuts in service. The NHS is struggling to function as it is and it is a testament to all the staff who work in it that it still provides such an excellent service.

    We are not against change that is clinically evidenced but we cannot sanction this financially driven exercise.

    January 7, 2017 Reply
  8. Roger Kirby Professor of Urology

    Plans to rescue the NHS are in “chaos” after a weakened Theresa May backed down from a fight with MPs likely to involve hospital closures. Legislation to allow local health chiefs to transform the delivery of care – and, crucially, save many billions of pounds – has been shelved after the Conservatives lost their Commons majority.

    Health Secretary Jeremy Hunt has admitted the legal shake-up cannot go ahead without a “consensus” and that it will not happen while the Government is fixated on Brexit. Two thirds of the 44 Sustainability and Transformation Plans (STPs) propose closing a hospital, or moving treatment to a different site. The STPs have not been stopped in their tracks. Local health bodies will continue to create them, but without any legal underpinning. Now it is feared that, without that legal footing, it will be significantly harder to compel the many different parts of the NHS to force through unpopular changes.

    July 2, 2017 Reply
  9. Roger Kirby Professor of Urology

    Earlier this week, NHS England Chief Executive, Simon Stevens, and Secretary of State for Health, Jeremy Hunt, jointly announced capital investment totalling £325 million to support local projects and initiatives that are being developed through the ongoing Sustainability and Transformation Plans. As part of the announcement, NHS England identified three projects that would benefit from additional funding. This included £50 million to deliver improvements to urgent and emergency care in Greater Manchester and a further £50 million of funding for chemotherapy and radiology services in Cumbria. There are 13 other areas receiving the financial support, which is going to STPs that are deemed by NHS England as the most advanced.

    These particular projects are likely to cause additional political tensions on top of those that exist around the STP process currently. On a macro level, it was expected that had the Conservatives secured an increased majority at the recent General Election, that would give the political cover necessary to accelerate the process. Labour has claimed that the process is a cover for cuts to the service whereas the Government and NHS officials state the locally developed plans are designed to allow the NHS to adapt to changing patient needs at a time when demand is increasing.

    In Greater Manchester, the controversial Healthier Together consultation over health services in the region was used by Labour to attack the Government’s approach. The developing devolution agenda will give the region greater ownership over the process. There is acknowledgement within Greater Manchester that service change is necessary. In Cumbria, one of the most challenged health economies in the country, some cancer patients have been expected to travel to Hexham to receive treatment. This new facility will be welcomed by the region’s MPs, but longstanding tensions will still exist as the size of the county means many patients will still be expected to travel long distances.

    It is within these individual examples that the regional difficulties that may be highlighted through the STP process can be really seen. If local pressure on MPs manifest into disgruntlement on the backbenches, it could cause real problems for the Government.

    July 21, 2017 Reply

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